Management of Medically Compromised Patients
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  • 1. February 22, 2010 Suzanna Lekht, DMD UMDNJ Orthodontic Dept.
  • 2.
    • A pilot study performed in 2002 of several orthodontic practices revealed that more than 25% of patients seeking orthodontic therapy had some medical diagnosis that potentially impacted their care
    Seminars in Orthodontics Volume 10, Issue 4 , December 2004, Page 239 The Medically Compromised Orthodontic Patient , Andrew L. Sonis DMD, Guest Editor
  • 3.
    • Hypersensitivity reactions
    • Adenotonsillar hypertrophy
    • Seizure disorders
    • Diabetes
    • Psychiatric disorders
    • Pediatric cancer
    • Special needs
    • Cardiac disorders
    • Bleeding disorders
    • Asthma
  • 4.
    • Hypersensitivity reactions
    • Seizure disorders
    • Pediatric cancer patients
    • Cardiac disease
    • Bleeding disorders
    • Asthma
  • 5.
    • Most common hypersensitivity reactions in orthodontic practice are due to the use of latex-based products and to the alloy components of metal-based orthodontic appliances
    • Reactions of irritant origin are usually associated with direct friction between soft tissues and orthodontic appliances
    • Hypersensitivity reactions are related to the antigenicity of some materials that results in an adverse patient response
  • 6.
    • Type I hypersensitivity to natural rubber latex represents an immediate antibody-mediated allergic response to multiple proteins on the latex product
    • Less than 1% of the general population are reported to be diagnosed with potential type I natural rubber hypersensitivity
    • A higher prevalence (between 6% and 12%) is reported among dental professionals
  • 7.
    • People with a history of atopy
    • Atopy is a disease characterized by a tendency to be “hyperallergic”--A patient with atopic allergies has atopic eczema or atopic dermatitis since infancy
    • Those who have had repeated operations and extensive contact with rubber surgical drains
    • Those with spina bifida
    • A history of itching and redness from contact with balloons, rubber dams, etc.
  • 8. Atopic eczema is an extremely itchy skin condition with a hallmark rash that appears most often over the flexural regions
  • 9.
    • Hay fever
    • Asthma
    • Eczema
    • Contact dermatitis
    • Food allergy can also point to a potential latex allergy
    • bananas, avocado, passion fruit, kiwi, and chestnuts have proteins that are capable of cross-reacting with latex proteins
    • These foods can thereby act as a possible mode of sensitization to the natural rubber latex materials
  • 10.
    • Clinical tests, of which the skin prick test is considered the most accurate , can determine the presence of circulating antinatural rubber latex antibodies
  • 11. This more delayed reaction usually presents a reaction localized to the area of skin contact More commonly known as allergic contact dermatitis This generally localized reaction is typically characterized by diffuse or patchy eczema on the contact area It is often accompanied initially by itching, redness, and vesicle formation, and later on as dry skin, fissures, and sores Initial signs of reaction develop in minutes to hours and may persist for several weeks These reactions are not considered life-threatening but can cause permanent damage to the skin if mismanaged or left untreated
  • 12.  
  • 13.
    • Patch testing, which consists of a series of allergens applied to the upper back for 24 to 48 hours, is followed by a specialist examination for 1 to 7 days after the patches are removed
    • Positive testing reveals areas of red and inflamed skin under the patches, indicative of an allergy to the applied chemical
  • 14.
    • Elastic bands represent another potential source of latex allergy protein that must considered
    • The extension force pattern was reported to be different for NRL (Natural Rubber Latex) and NRL-free alternatives (Silicone Bands)
    • Silicone bands showed greater force decay than NRL elastics, and it was concluded that great improvements in the physical properties of the silicone bands would be required before they could be considered as an acceptable alternative to NRL elastics
    • After static force extension of 450% for 1 day in saliva, the force decay was 33% for the silicone bands and 28% for the NRL elastics
    • .
  • 15.
    • The ideal force required to maximize the rate of tooth movement is still unknown, although most evidence would suggest that there is a wide force spectrum to which teeth will respond appropriately
    • Although NRL-free elastics do not perform as well as NRL elastics in laboratory studies, it is unlikely that the relatively small mechanical differences in force decay would have a clinically significant effect
    • No clinical trial has compared NRL and NRL-free elastics to date
  • 16.
  • 17.
