Orthodontic management of medically compromised patients by almuzian

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Orthodontic management of medically compromised patients by almuzian

  1. 1. University of Glasgow 2013 Orthodontic Management of Medically Compromised Patients Mohammed Almuzian
  2. 2. Orthodontic Management of Medically Compromised Patients Key article Burden paper in 2001 BOS guidelines regarding medical guidance • A medical history should be comprehensive • The medical history should be kept safely with the patient’s record • A patient’s medical history should be updated regularly. 1. At the first visit of a patient to the clinic. 2. At the start of any new course of orthodontic treatment. 3. Before referral to another practitioner or specialist for additional treatment. • A competent person who is likely to be aware of the patient’s full medical details should give details of the medical history. This may be the patient, parent or carer. • If using a medical history questionnaire that patients/parents complete on their own, the orthodontist should always check the accuracy of answers. • For some patients e.g. with complex or serious medical problems, it would be prudent to check details of the medical history with the patient’s doctor (with the patient’s consent) and to ask for appropriate guidance about management. Mohammed Almuzian, University of Glasgow, 2013 2
  3. 3. A. Infective Endocarditis Implications for orthodontic therapy: 1. Its incidence does not appear to be higher during orthodontic treatment. However, only 4 cases have been reported in relation to orthodontics. 2. But bacteraemia can be increased by plaque accumulation which in turn increased with orthodontic appliances. 3. NICE guidelines 2008 (no Antibiotic nor chlorohexidine mouth was is given to dental patient) except very high risk patients. Procedures that can cause bacteraemia: 1. Impression 2. Separator placements (greatest bacteraemia) 3. Fitting or removing bands 4. Surgical exposure of teeth. Management according to BOS 1. Informed consent – patient needs to know of any increased risk and should be informed about the uselessness of AB. 2. Need high standard OH with daily antimicrobial M/W – (eg. chlorhexidene 0.2%) to aid plaque control, particularly for 2 days up to fitting or removal or major adjustment of fixed appliances. 3. Bonded appliances – preferred to banded – where possible (exceptions are RME, HG, QH) Mohammed Almuzian, University of Glasgow, 2013 3
  4. 4. 4. Un-erupted teeth - avoid bonding w closed eruption. 5. Antibiotic prophylaxis • In medium risk cases AB is not used. • In high risk cases all procedures liable to cause bacteraemia should be covered by antibiotic prophylaxis. Note that antibiotic administration is not without risk and should only be used where a clear indication exists. 6. Antibiotic prophylaxis regime 1. No Penicillin allergy • 0-5 years Amoxycillin oral 750mg 1 hr pre-op • 5-10 years Amoxycillin oral 1.5g 1 hr pre-op • 10+ years Amoxycillin oral 3g 1 hr pre-op 2. Penicillin allergy or penicillin more than once in last month • 0-5 years Clindamycin oral 100mg 1 hr pre-op • 5-10 years Clindamycin oral 300mg 1 hr pre-op • 10+ years Clindamycin oral 600mg 1 hr pre-op 3. Note that an additional post-op dose of antibiotic is no longer recommended. Mohammed Almuzian, University of Glasgow, 2013 4
  5. 5. B. Prosthetic joints 1. No AB prophylaxis needed C. CNS Hydocephalus and Cerebrospinal shunts ABP may be needed – consult specialist Seizure Disorders: eg. Epilepsy (eg. Grand Mal) 1. Anti-epileptic drugs should be taken regularly. 2. Sedation may be indicated in stress induced procedure like surgical exposure. 3. For patients with recurrent hyperplasia, the patient’s physician should be contacted to discuss alternative medication1 4. Avoid removable if epilepsy poorly controlled 5. If an individual having a class II Division I incisor relationship experiences an aura before a seizure, he or she should carry a soft mouth guard with palatal coverage and extending into the buccal sulci to use at such times 6. Space closing mechanics including nickel titanium closing springs, elastomeric power chain or active elastics can impinge on the hyperplastic gingival tissue. Therefore, they are not used in these patients. 7. Small low profile brackets are recommended. 8. Bands are avoided. Mohammed Almuzian, University of Glasgow, 2013 5
  6. 6. 9. Essix based retainers should be relieved around the gingival margins to maintain alignment. 10. Bonded retainers are avoided in patients at risk of DIGO D. Pregnancy 1. Avoid X-rays or drug therapy, especially in first trimester. 2. Avoid supine position in late pregnancy. 3. Good OH E. Latex allergy Prevalence: 1% of population Who at risk? 1. Individuals with allergic rhinitis, Asthma and eczema; 2. Patient hypersensitive to certain food 3. Atopic patient 4. Patients with spina bifida. Spina bifida (Latin: "split spine") is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. 68% of children with spina bifida have an allergy to latex 5. Pts w urogenital anomalies 6. Patient with multiple previous operation 7. Healthcare professional Mohammed Almuzian, University of Glasgow, 2013 6
