Download orthodontic management of the medically compromised patient

British Orthodontic Society - Development and Standards Committee
ORTHODONTIC MANAGEMENT OF THE MEDICALLY COMPROMISED PATIENT
ALWAYS REVIEW THE PATIENT’S MEDICAL HISTORY --- CONSULT THE PATIENT'S GENERAL MEDICAL PRACTITIONER OR SPECIALIST IF IN DOUBT
CONDITION
IMPLICATIONS FOR ORTHODONTIC THERAPY
ALLIED THERAPY
INFECTIVE ENDOCARDITIS (IE)
High risk patients:
• previous endocarditis
• prosthetic heart valves
• complex cyanotic congenital heart
disease
Medium risk patients:
• congenital heart defects eg VSD
• acquired valvular disease (e.g. from
rheumatic fever)
• hypertrophic cardiomyopathy
• mitral prolapse with regurgitation
Low risk patients:
• general population
• repaired VSD's
• isolated secundum atrial defects
• note that coronary artery bypass
grafts are not at risk .
If in doubt consult with the cardiologist
as patients with a positive history eg
"heart murmur" are not necessarily at
risk.
Low risk patients need no special
precautions
High risk patients are best referred to
a specialist centre for treatment in
conjunction with the physician. A
particularly careful assessment of the
relative risks and benefits of
orthodontic treatment is needed in
such cases before proceeding.
PROSTHETIC JOINTS
CENTRAL NERVOUS SYSTEM
Seizure disorders
• Epilepsy (e.g. Grand mal)
Hydrocephalus
• Cerebrospinal shunts
PREGNANCY
Only a small minority of cases of infective endocarditis (IE) has
any possible connection with dentistry. IE is extremely rare in
adolescents and its incidence does not appear to be higher during
orthodontic treatment. Most bacteraemia arises from everyday
activities such as chewing and toothbrushing.
The bacteraemia experienced by the patient may be increased by
plaque accumulation which can be greater in the presence of
orthodontic appliances.
During orthodontic treatment, operative procedures are frequent.
Various orthodontic procedures can produce a bacteraemia
including impressions, fitting or removing bands and surgical
exposure of teeth. Gingival bleeding is not a reliable indicator of
bacteraemia: the severest bacteraemia in fact appears to be
caused by fitting separators.
The most rational approach is to deal with the risk of IE arising
during the period of treatment as a whole rather than from the
isolated treatment episodes, and take steps to minimise any
overall risk posed by the course of treatment. Informed consent
requires that a patient is aware of any significantly increased risk.
• Patients must understand the need to maintain a high standard
of oral hygiene and make a firm commitment to do so.
• Patients may be encouraged to use a daily antimicrobial
mouthwash, e.g. chlorhexidine 0.2% to aid plaque control,
particularly for the two days leading up to fitting, removal or
major adjustments of a fixed appliance.
• Bonded appliances are to be preferred to banded appliances
where possible, exceptions being cases needing RME,
quadhelix or headgear.
• For unerupted teeth avoid bonding with closed eruption.
Antibiotic prophylaxis
Note that antibiotic administration is not without risk and should only be
used where a clear indication exists. In high risk cases all procedures
liable to cause bacteraemia should be covered by antibiotic prophylaxis.
In medium risk cases it is not currently clear how far antibiotic
prophylaxis is justifiable for orthodontic procedures; if it is to be used to
cover selected procedures only, it would be rational to concentrate on
procedures causing the severest bacteraemia, i.e. fitting separators and
possibly scaling/polishing.
ANTIBIOTIC PROPHYLAXIS REGIME *
Antibiotic
Route
Dose
Timing
For procedures under local or no anaesthesia in medium risk
patients
No Penicillin allergy
0-5 years
Amoxycillin
oral
750mg
1 hr pre-op
5-10 years
Amoxycillin
oral
1.5g
1 hr pre-op
10+ years
Amoxycillin
oral
3g
1 hr pre-op
Penicillin allergy or penicillin more than once in last month
0-5 years
Clindamycin
oral
100mg
1 hr pre-op
5-10 years
Clindamycin
oral
300mg
1 hr pre-op
10+ years
Clindamycin
oral
600mg
1 hr pre-op
Note that an additional post-op dose of antibiotic is no longer
recommended.
*See also BNF or local strategies for additional information.
Recommendations for high risk patients or GA treatments differ from the
above - see BNF.
• Antibiotic prophylaxis is not required
• Avoid removable appliances if epilepsy is poorly controlled
• Phenytoin may cause gingival hyperplasia
• Antibiotic prophylaxis may be required. Consult specialist
• Avoid X-rays or drug therapy, particularly in the first trimester
• Stress may occasionally precipitate seizures. Sedation may be
indicated
• Avoid supine position in late pregnancy
CONDITION
IMPLICATIONS FOR ORTHODONTIC THERAPY
LATEX ALLERGY
Groups at increased risk of allergy:
• Atopic individuals
• Oral health care staff
• Patients who have undergone
multiple surgical interventions
• Spina bifida patients
• Patients with urogenital anomalies
NICKEL ALLERGY
• Nickel allergy as detected by skin
testing is common.
An increasing problem for both clinicians and patients
Latex can cause:
• Irritant contact dermatitis
• Delayed cutaneous reaction which can extend beyond the area
of latex contact.
• Immediate hypersensitivity reaction e.g. angioedema
•
•
•
The outer bow of the headgear or any studs can be covered if a skin
reaction occurs
•
In case of doubt, a trial appliance with one or two bands and brackets
may be used to assess reaction. A length of archwire should also be
fitted in case nickel is released by galvanic reaction.