    • Best management of natural rubber latex hypersensitivity is to avoid contact with the product and use of alternative products made of synthetic rubber or plastic
    • Natural rubber latex gloves should be substituted with alternative ones made of other components such as nitrile, neoprene, vinyl, polyurethane, and styrene-based rubbers
    • The use of powder-free gloves will diminish the amount of aerosolized allergens
  • 18.
    • More frequent office cleanings
    • Air-duct filter changes and cleanings
    • Early morning appointments can reduce patient exposure to airborne natural rubber latex particles
    • Administration of pretreatment antihistamines
    • In the event of a severe type I reaction, emergency procedures such as administration of epinephrine are recommended ( i.e. EpiPen ® )
    • Use of latex free products during treatment
  • 19.
    • Epinephrine constricts blood vessels, relaxes smooth muscles in the lungs to improve breathing, stimulates the heartbeat, and works to reverse hives and swelling around the face and lips
    • The effects of epinephrine usually last 10 to 20 minutes so immediate medical attention is still required
    • EpiPen ® auto-injector should only be used on the fleshy outer portion of the thigh and can be used through clothing
  • 20. The metal components of orthodontic appliances are generally composed of 18/8 stainless steel (18% chromium and 8% nickel) Both of these metal components are known allergens, but the nickel in particular is considered a common cause of contact allergy
  • 21. Nickel is the most common metal-based contact allergy among women, with the incidence of nickel sensitivity in the female population reported as high as 30% compared with only 3% of males among the studied individuals Nickel sensitivity was higher among subjects with a history of pierced ears; there was 31% prevalence compared with subjects without pierced ears at 2% prevalence Nickel titanium alloys contain up to 70% nickel
  • 22.
    • A study by Bass and colleagues of 29 subjects (18 female, 11 male) reported an initial positive skin patch test to nickel sulfate in five of the female patients and in none of the male patients
    • These five subjects (who tested positive with the skin patch test) plus the negative patch-testers were followed over the course of treatment after banding and bracketing with fixed stainless steel appliances
    • None of the positive or negative test patients evidenced inflammatory reactions or discomfort as a result of the orthodontic appliances
    • Two of the original negative test result patients, one female and one male, converted to a positive patch test to nickel. Again, no localized allergic-type responses were noted relative to the appliances.
    • The authors concluded that the nickel-containing appliances had no allergic effects on the oral tissues, although the appliances may play a role in inducing nickel sensitivity
    • Seminars in Orthodontics Volume 10, Issue 4 , December 2004, Pg 240-243 The Medically Compromised Orthodontic Patient
  • 23.
    • An in vitro corrosion study by Grimsdottir and colleagues reported that nickel release from orthodontic metal appliances is most related to the solder composition and manufacturing of the appliances rather than being directly related to the actual nickel content
    • The study analyzed facebows, brackets, molar bands, and both stainless steel and nickel titanium arch wires for nickel release when stored in physiologic saline
    Seminars in Orthodontics Volume 10, Issue 4 , December 2004, Pages 240-243 The Medically Compromised Orthodontic Patient
  • 24.
    • The analysis indicated that appliances using silver and gold solders (eg, facebows and molar bands) showed enhanced release of nickel and chromium
    • In contrast, alloys containing titanium, for example arch wires, released little nickel when tested under the static conditions of this study
    • As noted by these studies, titanium has the advantage of being highly resistant to corrosion and may bind the nickel from release in these in vitro studies
    • What is unknown is whether friction of the archwires in brackets might enhance the release of metal components from the appliances
  • 25. In a survey of Norwegian orthodontists by Jacobsen and Hensten-Patterson,30 participants were asked to assess the number and nature of adverse reactions among their patients and to relate them to materials or treatment provided Dermal reactions reported included redness, irritation, itching eczema, soreness, fissuring, and desquamation most often attributed to a metal extraoral (eg, headgear facebow) component of the appliances Intraoral reactions included redness, swelling, itching and soreness of the lips and oral mucosa, and inflammation of the gingival tissues Occasionally, symptoms such as fever were reported. Although not all the symptoms were attributed to the presence of metal components, they were assumed to be the primary allergens in these reported cases of hypersensitivity reactions
  • 26.
