Download Medical disorders and orthodontics

Journal of Orthodontics, Vol. 36, 2009, 1–21
Medical disorders and orthodontics
Anjli Patel
Chesterfield Royal Hospital NHS Foundation Trust, Charles Clifford Dental Hospital, Sheffield, UK
Donald J Burden
Orthodontic Division, The Queen’s University of Belfast, UK
Jonathan Sandler
Chesterfield Royal Hospital NHS Foundation Trust, UK
The orthodontic treatment of patients with medical disorders is becoming an increasing aspect of modern day practice. This
article will draw attention to some of the difficulties faced when orthodontic treatment is provided and will make
recommendations on how to avoid potential problems.
Key words: Medical disorders, orthodontics, guidelines
Introduction
An increasing number of patients with complicated
medical conditions and drug regimes are seeking orthodontic treatment. Progress in medicine, higher expectations of quality of life, increased life expectancy have
resulted in a greater demand for elective dental and
medical treatment.1 Orthodontists need to be aware of the
possible clinical implications of many of these diseases. In
addition orthodontists see their patients every 6 to 8 weeks
and rapidly developing medical problems can manifest
themselves at any age. Orthodontists must remain vigilant
as they may be the only health care professional seen by
otherwise fit, young patients on a regular basis.
This article examines aspects of some of the conditions
that are of relevance to orthodontic practice. A
comprehensive medical history should be taken and
regularly updated. Case notes should alert the clinician
to the patient’s medical status. All medical conditions
should be accurately understood before any treatment is
planned and this may involve seeking guidance from the
patient’s physician. Patients should be well informed of
all the options and made aware that any orthodontic
treatment has been planned with their best interests at
heart. It should be highlighted they are not being
penalized for their medical condition.2 The importance
of excellent oral hygiene should be emphasized to all
patients considering a course of orthodontics.
prior to an invasive procedure that could generate a
bacteraemia has been a founding principle of dental
practice for half a century, although the evidence of
benefit is limited. Very few cases of IE are now
secondary to oral streptococci and Staphylococcus
aureus is now the most common pathogen.4
The lack of evidence from human models and
changing clinical profile of IE has led several authorities
to update their guidelines in recent years (Table 1).
Most authorities across Europe and from the United
States of America recommend the use of prophylaxis
prior to invasive procedures in high-risk patients.5–8
The National Institute for Health and Clinical
Excellence (NICE) issued the most recent guidance for
dental practitioners in the United Kingdom in March
2008. NICE has recommended that antibiotic prophylaxis should not be used in patients at risk of infective
endocarditis undergoing dental procedures. In addition
NICE advises that chlorhexidine mouthwash should not
be offered as prophylaxis against IE in at risk patients.9
NICE have based their guidelines on the following facts:
N
N
Cardiovascular system
Infective endocarditis (IE)
IE is a rare condition with a high mortality and
morbidity.3 The primary prevention of IE is very
important. Antibiotic prophylaxis for such patients
N
N
The efficacy of antibiotic prophylaxis for IE has never
been shown in a randomized trial. A Cochrane review
concluded that there was no evidence to support the
use of penicillin prophylaxis.10
A direct link between routine orthodontic or dental
procedures and IE has never been established
conclusively. Although four cases of endocarditis
have been reported in patients undergoing orthodontic treatment, no evidence was presented to confirm
that orthodontic treatment was a causal factor.11–13
General dental and skin hygiene are probably more
important for the prevention of IE.
The use of antibiotics is by no means risk free.
Although prophylactic regimes suggest single dose
Address for correspondence: Jonathan Sandler, Chesterfield Royal
Hospital NHS Foundation Trust, Chesterfield Rd, Calow,
Chesterfield, S44 5BL, UK.
Email: [email protected]
# 2009 British Orthodontic Society
Originally translated into German and published in Information aus Orthodontie und Kieferorthopäedie 2009; 41: 23–41.
Republished here by permission of Georg Thieme Verlag kG Stuttgart. New York
DOI 10.1179/14653120723346
Secundum type artial septal defect
Dental procedures with risk of
gingival/mucosal trauma
Low-risk patients
Dental procedures
requiring prophylaxis
in high-risk patients
All invasive dental procedures
Previous IE. Cardiac valve
replacement. Prosthetic systemic
or pulmonary shunt or conduit.
Previous IE.
Acquired valvular
heart disease with
stenosis/regurgitation.
Prosthetic valve.
Structural CHD
including surgically
corrected or palliated
structural defect
excluding isolated
atrial septal defect,
fully repaired
ventricular septal
defect or fully
repaired patent
ductus arteriosus,
and closure devices
deemed to be
endothelialised.
Hypertrophic
cardiomyopathy
None
Dental procedures involving
manipulation of gingival tissue,
periapical area of teeth or
perforation of oral mucosa.
None
None
Prosthetic valve. Previous IE.
Unrepaired or incompletely
repaired cyanotic congenital
heart disease (CHD). CHD
repaired with prosthetic
material for 6 months after
procedure. Valve disease in
cardiac transplant recipients
British Society for Antimicrobial American Heart Association
Chemotherapy 2006
2007
Clinical Section
None
Optional – based on
clinical assessment of
patient and procedure.
Can be given post-op if
procedure unduly complex
Other valve disease –
mitral valve prolapse
with mitral insufficiency,
valve thickening. Noncyanotic CHD except
Atrial septal defect.
Hypertrophic obstructive
cardiomyopathy
All invasive dental
procedures
Previous IE. Cardiac
valve replacement.
Prosthetic systemic
or pulmonary shunt
or conduit.
French Guidelines
2002
National Insitute
for Health and
Clinical Excellence
2008
Patel et al.
Dental procedures
None
requiring prophylaxis
in moderate- and lowrisk patients
Prosthetic heart valve, complex
congenital cyanotic heart diseases.
Previous IE. Prosthetic systemic
or pulmonary shunt or conduit.
Mitral valve prolapse with valvular
regurgitation/severe valve thickening.
Non cyanotic congenital heart
diseases including bicuspid aortic
valves. Hypertrophic cardiomyopathy
European Society of Cardiology
2004
Guidelines for the prevention of IE in dentistry
High-risk patients
Table 1
2
JO December 2009
JO December 2009
Clinical Section
administration, from which non-fatal side effects are
usually minor, there is a risk of fatal anaphylaxis,
which affects 12–25 people per million.14
The orthodontist should communicate with the patient’s
physician to confirm the risk of IE.
The orthodontist should offer people at risk of IE clear and
consistent information about prevention including the
following factors:
# The risks and benefits of antibiotic prophylaxis and an
explanation of why antibiotic prophylaxis is no longer
routinely recommended in the United Kingdom.
# The importance of maintaining an exemplary standard of
oral hygiene and that it is their responsibility to protect
themselves. Regular supportive therapy from a hygienist
is also advisable. The risk of using electric toothbrushes is
poorly defined but a pilot study showed that brushing
with a powered toothbrush results in a transient
bacteraemia more frequently than brushing with a
manual or ultrasonic toothbrush.15 The authors
concluded that the resulting bacteraemia might affect
patients with congenital heart defects at risk of bacterial
endocarditis. However, their results show that vigorous
brushing increased bacteraemia from brushing once but
do not answer whether bacteraemia incidence would
decrease with a program of vigorous daily brushing.
# Symptoms that may indicate IE and when to seek
specialist advice. The risk of undergoing invasive
procedures, including non-medical procedures such as
body piercing or tattooing.
N
N
Any episode of infection in people at risk of IE should be
investigated and treated promptly.
Haematology and patients with bleeding problems
Disorders of the blood, whether acquired or inherited
can affect the management of orthodontic patients. Mild
bleeding disorders are not problematic to the orthodontist but patients with severe disorders may require more
care.
A history of a clinically significant episode is one that
N
N
N
N
continues beyond 12 h
requires a patient to call or return to their dental
practitioner or seek medical treatment or emergency
care
results in the development of a haematoma or
ecchymosis within the soft tissues
requires blood product support.19
The main orthodontic procedure that has been postulated to
cause a bacteraemia has been placement of a separator.16 Lucas
and co-workers investigated the bacteraemia associated with an
upper alginate impression, separator placement, band
placement and adjustment of an archwire on a fixed appliance.
