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DEPARTMENT OF ORTHODONTICS
AND
DENTOFACIAL ORTHOPAEDICS

SRI AUROBINDO COLLEGE OF DENTISTRY AND P.G.

INSTITUTE

JOURNAL CLUB-1
Orthodontic Care Of Medically Compromised Patient
By: Sandhya Maheswari, S.K. Verma, Juhi Ansar, Kc Prabhat
Indian Journal Of Oral Sciences; Vol. 3;issue 3; Sep-dec 2012

By Ankita Rawat (P.G. 1st Year)

Content :- 2

 Introduction

 Risk assessment

 Various Medical conditions and

their orthodontic considerations.

 Conclusion
Introduction : 3

 Orthodontic therapy is no longer reserved for only healthy

patients.

 Being almost completely non invasive, specific orthodontic

procedures may place some patient at risk for serious sequelae.

 Aggressive risk assessment is the key factor in identification and

prevention of medically associated problems.
Risk assessment: 4

 Its the best way to effectively manage medically compromised

patient.

 A thorough written medical history and verbal review is the

corner stone.

 It provides an opportunity to establish a good rapport with

parent and patient.
Various medical conditions:
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1. Infective Endocarditis 7. Hemophilia

2. Hematological Malignancies 8. Thalassemia

3. Bronchial Asthma 9. Epilepsy

4. Diabetes Mellitus Renal Disorders 10. Osteoporosis

5. Thyroid And Parathyroid Disorders 11. Liver Diseases

6. Down Syndrome 12. Autism

1. Infective Endocarditis 6

 Bacterial endocarditis is the infection of endothelial surface of

the heart, including heart valves.

 It relatively uncommon and life threatening.

 Common in individuals with structural cardiac defects.

 Endocarditis can also occur in person who develops bacteremia

of oral origin.
Orthodontic Consideration:
7
1. Communication with the patient’s physician.

2. Informed consent.

3. Patient should be explained importance of maintaining ideal standard of oral

hygiene.

4. Main orthodontic procedure causing bacteremia is placement of separators.

5. Use of band should be avoided, if necessary, antibiotic prophylaxis is must.

6. Drug of choice is penicillin.

2. Haemophilia:- 8
 Most common congenital bleeding disorder.

 The normal concentrations of clotting factors are between 50% and

150%.

 Minimum concentration of factor for adequate haemostasis is 25%.

 Haemophilia A - Deficiency of Factor VIII 9
- Sex linked disorder

 Haemophilia B - Christmas disease

- Deficiency of Factor IX

 Von Willebrand’s disease - defects of von Willebrand’s factor.

Orthodontic consideration:- 10

1. Chronic irritation from orthodontic appliance should be avoided.

2. Removable appliance should be avoided as they can cause gingival
irritation.
3. Self ligating brackets are preferable to conventional brackets, if used
then elastic module should be preferred.
4. In need of extractions or surgery, 1-desamino-8- 11
vasopressin(DDAVP) can be used parentally.

5. It raises the factor VIII levels 2-3 folds to prevent surgical

haemorrhage.
Haematological malignancies :- 12
 40% of pediatric malignancies are hematological.

 Cranial radiation given in acute lymphocytic leukemia (ALL) cause growth

retardation.

 It effects pituitary function causing growth hormone deficiency.

 The bone mineral density is also reduced.

 Arrested root development with short v-shaped roots and premature apical
closure may also present.
Orthodontic consideration:- 13

1. Minor irritations can lead to opportunistic infections as the

regenerative capacity of mucosa is weak.

2. Use lighter force should be chosen to minimize risk of root

resorption.

3. Treatment of lower jaw should be avoided.

4. Orthodontic treatment should be started after 2 year event-free 14
survival.

5. Atraumatic extraction should be preferred.

Thalassemia:
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 It inherited disorder of haemoglobin synthesis.
 4 types:
1. α thalassemia
2. β thalassemia
3. γ thalassemia
4. δ thalassemia

 It can be homozygous or heterozygous.

 β thalassemia major (Cooley’s anaemia) is the most severe form of

congenital haemolytic anaemia.
Oral and facial manifestations-
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 Enlargement of maxilla.