    • Research literature suggests that metal-based orthodontic appliances do not increase the risk for nickel hypersensitivity to patients
    • Our current knowledge of intraoral orthodontic appliance corrosion patterns and the rare occurrence of possible nickel allergic responses in patients suggests that concerns about sensitizing orthodontic patients to nickel are not supported in the literature
    • Caution and close monitoring should be exercised in patients with a defined history of atopic dermatitis to nickel-containing metals but that orthodontic treatment avoidance is unnecessary
  • 27.
    • A seizure is a sudden, involuntary, time-limited alteration in neurologic function resulting from abnormal electrical discharge of cerebral neurons
    • Seizures manifest as altered sensation, behavior, or consciousness
    • Epilepsy is defined as two or more seizures that are not provoked and are not due to an acute disturbance of the brain
    • It is a sign of underlying brain dysfunction, rather than a single disease
    • There are many different types of epilepsy and treatment and prognosis varies by type
  • 28.
    • The cumulative incidence of epilepsy from birth through age 20 years is about 1% and increases to 3% at age 75
    • Epilepsy with a recognized cause is termed “secondary” ; those patients for whom a cause cannot be determined have “primary” epilepsy
    • Etiology in childhood includes congenital abnormalities, birth-related complications, trauma, meningitis, encephalitis, and malignancy
    • Adult etiologies are brain tumors, cerebral vascular disease, head trauma, and degenerative changes
  • 29.
    • Seizure disorders are the most common serious chronic neurological condition
    • Contemporary management may include medications, surgery, an implanted nerve-stimulation device, and/or a ketogenic diet
  • 30.
    • Normally, our bodies run on energy from glucose, which we get from food
    • We can't store large amounts of glucose however, and only have about a 24-hour supply
    • The ketogenic diet is a low carbohydrate and high fat diet
    • 80% of calories come from fat and the rest from carbs and proteins
    • Each meal has about four times as much fat as protein or carbohydrate
    • More effective in children (length of diet is about 2 years)
    • It forces the child's body to burn fat round the clock by keeping calories low and making fat products the primary food that the child is getting
  • 31.
    • About a third of children who try the ketogenic diet become seizure free, or almost seizure free
    • Another third improve but still have some seizures
    • The rest either do not respond at all or find it too hard to continue with the diet, either because of side effects or because they can't tolerate the food
  • 32. Dehydration Constipation Kidney stones or gall stones Menstrual irregularities Pancreatitis Decreased bone density Eye problems
  • 33.
    • Seizures lasting longer than 30 minutes or rapidly recurring seizures are termed “status epilepticus”
    • Convulsive seizures that continue longer than 10 minutes require treatment by medical professionals who can administer intravenous anticonvulsive medication and support the patient’s respirations as needed
    • With early recognition and appropriate treatment, patients with an episode of status epilepticus should have no residual adverse effects
  • 34.
    • Absence --10–30 sec loss of consciousness, brief eye or muscle fluttering, sudden halt in activity
    • Tonic-clonic – loss of consciousness with falling, 10–20 sec muscle rigidity followed by 2–5 min clonic contractions of muscles of extremities, head, trunk; urinary and/or fecal incontinence, postictal deep sleep 10–30 min
    • Atonic --Brief loss of muscle tone with falling
    • Clonic --Alternating muscle contraction and relaxation
    • Tonic-- persistent firm muscle contractions
  • 35.
    • Having a seizure disorder affects almost every aspect of life
    • Education, social life, emotional health, physical abilities, and financial resources are all impacted
    • Cognitive impairments occur frequently; this is thought to be multifactorial with underlying brain abnormalities, effects of seizures, and medication side effects playing additive roles
    • Patients with epilepsy have an increased prevalence of depression and anxiety compared with the general population
  • 36.
    • Some patients have identified triggers that impact the number and severity of seizures including:
    • Flashing lights
    • Anxiety
    • Illness
    • Hyperventilation
    • 7 Factors reported to increase seizures include:
    • Stress
    • Missed medication
    • Sleep deprivation
    • Alcohol consumption
    • Nonprescription medications
    • Vitamin or mineral deficiencies
    • Parts of the menstrual cycle
  • 37.
    • Record a detailed history: specific details about seizure onset, frequency, and type, behavior during seizures, duration, triggers, recovery period, medical management, and compliance
    • Be prepared to respond: The practitioner and staff should be prepared to respond appropriately when a patient has a seizure in the orthodontic office
    • Gingival hypertrophy associated with anticonvulsant medication and past dental or facial trauma should be considered when planning treatment and reviewed as part of patient informed consent
  • 38.