Blood samples were taken from randomly allocated
orthodontic patients immediately before the intervention and
then 30 s after the procedure. The mean total number of
anaerobic and aerobic bacteria was significantly greater
following the placement of a separator, compared with baseline
blood cultures. There was no difference noted between baseline
and taking an impression or placement of a band. Using similar
methodology, Burden and colleagues did not detect a
significant difference in the prevalence of pre-debanding (3%)
and post-debanding (13%) bacteraemia.17 The authors
concluded that this is lower than the prevalence of bacteraemia
following toothbrushing and those procedures do not warrant
antibiotic prophylaxis.
N
A risk of bacteraemia induced by traction of unerupted,
exposed and bonded teeth has been suggested. Lucas and
associates studied the prevalence, intensity and nature of
bacteraemia following upper arch debanding in 42 patients and
gold chain adjustment in seven patients.18 The authors found
no significant difference in the prevalence of bacteraemia
between baseline and following debanding or gold chain
adjustment. Admittedly the sample size for gold chain
adjustment was small
Orthodontic considerations in patients with cardiovascular
disorders
N
3
Orthodontic considerations in patients with cardiovascular
disorders
N
N
Medical disorders and orthodontics
The use of orthodontic bands and fixed acrylic appliances
should be avoided whenever possible in high-risk patients with
poor oral hygiene.
Inherited coagulopathies – deficiencies in clotting
factors
Haemophilia is a common example of a clotting factor
deficiency. Haemophilia A is a sex-linked disorder due
to a deficiency of Factor VIII. When the Factor VIII
level is less than 1% of normal, the condition is classified
as severe.20 Other bleeding disorders include
Haemophilia B or Christmas disease (factor IX deficiency) and von Willebrand’s disease (defects of von
Willebrand’s factor).
As well as problems with bleeding, these patients may
be infected with HIV or hepatitis viruses because of the
transfusion of infected blood or blood products before
1985. The methods of screening and manufacture have
improved, but they do not rule out the risk of virus
transmission entirely. The UK Department of Health
4
Patel et al.
Clinical Section
(DoH) carried out a risk assessment concluding that all
recipients of UK sourced plasma-derived coagulation
factor concentrates used in the period 1980–2001 should
be regarded as being at risk of developing variant
Creutzfeldt-Jakob disease (vCJD) for public health
purposes.21 Risk assessments have been carried by both
the DoH and the World Federation of Haemophilia
which could not identify any person with haemophilia
who has developed vCJD.22,23 Moreover, they concluded that routine dental treatment including minor
oral surgery is unlikely to pose a cross-infection risk.
Orthodontic considerations in patients with bleeding disorders
N
Orthodontic treatment is not contraindicated in patients with
bleeding disorders.24 A thorough history and close liaison with
the patient’s haematologist, oncologist or physician will help
reduce the risk of problems occurring.
N
Patients should be encouraged to maintain excellent,
atraumatic oral hygiene.25
N
If extractions or surgery cannot be avoided, the management of
patients with haemophilia relies on careful surgical technique,
including an attempt at primary wound closure and the
following regimen to:
# increase Factor VIII production with 1-desamino-8-Darginine vasopressin (DDAVP)
# replace missing Factor VIII with cryoprecipitate, Factor
VIII, fresh frozen plasma or purified forms of Factor
VIII
# antifibrinolytic therapy with transexamic acid or epsilonamino caproic acid (EACA)25
N
Nerve-block anaesthetic injections are contra-indicated unless
there is no better alternative and prophylaxis is provided to
prevent the risk of a haematoma forming.26
N
JO December 2009
their movement through capillaries and hence deprives
the tissues of oxygen and in conscious patients causes
intense pain. The disease is chronic and life expectancy is
shortened to about 45 years.29
Sickle cell trait is the term given to patients who
inherit one of the genes of sickle cell disease but without
developing the recurrent symptoms. It is not benign and
can also have symptoms due to co-morbidity and
conditions that can lead to overheating, dehydration
and sickling.
Sickle cell anaemia is more common in people of
African origin where malaria is common but it also
occurs in people of Asian and West Indian descent.30
Treatment ranges from NSAIDs for milder vasoocclusive crises to IV opioids.31 Acute chest crises are
treated with antibiotics and blood transfusions to reduce
the percentage of HbS in the blood. The risks of blood
transfusions have been discussed above. Tetracycline
may need to be given as an alternative to amoxicillin or
flucloxacillin when the child develops multiple drug
sensitivity. Chemotherapy32 and bone marrow transplants have also been advocated and these treatments
come with their own list of orthodontic considerations.
Oral manifestations of sickle cell disease include
enamel hypoplasia in the form of white spots on the
tooth surface, dentinal hypomineralization, delayed
tooth eruption, pale lips and oral mucosa and glossitis.
Radiographic signs include osteoporosis and parallel
trabeculae amidst teeth but not in edentulous areas.33
Mandibular osteomyelitis in the absence of other
problems can occur due to the limited blood supply.
Vaso-occlusive crises can predispose the patient to pain
and paraesthesia of the inferior alveolar nerve and the
lower lip.
Chronic irritation from orthodontic appliances should be
avoided. Fixed appliances are preferable to removable
appliances as the latter can cause gingival irritation.27
N
Self-ligating brackets are preferable to conventional brackets.
If conventional brackets are used, archwires should be secured
with elastomeric modules instead of wire ligatures.27
N
N
Orthodontic considerations in patients with sickle cell anaemia
N
patients, provided the patient has no or very mild
complications and the oral hygiene is excellent.
Care is required when placing and removing archwires.1
The duration of orthodontic treatment should be kept to a
N
minimum to reduce the potential for complications.28
Intervention in these patients favours a multidisciplinary
approach involving the patient’s physician, haematologist,
dentist, and family.
N
Sickle cell anaemia
This is a genetic disorder that is characterized by a
haemoglobin gene mutation (HbS as opposed to HbA).
Deoxygenation, for example during anaesthesia induces
the red cells to deform into a sickle shape. This restricts
Orthodontic treatment is not contra-indicated in sickle cell
Emotional stress should be avoided and care should be taken to
ensure the surgery is well ventilated and at an ambient
temperature.34
N
A non-extraction approach to treatment is preferred. If
extractions are necessary they are best carried out in a hospital
environment.34
JO December 2009
Clinical Section
Orthodontic considerations in patients with sickle cell anaemia
N
General anaesthetics for elective procedures are contraindicated and hence orthognathic surgery should not be
recommended. If a GA in a sickle cell trait patient cannot be
avoided careful oxygenation must be ensured. Patients with
sickle cell disease itself may require a pre-anaesthetic
transfusion so the level of haemoglobin A is at least 50%.35
N
The orthodontist should be aware of possible pulpal necrosis
involving healthy teeth, the changes in bone turnover,
mandibular vaso-occlusive crises, and the greater susceptibility
to infections.34
N
It has been recommended that orthodontic forces should be
reduced and rest intervals between activations should be
increased to restore the regional microcirculation.34
Medical disorders and orthodontics
5
capacity to improve the height velocity.36 Bone density
is frequently reduced in long-term survivors of childhood malignancies.37 They also show acute and longterm complications in the oral cavity and in dental and
craniofacial development. The most common dental
disturbances are arrested root development with Vshaped roots, premature apical closure, microdontia,
enamel disturbances and aplasia.38 A common side
effect of radiation is salivary dysfunction leading to
xerostomia. Craniofacial disturbances were demonstrated by a case controlled study of 17 children treated
for ALL with allogeneic BMT and TBI. The ALL group
had reduced vertical dimensions of the face, alveolar
processes as well as reduced sagittal dimensions of the
jaws, characterized by mandibular retrognathism.39
Leukaemia
Orthodontic considerations in patients with leukaemia
Leukaemia is divided into acute and chronic forms.
