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practices revealed that more than 25% of patients seeking orthodontic therapy had some medical diagnosis that potentially impacted their care.
Pediatric cancer
Special needs Cardiac disorders
Bleeding disorders
Asthma
Hypersensitivity reactions
Most common hypersensitivity reactions in orthodontic practice are due to the use of latex-based products and to the alloy components of metal-based orthodontic appliances Reactions of irritant origin are usually associated with direct friction between soft tissues and orthodontic appliances Hypersensitivity reactions are related to the antigenicity of some materials that results in an adverse patient response
Type I hypersensitivity
Type I hypersensitivity to natural rubber latex represents
an immediate antibody-mediated allergic response to multiple proteins on the latex product Less than 1% of the general population are reported to be diagnosed with potential type I natural rubber hypersensitivity A higher prevalence (between 6% and 12%) is reported among dental professionals
Those who have had repeated operations and extensive contact with rubber surgical drains
Those with spina bifida
A history of itching and redness from contact with balloons, rubber dams, etc.
Food allergy can also point to a potential latex allergy bananas, avocado, passion fruit, kiwi, and chestnuts have proteins that are capable of cross-reacting with latex proteins
These foods can thereby act as a possible mode of
the most accurate, can determine the presence of circulating antinatural rubber latex antibodies
Type IV hypersensitivity
This more delayed reaction usually presents a reaction localized to the
formation, and later on as dry skin, fissures, and sores for several weeks
Elastic Bands
Elastic bands represent another potential source of latex
rubber latex elastics, and it was concluded that great improvements in the physical properties of the silicone bands would be required before they could be considered as an acceptable alternative to Non rubber latex elastics
After static force extension of 450% for 1 day in saliva, the
force decay was 33% for the silicone bands and 28% for the Non rubber latex elastics
hypersensitivity is to avoid contact with the product and use of alternative products made of synthetic rubber or plastic Natural rubber latex gloves should be substituted with alternative ones made of other components such as nitrile, neoprene, vinyl, polyurethane, and styrenebased rubbers The use of powder-free gloves will diminish the amount of aerosolized allergens
exposure to airborne natural rubber latex particles Administration of pretreatment antihistamines In the event of a severe type I reaction, emergency procedures such as administration of epinephrine are recommended ( i.e. EpiPen) Use of latex free products during treatment
EpiPen
Epinephrine constricts blood vessels, relaxes smooth
muscles in the lungs to improve breathing, stimulates the heartbeat, and works to reverse hives and swelling around the face and lips
The effects of epinephrine usually last 10 to 20 minutes so
Nickel
Nickel is the most common metal-based contact allergy
among women, with the incidence of nickel sensitivity in the female population reported as high as 30% compared with only 3% of males among the studied individuals
Nickel sensitivity was higher among subjects with a history of
pierced ears; there was 31% prevalence compared with subjects without pierced ears at 2% prevalence
Nickel titanium alloys contain up to 70% nickel
Findings
The analysis indicated that appliances using
silver and gold solders (eg, facebows and molar bands) showed enhanced release of nickel and chromium In contrast, alloys containing titanium, for example arch wires, released little nickel. titanium has the advantage of being highly resistant to corrosion and may bind the nickel from release in these in vitro studies
assess the number and nature of adverse reactions among their patients and to relate them to materials or treatment provided soreness, fissuring, and desquamation most often attributed to a metal extraoral (eg, headgear facebow) component of the appliances lips and oral mucosa, and inflammation of the gingival tissues
Occasionally, symptoms such as fever were reported. Although not all the
symptoms were attributed to the presence of metal components, they were assumed to be the primary allergens in these reported cases of hypersensitivity reactions
Seizure Disoders
A seizure is a sudden, involuntary, time-limited
alteration in neurologic function resulting from abnormal electrical discharge of cerebral neurons Seizures manifest as altered sensation, behavior, or consciousness Epilepsy is defined as two or more seizures that are not provoked and are not due to an acute disturbance of the brain It is a sign of underlying brain dysfunction, rather than a single disease
