Ortho Treatment Medically Compromised Patients

Orthodontic Treatment in Medically
Compromised
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction



Orthodontics is a dynamic and exciting specialty
of dentistry. The nature of the orthodontic
patient base continues to evolve, and the
practicing orthodontist will be increasingly
challenged to assist in the diagnosis and
management of patients with special medical
needs.




Given the age range of the majority of
orthodontic patients, it is important that the
orthodontist understand the basic management
of various medical disorders and specific
considerations in orthodontic treatment of these
patients. With an understanding of the
fundamental disease and the therapy for medical
problems, the orthodontist can be a positive part
of the health care team and support a family in
crisis.










Medical conditions commonly encountered in
orthodontic patients include:
risk of infective endocarditis;
bleeding disorders;
leukaemia:
diabetes;
cystic fibrosis;
Infections
juvenile rheumatoid arthritis;

Diabetes Mellitus






It is a clinical syndrome which produces an
excess of blood sugar, or hyperglycemia, due to
a deficiency or diminished effectiveness of
insulin.
Type I Insulin dependent, sometimes termed as
Juvenile onset.
Type II Insulin independent or maturity onset




In addition there is diabetes of pregnancy where
a hormone, human placental lactogen has a
contra-insulin effect. Should this occur the
pregnant patient requires insulin therapy during
second and third trimester to be discontinued as
the placenta is removed.


Diabetes- Complications






Hyperglycemia & Ketoacidosis- Coma of slow
onset
Hypoglycemia- coma of Sudden onset

Concurrent complications
Diabetes of pregnancy- up to 9% death of
fetus.


Chronic complications: Vascular
 Macroangiopathy -Large blood vessels
 Head –Cerebrovascular accident (stroke)
 Heart -Angina Pectoris and myocardial
infarction
 Limbs-Gangrene









Microangiopathy
Small blood vessels of
Eyes -Blindness
Heart -Cardiomyopathy
Kidneys-Renal failure
Skin -Necrosis





Non-vascular
Cataract
Neuropathy






There is a great deal of evidence to show that
good diabetic control and the achievement of
normoglycemic state prevents many if not all
complications of the disease.
Management involves diet control, insulin
therapy and oral hypoglycemic agents.


Oral Manifestations




Approximately half of the people with DM are
undiagnosed, and a dental examination might
give the first indication of the disease.
Xerostomia, oral candidiasis, burning mouth or
tongue (glossopyrosis), impaired wound healing,
recurrent oral infections, and acetone breath,
multiple periodontal abscesses




Several oral manifestations are associated with
DM, although they are mainly found in patients
whose DM is uncontrolled or poorly controlled.
Well-controlled patients without local factors,
such as subgingival calculus, have as healthy a
periodontium as nondiabetics.




Even well-controlled DM patients may have
more gingival inflammation, probably because
of impaired neutrophil function. Vascular
changes, such as DM-related microangiopathies,
have been shown to encourage periodontal
disease.




Because periodontal disease tends to be more
common and more extensive in patients with
uncontrolled or poorly controlled DM, one
could hypothesize that normalizing the blood
glucose levels should stop the progression of
periodontal disease. This is, however, not true;




Sastrowijoto et al (1990) demonstrated that
better metabolic control in type 1 patients did
not improve the clinical periodontal condition; it
ameliorates only when local oral hygiene
measures are used. The periodontal condition
will continue to deteriorate when the blood
glucose level is not well controlled.


Dental/ Orthodontic treatment


The key to any orthodontic treatment is good
medical control. Orthodontic treatment should
not be performed in a patient with uncontrolled
diabetes. If the patient is not in good metabolic
control every effort should be made to improve
blood glucose control. For DM patients with
good medical control, all dental procedures can
be performed without special precautions if
there are no complications of DM.



However it is very important that the procedure
be completed without stress and without causing
the patient to miss a meal.






The patient must be knowledgeable about the
disease, if on insulin must regularly determine
the blood glucose level, prior to the
appointment, must take the usual morning dose
of insulin or oral hypoglycemic and must have a
normal breakfast.
The dentist must arrange an early appointment,
create as little stress as possible and have
emergency drugs readily available.





Painless dentistry free of stress is required.
Topical anesthesia, aspirating syringe and
minimal epinephrine doses should be used.
Prilocaine plain (4%) or mepivacaine plain (3%)
are suitable solutions.
If there is any difficulty in obtaining local
anesthesia then articaine 4%with 1/200 000
epinephrine using a minimal amount of solution
is acceptable.



There is no treatment preference with regard to
fixed or removable appliances. It is important to
stress good oral hygiene, especially when fixed
appliances are used. These appliances might give
rise to increased plaque retention, which could
more easily cause tooth decay and periodontal
breakdown in these patients.




Daily rinses with a fluoride-rich mouthrinse can
provide further preventive benefits. Candida
infections can occur, and then blood glucose
levels should be monitored to rule out
deterioration of the DM control.




Diabetes-related microangiopathy can
occasionally occur in the periapical vascular
supply, resulting in unexplained odontalgia,
percussion sensitivity, pulpitis, or even loss of
vitality in sound teeth. Especially with
orthodontic treatment when forces are applied
to move teeth over a significant distance, the
practitioner should be alert to this phenomenon
and regularly check the vitality of the teeth
involved. It is advisable to apply light forces and
not to overload the teeth.



Holtgrave and Donath (1989) studied
periodontal reactions to orthodontic forces.
They found retarded osseous
regeneration, weakening of the periodontal
ligament, and microangiopathies in the gingival
area. They concluded that the specific diabetic
changes in the periodontium are more
pronounced after orthodontic tooth movement.

Diabetic coma





Should a diabetic patient lose consciousness
during dental treatment the dentist is presented
with a life threatening emergency that requires
immediate treatment.
The patient should be placed in a supine
position to rectify any syncope.
If the diagnosis( hypo or hyperglycemia) proves
difficult then the patient should be given a
diagnostic i.v dose of glucose.







This will not be harmful if it is a hyperglycemic
coma. However, if it is a hypoglycemic coma the
patient will improve and further oral glucose can
be given when as consciousness returns.
An unconscious patient with hyperglycemia
should be immediately transferred to the
hospital.
Never give insulin to an undiagnosed patient in
coma as it may precipitate brain damage or
death if the patient is hypoglycemic.



The best emergency drug is Glucagon 1 mg
which is far easier to administer as it can be
given subcutaneously, i.m or i.v. It takes 10 min
for the drug to take effect during which time the
patient airway should be secured.


Hypertension


Hypertension is very common in the North
American population. The disease is usually a
result of increased peripheral resistance and may
result from either renal or non-renal causes.
Approximately two thirds of all cases of
hypertension are classified as "idiopathic or
essential hypertension." In these cases, the
etiology is not known.