Acute lymphoblastic leukaemia (ALL) is the commonest
presentation in children accounting for 25% of all
childhood tumours. The prognosis in children with
ALL is better than that for adults for whom the longterm survival is low. Acute myeloblastic leukaemia
(AML) is more common in adults than children and the
prognosis is poor. The treatment for acute leukaemia
includes chemotherapy or bone marrow transplantation
(BMT). Total body irradiation (TBI) and immunosuppression are used to prevent graft-versus-host disease
after BMT.
Chronic leukaemia involves the proliferation of more
mature cells than those found in acute leukaemia. The
prognosis is better and adults are more commonly
affected than children. Chronic lymphocytic leukaemia
(CLL) is more common and patients tend to be
asymptomatic. Chronic myeloid leukaemia (CML)
affects adults of a younger age group than CLL. The
main signs of the chronic leukaemia tend to be
splenomegaly and lymph node enlargement. Treatment
is with chemotherapy and radiotherapy.
The sequelae of treatment may be immediate or may
occur several months after treatment. These effects can
be caused by the malignancy itself, by the treatment
including chemotherapy, radiotherapy and supportive
care such as transfusions, antibiotics and immunosuppressive treatment. The degree to which an individual is
affected is related to the age at which the disease is
diagnosed and treated and the type and intensity of the
treatment. The growth rate generally declines in children
during treatment for leukaemia. Soon after treatment
the normal growth rate is resumed and catch up growth
is sometimes seen. Growth hormone therapy has the
Dahlöf and Huggare have produced an excellent review on the risk
factors to be aware of when planning orthodontic treatment in longterm survivors of childhood malignancy.40
Before diagnosis
N
Significant orofacial complications of leukaemia in children
include lymphadenopathy, spontaneous gingival bleeding
caused by thrombocytopenia (reduction in platelets), labial and
lingual ecchymoses and mucosal petechiae, ulceration, gingival
swelling, and infections. The orthodontist may be the first to
notice signs of the illness.41 Patients presenting with
spontaneous bleeding in the presence of good oral hygiene
warrant an immediate referral to a physician.2
After diagnosis
N
Orthodontic treatment should be postponed if the patient
requires chemotherapy as the drugs can exacerbate the
thrombocytopenia and agranulocytosis.
After treatment
N
It has been suggested that orthodontic treatment should be
postponed until at least 2 years after BMT.2 By then the risk
for relapse of the malignancy has diminished and the patient is
no longer on immunosuppressive therapy. Additionally, the
growth rate and the need for supplemental growth hormone
have been assessed.
N
In view of the fact that TBI can suppress growth, the prognosis
for growth modification in skeletal Class II malocclusions is
guarded.40
N
The treatment should be modified to reflect the patient’s
medical condition and planned with the patient’s best interests
in mind. There are no reports about any adverse effects of
orthodontic treatment in these patients.42 Treatment mechanics
should be aimed at minimising the risk of root resorption,
keeping the forces low and accepting a compromised treatment
result. There may be merit in treating the upper jaw only to
reduce the risk of undesirable events.40
6
Patel et al.
Clinical Section
Orthodontic considerations in patients with leukaemia
N
In patients with short blunt roots, it is wise to monitor the
crown to root length after 6 months of fixed appliance
treatment. If there is evidence of apical root resorption,
treatment should be interrupted for 3 months. The appliance
should not be removed but the archwire should be left passive
so there can be no active tooth movement.43
N
The caries risk may be increased due to salivary dysfunction
and as with all patients the oral hygiene should be of a high
standard. Topical fluoride application and artificial saliva may
be recommended.
N
A further side effect of anti-cancer treatment is a reduced
resistance to infections and atrophy of the oral mucosa. Even
minor irritation from orthodontic appliances can lead to severe
ulceration. Vacuum formed aligners may be the appliances of
choice for selected malocclusions.
N
If a patient requires additional chemotherapy or radiotherapy,
appliances should be removed to reduce the risk for oral
complications. Treatment can be recommenced when the
patient is in remission with a good prognosis.27 Both the
patient and parent should be counselled that this regime is
being followed in the best interest of the patient.2
N
asthma.46 This increased prevalence of resorption
was confined to mild root blunting and the
researchers concluded that longevity or function of
posterior teeth would not be adversely affected.
Nonetheless patients should be informed of this risk
prior to treatment.
Cystic fibrosis
Tooth extractions have been implicated in causing
osteoradionecrosis (ORN) with a higher incidence in the
mandible. There are no reports on the incidence of ORN after
tooth extractions in children treated for malignancies.
Atraumatic extraction techniques will also reduce the risk of
ORN.44
N
JO December 2009
Removable retainers should fit well with little potential to be a
source of irritation, ulceration or infection.2
Respiratory system
Respiratory disorders are common and the use of
intravenous (IV) sedation and general anaesthesia
(GA) for elective procedures may be contraindicated.
The unwanted effects of prescribed drugs can also
influence the orthodontic treatment of these patients.
Asthma
Approximately 300 million people around the world
have asthma, and it has become more common in both
children and adults globally in recent years.45 The
severity varies from mild to severe. In moderate cases
episodes are severe but the patients are symptom free
between attacks. In severe asthma the attacks are severe
and the child is never asymptomatic and growth and
lung function can be affected.
There has been a tentative link between orthodontically induced external root resorption and patients with
Cystic fibrosis (CF) is the most common life limiting,
childhood-onset, autosomal recessive disorder among
people of European heritage. It affects the exocrine
glands of the lungs, liver, pancreas and intestines,
causing progressive disability due to multisystem failure.
The cells are relatively impermeable to chloride ions and
thus salt rich secretions are produced. The mucous is
viscid and blocks glands of the respiratory and digestive
systems. There is a non-productive cough that leads to
acute respiratory infection, bronchopneumonia, bronchiectasis, and pancreatic insufficiency. Diabetes mellitus
may be a complication and patients may have cirrhosis
of the liver.47,48 There is no cure for CF. Most
individuals with CF die young: many in their 20s and
30s from lung failure; however, with advances in medical
treatments, the life expectancy of a person with CF is
increasing to ages as high as 40 or 50.49 Heart and lung
transplantation are often necessary as CF worsens. Oral
effects include hypoplastic enamel and delayed eruption.
In the 1970s there were several reports of tetracycline
staining of teeth but alternative medications are now
used.50 A side effect of antibiotic treatment is the lower
prevalence of dental disease.51
Relevance of drugs in respiratory disorders
The chronic use of corticosteroid inhalers can lead
to localized lowered resistance to opportunistic infections. As a result of this oro-pharyngeal candidal
infection may occur.52 To avoid this complication,
patients should be advised to rinse and gargle with
water after the use of their inhaler especially if wearing
removable acrylic appliances.53 Candidiasis can be
treated with topical antifungal agents such as nyastatin.
Additionally the regular use of inhaled corticosteroids
can predispose the patient to an adrenal crisis if
subjected to stress. The need for steroid cover is
discussed in the general section on drugs and orthodontic treatment.
Beta-adrenergic agonist bronchodilators such as salbutamol, antimuscarinic bronchodilators, cromoglycates and antihistamines can all produce dry mouth,
taste alteration and discolouration of teeth.
JO December 2009
Clinical Section
Orthodontic considerations in patients with respiratory disorders
N
The patient’s physician should be contacted before treatment is
commenced to evaluate the severity and prognosis of the
problem.27 The orthodontist should ensure the patient has their
inhaler nearby.1
N
Patients may not be comfortable in the supine position if they
have difficulty breathing.53
N
The first objective is to prevent acute asthmatic attacks.
Treatment can be deferred in patients with poorly controlled
asthma and with a history of multiple emergency room visits. It
is best to minimize the factors that precipitate attacks in
patients at low or moderate risk. Morning appointments when
the patient is rested, short waiting and treatment times all help
ease stress and anxiety.1
N
Orthodontic extractions should ideally be carried out under
local anaesthesia (LA) with or without relative analgesia (RA)
and not GA. If GA is required the patient must be in optimal
health with no evidence of a respiratory infection.53 RA with
nitrous oxide and oxygen is favoured to intravenous sedation
(IV) since the former can be rapidly reversed.53
N
CF also affects the salivary glands and hence salivary flow can
be reduced. These patients, as well as those with drug-induced
xerostomia are at a higher risk of decalcification. Aggressive
oral hygiene, supplemental topical fluorides, and vigilance for
dental disease are necessary to combat these side effects.28
N
Patients with asthma should be prescribed non-steroidal antiinflammatory drugs (NSAIDs) with caution as many asthmatic
patients are allergic to aspirin like compounds. A retrospective,
cohort study identified that patients younger than 40 years
with a history of multiple respiratory reactions and prior
reactions associated with aspirin and NSAIDs were more likely
to have a positive oral aspirin challenge.54
Epilepsy
Epilepsy is a common symptom of an underlying
neurological disorder. The seizures can take a variety
of forms and epilepsy is considered to be active if a
person has had a seizure within the last 2 years or is
taking anti-epileptic medication.56
Brain damage due to injury, infection, birth trauma or
a cerebrovascular accident accounts for 25% of cases.
