ORTHODONTI C TREATMENT IN SYSTEMIC DISORDERS

As ho k C Mas hru MOS.

Pri va te pra ctice,
Bhavnagar 364001 Cuja ra l, In dia

Abstract Often an orthodontist ca n have a patient with a complicated chro nic system ic disease thai needs to be considered
when providing treatment. Common systemic problems encountered frequently in o rthodontic practice in India
include infective endocarditis,childhood diabetes, bleeding disorders like hemophi lia, hematologica l
malignancies, rheumatoid arthri tis, sickle·cell anemia, bro nc hial asthma and c hro nic renal failure. for the
majority, treatment of orthodontic problems is feasible, but special precautions usually are required . As
endocarditis is a life threatening disease, importance and indications for antibiotic prophylaxis is described . In
patients receiving ch emotherapy for hematologica l malignancy or h aving kidney transplant, resistance to
infection is decreased . So mucosa l irritation must be avoided and periodontal hea lth sh ou ld be constantly
ch ecked . In sickle-cell disease, rest interval sho uld be m o re to resto re microcirculation during tooth movement.
In asthma care should be taken to avoid allergic brochospasms while orthodont ic treatment. With appropriate
management, successfu l orthodontic treatment can be done for most patients. Thus an orthodontist can playa
posi tive roll in chro nica lly ill patient'swell-being.

Keywords system ic disorders, medically-compromised patient.

introdu ctio n : Systemic proble m s commonly encountered in ro utine

orthodon tic practice are:
T h e nature of the o rtho d o nti c pati ent base co ntinues to
grow, and the practicing o rth odontist is now inc reasingl y 1 . Endoca rditis
c h alle nged to assist in the diagnosis and manage ment of
2. Diabetes
p a tie nt with unusu al m edi ca l require m ents. While
orthod o ntic th erapy h as b ee n histOri ca ll y con sidered to 3. Bleed ingdi so rders
be co mpl e te ly n o ninva sive, specifi c orth odo nti c
4. H aemato logical malignanc ies
procedures m ay p lace so m e patients a t ri sk for se riou s
!>equelae. It h as been estimated that 10-15 p e rce nt of 5. Sickle ce ll an emia
chi ldren under age of 16 years are affected b y system ic
1 6 . Juve nil e rh eumatoid arthritis
long- term disease .Chro nic disease presents soci al and
emotional c hallen ges to the p atient and his/h er family. It 7. C hron ic Renal failure
has been also shown tha t con spi c u o us incisa l crowding
B. Bronc hial asthma
or spacing l ike midlin e diastema re presented a socia l
l
disadvantage co mpared to normal tee th . Orthodontic Endocarditis
treatme nt in systemica lly co mpromised pati ent c an
Endoca rditi s is a life t hreatening di sease, alt.hough it is
b e nefi t ove rall psycho logica l outcome along w ith o th er
re lative ly unc ommon in India. In one study th e number
m edi ca l trea tme nt.
o f children hosp italized with infective endoca rditis was
An o rth od o nti st who is trea ting m edic all y ill patie nt re ported 0.55/ 1000 h osp ital admission ). Substantial
.. hould be awa re of basic nature of syste mic disease and morbidity a nd mortality ca n result from this infection
it~ co nsequ en ces. Treatment plan sho uld b e modified despite ad va n ces in antimic robia l c h emothe rap y. As
ilccording to impact of the parti c ular disease in the o ral diagnosis of endocarditis is diffic ult to co nfirm,
cavity. Thus an o rthod o ntist ca n b e a positive part of th e preyention of e ndocarditis is very important. N owadays
hea lth ca re team and ca n support a family in c risis. d iagnos is of IE requires integration of clini ca l, laboratory
and ech ocardiograp hic data. A specific and hi ghl y
Th e purpose of this article is to review some commonly
se n sit.ive diagnostic sch em a known as th e Duke
occurring syste mi c di seases and various di sease
crite ria has b een develo p ed to assistdiagnos i s.~
processes and to he lp produ ce guidelines that are
prac ticable fo r o rthodo ntists faced with a child who has
::.y::.t£'mic disease and requests orthodontic treatme nt.

133
 O rthod o nti c procedur es , ri s k of d eve lo pin g
e ndoca rditi s a nd a nti biotic pro phy laxis :
Accord ing to recen t guidelines pub lished by A m e rica n
Heart Associatio n, ca rd iac co nditio n s associated w i th
t he h ighest risk of ad ve rse o utco m e fro m e nd oca rd itis
for w hi ch pro phy laxis is requ i red w ith d e ntal procedures
are 5 ~
Prosthetic ca rd iac va lve
Previous in fective e ndoca rdi tis
Congenital hea rt d isease (CHD)
U nrepai red cya no tic C H D, in cl udi ng pal li ative sh u n ts
and conduits
Completely repai red c o ngenital heart d efect wi th
prosthetic m ateri al or device, w heth e r pl aced b y surgery
or b y ca th eter interve n tio n, during the fi rst six m o nths
after th e procedure.