Patients with hypertension are treated with a
variety of medications. It has been stated that
there is "no particular best drug for the
treatment of high ,arterial pressure."
Patients may be receiving antihypertensive
medication such as reserpine, methyldopa,
guanethidine or propanolol. These agents have
side affects of nausea and vomiting, as well as
xerostomia.

Dental/Orthodontic Treatment




The patients medical history may indicate
hypertension or should the patient not be aware
of the condition, the drug history should alert
the dentist.
If a patient is on antihypertensive drugs, it is
important that the blood pressure be checked to
see if the hypertension is controlled.




The degree of control of the patient's
hypertension ,and compliance with the
therapeutic regimen should be determined. As
these patients may have postural
hypotension, care should be taken when the
patient rises from the dental chair, particularly if
the procedure has been long and; lounge-type
chair is used. lf nitrous oxide is
administered, hypoxia should be avoided.




For the known hypertensive on medication, the
diastolic pressure should be controlled at 90mm
of Hg. A diastolic pressure over 100mmHg
indicates hypertension or that the patient is one
who gives exaggerated response to stress.




Allow the patient to relax and rest in the dental
chair before repeating the blood pressure
reading. If the diastolic pressure remains
high, then carry out the emergency treatment
only and refer the patient to a physician. A
controlled hypertensive is at no greater risk than
a normal healthy patient.




Local anesthesia solution containing weak
concentration of epinephrine are acceptable.
Gingival packing material containing
vasopressors should not be used.


Acute hypertensive crisis




Should the patient have an acute hypertensive
crisis, eg a blood pressure of 180/120 mmHg,
then terminate the procedure as the patient
requires immediate treatment. In such an
emergency the patient should be given
Nifedipine. The patient must bite the capsule
and slide it under the tongue where it is
absorbed in 5 min.
In acute hypertensive crisis due to
phaeochromocytoma, the patient should be
referred directly to the care of physician.

Leukemia


Leukemias are a group of diseases that account
for one-third of all childhood malignancies.
Historically, leukemias were classified by the cell
of origin (lymphoid or myeloid) and by the
clinical course (acute or chronic). By using
current therapies, the course of leukemia is
generally chronic.




Acute lymphoblastic leukemia (ALL) is the
single most common malignancy in children
(75% to 80% of childhood leukemias). Acute
lymphoblastic leukemia (ALL) is the result of
malignant transformation and clonal
proliferation of a single cell.




The presenting features are caused by the
invasion of the bone marrow and organs with
malignant cells that crowd out the normal
functional hematopoietic elements. The patient
has fatigue, bone pain, fever, weight loss,
bleeding, malaise, and/or enlarged lymph nodes.
Definitive diagnosis is made by analysis of the
bone marrow (greater than 25% lymphoblasts).



Acute nonlymphocytic leukemia (ANLL)
accounts for 15% to 20% of childhood
leukemia. It results from malignant clonal
proliferation of a myeloid cell that infiltrates the
bone marrow and extramedullary tissues. The
clinical presentation is similar to that of ALL
with pallor, fatigue, infection, bleeding, and
bone pain. These patients may also exhibit
gingival hyperplasia.



Chronic myelocytic leukemia (CML) accounts
for less than 5% of pediatric leukemia. Chronic
myelocytic leukemia (CML) is characterized by
myeloid hyperplasia of the bone marrow,
extramedullary hematopoiesis, and severe
leukocytosis. Bone marrow transplantation
offers the only hope for long-term survival.



Lymphomas account for 10% of all childhood
malignancies with equal incidence of Hodgkins
and nonHodgkins types. Patients present with
fever, weight loss, anorexia, night sweats, and
itching. Excisional biopsy of involved lymph
nodes is performed for diagnosis followed by
bone marrow biopsy and radiographic imaging
studies for staging.




NonHodgkins lymphomas (NHL) are malignant
neoplasms of the cells of the immune system.
Three subgroups are found: undifferentiated
lymphomas (47%), lymphoblastic (33%) large
cell, or histiocytic (16%). The NHL may arise in
any lymphoid tissue and numerous extra
lymphoid sites including bone, skin and the
orbits. Lymphadenopathy, weight loss, anorexia,
fever, and malaise are common at presentation.

ROLE OF THE ORTHODONTIST



Not all patients show intraoral signs of
hematologic malignancy. Although oral
symptoms do not play a major role in the
diagnosis of chronic leukemia, it has been
reported that between 12% and 17% of patients
with acute leukemia first sought medical care
because of an oral problem.



Oral changes that should raise the orthodontist's
index of suspicion are gingival
oozing, petechiae, hematomas, ulcerations, gingi
val pain, gingival hypertrophy, mucosal
pallor, pharyngitis, and lymphadenopathy.
Referral to a physician is indicated for patients
exhibiting these oral symptoms without
evidence of accompanying local causative
factors.



Once a diagnosis of malignancy has been made,
the goal of the dental team, including the
orthodontist, is to prevent and to eliminate oral
infections for these patients. Patients receiving
chemotherapy have increased predisposition to
infection; infection is the leading cause of death
in immunocompromised patients.




Elimination of infectious foci that cause
septicemia is preferable to treatment for
infection. The prevalence of a probable or
possible oral origin of septicemia in the
immunosuppressed population has been
reported as 31%.




It is difficult for an orthodontist to discontinue
treatment on a patient who is only part way
through orthodontic treatment and, in the early
stages of hematologic malignancy, may not be
exhibiting any oral symptoms. Chemotherapy
usually causes significant oral complications.




Orthodontic appliances cause stress to the oral
mucosa and ulcerations may occur in reaction to
the slightest oral insult because the neutropenia
resulting from chemotherapy impairs the
regenerative capability of the mucous
membrane.




Mucositis may progress from swelling, soreness
and whitening of the mucosa to glossitis,
cheilitis, and stomatis, which can be so severe
that morphine or meperidine is required for
palliation of pain. Candidiasis is common. Oral
infection by opportunistic organisms may also
occur. Xerostomia can be a side effect from
chemotherapy or the radiation treatment given
before bone marrow transplant.



Patients and their families sometimes resist the
recommendation to terminate orthodontic
treatment. Ideally, there should be a joint
consultation among all the parties involved—
patient, parents, physician, family dentist, and
orthodontist—before discontinuing treatment
so that everyone is in agreement that what is
being done is in the best interest of the patient.




It should be stressed that the orthodontist is not
"giving up" on the patient when halting
treatment. In situations with a good prognosis,
the emotional acceptance of appliance removal
may be enhanced by a careful selection of words
by the orthodontist.