Wires and brackets are available in nickel-free alloys of titanium and
cobalt-chromium or non-metallic materials.
•
Contact hypersensitivity may occur on the skin of the cheeks
or neck in response to the outer headgear bow or studs of the
headgear in patients with nickel allergy.
• Most patients with nickel allergy can tolerate orthodontic
treatment with normal ort hodontic appliances. In the rare event
of a marked intra-oral reaction, nickel free components will
need to be used. Note that immediate hypersensitivity
reactions are not generally a feature of nickel allergy.
A one-tier cross infection control policy should be adopted
routinely.
Seek current advice before treating patients of this type
See Porter et al. BDJ 188 (April 2000) 432-436
Intra-oral reactions to nickel are
extremely rare and cannot
usefully be predicted from skin
tests
BLOOD BORNE VIRUSES
Hepatitis B, C, D and G, HIV
TRANSMISSIBLE SPONGIFORM
ENCEPHALOPATHIES
PROBLEMS
HAEMATOLOGICAL DISORDERS
Leukaemia
Bleeding disorders
• Coagulation defect
Bleeding tendency, infection risk, anaemia risk
Consult with patients haematologist before any surgical procedure
• Deficiency of clotting factors, usually Factor VIII
•
•
A platelet count < 80-100 x 109/l is significant
•
•
Platelet deficiency
Anticoagulants
ALLIED THERAPY
•
•
•
•
Screening - All patients should be asked if they are allergic to any
drugs, food or latex products, or are prone to any allergic type
reaction.
If latex allergy is suspected refer to dermatologist.
If confirmed latex allergy use latex-free products and ensure the
patient's notes marked "latex allergy"
Use of powder free and low free latex protein gloves recommended for
all patients.
THERAPY / RISKS
Avoid regional nerve blocks, drugs that increase bleeding tendency (e.g.
aspirin) or cause gastric bleeding (e.g. NSAID).
Check patient's Hepatitis and HIV status.
• Replace missing factors
• Antifibrinolytics should be used post surgery
• Correct with platelet transfusion immediately prior to surgery so that
platelet levels are at least 50 x 109/l
• Warfarin interacts with other drugs e.g. aspirin, NSAID,
metronidazole, erythromycin, cephalosporins and tetracyclines
CORTICOSTEROIDS
Steroid cover should be considered
for minor oral surgery procedures
•
If only 1-2 teeth are extracted, an INR < 3.5 is acceptable, with
local control of haemostasis
Current corticosteroid therapy
•
Corticosteroid therapy in the last 12 months
•
ORAL CONTRACEPTIVES
MRI SCANS
•
•
•
CT SCANS
•
Antibiotic therapy can reduce effectiveness of the pill
Fixed appliances cause degradation of image quality locally,
although there are only minor effects on image quality of the
surrounding structures
Significant scatter will occur if the plane of the scan passes
•
200 mg hydrocortisone (IV/IM immediately pre-op or orally 1 hour preop) and continue normal dose of steroids post-op
200 mg hydrocortisone (IV/IM immediately pre-op or orally 1 hour preop)
Always warn patient of likely interactions
through an orthodontic appliance
References:
British Dental Association Advisory Service
Infection Control in Dentistry
British Dental Association (1996)
Dajami A S et al
Prevention of Bacterial Endocarditis. Recommendations by the American Heart Association
Journal of American Heart Association (1997)
Dental Practitioners Formulary (1996-98)
Pp D2-D8
British Medical Association and The Pharmaceutical Press, London, England
Field E A and Fay M F
Issues of Latex Safety in Dentistry
British Dental Journal 179 247-253 (1996)
Hobson R S and Clark J D
Management of the Orthodontic Patient ‘At Risk’ from Infective Endocarditis
British Dental Journal 178 289-295 (1995)
Khurana M and Martin MV
Orthodontics and Infective Endocarditis
British Journal of Orthodontics 26 295-298 1999)
Meechan J G and Welbury R R
Medical Problems Affecting the Management of Children in Dentistry
Dental Update, July/August 242-245 (1996)
Porter S et al
The human transmissible spongiform encephalopathies (TSE's): implications for dental practitioners
British Dental Journal188 (8) 432-436 (2000)
Roberts G J
Dentists are Innocent! “Everyday” Bacteraemia is the Real Culprit: A Review and Assessment of the Evidence that Dental Surgical Procedures are a Principle Cause of Bacterial Endocarditis in Children
Pediatric Cardiology 20 317-325 (1999)
Roberts G J, Gardner P, Longhurst P, Black AE and Lucas VS
Intensity of Bacteraemia Associated with Conservative Dental Procedures in Children
British Dental Journal 188(2) 95-98 (2000)
Roberts GJ, Lucas VS & Omar J
Bacterial Endocarditis and Orthodontics
Journal of the Royal College of Surgeons of Edinburgh 45 141-145 (2000)
Scully C and Cawson R A
Medical Problems in Dentistry, Fourth Edition
Reed Educational and Professional Publishing, Oxford (1998)
Staerkjaer L and Meanne T
Nickel Allergy and Orthodontic Treatment
European Journal of Orthodontics 12 284-289
Working Party of the British Society for Antimicrobial Chemotherapy
Antibiotics Prophylaxis of Infective Endocarditis
Lancet 339 1292-1293 (1992)
Yen S L-K and Yamashita D-D
New American Heart Association Recommendations for Prevention of Bacterial Endocarditis
Journal of Clinical Orthodontics 31 758 (1997)
Document produced 3rd July 2000. Note that recommendations may change in the light of fresh evidence. Updates will be posted on the BOS Website at
www.bos.org.uk