Repai red C HD w it h res idual defects at the site or
adja cent to th e site of a prosthetic p atch o r pro sth eti c
devi ce (which inh ibi tendothe li aliza li o n ).
Card iac tran sp lantati o n recipie n ts w h o d eve lo p ca rd iac
va lvu lopa th y.
America n H ea rt Assoc iatio n recom m e nds that antibioti c
p rop hy laxis sh o uld be given, in all ca rd iac patie n ts wi th
th e highest risk o f IE men t io ned befo re, in all denta l
p rocedures that in vo lve m an ipu lati o n o f gingiva l ti ssue
o r the pe riap ical regio n of teeth o r perfo rat io n o f the o ra l
mu cosa? Th ey d o n o t reco mme nd p roph ylax is at t he
p laceme nt of re m ovable orthodo n tic appli ances,
adjustmen t of orth odont ic ap p liances, p lacem e n t of
orthodontic brackets, and b leed ing f ro m trau m a to the
lips orora l mucosa.
T he Bri tish Soc iety fo r Antimic ro bi al C he m othe rapy has
given draft for con sultation rega rding cl inica l guidel ines
ll
for t h e p reve n tion of e n do ca rd i tis Nowadays
prophylaxis is no t recommended so lely o n an increased
lifetime risk of acqu isi ti on of in fecti ve endoca rditis. Th is
group now recomme nd s prophy lax is be fo re d e nta l
procedures o n ly fo r pati en ts w ho h ave a hi story o f
previo us IE o r w ho h ave had ca rd iac va lve re place m e nt
or surgical ly con stru cted pu lm onary shu n ts o r conduits.
A ll denta l pr ocedures i n vo l v in g
d en togingival m anipu lati o n s sho uld be SITUAT10N
9
given coverage o f an ti biotics In t hese
guidelines t hey d o n o t m ake any speci fic
recomme nd at io n s abo ut th e use of
Al le rgic
antibiotic pro phy lax is p ri o r to o rth od o ntic Peni ci UiM or
band fi tt ingor re m ova l. Ampi c illin
an.
Au st rali an De ntal Jo urnal reco mm e nds
antibiotic prophy lax is during initial place m ent of
1
o rth o d o nti c ba n d s !) A ntibi o ti c pro ph y laxis is not
necessary in p lacem e nt of orthodonti c devices and
adju stme nt of th e sa m e.
Infective e ndoca rditi s, orthodontic tr eatm e nt a nd
bacte raemia :
Th e p reva lence and m agnitud e o f bacte raem ia of ora l
o rigin are d irectly p ro p o rtio nal to th e degree of oral
i nflammation p rese n t. In o ne study, it has b een rep o rted
th at sixty fi ve percent of o rth o d o ntists i n A m erica use
an tibio ti c pro phy lax is during band fitting and thirty five
11
percen tages during re m ova l The re are te n perce nt
c hances o f in ci d e nc e o f bacte raem ia w he n m o lar band s
ll
are fitted A case h istory of an end ocard itis pa t ient
showed th at th e o nl y t reatme n t, d o ne in last six mon th s,
11
was adjustmen t of o rth od o ntic appl iances In a se pa rate
stud y of bacterae m ia at d ebanding and d ebo ndi ng,
bacterae m ia was fo und in 6.6 per ce nt o f th e to tal
1
patien t's studi ed •
T he em ph aSiS for e ndocarditi s ca usa ti o n has now sh ifted
from procedure -related bacterae mi a to c umulati ve
bacterae mia . T hi s was exte nded i n a theo retical stu dy o f
cumula ti ve bacte raem ia ove r 1 yea r w h ic h p ostLJlated
that 'everyd ay' bacte re mia is six mil lio n t i mes greater
t han bacterae m ia fro m a single ex tractio n "· 1 ~ A n y
ba ct eraem ia occurring during n o nin vasive den ta l
treatm e nt th erefore d oes n o t sign ificantly i nc rease the
ri sk of e nd oca rditi s.