The appliance removal can be presented as a
transition point that divides the orthodontic
treatment into two distinct stages. The patient's
comfort and safety during all phases of
chemotherapy are enhanced if all fixed
appliances are removed. Removable retainers
should fit well so they do not become a source
of irritation, ulceration, and infection.



Orthodontic treatment is an elective procedure
for most patients. For patients undergoing
treatment for hematologic malignancies, the risk
benefit balance is heavily weighted against
ongoing orthodontic treatment. Once a patient
has completed chemotherapy and is in long-term
remission, orthodontic treatment can be
restarted with the goal of achieving the originally
planned outcome of orthodontic treatment.

Children with bleeding disorders


Patients with mild bleeding disorders do not
usually present difficulties to the orthodontist.
However, those with severe bleeding disorders
can be more problematic. In addition to
haemophilia A (Factor VIII deficiency), which
affects about 1 in 10,000 males, a number of
congenital coagulation abnormalities caused by
deficiency of other clotting factors have been
recognized.



As the prevalence of malocclusion in these
children is similar to the rest of the population
and the long-term outlook is good, orthodontic
treatment is often requested.








Patients with haemophilia and related bleeding
disorders require special consideration in two
areas:
Viral Infection risk
Bleeding risk


Viral Infection risk


Factor concentrates are derived from human
blood donations. Since the mid- 1980‘s methods
of manufacture have been developed to remove
hepatitis B, C and HIV from human derived
concentrates. However, the continued use of
concentrates, despite careful donor selection and
screening, and improved methods of
manufacture, still carries a small risk of
transmitting serious transfusion derived viral
infection.



Most patients with moderate to severe
haemophilia A require Factor VIII concentrate
infusion before oral surgical procedures. The
recent introduction of genetically manufactured
Factor VIII products and their current
widespread use in affected children has further
reduced the risk of viral transmission in this age
group.

Bleeding risk


Generally, orthodontic treatment is not
contraindicated in children with bleeding
disorders. If tooth extraction or other surgery is
required in patients with severe bleeding
disorders they are usually hospitalized and given
transfusions of the missing clotting factor in
advance of the procedure. Whenever possible
non-extraction approach should be adopted.

Special Orthodontic considerations
1. It is desirable to prevent gingival bleeding
before it occurs. This is best achieved by
establishing and maintaining excellent oral
hygiene.
2. Chronic irritation from an orthodontic
appliance may cause bleeding and special efforts
should be made to avoid any form of gingival or
mucosal irritation.

3. Archwires should be secured with elastomeric
modules, rather than wire ligatures which carry
the risk of cutting the mucosal surface. Special
care is required to avoid mucosal cuts when
placing and removing archwires.
4. The duration of orthodontic treatment for any
patient with a bleeding disorder should be given
careful consideration. The longer the duration of
treatment the greater the potential for
complications. (Van Venrooy, Proffit 1985)

Children with juvenile rheumatoid arthritis


Juvenile Rheumatoid Arthritis (J RA) is an
inflammatory arthritis occurring before the age
of 16 years and now embraces Stills disease
(Grundy et al 1993). Although uncommon
compared with adult rheumatoid arthritis, at its
worst, JRA is considerably more severe than the
adult disease and leads to gross deformity.




One form of this disease which affects girls in
late childhood may involve virtually any joint
and is associated with rheumatoid nodules, mild
fever, anaemia, and malaise (Scully and
Cawson, 1987). Damage to the
temporomandibular joint (TMJ) has been
described, including complete bony ankylosis.




It has been suggested that restricted growth of
the mandible resulting in a severe Class II jaw
discrepancy occurs in 10-30 per cent of subjects
with JRA (Wallon et al., 1999). Classic signs of
rheumatoid destruction of the TMJ include
condylar flattening and a large joint space.


Special Orthodontic considerations




1.If the wrist joints are affected these patients
can have difficulty with tooth brushing. They
may require additional support from a hygienist
during their orthodontic treatment and the use
of an electric toothbrush should be considered.
2. Some authors have suggested that orthodontic
procedures that place stress on the TMJs, such
as functional appliances and heavy Class II
elastics, should be avoided if there is rheumatoid
involvement of the TMJs (Proffit, 1991).



Instead, consideration should he given to using
headgear to treat children with rheumatoid
arthritis who have moderate mandibular
deficiency. However, others feel that functional
appliances may unload the affected condyle and
act as a ‗joint-protector‘ (Kjellberg et al., 1995).




3. It has been suggested that in cases of severe
mandibular deficiency mandibular surgery
should be avoided, and a more conservative
approach using maxillary surgery and genioplasty
should be considered (van Venrooy and Proffit
1985)


Children with cystic fibrosis


Cystic fibrosis is an autosomal recessive
disorder of the exocrine glands. It is the
commonest inherited disease among Caucasians
with an incidence of one in 2500 live births
(Jaffe and Bush, 1999). The main clinical
manifestations of cystic fibrosis relate to
changes in the mucous glands of the pulmonary
and digestive systems. Males and females are
equally affected.





The lungs are invariably involved and there is a
non-productive cough that leads to acute
respiratory infection, bronchopneumonia,
bronchiectasis, and lung abscesses. The disease
pursues a relentless course and, until recently,
the life expectancy was not much more than the
second decade. Heart and lung transplants have
proved successful in a small group of patients
with respiratory failure (Grundy et al,. 1993).
The current median survival for subjects with
cystic fibrosis is 30 years (Jaffe and Bush, 1999).

Orthodontic considerations


Before contemplating orthodontic treatment for
patients with cystic fibrosis the patient's
physician should be contacted to determine the
severity of the problem and the likely prognosis.




General anaesthesia should usually be avoided
and any orthodontic extractions should be
delayed until an age when extraction under local
anaesthesia is feasible. Local anaesthesia
combined with inhalation sedation has an
important role to play in the management of
these children.




It has been suggested that for the majority of
these children only limited orthodontic
treatment should be contemplated (Grundy et
al., 1993). However, life expectancy varies and
orthodontic management will depend on the
general prognosis of each individual case.




It should also be remembered that salivary
glands, particularly the submandibular glands are
often affected by cystic fibrosis. Salivary volume
can be reduced and there may be an increased
risk of decalcification during orthodontic
treatment, due to changes in saliva or dietary
alterations (van Venrooy and Proffit, 1985).
Appropriate preventive measures must be
instigated from the outset including dietary
advice and daily fluoride mouthrinses.

Endocarditis


Endocarditis is a life-threatening disease,
although it is relatively uncommon. Substantial
morbidity and mortality can result from this
infection despite advances in antimicrobial
therapy. Primary prevention of endocarditis is
therefore very important (Dajani et al 1997).