    • Often, the patient’s physician requests the removal of appliances for an MRI scan
    • The metal in a fixed orthodontic appliance may distort images obtained by the MRI
    • In some patients, an MRI may be obtained if archwires are removed before the scan
    • Oftentimes, though, the removal of the entire orthodontic appliances is required
  • 39.
    • There is little in the dental literature regarding the implications of seizure disorders on oral health and delivery of dental care
    • Dentofacial trauma occurring during seizures has been reported to include injuries to the tongue, buccal mucosa, facial fractures, avulsion, luxation or fractures of teeth, and subluxation of the temporomandibular joint
  • 40.
    • Gingival Hyperplasia
    • reported to occur in up to 50% of patients treated with phenytoin (Dilantin), sodium valproate (Depakote), and ethosuximide ( Emeside and Zarontin)
    • Other side effects of medications
    • recurrent aphthous-like ulcerations, gingival bleeding, hypercementosis, root shortening, anomalous tooth development, delayed eruption, and cervical lymphadenopathy
    • Asymmetry
    • Of particular interest to the orthodontist is a recent report of facial and body asymmetries affecting 41% of patients with partial seizures in the population studied; asymmetries included both hemihypertrophy and atrophy
  • 41.
    • Clinically differentiating between localized related epilepsy and generalized epilepsy is important because it carries significant implications for planning diagnostic management strategy
    • Body asymmetry was found in 88 out of 282 cases, in which 64 (73.5%) suffered from localization related epilepsy. Among localization related epilepsy, asymmetries were found in 41.5% of patients
    • In contrast, only 18.75% of patients with generalized seizure disorders showed similar findings
    Body part asymmetry in partial seizure G. C. Y. FONG et al Seizure Volume 12, Issue 8 , December 2003, Pages 606-612
  • 42.
    • Study validates the importance of clinically observed body asymmetry in patients with localization related epilepsy
    • Although these changes are definite, they can be subtle and special attention is necessary
    • Hence, detection of body asymmetries in patients with a seizure disorder is a useful clinical clue for the diagnosis of complex partial seizure as well as the likely lateralization of seizure origin contralateral to the atrophic limbs
  • 43. Patient with partial seizure originated from his right parietal lobe. Physical examination revealed smaller left arm, thumb, thigh and calf. Body part asymmetry in partial seizure G. C. Y. FONG et al Seizure Volume 12, Issue 8 , December 2003, Pages 606-612
  • 44.
    • Stay calm
    • Remove dangerous items from the immediate area
    • Do NOT try to restrain the patient
    • Note the time the seizure begins
    • Keep onlookers away
    • Activate the emergency medical system if any seizure lasts for more than 10 minutes or if the patient has three or more seizures within a short time
    • Speak quietly and calmly remove the patient from a dangerous or embarrassing environment by guiding them to a safe location and stay with the patient until they are alert
  • 45. “ A new study found that seizure care in particular was depicted appropriately less than half the time on major fictional medical shows. “
  • 46.
    • Childhood cancer is a relatively uncommon disease affecting approximately 12 of 100,000 children
    • The three most frequent major childhood cancers, comprising about 69% of all childhood neoplasms are:
    • - leukemias (30.1% of all cancers diagnosed among children below 15 years of age)
    • -central nervous system tumors (27.8%)
    • - lymphomas (11.0%)
  • 47.
    • Entering into the 21st century, an estimated 1 in every 900 young adults between the ages of 16 and 44 is a survivor of childhood cancer
    • A survivor of childhood cancer is defined as one who has been free of disease for 5 years and off therapy for 2 years
    • The overall survival rate for all types of childhood cancer is now approaching 80%
  • 48.
    • Both chemotherapy and radiation therapy given to the growing individual will have consequences for growth, dental development, and craniofacial growth
    • The caries risk may also be increased due to salivary dysfunction
    • It has been shown that although ideal treatment results are not always achieved, orthodontic treatment does not produce any harmful side effects
  • 49.
    • Late effects of treatment (radiation and chemotherapy) include:
    • Organ dysfunction
    • Decreased growth
    • Second malignant neoplasm
    • Early mortality
    • Reduced bone mineral density (increased fractures)
    • Decreased fertility
    • Adverse psychosocial effects
  • 50.