 Bossing of skull.

 Prominent malar eminences.

 Expansion of marrow cavity.

 ‘Chipmunk’ like facial appearance.

 Increased overjet and spacing of maxillary teeth.

Orthodontic considerations:-
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1. Antibiotic prophylaxis is must for invasive procedure in patient with
splenectomy.

2. Light skeletal forces should be used because of thin cortical plate.

3. Radiographs should be taken in every 3 months.

4. Regular prophylaxis and fluoride application is recommended.

5. Extractions should be planned just after blood transfusion.

6. Screening test for AIDS and Hepatitis should be carried out regularly.
Bronchial Asthma: 18
 It is a chronic disease affecting lower airways.

 It is characterized by recurrent and reversible airflow

limitations.

Signs and symptoms:

1. Intermittent wheezing
2. Coughing
3. Dysponea
4. Chest tightness
Oral manifestations- 19

1. Candidiasis

2. Decreased salivary flow

3. Increased calculus

4. Increased gingivitis

5. Increased periodontal diseases

Orthodontic consideration:-
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1. Appointments should be scheduled for late morning.

2. Use of rubber dam should be avoided.

3. Positioning of suction tip should be done carefully to elicit cough

reflex.

4. It should be ensured that patient is

having their inhaler nearby.

5. A careful history about the drug

allergy should be noted.
Epilepsy: 21
 The most common serious chromic neurological condition.

 It is characterized by frequent recurrent seizures.

Post-epileptic attack complications: 22
1. Injury to tongue.

2. Injury to buccal mucosa.

3. Injury to facial structures.

4. Avulsion, luxation and fractures of teeth.

5. Sublaxation of the tempero-mandibular joint.

Orthodontic considerations:- 23

1. Regular and rigorous preventive dental care.

2. Gingivectomy is recommended for phenytoin induced gingival

hyperplasia.

3. The metal in fixed orthodontics can distort MRI images so

removable components should be removed before it.

4. Removable appliance should be avoided or made of high impact

acrylic and with maximum retention.
Diabetes mellitus: 24
 It is most common endocrine disorder.

 Persistent hyperglycaemia

 It is due to deficiencies of insulin secretion, insulin action, or both.

It of two types:
1. Type 1- insulin dependent diabetes or juvenile onset
2. Type 2- non insulin dependent or mature- onset
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Orthodontic considerations:- 26

1. For the patient with diabetes mellitus the for orthodontic

treatment is good medical control.

2. Maintenance of good oral hygiene is important.

3. Diabetic microangiopathy can result in unexplained toothache,

tenderness on percussion or even loss of vitality.
Renal disorders:- 27

 Chronic renal failure is the conditions which shows oral

signs and symptoms.(90%)

 Soft and hard tissue both are affected.

 The steroids given for the disease or to avoid transplant

rejection also affect the oral cavity.
Orthodontic consideration:- 28
1. Extraction should be planned cautiously as there is abnormal bone healing.

2. Orthodontic forces should be reduced and re-adjusted at short intervals.

3. Doses of antibiotic should be adjusted by amount or frequency.

4. During surgical procedure, double the dose of corticosteroids if patient is

under them.

5. Gingival overgrowth is secondary to immunosuppressive drugs so

gingivectomy should be considered.
Osteoporosis:- 29

 It is chronic systemic degenerative disease.

 It is characterized by decreased bone mass, microarchitectural

deterioration of the bone.

 There is increase in bone fragility.

 Drugs commonly used in the treatment are bisphosphonates,

oestrogens, calcitonins.
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Orthodontic considerations:- 31
1. Problems such as bone loss, retention instability, TMJ dysfunctions
should be considered before treatment.

2. Estrogen decreases the rate of tooth movement.

3. Use of bisphosphonates can effect tooth eruption and inhibit tooth

movement.

4. Temporary anchorage devices should be avoided.

5. BPs also impairs bone healing.

Thyroid and parathyroid disorders: 32

 Thyroid occur more often in women.

 It is most common endocrine disorder after diabetes mellitus.