High risk-endocarditis Prophylaxis
recommended (Dajani et al., 1997)


Individuals at high risk of developing severe
endocardial infection include those with
prosthetic cardiac valves, previous bacterial
endocarditis, complex cyanotic congenital heart
disease (Fallot's tetralogy), or surgically
constructed systemic pulmonary shunts or
conduits.






Moderate risk-endocarditis; prophylaxis
Includes most other congenital cardiac
malformations, acquired valvular dysfunction
(rheumatic heart disease), hypertrophic
cardiomyopathy, and mitral valve prolapse with
regurgitation.


Negligible risk-endocarditis prophylaxis NOT


This category includes cardiac conditions in
which the development of endocarditis is not
higher than in the general population. This list
includes isolated secundum, atrial septal
defect, surgical repair of atrial or ventricular
septal defects, or patent ductus
arteriosus, previous coronary artery bypass
graft, mitral valve prolapse without valvular
regurgitation, innocent heart murmurs, previous
Kawasaki disease or rheumatic fever without
valvular dysfunction, cardiac pacemakers, and
implanted defibrillators.

Orthodontic procedures requiring
antibiotic prophylaxis


In the United Kingdom the British Society for
Antimicrobial Chemotherapy (Simmons et al
1991) recommend the use of antibiotic
prophylaxis before the following dental
procedures: extractions, scaling, ,and surgery
involving the gingival tissues.




The American Heart Association
recommendations state that antibiotic
prophylaxis should be given at the initial
placement of orthodontic bands, but not
orthodontic brackets (Dajani et al 1997).


Prophylaxis regimen for dental, oral
respiratory tract, or esophageal procedures








Standard general prophylaxis
Amoxicillin
Adult 2g; children 50mg/kg
orally 1 hr before the procedure
Unable to take oral medication
Ampicillin
Adult 2g i.m or i.v; children
50mg/kg i.m or i.v within 30 min before the
procedure










Allergic to penicillin
Clindamycin Adult 60mg; children 20mg/kg
orally 1hr before the procedure
Cephalexin
Adult 2 g; children 50mg/kg
orally 1hr before the procedure
Azithromycin or clarithromycin Adult 600mg;
children 20mg/kg orally within 30 min before
the procedure







Allergic to penicillin and Unable to take oral
medication
Clindamycin Adult 600mg; children 20mg/kg
i.v within 30 min before the procedure
Cefazolin Adult 1g; children 25mg/kg i.v or
i.m within 30 min before the procedure


Orthodontic procedures causes
bacteremia?




Digling (1972) failed to detect any bacteraemias
when fitting or removing orthodontic bands for
10 patients. However, McLaughlin et al (1996)
reported bacteraemias in three (10 per cent) out
of 30 patients when molar hands were fitted.
More recently a study among 40 patients
reported a lower prevalence of bacteraemia or
7.5 per cent in initial banding (Erverdi et al
1999).



In a separate study of bacteraemia at debanding
and debonding the same authors detectcd
bactememias in 6.6 per cent of the 30 patients
studied (Erverdi et al, 2000).






The orthodontist has to make a decision on a
case by case approach in agreement with the
patient's cardiologist. The risk of endocarditis
must be weighed against the risk of an adverse
reaction to the antimicrobial therapy prescribed.
I. As an initial step the level of risk of
endocarditis occurring must be established. This
will involve contacting the patient's cardiologist,
although the American Heart Association
guidelines offer guidance on the risk categories
of various heart defects (Dajani et al. 1997).



Orthodontic treatment should never be
commenced until the patient has exemplary oral
hygiene and excellent dental health. The
prevalence and magnitude of bacteraemias of
oral origin are directly proportional to the degree
of oral inflammation and infection (Pallasch and
Slots 1996). Guntheroth (1984) highlighted the
fact that most bacteraemias occur as a result of
mastication, tooth brushing, or randomly as a
result of oral sepsis.





In a review of the orthodontic treatment of
patients at risk from infective endocarditis, it has
been suggested that prior to any orthodontic
procedure a 0.2 percent chlorhexidine
mouthwash should be used (Khurana and
Martin, 1999).
If possible, the orthodontist should avoid using
orthodontic bands and instead, use bonded
attachments. Antibiotic prophylaxis is
considered unnecessary when bonding brackets
or adjusting orthodontic appliances.




If banding is necessary the orthodontist must
decide if antibiotic prophylaxis is required.
This decision should be based on the risk of
endocarditis represented by the patient's heart
defect (high or moderate risk) and the patient's
dental health. Two recent studies have found a
relatively low prevalence of bactcraemia during
orthodontic banding (McLaughlin et al. 1996;
Erverdi et al, 1999).





Prior to giving antibiotic prophylaxis it is
important to establish that no known penicillin
allergy exists,
The latest American guidelines recommend the
use of antibiotic prophylaxis for initial banding.
but not when removing bands (Dajani et al..
1997). It could be argued that the risk of
bacteraemia might be higher at band removal
when the gingival tissues adjacent to the bands
are often inflamed.



Erverdi et al. (2000) found a low prevalence of
bacteraemia at debanding (6.6 per cent), but
patients with poor oral hygiene were specifically
excluded from their study. Plainly, it would be
prudent to consider using antibiotic prophylaxis
if the gingivae adjacent to the orthodontic bands
are inflamed and the patient has a high-risk
cardiac lesion.

Hepatitis




In recent years the prevalence of Hepatitis has
increased markedly. At the same time, many new
diagnostic techniques have been developed
permitting a very accurate determination of the
active and carrier states of the disease.
The etiologic agents of viral hepatitis are
currently recognized as atleast three distinct
viruses: HepatitisA, Hepatiti.s B, and ―non AnonB‖ Hepatitis. There is considerable overlap
in the clinical presentation of infection with the
various viral agents.





Hepatitis A has been traditionally called
"infectious hepatitis". The main route of
transmission is via a fecal/oral route. An attack
is thought to confer lifetime immunity and the
carrier state is almost nonexistent. The diagnosis
of Hepatitis is made on clinical basis, although
certain immunologic markers have been
reported.
For example, there is an increased IgM in recent
infection and an increased IgG in old infections





Hepatitis B has been traditionally called "serum
hepatitis". Although parentral transmission has
been the classical route for Hepatitis B, nonparentral infection via saliva, urine, feces and
semen are now known to be significant factors
in the transmission of this disease.
Approximately 5 to 10 % of the patients develop
a carrier state and continue to have high level of
Hepatitis B surface antigen. The diagnosis or
Hepatitis B is via three markers: Hepatitis B
surface antigen, Hepatitis B surface antibody
and Hepatitis core antibody.