    • In a sample of 97 children diagnosed with ALL (Acute Lymphoblastic Leukemia) before 10 years of age, treated with combination chemotherapy and cranial irradiation, and followed at least 5 years after diagnosis, the main finding was that patients younger than 5 years at the commencement of anticancer therapy had a markedly increased risk of craniofacial aberrations, characterized by mandibular retrognathism
    • The growth repressive action of irradiation has been explained to be due to growth hormone deficiency in children who receive cranial radiation
    • Several studies stress the importance of growth hormone for a normal mandibular growth
    • Although several animal studies indicate that various chemotherapeutic agents used in anticancer therapy are potentially growth restricting, the clinical effect in humans seem to be fairly moderate
  • 51.
    • Holtgrave and colleagues studied long-term effects of antineoplastic chemotherapy and radiotherapy on dentofacial development in 26 children with solid tumors treated with chemotherapy alone and in 34 patients with ALL treated with intensive chemotherapy and cranial irradiation to the neurocranium
    • There was a marked long-term effect on dental development , whereas the effect on craniofacial dimensions was minor, including a 5% growth reduction in the distances sella-nasion, sella-pogonion, and articulare-pogonion in children who received radiation therapy
    Orthodontic considerations in the pediatric cancer patient: A review Pages 266-276 Göran Dahllöf, Jan Huggare
  • 52.
    • Strategies used by orthodontists in treating this patient group may include:
    • using appliances that minimize the risk of root resorption
    • low force application
    • accepting a compromised treatment result by simplistic mechanics
    • terminating the treatment earlier than normal
    • not treating the lower jaw
    • It is advised to postpone the start of orthodontic treatment at least 2 years after completion of cancer therapy
    • Since radiation therapy has a growth-suppressive effect, especially on cartilage growth , avoid treating a skeletal Class II malocclusion with growth modification
  • 53.
    • There are no reports on occurrence of osteoradionecrosis after tooth extractions in children treated for malignancies
    • In the group of children subjected to orthodontic treatment, healing after extractions was uncomplicated
    • Since orthodontic treatment should not be started until 2 years after completion of cancer therapy, extractions for orthodontic indications should likewise be deferred until that time
  • 54.
    • Antineoplastic treatment results in decreased resistance to infections and atrophy of the oral mucosa
    • Patients are at increased risk of complications related to anything that might irritate the mucosal surface
    • To minimize this risk, nonirritating orthodontic appliances should be a consideration in the orthodontic treatment planning of these patients
    • Regular rinsing with artificial saliva and daily topical fluoride application are recommended
    • Because of the reduced regeneration capacity of the mucous membrane even minor irritation from orthodontic appliances can lead to severe ulceration
    • Should the patient require additional chemotherapy or radiotherapy during the course of their active orthodontic therapy, appliances should be removed to minimize the potential for oral complications
    • Once the patient is in remission and the prognosis is considered good, orthodontic therapy can recommence
  • 55.
    • While orthodontic therapy has been historically considered to be completely noninvasive, specific orthodontic procedures may place some patients at risk for serious complications
    • Among the most common of these conditions are those associated with cardiac disease, bleeding disorders, and asthma
  • 56.
    • Although most orthodontic treatment is minimally invasive, the placement and removal of orthodontic bands has been suggested to produce bacteremias
    • The actual data to support this hypothesis are sparse
    • McLaughlin and colleagues studied the incidence of bacteremias after orthodontic banding in 30 healthy adults
    • Elastomeric separators were placed 1 week before the placement of a single band on a permanent first molar
    • Blood samples for culture were taken before and 1 to 2 minutes after band placement
    • Bacterial cultures revealed that the frequency of bacteremias following banding was 10% compared with 3% in the preoperative sample
  • 57.
    • The impact of gingival health on bacteremias associated with band placement can be further appreciated when one compares the incidence of bacteremia following matrix band placement between individuals without gingival inflammation (0%) and those who had gingivitis associated with bleeding (32%)
    • From a risk standpoint, the frequency of banding-induced bacteremias appears to be less than that reported for flossing (20%) or toothbrushing (25%)
  • 58.
