Orthodontic Management of Medically Compromised Patients PDF

Orthodontic Management in Medically Compromised Patients Introduction n 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 ma...

Orthodontic Management in Medically Compromised Patients Introduction n 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. n 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. n n n n n n n n Medical conditions commonly encountered in orthodontic patients include: risk of infective endocarditis; bleeding disorders; leukaemia: diabetes; cystic fibrosis; Infections juvenile rheumatoid arthritis; Diabetes Mellitus n n n 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 n 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 n n n 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 n Macroangiopathy -Large blood vessels n Head –Cerebrovascular accident (stroke) n Heart -Angina Pectoris and myocardial infarction n Limbs-Gangrene n n n n n Microangiopathy Small blood vessels of Eyes -Blindness Heart -Cardiomyopathy Kidneys-Renal failure Skin -Necrosis n n n Non-vascular Cataract Neuropathy n n 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 n n 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 n 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. n 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. n 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; Dental/ Orthodontic treatment n 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. n However it is very important that the procedure be completed without stress and without causing the patient to miss a meal. n n 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. n 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. n 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. Diabetic coma n n n 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. n n n 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. n 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 n Hypertension is very common .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. n n 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 n n 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. n 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. n 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. n 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. n Local anesthesia solution containing weak concentration of epinephrine are acceptable. Gingival packing material containing vasopressors should not be used. Acute hypertensive crisis n n 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 n 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. n 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. n 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). n 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. n 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. n 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. n 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 n 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. n Oral changes that should raise the orthodontist's index of suspicion are gingival oozing, petechiae, hematomas, ulcerations, gingival 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. n 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. n 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%. n 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. n 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. n 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. n 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. n 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. n 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. n 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 longterm remission, orthodontic treatment can be restarted with the goal of achieving the originally planned outcome of orthodontic treatment. Children with bleeding disorders n 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. n 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. n n n Patients with haemophilia and related bleeding disorders require special consideration in two areas: Viral Infection risk Bleeding risk Viral Infection risk n 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. n 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 n 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 n 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. n 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. n 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 n n 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). n 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). n 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 n 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. n n 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 n 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. n 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. n 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. n 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 n 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) n 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. n n Moderate risk-endocarditis; prophylaxis recommended (Dajani et al., 1997) 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 recommended (Dajani et al., 1997) n 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 n 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. n 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 n n n n 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 n n n n 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 n n n 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? n n 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). n 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). Orthodontic considerations n n 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). n 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. n n 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. n n 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). n n 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. n 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 n n 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. n n 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 n n 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 n 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. n n 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. n 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 n n 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. n In immunocompromised patients, as a rule, the infection is followed by the disease, which shows severe course and frequent extrapulmonary involvement. Dental Considerations n 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. n 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. n 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 n n 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. n 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 n n n 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. n 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 n 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. n 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. n 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. n 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. n 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. n 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. n Elective procedures are best done in immediate postpartum period and should be scheduled appropriately. n n 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 n n n 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. n 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. n 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. n n 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. n 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 n n n 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. n n 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. n 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. n n n n 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 n n 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. n n 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. n n 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. n n 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 n 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 n 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. n 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. n 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 n 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. n 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 n 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, cyclosporineinduced gingival hyperplasia has been observed to counteract or complicate orthodontic therapy. n 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. n 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. n 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: n 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. n n 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. n n 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 n 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? n 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. n 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. n 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. n 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. n 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. n 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. Orthodontic considerations n 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. n 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. n 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. n 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. n 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. n 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. n 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. n 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. n 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. n n 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. n n 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. n n 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. n 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 n n 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. n n Adjunctive and comprehensive orthodontic treatment is feasible for medically compromised individuals if proper precautions are taken. 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