  7. 7. 8. Latex industry worker Management 1. Definitive diagnosis • Patch testing • Pin prick testing, • Blood test 2. Staff training and communication: Staff should be aware of emergency protocols for dealing with anaphylactic reactions and auxiliary staff should be aware of the diagnosis. 3. Appointment and surgery management: Appointments should be scheduled for the early morning with use of a latex-screened area to segregate latex-free products to avoid contamination. 4. Appliance design and handling • Latex free gloves. • The use of elastomeric ties could be avoided with use of self- ligating brackets. • Space closure should be undertaken with nickel– titanium coils. • Where inter-maxillary elastics are required, latex-free elastics can be used, although they are subject to greater force degradation. Mohammed Almuzian, University of Glasgow, 2013 7
  8. 8. Types of reaction to Latex 1. Type I hypersensitivity reaction 2. Type IV hypersensitivity reaction (Allergic contact dermatitis) F. Nickel allergy • Nickel induces a contact dermatitis, which is a Type IV delayed hypersensitivity immune response, cell-mediated by T lymphocytes. 1. More common in girls (30%), than in boys (3%) in Finnish and in adolescents with pierced ears (31%) than those without ear piercings (2%) (Bass et al., 1993) . 10 % in female and 3% in male (Nelsen and Menn 1993) • The use of nickel containing jewellery and the increased popularity of body piercings, in particular intra-oral piercings means that many patients may have been sensitized to nickel by the time they visit an orthodontist. As a result, this allergy may become an increasingly common presentation to the orthodontist. • Nickel hypersensitivity has also been found to be higher in asthmatic patients • More serious if contact the skin than mucosa, 5 - 12 times the concentration of nickel required to provoke mucosal lesions compared with skin lesions • Nickel is found in arch wires, bands, brackets and headgear, with stainless steel containing nickel in the ratio of 18:8, with 8 referring to the level of nickel. Mohammed Almuzian, University of Glasgow, 2013 8
  9. 9. Signs and symptoms of nickel allergy 1. For the gingivae: • Gingivitis in the absence of plaque • Gingival hyperplasia 2. For the tongue: • Burning sensation in the mouth • Metallic taste • Numbness/tingling sensation • Soreness of the side of the tongue 3. For the lip: • Labial swelling • Angular cheilitis • Labial desquamation 4. Extra-oral signs and symptoms can include localised dermatitis in sites of prolonged skin contact with nickel-containing objects, for example, headgear studs. This can present as a maculopapular skin rash or vasculitis-like skin lesions. Management according to BOS guidelines 1. Definitive diagnosis: • History • In case of doubt, a trial appliance can be placed which may include two to four brackets with a Ni-Ti archwire and the patient monitored carefully to assess a reaction. Mohammed Almuzian, University of Glasgow, 2013 9
  10. 10. • Patch testing using 5% nickel sulphate in a petroleum jelly substrate. • Pin prick testing, • Blood test 2. Appliance design and handling a. Nickel free brackets • SS because it release less nickel than niti • Ceramic brackets • Polycarbonate brackets • Titanium brackets • Gold brackets • Plastic aligners b. Nickel free archwires • Titanium Molybdenum alloy (TMA) archwires • Fibre-reinforced composite archwires • Pure Titanium archwires • Gold plated archwires c. Extra oral appliances • For nickel sensitive patients, exposed metalwork should be covered with tape or plasters or headgear use discontinued. Plastic coated headgear studs are also available. Mohammed Almuzian, University of Glasgow, 2013 10
  11. 11. G. Diabetes mellitus • Diabetes mellitus (DM) is a metabolic disorder diagnosed in approximately 3% to 4% of the population. • The disease is characterized by chronic hyperglycemia caused by a deficient insulin management. • Two main types of DM exist: type 1 DM, being a total deficiency in insulin secretion, and type 2 DM, which is a combination of resistance to insulin action and inadequate compensatory insulin secretion Orthodontic considerations in patients with DM 1. Orthodontic treatment is avoided in patients with poorly controlled DM 2. Morning appointments are preferable 3. If longer sessions are scheduled then patient is advised to take meal and medication 4. Periodontal health is to be evaluated regularly. 5. Strict oral hygiene measures are adopted. 6. Orthodontic forces are kept to minimum because there is weakening of periodontal ligament and osseous regeneration; Diabetic related peripheral microangiopathy can affect the peripheral vascular supply, resulting in unexplained toothache, tenderness to percussion and even loss of vitality. 7. The orthodontic team should be trained to deal with diabetic emergencies Mohammed Almuzian, University of Glasgow, 2013 11