The other 75% of cases have no identifiable cause but
there is a familial trend. Epilepsy can develop in some
genetic syndromes such as Down’s syndrome57 or in
Sturge-Weber syndrome.58
7
The risk of developing epilepsy is 2–5% over a lifetime.
The prevalence of active epilepsy is between 5 and 10
people per 1000 of the population.59 The condition is
more common in men and the incidence is high in the
first two decades of life, and then reduces before
increasing after the age of 50 years as a result of
cerebrovascular disease.56
Hyperventilation, fever, photic stimulation, withdrawal or poor lack of compliance with anticonvulsants,
lack of sleep, over-sedation, emotional upset and some
medications such as antihistamines can stimulate
attacks.
Both the condition and the medical management can
affect oral health. Phenytoin was once the first choice in
managing epilepsy in younger people but this has fallen
out of favour because of its many side effects. These
include nausea, mental confusion, acne, hirsutism,
hepatitis, erythema multiforme and gingival overgrowth. However, the orthodontist may still encounter
patients taking phenytoin. Alternatives such as carbamazepine also have oral side effects including oral
ulceration, xerostomia, glossitis and stomatitis.56
Prevention of oral disease and carefully planned
dental and orthodontic treatment are essential to the
well being of patients with epilepsy.
Other forms of treatment for epilepsy such as surgery
are unlikely to have implications for orthodontic care.
Orthodontic considerations in patients with epilepsy
N
Most people who have seizure disorders are able to undergo
conventional orthodontic care in the primary care setting.
Nonetheless, the orthodontist should ensure the patient has
taken their normal anti-epileptic medication, is not too tired
and has eaten normally before each appointment.
Neurological disorders
It is important that orthodontists have knowledge of the
most common neurological conditions as some problems may manifest initially in the orthodontic chair.55
Medical disorders and orthodontics
N
The orthodontist should ensure the patient is receiving regular
and rigorous preventative dental care to avoid/minimize dental
disease.
N
Patients should be aware of and consented for the risk of soft
tissue and dental injuries as a result of a seizure.60
N
Gingival overgrowth associated with phenytoin is the most
widely known complication of anti-epileptic medication, with
50% of individuals being affected within 3 months of starting
the drug.61 Gingival hyperplasia is greater in those with high
plaque scores but there is also a genetic link.62 Gingivectomy is
recommended to remove any hyperplastic tissue that interferes
with appearance or function. For patients with recurrent
hyperplasia, the patient’s physician should be contacted to
discuss alternative medication. Gingival hyperplasia resolves
spontaneously within 1–6 months of phenytoin
withdrawal.63
8
Patel et al.
Clinical Section
Orthodontic considerations in patients with epilepsy
N
Removable appliances need to be used with caution as they can
be dislodged during a seizure. It is not always possible to avoid
the use of removable appliances. Wherever possible removable
appliances should be designed for maximum retention and
made of high impact acrylic.56 Trauma can also result in
subluxation of the temporomandibular joints and tooth
devitalization, fractures, subluxation or avulsion.
N
If an individual with a Class II division 1 incisor relationship
experiences an aura before a seizure, he or she should carry a
soft mouth guard with palatal coverage and extending into the
buccal sulci, to use at such times.56
N
The orthodontic team should be well trained in seizure
management. Status epilepticus is a medical emergency and
there should be given a benzodiazepine from the emergency
drug kit.56
Multiple sclerosis (MS)
MS is a complex neurological condition that occurs as a
result of damage to the myelin sheathes within the
central nervous system. The damaged areas result in
inflammation and interference in both sensory and
motor nerve transmission.
MS is the most common cause of severe disability
among young adults in the UK. It has an incidence of
0.1% (1 : 1000) in the general population.64 The diagnosis of MS is usually made between the ages of 20 and
40 years. It is more common in women than men with a
ratio of 3 : 2.65 The prognosis depends on the subtype of
the disease. The life expectancy of patients is nearly the
same as that of the unaffected population, and in some
cases a near-normal life is possible.
have been implicated. It is not an inherited condition but
there is a familial link.
The main symptoms relevant to oral care include pain
and numbness of varying severity in the facial and oral
tissues. The arms and hands can also be affected
challenging the patient’s ability to carry out effective
oral hygiene. Trigeminal neuralgia is atypical in that
patients are younger, the pain may be bilateral and
unstimulated. Indeed trigeminal neuralgia in people
under 40 can be indicative of MS. Orthodontists should
be aware of this and refer affected individuals for a
neurological assessment.
Transient spasticity occurs when opposing muscles
contract or relax at the same time leading to muscle
stiffness, lack of coordination, clumsiness, muscle spasm
and related pain. This can interfere with the safe delivery
of orthodontic treatment and treatment should be
delivered until the individual is in remission. Some
patients also suffer from a tremor making satisfactory
oral hygiene problematic.
There is no cure for MS. The focus of treatment is on
the prevention of disability and maintenance of quality
of life. Drugs, physical treatments and psychological
techniques are used. Steroids are often used to help a
person over a severe relapse. A plethora of other
drugs can be prescribed, several of which can cause
dry mouth, ulceration, gingival hyperplasia amongst
other symptoms.66
Orthodontic considerations in patients with MS
N
N
Preventative regimes should be based on the nature of the
individuals MS. Custom made toothbrush handles to improve
grip and the use of electric toothbrushes to compensate for the
loss of manual dexterity and coordination have been
recommended.67
Benign
The aetiology of MS is not understood and various
environmental factors such as viruses, climatic factors
Treatment should involve a multidisciplinary approach
including the patient’s physician, neurologist, MS specialist
nurse and care worker.67
Subtypes of MS
20% of people with MS. Mild attacks
followed by complete recovery and no
permanent disability
Relapsing/remitting
25% of confirmed cases. Remissions
occur spontaneously, relapses unpredictable,
some residual damage
Secondary progressive 40% of cases. Follows on from
relapsing/remitting phase and then
remissions cease to occur. Usually
15–20 years from onset of symptoms
Primary progressive
15%. Symptoms worsen and disability
progresses.
JO December 2009
N
It is important to discuss with every patient with MS how he or
she prefers to manage his or her symptoms. Appointments
should be at their convenience, the environment kept at a
comfortable temperature. Patients with spasms should be
allowed to get out of the dental chair and move around to
relieve them. Individuals with dysphagia should be treated in a
semi-reclined position.
N
Treatment objectives should be tailored to the patient’s
condition. Patients with severe MS may be best treated to a
compromised result. Removable appliances may not be
tolerated well. In patients with poor coordination the use of
intermaxillary traction may be contraindicated.
JO December 2009
Clinical Section
Liver disease
Liver disease can result from acute or chronic damage to
the liver, usually caused by infection, injury, exposure to
drugs or toxic compounds, an autoimmune process, or
by a genetic defect. For most childhood liver diseases the
cause is unknown.
The main effects of liver disease can be categorized
into:
N
N
N
N
N
coagulation disorders;
drug toxicity;
disorders of fluid and electrolyte balance;
problems with drug therapy;
infections.35
Medical disorders and orthodontics
9
Orthodontic considerations in patients with liver disease
Hepatitis
N
All patients should be treated as though they are infected and
universal cross-infection control precautions should be taken.