    • Patients at HIGH RISK are those with a prior history of endocarditis, those who have prosthetic valves or surgically corrected systemic pulmonary shunts or conduits, or those with complex cyanotic congenital heart disease (tetrology of Fallot)
    • Patients at MODERATE RISK are those with congenital cardiac malformations, acquired valvular dysfunction (such as that caused by rheumatic fever), hypertrophic cardiomyopathy, and mitral valve prolapse with regurgitation
    • Patients at NEGLIGIBLE RISK for endocarditits, defined as being no more likely to develop BE than the general population, are those with secundum atrial septal defects, surgical repair of atrial or ventricular septal defects or patent ductus arteriosus, previous coronary artery bypass grafts, mitral valve prolapse without valvular regurgitation, innocent heart murmurs, previous Kawasaki disease or rheumatic fever without valvular dysfunction, cardiac pacemakers, and implanted defibrillators
  • 59.
    • The major changes in the updated recommendations include the following:
    • The committee concluded that only an extremely small number of cases
    • of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective
    • IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE
    • For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
  • 60. Prevention of Infective Endocardititis: Guidelines from the American Heart Association Wilson, Walter (et. al) J Am Dent Assoc 2008;139;3S-24S
  • 61. Prevention of Infective Endocardititis: Guidelines from the American Heart Association Wilson, Walter (et. al) J Am Dent Assoc 2008;139;3S-24S
  • 62.
    • Three management guidelines form the basis for patients at risk of bacterial endocarditis:
    • • Communication with the patient’s physician to confirm that a risk for bacterial endocarditis truly exists
    • • Aggressive pre-treatment and intra-treatment oral hygiene to minimize the presence of gingival inflammation
    • • Prudent use of prophylactic antibiotic therapy
    • Prevention of Infective Endocardititis: Guidelines from the American Heart Association: Wilson, Walter (et. al) Am Dent Assoc 2008;139;3S-24S
  • 63.
    • The current recommendations for endocarditis prophylaxis by the American Heart Association are a single dose of Amoxicillin (2 g in adults or 50 mg/kg in children) administered 1 hour before the procedure
    • For penicillin-allergic patients, Clindamycin (600 mg for adults and 20 mg/kg for children)
    • If a patient forgets to take his or her premedication, or if unanticipated bleeding occurs, the American Heart Association guidelines suggest that antibiotic given at the time of treatment or up to 2 hours from the time of insult is effective
  • 64.
    • Effective hemostasis is the consequence of a sequence of events in which platelets and plasma proteins produce clotting
    • Defects in either may result in a clinically relevant coagulopathy with consequent bleeding
    • Bleeding disorders result from qualitative or quantitative platelet deficiencies, or inadequate or insufficient levels of plasma-clotting factors
  • 65.
    • Platelet deficiencies of interest to the orthodontist are associated with conditions that result in a reduction of platelets (thrombocytopenia)
    • Thrombocytopenia may result from a reduction in the production of platelets caused by disruption of the bone marrow
    • The most likely sources for this etiology are malignancies involving the bone marrow (leukemia) or autoimmune conditions in which the platelet-producing cells in the marrow are destroyed (aplastic anemia)
  • 66.
    • Leukemia is among the most common malignancies of patients in the most frequently orthodontically treated age groups
    • Gingival bleeding caused by thrombocytopenia often heralds the onset of acute leukemia
    • Unlike most gingival bleeding, which is elicited by some type of provocation, gingival bleeding associated with profound thrombocytopenia is spontaneous
    • Spontaneous gingival bleeding is associated with platelet counts of 20,000 cells/mm 3 or less (normal 150,000–450,000 cells/mm 3 )
    • Because orthodontists see patients frequently, they are often in the position of being the first health care provider to recognize this early sign of leukemia
  • 67.
    • In contrast to platelet-related bleeding disorders, factor-related diseases are most often congenital
    • As a result, the orthodontist should be able to determine the presence of these conditions before the initiation of treatment
    • Three congenital clotting factor deficiencies account for more than 90% of inherited disorders:
    • Hemophilia A (def of Factor VIII)
    • Hemophilia B (def of Factor IX)
    • Von Willebrand’s disease (defects of von Willebrand’s factor ) **most common congenital bleeding disorder***
  • 68.
    • For patients with a congenital bleeding disorder, probably the biggest orthodontic-associated risk is associated with extractions associated with treatment
    • In these cases, the administration of factor replacement along with Amicar or tranexamic acid is prudent
    • Amicar (aminocaproic acid) and tranexamic acid are anti-fibrinolytic agents that prevent the breakdown of the clot in the extraction site, allowing for better organization, and thereby decreasing the likelihood of postoperative bleeding
  • 69.