Orthodontic cons ide ration s:
1. Any ca rd iac patho logy sh o uld be evalua ted in
ini tia l m edica l h istory. Pati en ts at ri sk of endoca rditi s
sh o ul d be treated i n co nsu ltati o n w ith thei r card iologist
and w ith i n t he appro priate guid el ines. A ntib io tic
p ro ph ylax is w i ll be req ui red for in vasive procedures
w h ich in vo lves m u cogin g iva l a ndl o r pe ri ap ic a l
m anipulati o ns such as extractio n s, sepa ratio n, ba nd
place m e nt an d ba nd re m oval. A ntibiot ic prop hylaxi s
shou ld be given if ging iva l adjacen t to th e ba nds is
infl amed and pati ent isat hi gh ri sk level o f ca rd iac les ion .
Recomm en d ed single dose fo r patient w h o can take
m edi cin e o ral ly is as fo llows"
AGENT (S i~l e dose:30· 60 ADULTS CHILDREN
ninutes befo re procedure)
Amoxycillin 2 g nlflll'i 50
milligrnl11§/kg
to Ceplwexi n 2g 5 0 onw1<g
OR
O indamycin 600"1l 2 0 ntglkg
OR
Az ithrom'l.'cinfClaridu1)(uvc in 500_ I S m l!l1u!
134
2. Immaculate ora l hygiene is must for starting
o rth odontic treatment. It has been suggested that pri o r
to an y orthodontic procedure a 0.2 pe rcentage
ch lorhex idin e mouthwash sh ou ld be u sed '''·17 During
treatm ent , orth odo ntist shou ld be particu larly vigi lant
lor an y deterioration in gingival hea lth . Bonded
dtlachment should be u sed avoiding band ed
attachments. Finally, the patient shou ld give a clear
commitm ent to 'maintain a very high standard of oral
clean liness'. T he patient sh o uld herlhi m self sign an
appropri ately word ed statem e nt to that e ffect in th e
pati ent's clini ca l record .
3. In case of surgi ca l ex posure of un erupted tooth ,
it sh o uld be exposed and direct trac ti o n should be
appli ed . Use o f bonded attachm ent w ith closure of
mucoperiosteum is contra -indicated ' &
4. Th e patient and famil y sho u ld be ful ly involved
in th e con sent process fo r antibiotic prophylaxis. The
potentia l ri sk of contrac ting bacterial endoca rditis need s
to be ex plained to th e family'·
Diabetes
Diabetes mell itus affects peo ple of all ages. A cco rding to
one stud y d o ne in south ern Indi a, p reva lence o f
diabetes (childhood) amo ng those younger than 1 5
lO
yea rs wasO.26/1 000 patients
Diabetes m ellitus (OM) is a metabolic di sorde r of di ve rse
etiologic fa c to rs, chara c te ri zed by h y pe rglycemia
rc!> uiting from d eficienc ies in the insu lin secretion,
insulin aclion or bo th . It has two types . Type 1 OM th e
cause is an absolute defi ciency of insulin secretion . Type
1 OM is the most common endocrin e m etaboli c
di!>ord er of childhood and adolescence with a peak
incidence at 10-14 years o f age. The c ause of more
prevalent type 2 OM is a combination of res istance to
insulin action and an inadequate compen satory insu lin
!>ccrctory response.
For professiona ls the m ethod of ch o ice in m o nitoring th e
trea tment of OM is the d etermination of the glycosylated
he m oglo bin c once ntraLi o n (HbA 1 c). There is a lin ear
rise in HbA 1 c as th e b lood sugar increases i n OM
pati ents"
Ora l manifestations are mainly found in patie nts while
OM is un co ntrolled or poorl y co ntrolled . Several studi es
have shown that gi ngiv iti s is more seve re in children with
OM. Even in wel l co ntrolled OM pati ents have more
gi ngiva l inflammati on, probably bec ause of impaired
neutrophil (un ction U11
135
Orthodo ntic con sideratio n s:
1. The key for treating orthodonti c problem s in
diabetic patients is good m edica l control. If patient is n o t
in good m etaboli c co ntrol (HbA 1 c m o re than 9%). every
effort should be mad e to improve blood glucose control.
O rthodontic treatme n t shou ld be avoided in pati en ts
with poorly co ntrolled Insulin -depe nd ent OM as th ese
pati ents are partic ularly susceptible to pe ri od o ntal
breakdown. There is no upper age limit fo r orthodontic
treatme nt. The practitione r c an treat both type 1 and
11
type 2 OM patie nts
2. There is no trea tm ent preferen ce with rega rd to fi xed
or re movable appliances. It is important to stress good
hygi ene, especially when fixed appliances are used.