Dental considerations


The dental treatment of the patient with
Hepatitis requires careful planning. If the patient
has active hepatitis, only palliative care should be
given until the disease is under control. For
patients with a history of hepatitis, dentists must
determine, prior to therapy, the type of hepatitis,
and the carrier state of the patient. If the patient
has active hepatitis and requires emergency
treatment or is a carrier of the virus, strict
aseptic technique must be practiced.





It is essential that a rubber dam be used and that
efforts be taken to minimize aerosols. Some
authorities recommend that high speed drills not
be used and the ultrasonic prophylaxis units be
avoided. All instruments should be debrided
immediately following use, and sterilization of
instruments and handpieces is important.
Universal precautions gloves, mouth masks and
eye glasses should be worn.




The room should be disinfected following
treatment of the patient. Center for
Communicable Disease of the U.S. Public
Health Service has suggested that thorough
mechanical debridement of all instruments is the
most important step in preventing the spread of
Hepatitis.


Tuberculosis




Presently, tuberculosis is mainly a disease of
drug abusers, HIV infected patients and
disadvantaged people. Less
frequently, tuberculosis occurs in older subjects
debilitated by chronic diseases or malignancy or
immunosuppressant treatment.
Mycobacterium tuberculosis is the agent of
tuberculosis. The bacilli spread through
lymphatic and blood vessels to any organ.



In immunocompromised patients, as a rule, the
infection is followed by the disease, which
shows severe course and frequent
extrapulmonary involvement.


Dental Considerations


Most antitubercular drugs are metabolised in
liver, and they can cause liver toxicity with
coagulation abnormalities. Rifampin may cause
leukopenia and thrombocytopenia as well as a
noticeable discoloration of body fluids.


Acetaminophen is not recommended in a patient
on isoniazid to avoid liver toxicity.
Acetylsalicylic acid is not recommended in
patients on streptomycin to avoid ototoxicity.
Any antitubercular drugs can cause skin reaction,
which potentially can involve the oral mucosa.




Dental treatment should be postponed in any
patient with active or suspected active
pulmonary tuberculosis. Such patients must
receive a complete medical assessment to rule
out tuberculosis. An extreme barrier protection
(gloves, gowns, masks, goggles, eye protection
and face shields) is indicated during emergency
dental treatment of patients with suspected or
active pulmonary tuberculosis.



After treatment of such a patient, the dental
health workers should be started on prophylaxis
for tuberculosis based on M. tuberculosis
susceptibility test.


HIV and related infections




HIV type 1 and type 2 are retroviruses that
cause progressive immunologic dysfunction
complicated by opportunistic diseases resulting
in the Acquired immunodeficiency syndrome
(AIDS).
HIV transmission is similar to Hepatitis B: it is
usually by sexual, parentral and vertical
transmission. Hepatitis B is much more virulent
however.



There is a 0.3 % risk of HIV infection after a
stick with contaminated material from a
documented HIV infected patient. This risk of
HIV infection is 0.1% if the mucosal membrane
or abraded skin is exposed to the contaminated
material.


Dental considerations





Universal precautions should be followed.
HIV infected patients receive multiple
medications including drugs for HIV
infection, prophylaxis, opportunistic diseases
and many concurrent disorders. Side effects and
drug interactions are a major concern.
Ritonavir, for example, is contraindicated in
combination with 24 other drugs because of
interaction.



HIV infected patients with advanced disease
have high risk for skin reaction to common
antibiotics, including trimethoprimsulfamethoxazol, amoxicillin-clavulanic acid,
ciprofloxacin, clindamycin and many others.


Pregnancy


The pregnant patient requires special
considerations in the planning and executing of
dental treatment. Preventive dentistry should be
emphasized, both by the dentist and the
physician throughout the patient's pregnancy.




The dentist should exercise discretion in the use
of radiographs in dental treatment. Only those
films considered absolutely necessary for proper
dental care should be taken. With modern
technique, including filtration, collimation of the
beam, and the use of a lead apron for the
patient, gonadal radiation should be below the
measurable level.



Similarly, medication prescribed for the patient
should be minimal. Drugs which have been
shown to be non-teratogenic by long clinical
experience are preferable to newer medications.




If antibiotics are required, penicillin or
erythromycin should be prescribed. Sedatives
and hypnotics should generally be avoided, as
many of these have been shown to be
teratogenic. Prior to prescribing any medication,
the dentist should familiarize himself with
possible teratogenic effects of the agent and
should consult with patient‘s obstetrician.



Careful treatment planning is necessary for
dental care during pregnancy. In general, the
second trimester is the best time for therapy. At
this time the fetus is more developed than in the
first trimester and the patient is more
comfortable.. The danger of premature uterine
contraction is less than during the third
trimester.




The supine hypotensive syndrome has been
described in patients with a gravid utrerus, and it
is important to have the patient rise slowly from
the dental chair so as to avoid syncope.




Elective procedures are best done in immediate
postpartum period and should be scheduled
appropriately.






Oral complications of pregnancy have been
described.
Pregnancy gingivitis is a recognized
phenomenon and is probably related to
hormonal abnormalities and to a decreased
attention to gingival hygiene by the pregnant
women. Pregnancy tumors, an exuberant
response of the gingival epithelium to
inflammation, have also been reported. These
lesions may regress following delivery, but if
they do not they should be excised.

Neurologic and Psychiatric concerns





Seizures
Epilepsy is not a specific disease, but a symptom
of a brain abnormality which manifests as
chronic often recurrent paroxysmal discharge of
many neurons.
Treatable seizures include hypoglycemia, drug or
alcohol withdrawal, local anesthesia
overdose, stroke, vascular malformation, brain
abscess and brain tumors.



The dentist/orthodontist needs to be aware of
any medications and seizure history to be
prepared to face the possibility of a seizure and
to know the natural history of patients
condition.




The more serious complication of epilepsy is
status epilepticus. It may lead to hyperpyrexia
and acidosis, ultimately causing death. This
complication is a variant of grand mal activity in
which the seizures continue unabated for more
than 5 min or in which two or more seizures
occur consecutively without any intervening
period of consciousness.





Management of the epileptic patient in the
dental office includes three concepts:
comprehensive knowledge of the patients
seizure history and medications, and avoidance
of situations likely to provoke a seizure and
ability to treat the seizure (manage the acute
situation).
A dentist should also know the medications,
dosages, serum level compared to therapeutic
level, compliance of the patient, and whether or
not the seizure activity is fully controlled.



Seizure disorders must be under control before
any complex dental procedure is begun. A
dentist/orthodontist should also be aware of the
potential side effects of anti convulsant
medication, mainly gingival hyperplasia.
(Phenytoin)


Management of seizure






If the patient does develop a seizure in the
office, the following steps should be taken:
Terminate dental therapy and remove all
instruments from the mouth.
Position the patient supine on the floor , if
unconscious.