    • To minimize risk and cost to the patient, it seems most reasonable to perform all planned extractions at a single visit
    • It is imperative that this group of individuals be in absolute gingival health before the commencement of treatment
    • Care should be used in the placement and removal of orthodontic hardware to minimize the risk of mucosal injury
    • Elastomeric modules are preferential to wire ligatures
    • Overall treatment should be performed as expeditiously as possible
  • 70.
    • Episodic narrowing of the airways that results in breathing difficulty and wheezing
    • Asthma is most often the result of an inherited immunologic hypersensitivity (allergic) disorder
  • 71.
    • Almost half of cases of asthma develop before age 10
    • Prevalence of the condition was highest in blacks (15.8%), intermediate in whites (7.3%) and Asians (6.0%), and lowest in Latinos (3.9%)
    • These differences were unrelated to income or access to medical care
    • The severity of asthma, based on limitation of activities and need for acute medical care, was most notable among black and Latino children
  • 72.
    • The first objective is the prevention of acute asthmatic attacks and the key to this is the identification of patients at risk
    • Obtain information regarding the severity of the disease (limitation in activities, emergency room visits, etc.), medications, and factors that precipitate an attack
  • 73.
    • Communication with the patient’s physician will assist in risk assessment
    • Orthodontic treatment should probably be deferred in patients who report symptomatic disease or have frequent flares despite being adequately medicated
    • For patients at low or moderate risk, since anxiety and stress are often associated with acute attacks, morning appointments when the patient is rested, short waiting times, and visits of limited duration are most desirable
  • 74.
    • The orthodontist should assure that the patient has taken his or her medication and, if appropriate, has his or her inhaler present if needed during the appointment
    • Patients with asthma may be sensitive to several specific medications including the erythromycins, aspirin, antihistamines, and local anesthesia containing epinephrine
  • 75.
    • Chronic use of inhalers, especially those containing steroids, may result in a predilection for the development of oral candidiasis and xerostomia
    • If noted candidiasis can be treated with topical antifungal agents such as Nystatin
    • Xerostomia enhances the risk of caries, therefore, aggressive oral hygiene, supplemental topical fluorides are essential
  • 76.
    • It has been suggested that orthodontic-induced external root resorption occurs with greater frequency in patients with asthma than in the non-asthma population
    • McNab and colleagues compared the incidence and severity of external root resorption following fixed orthodontic therapy between patients with asthma and a healthy population
    • They found that while the incidence of external apical root resorption was elevated in the asthmatic population, the severity of resorption was the same between groups
    • It would seem prudent, therefore, for orthodontists to disclose the heightened risk of external root resorption to patients before initiating treatment
  • 77.
    • Root Resorption and Immune System Factors in the Japanese
    • The objective of this study was to determine whether there is an association between excessive root resorption and immune system factors in a sample of Japanese orthodontic patients
    • The records of 60 orthodontic patients (18 males, age 17.7 ± 5.7 years; 42 females, age 16.4 ± 6.0 years) and 60 pair-matched controls (18 males, age 15.9 ± 4.5 years; 42 females, age 18.5 ± 5.2 years) were reviewed retrospectively
    • The pretreatment records revealed that the incidence of allergy and root morphology abnormality was significantly higher in the root resorption group
    • The incidence of asthma also tended to be higher in the root resorption group
    • From these results, we concluded that allergy , root morphology abnormality , and asthma may be high-risk factors for the development of excessive root resorption during orthodontic tooth movement in Japanese patients
    The Angle Orthodontist: Vol. 76, No. 1, pp. 103–108.
  • 78. Seminars in Orthodontics Volume 10, Issue 4 , December 2004, Pages 266-276 The Medically Compromised Orthodontic Patient . G.C.Y. Fong, Y.F. Mak, B.E. Swartz, G.O. Walsh and A.V. Delgado-Escueta, Body part asymmetry in partial seizure, Seizure 12 (2003), pp. 606–612. “ Adverse hypersensitivity reactions in orthodontics Pages 240-243 Luis P. Leite, Ronald A. Bell Orthodontic management of patients with seizure disorders Pages 247-251 Barbara Sheller Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma Pages 277-280 Stephen T. Sonis
  • 79. Orthodontic considerations in the pediatric cancer patient: A review Pages 266-276 Göran Dahllöf, Jan Huggare Prevention of Infective Endocardititis: Guidelines from the American Heart Association Wilson, Walter (et. al) J Am Dent Assoc 2008;139;3S-24S