Seizure Triggers
Some patients have identified triggers that impact the number and severity of seizures including: Flashing lights Anxiety Illness Hyperventilation
7 Factors reported to increase seizures include:
Stress Missed medication Sleep deprivation Alcohol consumption Nonprescription medications Vitamin or mineral deficiencies Parts of the menstrual cycle
Etiology of seizure
The cumulative incidence of epilepsy from birth
through age 20 years is about 1% and increases to 3% at age 75 Epilepsy with a recognized cause is termed secondary; those patients for whom a cause cannot be determined have primary epilepsy Etiology in childhood includes congenital abnormalities, birth-related complications, trauma, meningitis, encephalitis, and malignancy Adult etiologies are brain tumors, cerebral vascular disease, head trauma, and degenerative changes
Ketogenic Diet
Normally, our bodies run on energy from glucose, which
we get from food We can't store large amounts of glucose however, and only have about a 24-hour supply The ketogenic diet is a low carbohydrate and high fat diet 80% of calories come from fat and the rest from carbs and proteins Each meal has about four times as much fat as protein or carbohydrate More effective in children (length of diet is about 2 years)
Effectiveness of the diet: About a third of children who try the ketogenic diet become seizure free, or almost seizure free Another third improve but still have some seizures The rest either do not respond at all or find it too hard to continue with the diet, either because of side effects or because they can't tolerate the food
Side effects: Dehydration Constipation Kidney stones or gall stones Menstrual irregularities Pancreatitis Decreased bone density Eye problems
Types of Seizures
Seizures lasting longer than 30 minutes or rapidly
minutes require treatment by medical professionals who can administer intravenous anticonvulsive medication and support the patients respirations as needed
or muscle fluttering, sudden halt in activity Tonic-clonic loss of consciousness with falling, 10 20 sec muscle rigidity followed by 25 min clonic contractions of muscles of extremities, head, trunk; urinary and/or fecal incontinence, postictal deep sleep 1030 min Atonic --Brief loss of muscle tone with falling Clonic --Alternating muscle contraction and relaxation Tonic-- persistent firm muscle contractions
Orthodontic considerations
Record a detailed history: specific details about seizure
onset, frequency, and type, behavior during seizures, duration, triggers, recovery period, medical management, and compliance should be prepared to respond appropriately when a patient has a seizure in the orthodontic office
medication and past dental or facial trauma should be considered when planning treatment and reviewed as part of patient informed consent
been reported to include injuries to the tongue, buccal mucosa, facial fractures, avulsion, luxation or fractures of teeth, and subluxation of the temporomandibular joint
phenytoin (Dilantin), sodium valproate (Depakote), and ethosuximide (Emeside and Zarontin) Other side effects of medications recurrent aphthous-like ulcerations, gingival bleeding, hypercementosis, root shortening, anomalous tooth development, delayed eruption, and cervical lymphadenopathy Asymmetry Of particular interest to the orthodontist is a recent report of facial and body asymmetries affecting 41% of patients with partial seizures in the population studied; asymmetries included both hemihypertrophy and atrophy
Stay calm Remove dangerous items from the immediate area Do NOT try to restrain the patient Note the time the seizure begins Keep onlookers away Activate the emergency medical system if any seizure lasts for more than 10 minutes or if the patient has three or more seizures within a short time Speak quietly and calmly remove the patient from a dangerous or embarrassing environment by guiding them to a safe location and stay with the patient until they are alert
Pediatric Cancer
Childhood cancer is a relatively uncommon disease
affecting approximately 12 of 100,000 children The three most frequent major childhood cancers, comprising about 69% of all childhood neoplasms are: - leukemias (30.1% of all cancers diagnosed among children below 15 years of age) -central nervous system tumors (27.8%) - lymphomas (11.0%)
Impact of Treatment
Both chemotherapy and radiation therapy given to the
growing individual will have consequences for growth, dental development, and craniofacial growth The caries risk may also be increased due to salivary dysfunction It has been shown that although ideal treatment results are not always achieved, orthodontic treatment does not produce any harmful side effects
