Management of medically compromised orthodontic patients

Management of medically compromised orthodontic patients Introduction A pilot study performed in 2002 of several orthodontic practices revealed that more than 25% of patients seeking orthodontic therapy had some medical diagnosis that potentially impacted their care.Most common medical problems include:Hypersensitivity reactionsAdenotonsillar hypertrophySeizure disordersDiabetes

Psychiatric disordersPediatric cancerSpecial needsCardiac disordersBleeding disordersAsthma

Hypersensitivity reactionsMost common hypersensitivity reactions in orthodontic practice are due to the use of latex-based products and to the alloy components of metal-based orthodontic appliancesReactions of irritant origin are usually associated with direct friction between soft tissues and orthodontic appliancesHypersensitivity reactions are related to the antigenicity of some materials that results in an adverse patient response

Type I hypersensitivity Type I hypersensitivity to natural rubber latex represents an immediate antibody-mediated allergic response to multiple proteins on the latex productLess than 1% of the general population are reported to be diagnosed with potential type I natural rubber hypersensitivity A higher prevalence (between 6% and 12%) is reported among dental professionals

Patients at particular risk of allergy to natural rubber latex include:with a history of atopy Atopy is a disease characterized by a tendency to be hyperallergic--A patient with atopic allergies has atopic eczema or atopic dermatitis since infancyThose who have had repeated operations and extensive contact with rubber surgical drains Those with spina bifida A history of itching and redness from contact with balloons, rubber dams, etc.

A typical atopic manifestation: Eczema

Potential Risk factors for latex allergy:Hay feverAsthma EczemaContact dermatitis

Food allergy can also point to a potential latex allergy bananas, avocado, passion fruit, kiwi, and chestnuts have proteins that are capable of cross-reacting with latex proteins

These foods can thereby act as a possible mode of sensitization to the natural rubber latex materials

Test for Type I hypersensitivityClinical tests, of which the skin prick test is considered the most accurate, can determine the presence of circulating antinatural rubber latex antibodies

Type IV hypersensitivityThis more delayed reaction usually presents a reaction localized to the area of skin contact

More commonly known as allergic contact dermatitis

This generally localized reaction is typically characterized by diffuse or patchy eczema on the contact area

It is often accompanied initially by itching, redness, and vesicle formation, and later on as dry skin, fissures, and sores

Initial signs of reaction develop in minutes to hours and may persist for several weeks

These reactions are not considered life-threatening but can cause permanent damage to the skin if mismanaged or left untreated

Elastic BandsElastic bands represent another potential source of latex allergy protein that must considered

Silicone bands showed greater force decay than Non rubber latex elastics, and it was concluded that great improvements in the physical properties of the silicone bands would be required before they could be considered as an acceptable alternative to Non rubber latex elastics

After static force extension of 450% for 1 day in saliva, the force decay was 33% for the silicone bands and 28% for the Non rubber latex elastics

Examples of Non rubber latex-free products

Ways to Minimize RiskBest management of natural rubber latex hypersensitivity is to avoid contact with the product and use of alternative products made of synthetic rubber or plasticNatural rubber latex gloves should be substituted with alternative ones made of other components such as nitrile, neoprene, vinyl, polyurethane, and styrene-based rubbers The use of powder-free gloves will diminish the amount of aerosolized allergens

More frequent office cleanings Air-duct filter changes and cleanings Early morning appointments can reduce patient exposure to airborne natural rubber latex particles Administration of pretreatment antihistamines In the event of a severe type I reaction, emergency procedures such as administration of epinephrine are recommended ( i.e. EpiPen)Use of latex free products during treatment

EpiPenEpinephrine constricts blood vessels, relaxes smooth muscles in the lungs to improve breathing, stimulates the heartbeat, and works to reverse hives and swelling around the face and lips

The effects of epinephrine usually last 10 to 20 minutes so immediate medical attention is still required

EpiPen auto-injector should only be used on the fleshy outer portion of the thigh and can be used through clothing

Metal-based allergic reactionsThe metal components of orthodontic appliances are generally composed of 18/8 stainless steel (18% chromium and 8% nickel)