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Orthodontic considerations:- 34

1. Enlarged tongue in hyperthyroidism may cause problem.

2. Bone turn over affects the treatment.

3. Hyperthyroidism shows high bone turnover increasing amount of

tooth movement.

4. Hypothyroidism shoes low bone turnover causes more root

resorption.
Liver diseases 35

 Liver disease can be

1. Acute- characterized by rapid resolution and complete restitution of

organ structure and function after etiology has been resolved
2. Chronic- characterized by persistent damage with progressively
impaired organ function

 The liver functions like haemostasis and essential protein synthesis,

metabolism are effected.
Orthodontic considerations:- 36

1. Care should be taken while dealing patients of hepatitis B, hepatitis C

and hepatitis D virus infection.

2. Aerosols generated by dental hand pieces are also infectious.

3. HBV can survive on innate subjects for 7 days so impressions should

be disinfected by glutaldehyde or spraying sodium hypochlorite for
10 mins.
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4. Haemostasis is also affected so care should be taken during
invasive procedures.

5. Caution should be used in prescribing medications

metabolized in the liver
Down syndrome: 38
 It is the most common genetic disorder.

 Orofacial features:
1. Underdevelopment if mid facial region and maxilla.
2. Small bridge of nose.
3. Many cases show prognathic class 3 occlusal relationship.
4. Open-bite is seen.
5. Delayed eruption of teeth and congenitally missing teeth.
6. Unsual shapes of teeth seen.
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Orthodontic consideration:- 40

1. Antibiotic prophylaxis for patient with congenital heart defect(40-60%).

2. Reduced muscle tone

less efficient chewing

less natural cleansing of teeth

good oral hygiene is required

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3. Impressions should be taken from quick setting materials

with fun flavors.

4. High memory wires allow longer activation interval

between appointments.

5. Self ligating brackets are more patient friendly.

 Autism: 42
 It is a pervasive developmental disorder defined behaviourally as a
syndrome.
 It consist of –
1. Abnormal development of social skills- withdrawal lack of interact in
peers
2. Limitation in use of interactive languages- speech as well as non
verbal communications
3. Sensorimotor deficits- inconsistent response to environmental stimuli
4. Delayed speech
o Behaviour modification is the primary management program.
Orthodontic considerations:-
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1. The main challenge here the communication with the patients.

2. The most suitable way of the treatment procedures should be

estimated.( behaviour management or conscious sedation or GA)

3. Patient should be treated in a quiet shielded single operatory .

4. Positive reinforcement, tell show do, voice control are effective.

5. Use self stimulation as reinforcement for autistic child.

 Tuberculosis and AIDS are also important medical conditions but 44
they does not necessitate changes in orthodontic treatment.

 Caution is necessary as they can transmit to the operator.

 Universal infection control procedures should be employed to all

the patients

 Oral hygiene is very important in such patients.

 Post exposure prophylaxis(PEP) should be immediately given after

accidental procedure.
Conclusion:- 45
 An Orthodontist be able to diagnose various medical conditions and
know their impact on treatment procedures.

 Treatment should be postponed until the medical problem has

resolved.

 Consent before the treatment is very important.

 Constant monitoring and good patient compliance is necessary to

minimize physical damage and to maximize treatment outcome.
Take home message:- 46
 Many of the medically compromised patients are seeking orthodontic
therapy.

 The doctor should know the oral signs of common disease for easing
further treatment planning.

 An orthodontist should know how to deal with various medical

compromised patients common in clinics.

 The universal infection control procedures should be followed for

each patient despite of their health status.
References:- 47

1. Reddy k anitha E orthodontic management of medically

compromised patients. Ann Essence Dent 2009;1:1-12.
2. Sonis ST. orthodontic management o selected medically
compromised patients: cardiac disease bleeding disorders and
asthma. Semin orthod 2004;10:277-80.
3. Grossman RC. Orthodontics and dentistry for the hemophilic
patients. Am J orthod 1975;68:391-403
4. Dahllof G, Huggare J. Orthodontics considerationin pediatric
cancer patients: a review, Semin orthod 2004;10:266-76
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