Lymphoblastic Leukemia) before 10 years of age, treated with combination chemotherapy and cranial irradiation, and followed at least 5 years after diagnosis, the main finding was that patients younger than 5 years at the commencement of anticancer therapy had a markedly increased risk of craniofacial aberrations, characterized by mandibular retrognathism The growth repressive action of irradiation has been explained to be due to growth hormone deficiency in children who receive cranial radiation
Orthodontic considerations
Strategies used by orthodontists in treating this patient group may include: using appliances that minimize the risk of root resorption low force application accepting a compromised treatment result by simplistic mechanics terminating the treatment earlier than normal not treating the lower jaw It is advised to postpone the start of orthodontic treatment at least 2 years after completion of cancer therapy Since radiation therapy has a growth-suppressive effect, especially on cartilage growth , avoid treating a skeletal Class II malocclusion with growth modification
osteoradionecrosis after tooth extractions in children treated for malignancies In the group of children subjected to orthodontic treatment, healing after extractions was uncomplicated Since orthodontic treatment should not be started until 2 years after completion of cancer therapy, extractions for orthodontic indications should likewise be deferred until that time
considered to be completely noninvasive, specific orthodontic procedures may place some patients at risk for serious complications Among the most common of these conditions are those associated with cardiac disease, bleeding disorders, and asthma
invasive, the placement and removal of orthodontic bands has been suggested to produce bacteremias. McLaughlin and colleagues studied the incidence of bacteremias after orthodontic banding in 30 healthy adults Elastomeric separators were placed 1 week before the placement of a single band on a permanent first molar. Bacterial cultures revealed that the frequency of bacteremias following banding was 10% compared with 3% in the preoperative sample.
with band placement can be further appreciated when one compares the incidence of bacteremia following matrix band placement between individuals without gingival inflammation (0%) and those who had gingivitis associated with bleeding (32%) the frequency of banding-induced bacteremias appears to be less than that reported for flossing (20%) or toothbrushing (25%)
Risk assesment
Patients at HIGH RISK are those with a prior history of
endocarditis, those who have prosthetic valves or surgically corrected systemic pulmonary shunts or conduits, or those with complex cyanotic congenital heart disease (tetrology of Fallot)
Patients at MODERATE RISK are those with congenital
cardiac malformations, acquired valvular dysfunction (such as that caused by rheumatic fever), hypertrophic cardiomyopathy, and mitral valve prolapse with regurgitation
defined as being no more likely to develop BE than the general population, are those with secundum atrial septal defects, surgical repair of atrial or ventricular septal defects or patent ductus arteriosus, previous coronary artery bypass grafts, mitral valve prolapse without valvular regurgitation, innocent heart murmurs, previous Kawasaki disease or rheumatic fever without valvular dysfunction, cardiac pacemakers, and implanted defibrillators
Premedication Protocol
The current recommendations for endocarditis
prophylaxis by the American Heart Association are a single dose of Amoxicillin (2 g in adults or 50 mg/kg in children) administered 1 hour before the procedure For penicillin-allergic patients, Clindamycin (600 mg for adults and 20 mg/kg for children)
If a patient forgets to take his or her premedication, or if
unanticipated bleeding occurs, the American Heart Association guidelines suggest that antibiotic given at the time of treatment or up to 2 hours from the time of insult is effective
Bleeding Disorders
Effective hemostasis is the consequence of a sequence of
events in which platelets and plasma proteins produce clotting. Defects in either may result in a clinically relevant coagulopathy with consequent bleeding Bleeding disorders result from qualitative or quantitative platelet deficiencies, or inadequate or insufficient levels of plasma-clotting factors
associated with conditions that result in a reduction of platelets (thrombocytopenia). Thrombocytopenia may result from a reduction in the production of platelets caused by disruption of the bone marrow The most likely sources for this etiology are malignancies involving the bone marrow (leukemia) or autoimmune conditions in which the platelet-producing cells in the marrow are destroyed (aplastic anemia)