Several studies have shown that orthodontists are more
complacent than general dental practitioners with regard to
cross-infection.70
N
All members of the team should be immunized against HBV. A
booster is required in those with anti-HBs level less than
100.69
Endocrine conditions
Diabetes mellitus (DM)
Infections
Viral hepatitis is undoubtedly of importance to the
orthodontist. Hepatitis B (HBV), hepatitis C (HCV) and
hepatitis D are blood borne and can be transmitted via
contaminated sharps and droplet infection. Aerosols
generated by dental hand pieces could infect skin, oral
mucous membrane, eyes or respiratory passages of
dental personnel and patients. The main orthodontic
procedures to result in aerosol generation are removal of
enamel during interproximal stripping, removal of
residual cement after debonding, and prophylaxis.68
HBV has an incubation period of 6 weeks to 6 months
and a small number of infected persons can progress to
the carrier state associated with chronic active hepatitis
and eventually cirrhosis. Hepatitis B Surface Antigen
(HBsAg) is the first sign of infection. Antibody to
HBsAg is associated with protection from infection.
Hepatitis B Core Antigen (HBcAg) is detected by the
development of an antibody to it. If the person is
HBsAg negative but HBcAg positive they are infective.
Hepatitis B e Antigen is only found if HBsAg is present
and is an indication of infectivity.
Orthodontic considerations in patients with liver disease
General liver disease
N
Care should be taken when prescribing any medication for
patients with liver disease. Hepatic impairment can lead to
failure of metabolism of some drugs and result in toxicity.69
N
Patients undergoing liver transplantation will be receiving
immunosuppressive drugs that can cause gingival hyperplasia.
This effect is discussed in more detail on the section on
medication.
N
Haemostasis will be affected and this should be accounted for
when planning treatment.
The term DM is characterized by chronic hyperglycaemia. There are two main categories of DM:
Type 1 DM, (insulin dependent, IDDM or juvenileonset diabetes) results from defects in insulin secretion.
The onset is usually before adulthood and accounts for
approximately 5–15% of all people with DM. Type 1
DM occurs more frequently in people of European
origin than non-European origin. It is life threatening if
not treated with exogenous insulin.
Type 2 DM (non-insulin dependent NIDDM or
mature-onset diabetes) develops as a result of defects
in insulin secretion, insulin action or both. There is a
link with being overweight. Type 2 DM usually appears
in people over the age of 40, although in South Asian
and African-Caribbean people often appears after the
age of 25.71 However, recently, more children are being
diagnosed with the condition, some as young as seven.72
This form of DM is also more prevalent in less affluent
populations. It accounts for 85–95% of all cases of DM.
It is not usually life threatening but chronic complications can affect the quality of life and reduce life
expectancy.
Gestational diabetes is similar to type 2 DM in that it
involves insulin resistance; the hormones of pregnancy
can cause insulin resistance in women genetically
predisposed to developing this condition. Gestational
diabetes typically resolves with delivery of the child,
however types 1 and 2 diabetes are chronic conditions.
The prevalence of DM is increasing in the UK and
worldwide. The World Health Organisation predicts
that the global prevalence of type 2 DM will increase
from 135 million in 1995 to 300 million in 2025.73
DM is progressive and has potentially harmful
consequences for health. Strict blood glucose control,
lowering of blood pressure, together with a healthy
lifestyle improves well being and protects against long
10
Patel et al.
Clinical Section
term damage to the eyes, kidneys, nerves, heart and
major arteries.74
Oral complications include: xerostomia, burning
mouth and/or tongue, candidal infection, altered taste,
progressive periodontal disease, dental caries, acetone
breath, oral neuropathies, parotid enlargement, sialosis
and delayed wound healing. These complications can
occur even when the blood glucose is well controlled due
to impaired neutrophil function but are all more severe
in uncontrolled DM.
Orthodontic considerations in patients with DM
N
Orthodontic treatment should be avoided in patients with
poorly controlled DM as they are more likely to suffer from
periodontal breakdown.27 Well-controlled DM is not a
contraindication for orthodontic treatment.
N
Rigorous preventative regimes should be put in place. The
patient should be made aware of the consequences of poor oral
hygiene and the increased risk of periodontal disease.
N
Early morning appointments are least likely to interfere with
the diabetes control regime. Patients should be advised to eat a
usual meal and take the medication as usual prior to longer
appointments.
N
Diabetic related microangiopathy can affect the peripheral
vascular supply, resulting in unexplained toothache, tenderness
to percussion and even loss of vitality.75 It has been suggested
that patients with DM should be treatment planned as
periodontal patients. Light physiological forces should be used
in all patients to avoid overloading the teeth.
N
in medical care resulting in reduced morbidity and
mortality.76 The most common renal condition to
present to the orthodontist is chronic renal failure
(CRF).
CRF occurs after progressive renal damage.
The symptoms and signs vary and can affect diverse
body systems. Bone disease or renal osteodystrophy is
an almost universal feature of CRF. Calcium metabolism is compromised by an elevated parathyroid
hormone and by disruption in vitamin D metabolism.
This results in secondary hyperparathyroidism. Renal
disease also causes anaemia and marrow fibrosis leads to
a reduced platelet count and poor platelet function.
Haemostasis is impaired to varying degrees in patients
with CRF.
Initially treatment is conservative with dietary
restriction of sodium, potassium and protein. As the
disease progresses dialysis or transplantation are
required. Many patients are prescribed steroids to
either combat renal disease or to avoid transplant
rejection. Immunosuppressant drugs such as cyclosporine and calcium channel antagonists such as nifedipine
are also taken to prevent transplant rejection.
Immunosuppressants predispose the patients to infections. These drugs can also cause drug induced gingival
overgrowth as discussed in the section on drugs and
orthodontic treatment.
In children CRF leads to decreased growth and
sometimes delayed eruption and enamel hypoplasia.
The orthodontic team should be trained to deal with diabetic
emergencies. Hypoglycaemia is characterized by initial signs of
tremor, nausea, sweating, anxiety, tachycardia, palpitations,
shivering. The patient may complain of visual disturbance and/
or perioral tingling. If these warning signs are not recognized, a
second group of neuroglycopenic symptoms occur. These
include impaired concentration or confusion, irrational or
aggressive behaviour, slurred speech, and drowsiness
progressing to coma if untreated.
Treatment in the orthodontic surgery75
N
N
Conscious 50 g of glucose as a drink, tablet or gel
Orthodontic considerations in patients with renal disorders
N
N
N
Patients with kidney disorders are presenting more
frequently in orthodontic practice due to improvements
Appointments should be scheduled on non-dialysis days. The
day after dialysis is the optimum time for treatment for surgical
procedures as platelet function will be optimal and the effect of
heparin will have worn off.
When the patient is cooperative oral glucose should be given to
Renal disorders
Treatment could be deferred if the renal failure is advanced and
dialysis is imminent. If possible treatment could be carried out
prior to transplantation to avoid the risks associated with
immunosuppressant drugs.
Unconscious 20 ml of 50% Dextrose IV or 1 mg of glucagon
prevent recurrent hypoglycaemia. If recovery is delayed, the
emergency services should be called.
Orthodontic treatment is not contraindicated in patients if the
disease is well controlled.
should be administered intramuscularly.
N
JO December 2009
N
Surgical procedures are best carried out under local
anaesthetic. The anaemia and the potential electrolyte
disturbances that can predispose the patient to cardiac
arrhythmias can complicate general anaesthesia.
N
Haemostasis is impaired as a result of platelet dysfunction
Impaired drug excretion leads to the need for care with drug
prescriptions.
JO December 2009
Clinical Section
Orthodontic considerations in patients with renal disorders
N
The value of prophylactic antibiotics in renal transplant
patients on prevention of post-operative complications is
questionable or unproven, with the Working Party of the
British Society for Antimicrobial Chemotherapy (BSAC)
stating that there is no need for antibiotic prophylaxis for
dental treatment;77 however the decision to give prophylaxis
should be made on an individual basis, in conjunction with the
patient’s renal physician.78
N
These patients may be taking or have taken steroids but the use
of supplemental steroids in dentistry is controversial and is
discussed below in the section on drugs and orthodontic
treatment.