Protect the patient from injury by removing him
or her from proximity to sharp edges, possibility
of a fall, or other trauma. Loosen tight collar and
other clothing.
Observe the patient. Lightly strain if needed, and
be prepared to assist in maintenance of the
airway if needed. Supplemental oxygen may be
necessary.



Most seizures are self limited. The patient can be
monitored, then discharged home in the care of
an adult if the patient has a history of general
seizures, which are characteristic. The patient
should not drive.









There are two cases in which the patient cannot
be sent home after a seizure:
1. If this is the first seizure for this patient or the
first relapse after a seizure free period of
medication.
2. if status epilepticus has occurred.
In the latter case, immediate transfer to a
hospital is mandatory for prompt treatment.

Syncope




Syncope, a transient loss of consciousness, may
be caused by
cardiovascular, neurologic, metabolic, or
psychological disorders as well as iatrogenic
events.
Severe anxiety, however, may produce a near
syncopal or even true syncopal episode that
quickly resolves with local treatment.





Vasodepressor syncope is heralded by significant
changes in the depth or rate of respiration,
pallor, complaints of feeling ill and nauseated,
diaphoresis, decreased pulse and blood pressure.
Patient at risk includes anxious individuals as
well as patients with systemic illness that
predisposes them to hypoglycemia, chest pain or
shortness of breath.





It is important to treat the presyncopal patient
to prevent loss of consciousness, which
indicates 50 -70 % decrease in blood flow to the
brain. Once the patient has enough decrease in
blood flow to the brain, the possibility of greater
morbidity increases.
The first step is to stop all dental procedures, to
remove all objects from the mouth, and to
reposition the patient as to facilitate blood
return to the heart and thus better circulation to
the brain.





This last position is accomplished by adjusting
the Trendelenburg position in the supine
position to allow the legs to be above the level
of heart and, for the pregnant patient, by
adjusting the pillow to ensure that the patient is
lying on one side.
A pregnant patient requires frequent
repositioning during the procedure to avoid
compression of the inferior vena cava by the
uterus, thus ensuring adequate venous return.

Xerostomia


Xerostomia may be managed initially by
stimulating salivary gland function. The use of
saliva substitutes should only be considered
when gland function cannot be stimulated.
Furthermore, when gland function cannot be
improved, complications such as dental caries
and mucosal, salivary and periodontal infections
must be prevented and controlled.

Stimulation of Saliva Production


In patients with drug-induced xerostomia,
changing the prescribed medication(s) may
accomplish some improvement in saliva
production. In others, salivary gland function
may be stimulated mechanically, by taste stimuli,
or by drugs. Sugar-free gum or candies are useful
stimuli. Drugs that may be effective include
cholinergic agents.



Pilocarpine, given as ophthalmic drop placed
intra-orally, is effective in doses of up to five mg
administered three times daily. Anetholetrithione
(Sialor), which acts by increasing the number
and concentration of the salivary gland receptor
sites for neurostimuli, can increase saliva
production in xerostomic patients, unless there
is such advanced dysfunction that the gland has
virtually ceased to produce saliva.



Before sialogogues are prescribed, it is important
that the possible drug interactions and
side-effects are understood. For
example, pilocarpine has the potential to cause
adverse effects on cardiovascular , pulmonary
and gastrointestinal function. In the case of
Sialor, the principal complication is that of
gastrointestinal upset.

Symptomatic Management


Several saliva substitutes or mouth-wetting
agents are now marketed. Most contain
carboxymethylcellulose, although there are some
that contain animal mucins, and some also
contain constituents that may facilitate the
remineralisation of enamel. While some patients
find these products useful, clinical experience
suggests that they are not always well accepted.



Xerostomia patients should be given dietary
instruction, cautioning them against foods that
contain sugar, alcohol, caffeine or spices (which
worsen the xerostomia or irritate the mucosa) to
reduce the risk of caries and candidiasis.


Drug induced reactions


Previous studies have shown that the severity of
cyclosporine-induced gingival enlargement is
related, at least in part, to the presence of
chronic external stimuli, such as plaque and
mouth breathing. Irritation from orthodontic
appliances would potentiate this form of gingival
hyperplasia. Furthermore, cyclosporine-induced
gingival hyperplasia has been observed to
counteract or complicate orthodontic therapy.



The enlarged gingiva grows over the ends of the
buccal or lingual tubes, occluding their lumina;
springs impinge on bulbous interdental papillae
instead of the intended tooth; loops in arch
wires are pushed outward, altering the direction
of intended force; and the embrasures where
various types of retention clasps of removable
appliances fit are filled with hyperplastic
gingivae, preventing proper seating and
retention of the appliance.



Daley et al (1991) showed that another
complicating factor associated with cyclosporine
is the finding that cyclosporine-induced gingival
hyperplasia prevented the eruption of at least
some of the teeth in almost 5% of the patients.
An operculectomy may be necessary to treat this
problem.




This study also indicated that orthodontic
treatment of the cyclosporine-treated patient
may significantly increase gingival enlargement
as a result of direct contact of orthodontic
apparatuses with the gingivae. It seems
reasonable, therefore, to reduce this contact
whenever possible in an attempt to control the
hyperplasia. The following guidelines are
suggested:



Whenever possible, brackets, bands, wires,
elastics, springs, and loops should be designed to
avoid any contact, however small, with any part
of the gingivae. Reduced bracket heights and
small brackets are recommended. Whenever
possible, fixed appliances should be limited to
brackets only, and cemented bands should be
avoided. Similarly, cemented retainers such as
arch bars should not contact the interdental
papillae.





All tubes, springs, loops, brackets, and bands
should be removed as soon as possible after
their purpose is fulfilled.
3. The use of removable appliances should be
avoided if at all possible. The retention clasps
for these appliances fit into interdental
embrasures resulting in localized gingival
enlargement, and the gingivae adjacent to the
acrylic may exhibit generalized enlargement in
adolescents. There is a high risk that appliances
will fail to fit, resulting in the need for sequential
appliances to accommodate the alterations in the
gingivae.





If possible, delay orthodontic treatment until the
patient has been on cyclosporine therapy for at
least 6 months. The greatest change in the
gingivae occurs in the first 6 months of
cyclosporine therapy in most patients. The delay
will give the orthodontist a better idea of the
patient's gingival response to the drug and the
degree of complication to expect in orthodontic
therapy.
Dental plaque formation should be controlled
by meticulous oral hygiene.

Learning Disability


Discrimination of any type against any individual
with a disability, regardless of the nature or
severity of the disability, is morally, ethically and
legally indefensible, since persons with Downs
syndrome and other developmental disabilities
have equal human rights (Pueschel,1989).