Dail y rinses with fluo rid e mouthwash can provide
further be nefits. Diabetes related microa ngi opath y ca n
occasiona ll y occur in the periapi al vascular supply
res u l ting in un ex p lained odontalgia , p e rc u ss ion
sen sitivity, pulpitis or even loss of vita lity. Orthodo ntist
sho u ld be awa re of this ph enome non and regular vitality
c heck ups are advised l~
3. In adu lts especia ll y it is important to eva luate
pe riodonta l statu s b e rore initiating orthodonti c
treatment. If p laque control is difficult to achieve with
m echanica l aids like too thbrush and interdental aids,
ch lorhexidine mouthwash sh o uld be used . To minimize
neutrali zing effect o f th e c hl o rhex idin e molecule, the re
shou ld be at least a 30 minute interval between tooth
b rush ing and the c hlorhexidi ne rin sel~
4 . Morning appointment is pre fe rable. It a pati ent is
scheduled for a lo ng treatment session e. g. about 90
minutes, he or she sh o uld be advised to eata usua l m ea l
and take the m edic ation as usual. Thi s is important to
avoid h y poglycemic reaction ?) Whe n a hy poglycemic
rea ct ion occurs in t he dental offi ce, th e orthodonti st
sh o u ld recognize the symptoms and act appropriate ly.
M ost patients are familiar with these sy mptom s and can
te ll orthodontist in time. The coopera ti ve and con scio us
pati e nt who d e m o n strates clini ca l symptoms o f
hypoglycemia should be given high ca rbohydra te
beverage suc h as orange juice. M anage m e nt of the
unco nscious pati ent incl udes airwa y mainte nance,
oxyge n administration and monitoring of vital signs.
5. Children with diabetes are at nutritional ri sk and
should undergo nutritio n scree ning to identify those
w h o reqU i re fo r m a l nutrition assess ment with
16
development of a nutritio n ca re plan
Juvenile rheumatoid arthritis
Juve nile rheumatoid arthritis ORA) is an inflammatory
arthritis occurring be fore th e age of 1 6 yea rs. Juvenile
rheu m atoid arthriti s is more seve re t.h an the adult
disease and lead s to gross d eformity. In o ne study in
India, preva lence of rheumatic fever was 0 .09 pe rcent.
Incid e nce of arthritis was observed in 75 pe rce nt of the
total pati ents affected by rh eumatic infection 27
One form of thi s disease wh ic h affects gi rls in late
childhood may involve any jo int and is associated with
rh eu m atoid nodul es, mild f eve r, a n e mia and
m a la ise. Te mporomandibul ar jOint (TMJ) ca n b e
d amaged up to co mplete bony ankylosis. In 3 0 pe r ce nt
o f the cases a severe skeletal class It jaw discrepancy
occurs due to restricted growth of the mandible 2ft·Classic
signs o f rhe umatic d estructio n of the TMJ include
29
condy lar flattening and a large joint spa ce
It has been suggested that o rtho d o ntic trea tme nt for
pati ents with JRA w ou ld preve nt worsening o f TMJ
condition b y redu cing m echani ca l loads resulting from
stabi lizati o n of occlusion. This co ntributes to long-term
stabi lity with a fu nctional improvement30·
Orthodontic consideratio n s:
1 . Rega rd ing load on TMJ in rhe umatoid arthriti c
patients receiving o rth od o nti c trea tm ent, th ere are
differe nt opinions. Proffit et al have suggested that
orthodontic procedures that place stress on the TMJ,
suc h as functional appl iances and heavy class It elastics,
shou ld be avoided if TMJ is involved in rheumatoid
arth ritis}9. Burden et al con side red use of headgea r in
21
m ode rate mandibul ar d efici ency pat ien ts On the
other hand, Kj ellbe rg et al suggested that functiona l
appli ances may unload th e affected co nd yle and act as a
" joi nt protector',l l.
2. If the w ri st jOints are affected these patie n ts have
difficu lty w ith too th brushing. Th ey require additional
suppo rt from a hygie nist during their orthodontic
treatme nt and th e use of an e lectri c toothbrush should
be co n sid ered . Sugar-free m edic ines should be
preferred to minimize ca ries.
3. It has been suggested that in cases of seve re
m and ibul ar d efici ency, mandibular surgery shou ld be
avoid ed and a more con servative approach using
m axi ll a ry surge ry a nd geniop l asty should b e
co nside red )}·
Bleeding disorders
H emophili a A is the m ost co mmonl y occurring b leeding
di sorder comm o nly encountered in d e n ta l cl ini c. In
addit io n he mophilia A (Factor V II I d efi ciency), a number
136
of co ngenital coagu lation abnormaliti es ca use by
d efi Cie n cy of othe r clotting factors have been
recogni zed.