N
Animal models have also shown that orthodontic tooth
movement is accelerated in rats with renal insufficiency.79 This
was attributed to the increase in circulating parathyroid
hormone. It has been suggested that orthodontic treatment
forces should be reduced and the forces re-adjusted at shorter
intervals.79
Musculoskeletal system
Medical disorders and orthodontics
11
resulting in mandibular retrognathism. JIA patients
commonly present with skeletal Class II and open bite
malocclusions.85 Mandibular asymmetry is seen in cases
with unilateral TMJ involvement.
Early orthodontic intervention facilitates both the
skeletal and the occlusal rehabilitation. The prevalence
of dental caries and periodontal disease is higher in
adolescents with JIA cases. This has been credited to a
combination of factors including difficulties in executing
good oral hygiene, unfavourable dietary practices and
side effects from the long-term administration of
medication.86 There are common human leucocyte
antigen associations between periodontal disease and
JIA which explains their similar inflammatory effects.
Treatment is aimed at controlling the clinical manifestations by suppressing the articular inflammation and
pain, preserving joint mobility and preventing deformity. NSAIDs are used in the early stages. More severe
cases are prescribed a variety of medicaments such as
gold, methotrexate, corticosteroids and antimalarial
drugs. These drugs have their own adverse effects which
must be reflected on during orthodontic treatment
planning.
Juvenile idiopathic arthritis
Orthodontic considerations in patients with JIA
Juvenile idiopathic arthritis (JIA) is a severe disease of
childhood. It comprises a diverse group of distinct
clinical entities of unclear aetiology. JIA is more
common in Norway and Australia than in other
countries. In Norway, the prevalence is 148.1 cases per
100,000 population and the incidence is 22.6 cases per
100,000 population.80 A cross sectional, community
based, point prevalence study reported a prevalence of
4.0 per 1000 in 12-year-old children in urban
Australia.81
JIA is classified according to the type of onset of the
disease and the number of joints affected during the first
4–6 months: pauciarthritis or oligoarthritis denotes four
or less joints being involved and polyarthritis when five
or more joints are involved. JIA can be of varying
severity with localized and/or systemic complications,
including functional impairment of the affected joints.
This may result in disturbances in growth and developmental anomalies. There is remission of the disease in
adolescence, which happens for 70% of patients.82
The temporomandibular joint (TMJ) is affected in
45% of cases with JIA.83 The diagnosis of TMJ
involvement is more difficult than the other joints as
the signs and symptoms are missing or weak.84 Hence
patients are most often seen when extensive changes
have occurred. This can lead to the development of
condylar hypoplasia, restricting mandibular growth
N
The main aim is to allow the child to live as normal life as
possible. The functional ability of the TMJ in JIA children
should be monitored closely in order to start medical treatment
as soon as inflammation begins in the joint. The TMJ in a
growing child has immense potential for structural changes and
growth can normalize, provided the inflammation is controlled
early and mandibular growth is supported.87 There is remission
of the disease in adolescence for 70% of patients.88 There are no
controlled human studies studying the efficacy of steroid
injections on reducing the inflammatory activity in the TMJ;
however, a study on rabbits with antigen induced TMJ arthritis
did not show any positive long-term benefit of intra-articular
steroid injections.89
N
Oral hygiene aids including modified toothbrush handles and
electrical toothbrushes can be recommended to patients with
JIA.90
N
A bite splint can be provided to unload the joint during any
acute periods of inflammation. A distracted splint has also been
suggested to modify mandibular growth in the same way as
conventional functional appliances.87 The use of functional
appliances in patients is a controversial area. It has been argued
that functional appliances and class II elastics put increased
stress on the TMJs and should be avoided;91 however, it has
also been suggested that functional appliances protect the joints
by relieving the affected TMJ, the aim being to move the
mandible into the normal anterior growth rotational pattern
thus correcting the skeletal Class II relationship.92
12
Patel et al.
Clinical Section
Orthodontic considerations in patients with JIA
N
Surgery can be considered if the problem cannot be treated
orthodontically; however, it has been suggested that
mandibular surgery should be avoided and instead a patient
with severe mandibular deficiency should have maxillary
surgery and a genioplasty.28
Osteoporosis
Osteoporosis is a common progressive metabolic bone
disease that decreases bone density and deterioration of
bone structure. Osteoporosis can develop as a primary
disorder or secondarily due to some other factor. It is
most common in women after menopause, but may
develop in men. Risk factors that cannot be altered
include advanced age, being female, oestrogen deficiency
after menopause,93 and being of European or Asian
origin.94 Potentially modifiable risk factors include
excessive alcohol intake, vitamin D deficiency, smoking,95
low body mass index,96 malnutrition, physical inactivity97
Osteoporotic bone loss affects cortical and cancellous
(trabecular) bone and animal studies have shown this
process can result in decreased oral bone density and
alveolar bone loss.98 Both bone resorption and formation are accelerated and excessive bone resorption leads
to loss of attachment. This theoretically can affect the
rate of tooth movement.
Treatment modalities include medication, exercise, a
diet sufficient in calcium and vitamin D and lifestyle
changes99 In confirmed osteoporosis, bisphoshonate
(BP) drugs are the first-line of treatment in women.
Oral BPs are poorly tolerated and are associated with
oesophagitis. The chronic nature of osteoporosis necessitates long-term administration of BPs and therefore
their safety is clinically important and requires some
attention. A recent review of the literature identified 26
cases of osteonecrosis of the jaws (ONJ) in patients on
oral BPs for the treatment of osteoarthritis.100 This
prevalence is relatively low compared with the 190
million patients with osteoarthritis and osteopenia on
oral bisphosphonates.101
The main implications on orthodontic treatment are
due to BP use and hence these are discussed in the
section below.
Side effects of medication
Non-steroidal anti-inflammatory drugs (NSAIDs)
Pain control during orthodontics is an important aspect
of patient compliance. In addition patients may be on
JO December 2009
pain relievers for a chronic illness. The effects of these
medications on tooth movement have been studied.
Prostaglandins are important mediators in tooth
movement and it has been suggested that the use of
over-the-counter NSAIDs can affect the efficiency of
tooth movement. A study to determine the effect
of aspirin, acetaminophen (paracetamol) and ibuprofen
on orthodontic tooth movement in rats showed acetaminophen did not affect movement whereas there was
a significant difference between the control group and
the aspirin and ibuprofen group. The authors suggest
paracetamol may be the analgesic of choice in orthodontic patients.102 Their results suggested that NSAIDs
reduce the number of osteoblasts by inhibiting prostaglandin synthesis. This led to the use of cyclooxygenase2 inhibitors (COX-2) drugs, but the effects of these
drugs on tooth movement can be very variable. The
effects of three different COX-2 inhibitors on tooth
movement in Wistar male rats showed that tooth
movement was inhibited in rats treated with
Rofecoxib. There was, however no significant difference
in tooth movement between the control group (saline)
and the other two COX-2 inhibitor groups; Celecoxib
and Parecoxib.103 Fortunately rofecoxib is now withdrawn from the market due to its cardiotoxicity.
Orthodontists should be aware that products from the
same class of drugs may have varying effects on
orthodontic tooth movement.
Corticosteroids
These drugs are used for many inflammatory and
autoimmune diseases. There are two main issues to
consider when patients present with a history of
corticosteroid use. Firstly, the use of supplemental
steroids prior to dental surgery in patients at risk of
an adrenal crisis is a contentious issue. The theoretical
basis to this practice is that exogenous steroids suppress
adrenal function to an extent that insufficient levels of
cortisol can be produced in response to stress, posing the
risk of acute adrenal crisis with hypotension and
collapse. The UK MHRA (Medicines and Healthcare
Products Regulatory Agency) and CSM (Committee of
Safety of Medicines) together published recommendations in which appear not yet to have been superseded,
that include ‘Patients who encounter stresses such as
trauma, surgery or infection and who are at risk of
adrenal insufficiency should receive systemic corticosteroid cover during these periods. This includes patients
who have finished a course of systemic corticosteroids of
less than 3 weeks duration in the week prior to the
stress. Patients on systemic corticosteroid therapy who
are at risk of adrenal suppression and are unable to take
JO December 2009
Clinical Section
tablets by mouth should receive parenteral corticosteroid cover during these periods.’104
In contrast various authors have suggested modified
guidelines for the management of patients on steroid
medications.105 These authors reported on a number of
studies confirming the low likelihood of significant
adrenal insufficiency even following major surgical
procedures. Patients on long-term steroid medication
do not require supplementary ‘steroid cover’ for routine
dentistry, including minor surgical procedures, under
LA. Instead the blood pressure should be monitored
throughout the procedure with IV hydrocortisone
available in the event of a crisis.106 Patients undergoing
GA for surgical procedures may require supplementary
steroids dependent upon the dose of steroid, duration of
treatment and severity of the planned surgery.105
The second factor to be aware of is that glucocorticoid
therapy is known to affect bone turnover. Kalia and coworkers studied the effect of acute and chronic
corticosteroid treatment in rats.107 Their results indicate
that bone turnover is reduced in subjects on acute
corticosteroid treatment and increased in patients on
chronic corticosteroid therapy. The authors postulated
that it may be wise to postpone orthodontic treatment
on patients on acute doses. They also suggested that
orthodontic forces should be reduced and checked more
frequently in patients on chronic steroid treatment.