WHY ORTHODONTICS?


It all comes down to the basic question: ―Do we
believe that persons with disabilities need
functional and esthetic considerations
comparable to that of ‗normal‘ persons?‖ The
reality is that the youngster with mental
retardation grows older, periodontal disease is
an increased possibility with a maloccluded
dentition. Severe esthetic malocclusions can
compromise already difficult social relationships
and potential employment opportunities.



All too often children with Mental Retardation
may have primary and secondary dentition
difficulties resulting from the following: (1)
untoward habit development (including finger
sucking, mouth breathing, tongue thrusting), (2)
the absence of a diet that includes rough and
course foods that require thorough chewing, (3)
increased levels of caries, and (4) the loss of
teeth and space maintenance.



In addition, malocclusions may have developed
as a consequence of prenatal or postnatal
trauma, hereditary factors, or general poor
muscle development. It may have been
―convenient‖ to approach the situation with the
view that behavioral management complications
precluded interceptive orthodontic services.




Factors related to mastication, including
swallowing patterns, food pocketing, bruxism,
drooling, and other problems associated with
neuromuscular control, may present further
difficulties. A higher incidence of traumatic
injuries also is prevalent in patients with special
needs as a result of problems of ambulating and
possible seizure activity.



Frequently patients with special needs take
multiple medications, the side effects of which
can affect adversely the oral health. Seizure
medications can cause gingival hyperplasia.
Psychotrophic and cardiovascular medications
can cause dry mouth. The high sugar content in
medications for children can contribute to
dental decay.



The population of children and adolescents with
special needs exhibits a higher percentage of
malocclusions than the normal population. This
is related to more frequent occurrences of
craniofacial deformities, abnormal growth and
development, and a higher incidence of
abnormal tongue posture and orofacial muscular
disturbances.



Jackson (1967) felt that children with learning
disability should not be discounted merely
because an ‗ideal‘ orthodontic result was not
possible. For these patients, the aims of
orthodontic treatment may need to be modified
from ‗ideal‘ but orthodontic treatment may offer
an aesthetic improvement and hence enhanced
social acceptance.



Hausdorff (1980) recommended that
orthodontic treatment of the mentally retarded
should be on a selective basis and that, to be
successful, appliance therapy must be adapted to
the needs of the specific patient. The use of a
multiband appliance with light wires was found
to be the most effective appliance and the use of
removable appliances was not recommended.



Close co-operation between the providers of
routine care for these patients and the
orthodontist is essential for their clinical
management. If a general anaesthetic is thought
appropriate for dental treatment, then placement
of an orthodontic appliance can be carried out at
the same time as any necessary extractions,
restorative or periodontal treatment.



A very high standard of moisture control can be
achieved under a general anaesthetic; in fact, the
conditions for bonding are excellent and a high
standard of bracket and band placement is
possible. The extractions are carried out
following bonding of the brackets, but before
placement of archwires.




Patients with learning disability frequently have
anterior teeth which have been traumatized and
it is advisable, if there is any doubt about
bonding these teeth, to place bands anteriorly. If
this procedure is followed, this group of patients
are no more prone to breakages compared with
a group of patients undergoing routine fixed
appliance therapy.



Routine orthodontic visits for adjustment of
appliances should be kept short and archwire
changes kept to a minimum. As far as
possible, treatment is carried out using round
wires and tipping mechanics. Tip-Edge brackets
have been found to be particularly useful.




However, some patients find they are able to
tolerate more complex fixed appliance therapy
once the appliances have been placed. During
orthodontic treatment some patients become
more tolerant during adjustment appointments,
but equally there are those whose behavior
deteriorates.




So long as the appliance is being well tolerated
and the oral hygiene is satisfactory then the fixed
appliance is used for retention. A period of 6
months retention with the fixed, followed by
fixed bonded retainers is recommended for this
group, as removable retainers are usually poorly
tolerated.




Bonded retainers for the upper labial segment
are particularly useful, but in some cases this
may be complicated by previous trauma and
restorative treatment to the upper labial segment
teeth. Occasionally, crown and bridge work can
complement permanent retention.






But when dealing with patients with any
disability, the need is for practitioners (and the
general public) to recognize the wide variations
in the abilities of individuals.
For example, the single notation of ―mental
retardation‖ (with no further description) in a
medical history form offers little to no guidance
for practitioner-staff-patient-family
communication, treatment planning, and home
care follow-up.





In addition, individuals with mental retardation
may not comprehend the need for oral hygiene.
Individuals with physical disabilities may lack the
dexterity to accomplish the needed oral hygiene.
Basically, the need is to create an awareness in
the practicing orthodontic community of the
increasing need for treatment of patients with
mental retardation; successful treatment plans
could then follow.


One approach emphasizes a series of important
steps including the following:
• The parents/guardians are made fully responsible
for the oral hygiene, caries prevention
prophylaxis, and appliance care.
• The use of behavior modification for particularly
difficult procedures.
• Redesigning appliances that are less patientreliant and more patient-resistant.





In addition to standard orthodontic treatment
plans, services for patients with disabilities may
require steps to improve nasal breathing, sucking
ability, chewing, swallowing, speech, and
orofacial functioning. Therapeutic exercises that
do not require conscious cooperation may need
to be instituted in a working relationship with
myofunctional therapists.

Root resorption in Medically
compromised


According to Becks, endocrine problems
including hypothyroidism, hypopituitarism,
hyperpituitarism, and other diseases are related
to root resorption. This hypothesis, based on
basal metabolic rates, has not been examined by
updated blood analyses.




Hyperparathyroidism, hypophosphatemia, and
Paget‘s disease have been linked to root
resorption in a few anecdotal case reports. It has
been suggested that hormonal imbalance does
not cause but influences the phenomenon.




A controlled animal study (Engstrom 1988) did
not support the hypothesis that secondary
hyperparathyroidism is primarily responsible for
increased root resorption. A further study
(Goldie 1984) suggested that the parathyroid
hormone plays a major role in bone
metabolism, but that low calcium levels are
necessary for root resorption to occur. Calcium
ions are reputed to play an important role in
mediating the effects of external stimuli
(force, hormones) on their target cells.





Nutrition. Marshall (1929)advocated that
malnutrition can cause root resorption. Becks
(1936)demonstrated root resorption in animals
deprived of dietary calcium and vitamin D. It
was later suggested that nutritional imbalance is
not a major factor in root resorption during
orthodontic treatment.(1983)
Controversial results were reported when a low
calcium diet was fed to rats undergoing active
orthodontic treatment. (Engstrom 1988)



Mc Nab et al 1999 (AJODO) determined if
asthmatic patients exhibited a higher incidence
or severity of external apical root resorption
compared with healthy patients after fixed
orthodontic treatment. Records were obtained
from patients treated with fixed appliances; 99
were healthy and 44 had asthma.