in the most frequently orthodontically treated age groups. Gingival bleeding caused by thrombocytopenia often heralds the onset of acute leukemia Unlike most gingival bleeding, which is elicited by some type of provocation, gingival bleeding associated with profound thrombocytopenia is spontaneous Spontaneous gingival bleeding is associated with platelet counts of 20,000 cells/mm3 or less (normal 150,000450,000 cells/mm3) Because orthodontists see patients frequently, they are often in the position of being the first health care provider to recognize this early sign of leukemia
related diseases are most often congenital As a result, the orthodontist should be able to determine the presence of these conditions before the initiation of treatment Three congenital clotting factor deficiencies account for more than 90% of inherited disorders: Hemophilia A (def of Factor VIII) Hemophilia B (def of Factor IX) Von Willebrands disease (defects of von Willebrands factor ) **most common congenital bleeding disorder***
Bleeding disorder
probably the biggest orthodontic-associated risk is associated with extractions associated with treatment In these cases, the administration of factor replacement along with Amicar or tranexamic acid is prudent Amicar (aminocaproic acid) and tranexamic acid are anti-fibrinolytic agents that prevent the breakdown of the clot in the extraction site, allowing for better organization, and thereby decreasing the likelihood of postoperative bleeding
reasonable to perform all planned extractions at a single visit It is imperative that this group of individuals be in absolute gingival health before the commencement of treatment Care should be used in the placement and removal of orthodontic hardware to minimize the risk of mucosal injury Elastomeric modules are preferential to wire ligatures Overall treatment should be performed as expeditiously as possible
Bleeding gums
Asthma
Episodic narrowing of the airways that results in
breathing difficulty and wheezing Asthma is most often the result of an inherited immunologic hypersensitivity (allergic) disorder
Prevalence
Almost half of cases of asthma develop before age 10
Prevalence of the condition was highest in blacks
(15.8%), intermediate in whites (7.3%) and Asians (6.0%), and lowest in Latinos (3.9%) These differences were unrelated to income or access to medical care The severity of asthma, based on limitation of activities and need for acute medical care, was most notable among black and Latino children
Management Considerations
The first objective is the prevention of acute asthmatic attacks
and the key to this is the identification of patients at risk Obtain information regarding the severity of the disease (limitation in activities, emergency room visits, etc.), medications, and factors that precipitate an attack The orthodontist should assure that the patient has taken his or her medication and, if appropriate, has his or her inhaler present if needed during the appointment
Patients with asthma may be sensitive to several specific
medications including the erythromycins, aspirin, antihistamines, and local anesthesia containing epinephrine
especially those containing steroids, may result in a predilection for the development of oral candidiasis and xerostomia If noted candidiasis can be treated with topical antifungal agents such as Nystatin Xerostomia enhances the risk of caries, therefore, aggressive oral hygiene, supplemental topical fluorides are essential.
resorption occurs with greater frequency in patients with asthma than in the non-asthma population external root resorption following fixed orthodontic therapy between patients with asthma and a healthy population. was elevated in the asthmatic population, the severity of resorption was the same between groups heightened risk of external root resorption to patients before initiating treatment
They found that while the incidence of external apical root resorption
The pretreatment records revealed that the incidence of allergy and root morphology abnormality was significantly higher in the root resorption group
The incidence of asthma also tended to be higher in the root resorption group From these results, we concluded that allergy, root morphology abnormality, and asthma may be high-risk factors for the development of excessive root resorption during orthodontic tooth movement in patients
Root resorption
references
Orthodontic considerations in the pediatric cancer patient: A review Pages 266-276 Gran Dahllf, Jan Huggare
Prevention of Infective Endocardititis: Guidelines from the American Heart Association Wilson, Walter (et. al) J Am Dent Assoc 2008;139;3S-24S