1. University of Glasgow
2013
Orthodontic Management
of Medically Compromised
Patients
Mohammed Almuzian

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
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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 are
given to dental patient) except very high risk patients.
4.
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.
Mohammed Almuzian, University of Glasgow, 2013
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4. 3. Bonded appliances – preferred to banded – where possible
(exceptions are RME, HG, QH)
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
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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 medication
4. 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
5. Avoid removable if epilepsy poorly controlled
6. Small low profile brackets are recommended.
7. Bands are avoided.
8. 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.
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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. Patient with allergic rhinitis,
2. Asthmatic patient
3. Eczema patient
4. Patient hypersensitive to certain food
5. Atopic patient
6. 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
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7. 7. Pts with urogenital anomalies
8. Patient with multiple previous operation
9. Healthcare professional
10. Latex industry worker
Management
1. Definitive diagnosis
•Patch testing
•Pin prick testing,
•Blood test (immunoassay)
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.
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8. •Where inter-maxillary elastics are required, latex-free elastics can be
used, although they are subject to greater force degradation.
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 than boys
• Girls (30%), in boys (3%) in Finnish
• 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)
2. 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.
3. Nickel hypersensitivity has also been found to be higher in
asthmatic patients
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9. 4. More serious if contact the skin than mucosa, 5 - 12 times the
concentration of nickel required to provoke mucosal lesions compared
with skin lesions
5. 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.
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.
Mohammed Almuzian, University of Glasgow, 2013
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10. 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.
•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 releases 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
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11. • 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.
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
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12. 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
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
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13. •Light force
J. Rickets
• Rickets in children and osteomalacia in adults are the classic
manifestations of profound vitamin D deficiency.
• The child has retarded growth.
• High risk of OIIRR
• 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.
Mohammed Almuzian, University of Glasgow, 2013
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14. Use of bisphosphonates
• Osteoporosis in post-menopausal women
• Paget’s disease and bone resorption caused by malignant osteolytic
lesions
• Childhood malignancy
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
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15. 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.
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
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16. •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
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:
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17. •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).
•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
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18. •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
•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:
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19. 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
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. Orthodontist may play an important role during initial diagnosis
2. Patient currently suffers from malignancy:
I. As orthodontic treatment is an elective procedure, orthodontic
treatment is not advisable.
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20. II. Patient who received chemo or radiotherapy are at risk of:
•Short root
•Hypodontia
•Malformed teeth
•Delayed dental development
3. 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.
•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
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21. 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
•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………………………….
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22. Mohammed Almuzian, University of Glasgow, 2013
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