Both of these metal components are known allergens, but the nickel in particular is considered a common cause of contact allergy

Nickel Nickel is the most common metal-based contact allergy among women, with the incidence of nickel sensitivity in the female population reported as high as 30% compared with only 3% of males among the studied individuals

Nickel sensitivity was higher among subjects with a history of pierced ears; there was 31% prevalence compared with subjects without pierced ears at 2% prevalence

Nickel titanium alloys contain up to 70% nickel

Orthodontic appliances and hypersensitivity reactions: Study A study on 29 subjects (18 female, 11 male) reported an initial positive skin patch test to nickel sulfate in five of the female patients and in none of the male patients These five subjects (who tested positive with the skin patch test) plus the negative patch-testers were followed over the course of treatment after banding and bracketing with fixed stainless steel appliances None of the positive or negative test patients evidenced inflammatory reactions or discomfort as a result of the orthodontic appliances Two of the original negative test result patients, one female and one male, converted to a positive patch test to nickel. Again, no localized allergic-type responses were noted relative to the appliances. The authors concluded that the nickel-containing appliances had no allergic effects on the oral tissues, although the appliances may play a role in inducing nickel sensitivityPossible Cause of HypersensitivityThe nickel release from orthodontic metal appliances is most related to the solder composition and manufacturing of the appliances rather than being directly related to the actual nickel content The study analyzed facebows, brackets, molar bands, and both stainless steel and nickel titanium arch wires for nickel release when stored in physiologic saline

FindingsThe analysis indicated that appliances using silver and gold solders (eg, facebows and molar bands) showed enhanced release of nickel and chromium In contrast, alloys containing titanium, for example arch wires, released little nickel. titanium has the advantage of being highly resistant to corrosion and may bind the nickel from release in these in vitro studies

Common Clinical FindingsIn a survey of Norwegian orthodontists,30 participants were asked to assess the number and nature of adverse reactions among their patients and to relate them to materials or treatment provided

Dermal reactions reported included redness, irritation, itching eczema, soreness, fissuring, and desquamation most often attributed to a metal extraoral (eg, headgear facebow) component of the appliances

Intraoral reactions included redness, swelling, itching and soreness of the lips and oral mucosa, and inflammation of the gingival tissues

Occasionally, symptoms such as fever were reported. Although not all the symptoms were attributed to the presence of metal components, they were assumed to be the primary allergens in these reported cases of hypersensitivity reactions

Seizure DisodersA seizure is a sudden, involuntary, time-limited alteration in neurologic function resulting from abnormal electrical discharge of cerebral neurons Seizures manifest as altered sensation, behavior, or consciousnessEpilepsy is defined as two or more seizures that are not provoked and are not due to an acute disturbance of the brainIt is a sign of underlying brain dysfunction, rather than a single disease

Seizure TriggersSome patients have identified triggers that impact the number and severity of seizures including: Flashing lightsAnxiety IllnessHyperventilation

7 Factors reported to increase seizures include:

StressMissed medicationSleep deprivationAlcohol consumptionNonprescription medicationsVitamin or mineral deficienciesParts of the menstrual cycle

Etiology of seizureThe cumulative incidence of epilepsy from birth through age 20 years is about 1% and increases to 3% at age 75Epilepsy with a recognized cause is termed secondary; those patients for whom a cause cannot be determined have primary epilepsy Etiology in childhood includes congenital abnormalities, birth-related complications, trauma, meningitis, encephalitis, and malignancyAdult etiologies are brain tumors, cerebral vascular disease, head trauma, and degenerative changes

Seizure disorders are the most common serious chronic neurological condition

Contemporary management may include medications, surgery, an implanted nerve-stimulation device, and/or a ketogenic diet

Ketogenic DietNormally, our bodies run on energy from glucose, which we get from foodWe can't store large amounts of glucose however, and only have about a 24-hour supplyThe ketogenic diet is a low carbohydrate and high fat diet 80% of calories come from fat and the rest from carbs and proteinsEach meal has about four times as much fat as protein or carbohydrateMore effective in children (length of diet is about 2 years)