It has been estimated that 1 300 c hildre n with
hemophilia a re born each yea r and there are nearly
5 0000 pati en ts with seve re hemophi lia A in the yea r
2000 in Indian ·Pati ents w ith mi ld b leeding di sorders do
not usua lly prese nt d iffi culti es to the orthodontist. As
occu rren ce of the malocclusio n in the childre n is similar
to th e rest of the popu lation and the long term o utlook is
goo d , orthodontic treatme nt is not contra-indicated.
Two m ain areas to be con sidered in treatment o f these
pati ents are chan ces of iatrogen;c vi ral infection and risk
of b leeding during extraction. M edical treatm ent of
choice in b leed ing d iso rde rs is admini stration of va ri ous
facto r concentrates. Co ncentrates are d e rived from
human blood donations. They ca rry a small risk of
tran smitting se ri ous transfusion derived v iral infections
like hepatitis B, C and HIV.
If extraction s are required as a part of o rthod o ntic
treatme nt, most pati en ts with m o d erate to seve re
hemophilia A are submitted to factor V III co ncentrate
infusion befo re extractions. The recent introduction of
genetica lly manufa ctured factor V III products has
redu ced the ri sk of v iral tran smiss io n in this age group19·lf
tooth extraction or othe r surgery like exp osure of
impac ted ca n i ne is required in pati ents with severe
bleeding d iso rders they a re usuall y hospitalized and
given transfusio n of the miss ing clo Wng factor in
advance o f th e procedure. So w herever possible a non-
surgi ca l approac h should be adopted .
Orthodontic considerations:
1 . Exce llent oral h ygie ne is mu st for preve nting gingiva l
b leeding before it occurs. Every effort should be made to
avoid any chroni c irritatio n from orthodonti ca ppliance.
2. A rch w ires should be secured with elastomeric
modules rathe r than wi re li gatures, whi ch ca rry the risk
of c utting the mucosa l surfaces. Special ca re is required
21
w he n placi ng and remov ingarchwires .
3. Durati o n of orthodonti c treatment fo r any pati ent
with a bl eeding di sorder should be given ca refu l
con side ration . The lo nger the duration of treatme nt,
12
greate r the potential forcomplications
4. Bleeding ca n be managed by re placem e nt of miss ing
cl otting facto rs, so extrac tions a nd orthognathic surgery
9
is not contraind ic ated if managed ca refull 1
He m a to logica l m a lig n an c ie s
In India more than 40 percent pediatric ma lign an c ies
arc h emato logical e ith er leukemia or lym p ho m a.
Leukemias account for 30 p e rce nt o f all c hi ldhood
malignancies}~
Ac ul e l e uk e mia include s two ty p e s: Ac ute
lymphoblastic leukemia (75-80 p e rce n t) and A c u te
no nl ymph ocytic leukem ia (1 5-2 0 perce n t).
C hronic m yelocytic leukem ia acco u nts for 5 p ercent o f
all chi ldhood mal ignancies.
Ly mphomas include H odgk in 's lym ph o m a and
non H odgkin 's lymphoma. Both accou nt fo r 10 p er cen t
wilh equ al inc idence.
Befo re diag nos is:
O ro pharyngeal lesion ca n be t he in itia l signs in 10% of
acule leukemia . In the abse n ce o f loca l c au sative factors,
o rth odonti st sh o u ld be susp iciou s o f patients w h o
pr ese nt w i th gingiva l ooz in g, p ai n o r
h yp ertrophy, p h aryngiti s an d lymp had e n opathy15 In
sLic h cases prompt refe rra l to a ph ys ic ian is n ecessary to
excl ude he m atologica l m al ignan cy.
Aft e r Dia gnos is:
In m ost cases o rthodontist w ill see a pa tient w h o h as
a lr eady b ee n diagnosed wi th a h ema to log i c a l
m align an cy. Those rece iv i ng c h emoth erapy h ave an
i nc reased potential for infecti o n w hic h is th e lead in g
36
ca u se of morbidity in immu noco mpro m ised p ati e n ts
The orthodo ntist sh ou ld be awa re of t he impl ications o f
preexisting infec t io n . Deve lopi n g d ental tissu es are
pa rti c u larly se n sitive to rad iatio n . C hemorad ia ti o n o fte n
17 16
ca u ses d eve l op m e n t a l a n o m a li es · Ca r ef ul
co nsideration should be given to th e pa ti en ts h aving
seve re root shorte ning w hi le p lann ing the treatme nt.