Medical disorders and orthodontics
13
The risk of side effects is greater if the dose is
administered intravenously and on a long-term basis.109
Symptoms and signs of ONJ may include pain,
swelling, pus formation, paraesthesia, ulceration of soft
tissue, intra-oral or extra-oral sinus tracts, loose teeth
and exposed bone.110
The pathogenesis of BP associated ONJ is not fully
known. One suggestion is that hypodynamic and
hypovascular bone is unable to meet an increased
demand for repair and remodelling due to physiological
stress (mastication), iatrogenic trauma (tooth extraction) or due to odontogenic infection. This can be
exacerbated by the following factors:
N
N
N
N
N
N
N
N
N
corticosteroid treatment;
chemotherapy;
medical co-morbidities such as diabetes mellitus;
the presence of dental disease;111
dental extractions;
oral bone surgery;
poorly fitted dental appliances;
smoking;
alcohol abuse.
Radiographic signs include widening of the periodontal
ligament space at the molar furcation areas and mottled
bone consistent with osteolysis.111
Orthodontic considerations in patients taking BPs
Bisphosphonates (BPs)
N
These drugs are commonly prescribed to manage
osteopenia and osteoporosis or to treat hypercalcaemia
caused by bone metastasis in cancer patients (see
Table 2). About half of the BP that is resorbed is
excreted unchanged by the kidneys; the remainder has a
high affinity for bony tissues and a reported half-life of
10 years. BPs inhibit the resorption of trabecular bone
by osteoclasts and hence preserve bone density.
Although their medical benefits have been proven, there
are increasing numbers of side effects that can affect
orthodontic treatment including delayed tooth eruption,
inhibited tooth movement,108 impaired bone healing,
and BP-induced osteoradionecrosis (ONJ) of the jaws.
Table 2
Amend the medical history form to identify patients who are
taking BPs.112
N
Orthodontic treatment can only be considered after discussion
with the patient’s physician and other medical specialists they
may be under the care of. Ascertain why the patient is on BPs.
Assess the risk of osteoradionecrosis via the route of
administration, duration of treatment, dose and frequency of
use.113
N
If possible treatment should be carried out prior to BP
treatment.
N
In patients at high risk of ONJ, it may be better to accept the
malocclusion and consider the benefits of cosmetic
dentistry.114
Commonly prescribed bisphosponates, brand names and dosage.
Mode of administration
Common third generation bisphosphonates
Dosage
Oral bisphosphonates – osteoporosis, Pagets disease, osteogenesis
imperfecta
Alendronate (Fosamax, Merck)
Risedronate (Actonel, Aventis)
Ibandronate (Boniva, Roche)
Pamidronate (Aredia, Novartis)
Zoledronate (Zometa, Novartis)
70 mg per week
35 mg per week
2.5 mg per day
90 mg per month
4 mg per month
IV bisphosphonates – cancer
14
Patel et al.
Clinical Section
Orthodontic considerations in patients taking BPs
Discontinuing the drug prior to treatment may not be effective
because of its long half life (risedronate, 480 h; alendronate, 10 years
z; pamidronate, 300 days; zoledronate, 146 h).115
N
N
Orthodontic considerations in patients with DIGO
N
N
N
A non-extraction approach is preferred in case treatment has to
be terminated due to medical problems or exacerbation of the
DIGO.76 Additionally, space closing mechanics including
nickel titanium closing springs, elastomeric power chain or
active ties can impinge on the hyperplastic gingival tissue.
Archwire loops could have a similar effect and be displaced
buccally, altering the direction of force.76
The clinician should look for signs of ONJ and the patient
Some clinicians suggest that one should try to avoid invasive
laser therapy or temporary anchorage devices in treatment
plans;112 however a recent study of implants placed in 61,
female patients taking oral BPs for longer than 3 years,
revealed no untoward postoperative sequelae. This suggests
that patients who take oral BPs are no more at risk of implant
or temporary anchorage device failure than other patients.
Treatment should be aimed at reducing the risk of DIGO
occurring or at least preventing the DIGO worsening. The
recurring message is to ensure patients have excellent oral
hygiene in order to reduce the risk of DIGO.117 A rigorous oral
hygiene programme should be instigated from the outset and
reinforced during treatment.
should be advised to have regular dental check-ups.
N
Patients at risk of DIGO require a team approach with the
patient, his or her physician, GDP, periodontist, hygienist and
the orthodontist.76 Early liaison with the patient’s physician is
recommended to investigate whether an alternative drug can be
prescribed.
Patients on oral BPs are at a lower risk of ONJ or osteoclastic
inhibition. Patients should be counselled about inhibited tooth
movement, ONJ and impaired bone healing with elective
surgery procedures. If orthodontic treatment is indicated, it
should be planned to minimize risks including a non-extraction
protocol favouring interproximal stripping to limit the
treatment time and the degree of tooth movement and so
treatment can be discontinued early if needed. Informed
consent should outline all the risks associated with
orthodontics and BPs.113
JO December 2009
N
Small low profile brackets are recommended and the excess
composite around the margins should be removed. Bands
should be avoided if possible as they have been associated with
significantly more gingival inflammation than bonded
molars.119
N
Essix based retainers should be relieved around the gingival
margins to maintain alignment. Bonded retainers should be
avoided in patients at risk of DIGO.76
Drug induced gingival overgrowth (DIGO)
DIGO affects a proportion of patients on medication
for hypertension, epilepsy and the prevention of organ
transplant rejection. The clinical signs can vary in
severity from minor overgrowth to complete coverage
of standing teeth. These effects are compounded by poor
oral hygiene but can occur in the absence of plaque.116
Drifting of teeth can also occur resulting in further
aesthetic and functional problems for the patient.78 The
main drugs that cause DIGO are phenytoin, cyclosporine and calcium channel blockers including nifedipine,
diltiazem, and amlodipine.78
There are a few alternatives for reducing gingival
overgrowth.117 One possibility is to have the patient
placed on a different drug. There is usually spontaneous
regression of the gingival hyperplasia provided the
oral hygiene is excellent.118 Non-surgical techniques
can limit the occurrence of DIGO, reduce the extent of
plaque-induced gingival inflammation and reduce the
rate of recurrence. In some patients, however the drug is
critical to control either their epilepsy, transplant,
cardiac condition. In these cases intensive periodontal
treatment with excision of the hyperplastic tissue is
necessary.
Allergies
Two key allergic reactions have been described in the
literature. Type I hypersensitivity reactions are an
immediate antibody mediated allergic response, occurring within minutes or hours after direct skin or mucosal
contact with the allergen.120 This reaction ranges from
contact urticaria to full-blown anaphylaxis with respiratory distress and or hypotension.
A delayed hypersensitivity reaction (Type IV) usually
presents with localized allergic contact dermatitis. It
presents with diffuse or patchy eczema on the contact
area and may be accompanied initially by itching,
redness, and vesicle formation. The reactions are not life
threatening but can cause permanent damage if not
treated. The face, especially the lips and mouth, is more
commonly affected in dental patients who develop a
latex allergy.