  12. 12. H. Juvenile Idiopathic Arthritis or Still’s disease Orthodontic considerations in patients with JIA • Limiting mouth opening might cause difficulty in brushing, so OH should be supported with additional regime • A bite splint can be provided to unload the joint during any acute periods of inflammation. • A distracted splint has also been suggested to modify mandibular growth in the same way as conventional functional appliances. • The use of functional appliances in patients is a controversial area. It has been argued that functional appliances and class II elastics put increased stress on the TMJs and should be avoided; however, it has also been suggested that functional appliances protect the joints by relieving the affected TMJ,. • Mandibular surgery to advance it should be avoided I. Renal problems • OH • Reduce treatment • Avoid exo • Avoid ulceration and sharp edges • Light force J. Rickets • Rickets in children and osteomalacia in adults are the classic manifestations of profound vitamin D deficiency. Mohammed Almuzian, University of Glasgow, 2013 12
  13. 13. • The child has retarded growth. • Impaired growth may influence our treatment plan in case of functional appliances. • Orthodontic forces are kept to minimum. K. Osteoporosis • Osteoporosis is a common progressive metabolic bone disease that decreases bone density and deterioration of bone structure. • Osteoporosis can develop as a primary disorder or secondarily due to some other factor. • It is most common in women after menopause, but may develop in men. Orthodontic considerations in patients with Osteoporosis • Patients on oral BPs are at a lower risk of bisphosphonates induced osteoradionecrosis (ONJ) or osteoclastic inhibition. This risk is about 0.5% in patient taking oral Bp and 96% in patient on IV Bps. The mandible is at higher risk than maxilla. Use of bisphosphonates • Osteoporosis in post-menopausal women • Paget’s disease and bone resorption caused by malignant osteolytic lesions • Childhood malignancy Mohammed Almuzian, University of Glasgow, 2013 13
  14. 14. Potential future use of BP • Reinforce anchorage • Reduce their relapse potential after alignment or maxillary expansion • Decrease the tendency for root resorption during orthodontic treatment Recommendation 1. Patient had treated previously with high dose, previous or current IV BP • Consult GP and avoid treatment 2. Patient had treated previously or currently with low dose Consult treatment and start considering the following: A. Consider the half life time and accumulative effect of BP B. Patient should be carefully consented, including the higher risks of ONJ C. Treatment should initially be on a non-extraction D. Compromised treatment preferred E. Short treatment F. Complex orthodontic treatment plans should only be initiated after the response to orthodontic forces has been established. Mohammed Almuzian, University of Glasgow, 2013 14
  15. 15. G. Treatment should be discontinued if teeth respond poorly to orthodontic force application. Signs of poor response to orthodontic force application include slow or no movement of teeth, excessive mobility, as well as radiographic evidence of sclerosis around teeth or other abnormal radiographic changes in the periodontal ligament space. 3. Patient will be treated by BP (try to end treatment as soon as possible) Krieger 2013 in systematic review show no correlation in low dose or short BP treatment L. Blood borne viruses (Hepatitis B, C, D and G, HIV) • All patients are treated as though they are infected and universal cross-infection control precautions are to be followed • All members of the team must be immunized against HBV and should get serological test done once in three months. • Follow up and booster dose are done regularly • One should wear heavy utility gloves and personal protective equipment during the decontamination procedure • Increase tendency to infection and ulceration • Increase tendency to bone resorption because of the hepatic malfunctioning Mohammed Almuzian, University of Glasgow, 2013 15
  16. 16. M. Inherited coagulopathies – deficiencies in clotting factors Implication • Bleeding tendency, • Infection risk, • Anaemia risk Management 1. Medically: • Consult with patient’s haematologist before any surgical procedure to check patient's Hepatitis and HIV status. • Replace missing factors factor VIII • Correct with platelet transfusion immediately prior to surgery so that platelet levels are at least 50 x 109/l • Anti-fibrinolytics should be used post-surgery 2. General dental management: • If only 1-2 teeth are extracted, an INR < 3.5 is acceptable, with local control of haemostasis • Avoid regional nerve blocks, • Avoid drugs that increase bleeding tendency (e.g. aspirin) or cause gastric bleeding (e.g. NSAID). Mohammed Almuzian, University of Glasgow, 2013 16