O rlhodontic con s id e ra tio n s:
1. Ir o rthod o nti c treatment h as n ot bee n stared , it sho uld
be d e laye d unti l t h e patient h as c o m p le t e d
c he moth erap y and is o n lo n g term rem iss io n . As
()rthodontic treatm ent is an e lective proced ure, pa ti ent's
21
ph ysician shou ld be con su lted
2. Ir o rthod o nti c treatrnent has bee n already started the
ortho dontist sh ou ld conta ct the pa t ient's p h ysicia n
pos!:>ible fo r prognOSiS. A s t h e t im e o f d iagn osis of
malignancy is very st ressfu l for the p atien t and fami ly,
o rthodo nti st should b e awa re of its p sych o logica l
implications.
3. Inten se c h e moth erapy w eake ns rege n erative c ap acity
of mucosal'" M inor i rritation can lead to opportuni sti c
137
infecti o n and su bsequ ent seve re com p li cat ions. It is
ad v isab le to re m ove all o rth odon tic fixed appliances
be fo re starting c he m o th erap y as a sa fety procedure.
Pa ti en t and t h e fa mi ly may b e relu ctant to accept the
ad vice to sto p o rth od o ntic treatm e n t. T hi s is parti c ularl y
tru e if th e d e ntal esthetics is st ill poor, c rowding is
p rese nt o r extractio n spaces are open. T h is problem
sh o u ld b e h an d led sen siti ve ly. T h e orth odo n ti st should
info rm p atie nt, p are n ts, physician an d fa m ily d entist
rega rding the fact th at stop ping of th e treatment is in th e
s
best interest of th e patien e . The orthodontist should
exp lai n p a ti en t th at t h is is a te m porary situa tion on ly.
4 . A p art from sm ooth appl ian ces su ch as ba n d and loo ps
and fi xed lower lingual arch es, all fixed ap p li ance parts
sh o uld b e removed . Removab le ap p l ian ces and
retai n ers th at fit we ll m ay b e worn as long as tole rated b y
th e pa t ient w h o sh ows good ora l ca re . If b and remova l is
n ot poss ib le viny l m o u th guard s or orthodontic wax
sh o u ld b e u sed to d ecrease t issu e trauma·o
5. To cou nte r xerosto mi a during ca nce r the rapy use of
su gar free ch ewi n g gu m , ca n dy, sa liva su b stitutes,
frequ en t sip ping of wa ter, an d/o r moisturizers is
reco mme nd ed 12
6. O rtho d o n t ic trea tm en t may start o r resume after
compl e ti o n of all the rap y an d afte r at least 2-year eve nt
free su rviva l w h e n ri sk of relapse h as b ee n d ecreased
and p a ti en t is n ot o n i mmunosuppressive dru gs. A
th orou gh assessment o f an y den tal d eve lopmental
distu rb an ces ca u sed b y ca n ce r t h erap y m u st b e done
befo re in iti ating o rth o d o ntic treatmen t. Ame rica n
Acade m y of Ped iatric De n t istry recom men d s fo ll owi ng
strategy to p rovi d e o rtho d o nti c ca re fo r patient with
o
d e ntal sequ e lae·
a. A ppl ian ces th at min im ize root resorpt io n should be
u sed .
b . Li ght forcesh o uld b e u sed .
c. Treatme nt sh ou ld be term inated earl ier th an normal .
d. The simpler meth od fo r treatm ent need s sho u ld b e
ch ose n .
e. Lower jaw sh o uld notbe treated.
H oweve r sp eci fi c gui d e l i n es {or or th odonti c
m an age m e n t incl u din g o p t imu m force and pa ce rem ain
un defined .
Sic kl e - c e ll a n emi a
Sic kle-ce ll a ne m ia is d efined as a h ered itary type of
c h roni c he m o lytiC an em ia caused b y ge n etic m utation
o f th e h e m oglo bin molecul e. In one study o f
h ospitalized p ed iatri c patie n ts i n India, preva len ce of
this disease was found 5.7 percent"l The hi ghest 5. Intense orthodontic o r orthopediC fo rces such as
frequency of sickle cell gene is re ported in Orissa extraora l anchorage or max illary di stra ctio n sho uld be
followed by Assam, M adh ya Prad esh, Uttar Prad esh , managed with more ca re.