A 4-grade ordinal scale was used to determine
the degree of external apical root resorption.
Combined tooth analysis showed that asthmatics
had significantly more external apical root
resorption of posterior teeth after treatment
compared with the healthy group (P =.0194).




Tooth-by-tooth analysis (adjusted for treatment
time, appliance, extractions, headgear, overbite,
overjet, sex, and age at start of treatment) found
the upper first molars were most susceptible to
external apical root resorption. Although the
incidence of external apical root resorption was
elevated in the asthma group, both asthmatics
and healthy patients exhibited similar amounts
of grade 2 (moderate) and grade 3 (severe)
resorption.



Nishioka M (Angle Orthod 2006) determined
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) based on age, sex, treatment
duration, and the type of malocclusion were
reviewed retrospectively.



The pretreatment records revealed that the
incidence of allergy and root morphology
abnormality was significantly higher in the root
resorption group (P = .030 and .001)




The incidence of asthma also tended to be
higher in the root resorption group. From these
results, it was 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.


Conclusion




The medically compromised patient seeking oral
health care presents a special problem for the
dentist. Medication received by the patient or
the disease process itself may require
modification of the dental treatment plan.
The provision of comprehensive health care will
require the collaborative efforts of the physician
and the dentist.





Adjunctive and comprehensive orthodontic
treatment is feasible for medically compromised
individuals if proper precautions are taken.
Correction of malocclusion makes it possible to
improve the esthetics and quality of periodontal
tissues, in addition to providing psychosocial
benefits.


References






Padovan BA, Neurofunctional reorganization in myoosteodentofacial disorders: complementary roles of
orthodontics, speech and myofunctional therapy. Int J
Orofacial Myology 1995;21:33-40.
Grossman RC. Orthodontics and dentistry for the
hemophilic patient. Am J Ortho 1975;68:391-403.
van Venrooy JR, Proffit WR. Orthodontic care for
medically compromised patients: possibilities and
limitations. J Am Dent Assoc. 1985 Aug;111(2):262-6.








Shah AA, Sandler J. Limiting factors in
orthodontic treatment: 2. The biological
limitations of orthodontic treatment. Dent
Update. 2006 Mar;33(2):100-2, 105-6, 108-10.
Buttke TM, Proffit WR. Referring adult patients
for orthodontic treatment. J Am Dent Assoc.
1999 Jan;130(1):73-9.
Fischman SL. Dental management of the
medically disabled adult.J Can Dent Assoc. 1981
Oct;47(10):643-8.







Goss AN. The dental management of medically
compromised patients. Int Dent J. 1984
Dec;34(4):227-31.
Burden D, Mullally B, Sandler J. Orthodontic
treatment of patients with medical disorders.
Eur J Orthod. 2001 Aug;23(4):363-72.
Becker A, Shapira J, Chaushu S. Orthodontic
treatment for disabled children--a survey of
patient and appliance management. J Orthod.
2001 Mar;28(1):39-44.






Chaushu S, Becker A. Behaviour management
needs for the orthodontic treatment of children
with disabilities. Eur J Orthod. 2000 Apr; 22(2):
143-9.
Parnell AG. The medically compromised
patient. Int Dent J. 1986 Jun;36(2):77-82.
Barnard K, Smallridge J. Recognizing and caring
for the medically compromised child: 2.
Haematological disorders. Dent Update. 1998
Nov;25(9):402-10.








Hobson P. The treatment of medically
handicapped children. Int Dent J. 1980 Mar;
30(1):6-13.
Bensch L, Braem M, Van Acker K, Willems G.
Orthodontic treatment considerations in
patients with diabetes mellitus. Am J Orthod
Dentofacial Orthop. 2003 Jan;123(1):74-8.
Luke KH. Comprehensive care for children with
bleeding disorders. A physician's perspective.
J Can Dent Assoc. 1992 Feb;58(2):115-8.







Absi EG, Satterthwaite J, Shepherd JP, Thomas DW.
The appropriateness of referral of medically
compromised dental patients to hospital.Br J Oral
Maxillofac Surg. 1997 Apr;35(2):133-6.
Becker A, Shapira J, Chaushu S. Orthodontic treatment
for disabled children: motivation, expectation, and
satisfaction.Eur J Orthod. 2000 Apr;22(2):151-8.
Miley DD, Terezhalmy GT. The patient with diabetes
mellitus: etiology, epidemiology, principles of medical
management, oral disease burden, and principles of
dental management. Quintessence Int. 2005 NovDec;36(10):779-95.





Waldman HB, Perlman SP, Swerdloff M.
Orthodontics and the population with special
needs.Am J Orthod Dentofacial Orthop. 2000
Jul;118(1):14-7.
Sheller B, Williams B. Orthodontic management
of patients with hematologic malignancies.
Am J Orthod Dentofacial Orthop. 1996
Jun;109(6):575-80.







Treister N, Glick M. Rheumatoid arthritis: a
review and suggested dental care considerations.
J Am Dent Assoc. 1999 May;130(5):689-98.
Chadwick SM, Asher-McDade C. The
orthodontic management of patients with
profound learning disability. Br J Orthod. 1997
May;24(2):117-25.
Dajani et al: Prevention of bacterial
endocarditis- Recommendations by American
Heart Association. JAMA ;1997; 277; 1794







Engström C, Granstöm G, Thilander B. Effect of
orthodontic force on periodontal tissue metabolism.
AM J ORTHOD DENTOFAC ORTHOP
1988;93:486-95.
McNab S, Battistutta D, Taverne , Symons AL.
External apical root resorption of posterior teeth in
asthmatics after orthodontic treatment. Am J Orthod
Dentofacial Orthop. 1999 Nov;116(5):545-51.
Nishioka M, Ioi H, Nakata S, Nakasima A, Counts A.
Root resorption and immune system factors in the
Japanese.
Angle Orthod. 2006 Jan;76(1):103-8.





Sivakumar A, Ashima Valiathan. Vascular
anomaly in an orthodontic patient. A case
report. Aust Dent J, 2005,(In press).
Ashima Valiathan, A Siva Kumar, James S,
Murali Rao: Infection control measures in
dental practice. Brunei Medical Journal( In
press)


Thank you
For more details please visit


Ortho Treatment Medically Compromised Patients

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Ortho Treatment Medically Compromised Patients

Similar to Ortho Treatment Medically Compromised Patients (20)

More from Indian dental academy

More from Indian dental academy (20)

Ortho Treatment Medically Compromised Patients