Orthodontic staff should be trained in how to deal
with an anaphylactic shock. Figure 1 illustrates the
sequence of steps that have been outlined by the
Resuscitation Council (UK).121
JO December 2009
Clinical Section
Medical disorders and orthodontics
15
Figure 1 Anaphylaxis treatment algorithm – adapted from Resuscitation Council UK guidelines 2008
Nickel
Orthodontists are sometimes required to treat patients
with an allergy to nickel and nickel is present in a
number of orthodontic materials, notably nickel titanium (Ni–Ti) archwires. The nickel in stainless steel (SS)
is thought to be tightly bound to the crystal lattice of the
alloy making it difficult for it to leach out.
The immune response to nickel is usually a type IV cell
mediated delayed hypersensitivity reaction. The first
phase or sensitization to nickel is increasing with the
increasing use of jewellery containing the metal. The
prevalence of nickel allergy is estimated 11% of all
women and 2% of men.122 Re-exposure to nickel can
results in contact dermatitis or mucositis and develops
over a period of days or rarely up to 3 weeks.123
Fortunately most individuals with nickel allergy do not
report reactions to orthodontic appliances containing
nickel. A study by Bass and colleagues of 29 subjects (18
female and 11 male) revealed an initial positive skin
patch test to nickel sulphate in five female patients
only.124 All 29 patients were followed over their fixed
appliance treatment. None of the subjects including the
positive test patients demonstrated an inflammatory
reaction or discomfort as a result of orthodontic
treatment. It is postulated that a much greater
concentration of nickel in the oral mucosa than the
skin is necessary to elicit an immune response. Nickel
leaching from orthodontic bands, brackets, stainless
steel or Ni–Ti archwires has been shown in vitro to occur
within the first week and then decline thereafter.125 Oral
fluids, certain foods and fluoride media can corrode and
accelerate the leaching process.126 Concerns about
sensitising orthodontic patients to nickel are not
supported by the literature but there are a few case
reports of localized allergic responses attributed to
nickel containing orthodontic appliances.127,128
Oral clinical signs and symptoms of nickel allergy can
include the following: a burning sensation, gingival
hyperplasia, angular chelitis, labial desquamation,
erythema multiforme, periodontitis, stomatitis with mild
to severe erythema, loss of taste or metallic taste,
numbness, soreness of the side of the tongue.128
Orthodontic considerations in patients with a nickel allergy
N
N
A dermatologist should confirm a true nickel allergy.
Patients with a defined history of atopic dermatitis to nickel
containing metals should be treated with caution and closely
monitored during orthodontic treatment.129
N
In patients with diagnosed nickel hypersensitivity and where
intra-oral signs and symptoms are present the orthodontist
should replace Ni-Ti archwires with one of the following:
# stainless steel archwires with a low nickel content;
# titanium molybdenum alloy (TMA) which is nickel
free;
# fibre reinforced composite wires;
# pure titanium or gold plated wires.
16
Patel et al.
Clinical Section
Orthodontic considerations in patients with a nickel allergy
N
If the allergic reaction continues, all SS archwires and brackets
should be removed. If the allergic reaction is severe the patient
should be referred to a physician. Alternative nickel free
bracket materials include ceramic, polycarbonate, titanium and
gold.129 Fixed appliances may be substituted with plastic
aligners in selected cases.
Orthodontic considerations in patients with latex allergy
N
N
Pre-diagnosis
N
If a reaction to latex is suspected, patients should be referred to
an allergist, clinical immunologist or dermatologist for
testing.
Post-diagnosis
N
The orthodontic team including radiographers should be aware
of the implication of treating latex allergy patients.
Latex free goods should be stored in a ‘latex-screened’ area to
avoid prior contamination with latex products.
Latex allergy
Orthodontic considerations in patients with latex allergy
The goal is to significantly reduce exposure to patients
routinely. This can be done by cleaning the surgery more
frequently with a protein wash, cleaning or changing the air
filter more regularly.132
N
The increase in allergic reactions to natural rubber latex
over the past two decades has been accredited to the
increased use of latex based gloves and universal
precautions. Disposable medical gloves, particularly
powdered gloves are the main reservoir of latex
allergens. Orthodontic elastics used to apply intermaxillary forces are another potential source of the
latex protein. Both type I and type IV hypersensitivity
reactions can occur. The prevalence of potential type I
hypersensitivity to latex is lower than 1% in the general
population and between 6–12% among dental professionals. For the purpose of this review only risks to
patients will be discussed.
Patients at risk of allergy are those with a history of
atopy such as hay fever; asthma; eczema; contact
dermatitis and those with spina bifida.130 Allergies to
certain fruits such as banana, avocado, passion fruit,
kiwi and chestnut can also indicate a potential latex
allergy. They have proteins that are capable of crossreacting with latex proteins and hence help sensitize the
person to latex.131
Clinical tests, of which the skin prick test is considered
most accurate, can determine the presence of circulating
antibodies to latex. Multiple testing is recommended for
increased accuracy of diagnosis.
Definitive diagnosis should be based on the medical
history, and a positive skin reaction to specific chemicals
present in natural rubber latex.
JO December 2009
Patients with a diagnosed allergy can be offered early morning
appointments to reduce the exposure to airborne latex
particle.
N
The diagnosed patient should be monitored for signs of adverse
reactions. The team should be capable of instigating prompt
emergency care.
N
The emergency drugs and resuscitation equipment should be
free from latex.133
Latex free orthodontic materials
There are a number of latex free alternatives to commonly used
orthodontic materials. Natural rubber latex is found in gloves,
elastics, separators, elastomeric modules, elastomeric power chain,
polishing rubber cups, band removers and masks with latex ties.
N
Synthetic non-latex gloves made from nitrile, polychloroprene,
elastyren and vinyl, are readily available for clinical use. Both
latex free and latex gloves have to meet the European standard
for single use medical examination gloves.
N
Russell and coworkers reported that latex free elastics
demonstrated greater hysteresis than latex elastics (40% force
decay compared with 25% over 24 h).134 The range of forces
produced by the non-latex elastics was larger in vitro, but this
difference was not deemed to be clinically significant.
N
Elastomeric separators can be replaced with self-locking
separating springs.132
N
Manufacturers can provide alternatives such as latex free
power chain, ligature chain, rotation wedges, headgear
components, and masks. It is wise to check with retailers that
the product they are marketing is latex free.132
Eating disorders
The most common eating disorders are anorexia nervosa
(AN) and bulimia nervosa (BN). Eating disorders are
more common in females and generally have their onset
during the teen years but often continue as a chronic
illness. AN is an important cause of mortality in
adolescent females. Patients with AN have a combination of body image distortion and restricted eating.135
Binge eating and purging are also characteristics of BN.
JO December 2009
Clinical Section
Patients with eating disorders rarely present with
problems of compliance. Oral manifestations of eating
disorders include dental caries, erosion, dentinal hypersensitivity, salivary gland hypertrophy, raised occlusal
restorations and xerostomia.136
6.
7.
Orthodontic considerations in patients with eating disorders
N
The orthodontist is likely to notice these features and should be
suspicious of these illnesses and deal with them sensitively.137
The first referral should be to the patient’s physician. However,
it is important to maintain confidentiality and gain consent.138
Referral to another healthcare professional, such as a physician
may be a breach of confidentiality if the patient did not give
their consent. These patients are less likely to discuss their
illness as they tend to be embarrassed and secretive.
N
8.
Diet advice is vital as this cohort of patients may drink an
excessive quantity of acidic or carbonated drinks to as an
alternative to normal food.139
N
Patients should be counselled not to brush their teeth
9.
immediately after vomiting. They should be given advice on
how to increase the intra-oral pH by chewing gum, or rinsing
the mouth with water or milk.139
Summary
Orthodontic treatment is an elective procedure and
clinicians should consider all the treatment options to
ensure a satisfactory risk-benefit ratio for each and every
patient. Comprehensive treatment may not always
benefit the patient. Treatment should where appropriate
be postponed until the medical problem is in remission
or the side effects of the drug therapy are minimized.
Patients should always be involved in the treatmentplanning phase so that true informed consent can be
obtained.
10.
11.
12.
13.
14.
15.
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