H
Tamil N ad u and Gujarat
Chroni c re n a l failure
Cl inica l m anifest atio ns of sickle-ce ll ane mia a re
Chronic renal failure (C RF) is an irreversibl e condition
extrem e ly va ri able from asymptomatic pati en ts to
th at eve ntually progress to endstage re nal fai lure. It may
patients co nstantly plagued b y painful e pisodes. The
be du e to a variety o f ca u sa ti ve factors, which lead to a
sic kle-cell anemia ma y have periods of acuteness better
loss of kidn ey fun ction . It is an important ca use of
known as vasoocclusive crisis or rec urrent painful cri sis,
m o rbidi ty and mortality in childre n worldwide . In the
origi nall y d enominated "sickle cri sis". Occurrence of this
abse nce of national reg istry in India, there is paucity of
is due to ischemi c injury to the ti ssues after the 47
inform atio n regarding preva lence ofCRF in children
obstru ctio n o f smal l blood vesse ls by th e sic kled re d
blood ce lls. Thi s occludes bloo d circ ulation lea ding to In c hildre n with ch ro nic renal failure, growth ca n be
necrosis and severe pain . Thi s lasts for 3-1 0 da ys. retarded and tooth erupti o n delayed . Earl y effect is
ename l hype rplasia due to a d efect of ename l
The orthod o nti st sh o uld know th e importance of 48
d evelopment and mine ralization
comp lete blood suppl y to whole dentitio n and b o n e
1
afte r application of intraoral and extrao ral forces·_ The o rthodonti st ca n have three types of patients with
CRF,
The increase in number o f malocclusions in patients
wi th sickle-cell disease can be re lated to mu scu lar 1 . Pati e nts with CRF and are not dialysis dependent-If
imbalance, absence of labial sea ling o r c hanges in th e th e re n al failure is ad va nced and dialysis is imminent,
osseous base" orthodontic treatme nt sh o uld be d efe rred .
Orthodontic co n s id erations : 2. Patients with CRF and o n di alysi s-If con se nt from th e
ph ysic ian is positive, the re is no contraindica tion for
1 . Because o f the di sease process, pati en ts are
orthodontic treatm e nt before the kidney transplant
com m o nly submitted to yea rl y blood repositi o n . Suc h
procedure.
procedure exposes th em to the risk of contaminati o n b y
45
blood diseases A lth o ugh o rthodonti c treatme nt is not 3. C h i ldren w ith kidn ey transplant- They o ften exhibit
contra -i ndica ted for such co ndition, necessary ca re drug- indu ced gingival overgrowth as a con sequ ence of
sho uld be take n to prevent o th er infection from t he ir lo ng term m edi ca tion (cyclosporine a nd/o r ca lcium
contaminating clinical setting, staff and the orthodontist channel antagon ists). Orthodontic app liance, espec ial ly
himse lf. fixed a pplian ces, ca n produce a dramatic response in
the gingiva l tissues eve n w hen no gingival overgrowth is
2. The clinica l appointments sh o uld be arranged during
present before the orthodontic trea tme nt.
the c hronic phase of the disease b eca u se orthodontic
procures ca n n ot be perfo rmed during pe ri od s of cri sis o r Orthodontic co ns iderations:
acuteness. In cases where painful symptoms appear
1. If gi ngival overgrowth is present, o rthodonti c
during acute crisis, the use o f acetyl sa licylic acid sh o uld
trea tm ent should be d e layed until the excessive gingival
be avoided because this drug c hanges th e platelet's
ti ssue has been successfully rem oved and patie nt can
ad hes io n ca pac ity, indu ces intestinal a nd gastri c
d e monstrate an adequate level of plaquecontrol.
ulceratio n and ca u ses frequent hepa tic lesio ns'"
2. As far as possibl e, th e treat m e nt time w ith fixed
3 . The o rth odontic shou ld pay atte ntion to the p ossible
app liances should be k eep to a minimum consiste nt
pulpal necros is involving hea lthy teeth and the changes
with a high standard of occlusal resul elOrtho dontic
in the bone turnover during o rtho donti c m ovem e nts
treatme nt should not be co mme nced until the oral
with heavy fo rces. Th ese may lead to mandibular painful
h ygien e is very good a nd the use o f 0.2 percent
ep isodes and the greater susceptibility to infections.
ch lorhex idine m outhwash is advisa bl e in these patients.
4. O rth od o ntic treatment planning shou ld be adjuste d
3. In some pati en ts recurre nce of gi ngiva l overgrowth
to resto re the regio nal mi crocirculatio n by increaSing t he
may be a probl em. Surgic al re mova l of excessive gingival
rest intervals as well as to redu ce th e move m e n ts of th e
tissue is som etimes necessary during o rthodontic
teeth and the fo rces applied on th em . Elective surge ries,
treatm ent . The patient and pare nts should be warned of
such as the extraction o f asymptomatic teeth for
lhi s in advance.
orth od o nti c indi catio n , are c ontra- indicated · )

138
Bronchial Asthma
Asthma is described as a chron ic inflammatory disorder
manifesting with episodes of chest tightn ess, coughing,
labo red breathing and wheezing, all ofwhich are related
to bronchiole inflammation . Symptoms can last for a few
moments or for as lo ng as a day lead ing to inflammation
and subsequent fibrosis.