  17. 17. • Be careful in prescribing analgesia and other drugs since Warfarin interacts with other drugs e.g. aspirin, NSAID, metronidazole, erythromycin, cephalosporins and tetracyclines 3. Orthodontically: • Self-ligating brackets are preferable to conventional brackets. • Archwires are secured with elastomeric modules instead of wire ligature • A Vacuum formed aligners may be the appliances of choice for selected malocclusions. N. Sickle cell anaemia This is a genetic disorder that is characterized by a haemoglobin gene mutation (HbS as opposed to HbA). Orthodontic considerations in patients withs sickle cell anaemia • Good oral • Long treatment duration to restore the regional microcirculation. • Emotional stress is avoided • The surgery is well ventilated and avoid EOA which compromise the airway • An Extraction is contraindicated to treatment and if extractions are necessary they are best carried out in a hospital by a maxillofacial surgeon under complete medical care Mohammed Almuzian, University of Glasgow, 2013 17
  18. 18. • General anaesthetics for elective procedures are contraindicated and hence no orthognathic surgery is recommended O. Asthma Episodic narrowing of the airways passages that results in breathing difficulties and wheezing. Orthodontic considerations for patients with respiratory disorders • The patient’s physician is contacted before the treatment is commenced. • First goal is to prevent acute asthmatic attacks so that, the orthodontist must ensure that patient is carrying inhaler with them and avoidance of the trigger factors • Patients with a history of asthma seem to be at a high risk for developing excessive root resorption during treatment .This emphasizes the prescription of low forces for these patients. • Pt who use oral inhaler might develop candidial infection and recommendation to gargles after inhaler is requested. • The following steps should be taken to manage an acute asthmatic attack in the dental office: 1. Discontinue the dental procedure and allow the patient to sit or lie down in a comfortable position 2. Keep the airway open and administer Beta2-agonists with inhaler or nebulizer 3. Administer oxygen via face mask nasal hood, or cannula Mohammed Almuzian, University of Glasgow, 2013 18
  19. 19. 4. If no improvement takes place and the patient is worsening, administer epinephrine subcutaneously (1:1000 solution, 0.01 mg/kg of body weight to a maximum dose) P. Corticosteroids Normal management except if the patients who have taken more than 10 mg prednisolone daily (or equivalent) within 3 months of surgery: A suitable regimen for corticosteroid replacement before surgery with • The usual oral corticosteroid dose on the morning of surgery • Or hydrocortisone 25-50mg IV at induction. Q. Oral contraceptives • Antibiotic therapy can reduce effectiveness of the pill • Always warn R. Malignancy 1. Patient currently suffers from malignancy: As orthodontic treatment is an elective procedure, orthodontic treatment is not advisable. 2. If orthodontic treatment has been already started • The orthodontist should contact the patient's physician possible for prognosis. • As the time of diagnosis of malignancy is very stressful for the patient and family, orthodontist should be aware of its psychological implications. Mohammed Almuzian, University of Glasgow, 2013 19
  20. 20. • Consider the effect of chemotherapy which can lead to opportunistic infection and subsequent severe complications. It is advisable to remove all orthodontic fixed appliances before starting chemotherapy as a safety procedure. • To counter xerostomia during cancer therapy use of sugar free chewing gum, candy, saliva substitutes, frequent sipping of water, and/or moisturizers is recommended. • Orthodontic treatment may start or resume after completion of all medical therapy and after at least 2-year event free survival when risk of relapse has been decreased and patient is not on immunosuppressive drugs. • American Academy of Pediatric Dentistry recommends following strategy to provide orthodontic care for patient with dental sequelae. 1. Simple treatment 2. Quick treatment 3. Low force 4. Upper jaw treatment only (Lower jaw should not be treated). S. Cystic fibrosis a condition which is hereditary and associated with loss of exocrine gland leading to dry non-productive cough and serious lung infection Management • Consult the physician • Good OH bec of dryness associated with the affected salivary glands • Avoid GA and extraction Mohammed Almuzian, University of Glasgow, 2013 20
  21. 21. • Short compromised treatment Cerebral palsy • Good motivation and oral hygiene • Keep treatment simple • Use URA if possible • Sedation can be used to ease treatment The end…………………………. Mohammed Almuzian, University of Glasgow, 2013 21

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