I n a study prevalence was found between three and four
percent in north Indian popu lation,"9
The strongest id entified ri sk factor for t he d eve lop m ent
of asthma is atopy, an inherited tendency to exhibit
all ergi c reactio ns. and people with a family history of
all ergy have and in creased predilection for developing
asthm a. Common precipitating all ergens include
tobacco smoke, dust mites, animal fur, cockroaches,
po llens, mold s aAd othe r airborne irri tants (incl uding
acrylic and other aeroso lized dental mate ri als).
A irwa y inflammation and hyper reactivity are the main
cl ini ca l features in asthma. Treatment depends upon
seve rity of the underlying pathophysiologic condition.
Usually it involves bronchodilators, inh a l ed
corticosteroids, theophylline and anticholinergetics.
Typical oral health conditio ns in asthma:
1. Pati ents with asthma have a greater rate of ca ries
development than do thei r nonasthmatic co unterparts
beca use of antiasthmatic drugs-induced xerostom ia. 50
2. Th e use o f nebulized co rticosteroids ca n result in
throal irritation, dysphonia and dryness of m o uth,
orophary ngea l ca ndidia sis a nd , rarely, tongue
e nlargement. t,.tl
3. Th e co mmon habit of mouth -breathing in asthmatic
patients and immunologica l factors lead to gingival
inflammation. u
a rt ho dontic co ns iderations:
Management in orthodonti c care ca n be d ivided in
three parts- before orthodontic treatment, during
treatment and after treatment.
Before treatment:
1. Wh en an asthmatic dental patient seeks ca re, the
clinician must assess his or her risk level by taking an o ral
history of th e illness: ascerta ining the frequency and
seve rity of acute e pisodes, reviewing th e pati ent'S
m edi ca tio ns thoroughl y (as they provid e an indicati o n of
di sease severity) and determ ining the pati ent's specific
triggering agents. Preventing a sudden e pi sode of airway
obstruction is essential when treating an asthmati c
patient ~'"
139
2. As a gene ral rule, elective orthodontics shou ld be
performed o nl y o n asthmatic patients who are
asymptomatic o r whose symptom s are well contro lled .
to minimize the risk of an attack, the patient's
appo intme nt shou ld be in the late morning or the late
afte rnoon 5S•
3. O rthodontist need s to be aware of t he potential for
dental materials and products to exacerbate asthma.
These items include dentifrices, fissure sea lants, tooth
e nam el du st ( during interproximal slic ing) and m ethy l
s7
m ethacrylateS6• •S6,59 Th erefo re Fixed applian ces and
bo nd ed retain ers without acrylic are preferable.
4 . Anxiety is a known asthma trigger60. For most patie nts,
asking fo r a si mpl e co nfirm atio n that they have taken
their m ost recent scheduled d ose of medication can
prevent stress. Oxyge n and bronchodilato r shou ld be
ava il able during treatment.
5. Before send ing patient to any invasive work to
another specialist, he shou ld be informed about the
medical hi sto ry. D e ntal loca l anestheti cs with
vasoconstrictors shou ld be used with caution in
asthmatic patie nts, as many vasoconstrictors contain
sodium m etab isu lfite, a preservative that is highly
alle rgenic ."
During treatment:
1 . It has been found that improper positioningof suction
tips, fluoride trays o r cotto n ro lls could trigger a
hype rreactive airway respo nse in sensitive subjects'2
Elicitinga coughing reflex sho uld be avoided.
2. Prolo nged supine positioning, bacteri a- laden aeroso ls
from plaque or ca rious lesions and ultrason ica lly
nebulized water can provoke asthma triggers in the
dental setting.')
3. In case of acute attack following steps shou ld be
taken ...·65
· Di sco ntinue t he procedure and all ow the patient to
assume a comfortable position .
Maintain a patent airway and admini ster
bronchodi lato r via inhaler/ nebu lizer.
· Administer oxygen v ia face-mask. If no improve m e nt is
observed and symptoms are worsening, administer
e pine phrine su bcutaneously (1 :1,000 so lutio n , 0 .01
milligram/k ilogram o f body weight to a maximum dose
0(0.3 mg)
· A le rt emergency m edica l services. Maintain a good
oxygen level until the patient stops wheez ing andlor
medical assista nce arrives.
After treatment:
Owing to chances of all ergy, offending NSAIDs include
ketoro lac, ibupro fe n and naproxe n sod ium sho uld be
avo ided after banding and b o nding66. Ana lgesic of
cho ice is aceta minophe n .
Conclusion:
An orth od o nti st need s to recogni ze th e syste mi c di sease
processes and significance o f differe nt systemi c diseases
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14 1