Effectiveness of the diet:About a third of children who try the ketogenic diet become seizure free, or almost seizure free Another third improve but still have some seizuresThe rest either do not respond at all or find it too hard to continue with the diet, either because of side effects or because they can't tolerate the food

Side effects:DehydrationConstipationKidney stones or gall stonesMenstrual irregularitiesPancreatitis Decreased bone density Eye problems

Types of SeizuresSeizures lasting longer than 30 minutes or rapidly recurring seizures are termed status epilepticus

Convulsive seizures that continue longer than 10 minutes require treatment by medical professionals who can administer intravenous anticonvulsive medication and support the patients respirations as needed

Absence --1030 sec loss of consciousness, brief eye or muscle fluttering, sudden halt in activity Tonic-clonic loss of consciousness with falling, 1020 sec muscle rigidity followed by 25 min clonic contractions of muscles of extremities, head, trunk; urinary and/or fecal incontinence, postictal deep sleep 1030 min Atonic --Brief loss of muscle tone with fallingClonic --Alternating muscle contraction and relaxation Tonic-- persistent firm muscle contractions

Orthodontic considerationsRecord a detailed history: specific details about seizure onset, frequency, and type, behavior during seizures, duration, triggers, recovery period, medical management, and compliance

Be prepared to respond: The practitioner and staff should be prepared to respond appropriately when a patient has a seizure in the orthodontic office

Gingival hypertrophy associated with anticonvulsant medication and past dental or facial trauma should be considered when planning treatment and reviewed as part of patient informed consent

Seizures and Dental CareThere is little in the dental literature regarding the implications of seizure disorders on oral health and delivery of dental care

Dentofacial trauma occurring during seizures has been reported to include injuries to the tongue, buccal mucosa, facial fractures, avulsion, luxation or fractures of teeth, and subluxation of the temporomandibular joint

Dental Side Effects Gingival Hyperplasiareported to occur in up to 50% of patients treated with phenytoin (Dilantin), sodium valproate (Depakote), and ethosuximide (Emeside and Zarontin)Other side effects of medicationsrecurrent aphthous-like ulcerations, gingival bleeding, hypercementosis, root shortening, anomalous tooth development, delayed eruption, and cervical lymphadenopathyAsymmetryOf particular interest to the orthodontist is a recent report of facial and body asymmetries affecting 41% of patients with partial seizures in the population studied; asymmetries included both hemihypertrophy and atrophy

Proper First ResponseStay calmRemove dangerous items from the immediate areaDo NOT try to restrain the patientNote the time the seizure beginsKeep onlookers away Activate the emergency medical system if any seizure lasts for more than 10 minutes or if the patient has three or more seizures within a short timeSpeak quietly and calmly remove the patient from a dangerous or embarrassing environment by guiding them to a safe location and stay with the patient until they are alert

Pediatric CancerChildhood cancer is a relatively uncommon disease affecting approximately 12 of 100,000 childrenThe three most frequent major childhood cancers, comprising about 69% of all childhood neoplasms are:- leukemias (30.1% of all cancers diagnosed among children below 15 years of age)-central nervous system tumors (27.8%)lymphomas (11.0%)The overall survival rate for all types of childhood cancer is now approaching 80%

Impact of TreatmentBoth chemotherapy and radiation therapy given to the growing individual will have consequences for growth, dental development, and craniofacial growthThe caries risk may also be increased due to salivary dysfunctionIt has been shown that although ideal treatment results are not always achieved, orthodontic treatment does not produce any harmful side effects

Treatment effects on cranial developmentIn a sample of 97 children diagnosed with ALL (Acute Lymphoblastic Leukemia) before 10 years of age, treated with combination chemotherapy and cranial irradiation, and followed at least 5 years after diagnosis, the main finding was that patients younger than 5 years at the commencement of anticancer therapy had a markedly increased risk of craniofacial aberrations, characterized by mandibular retrognathismThe growth repressive action of irradiation has been explained to be due to growth hormone deficiency in children who receive cranial radiation

Orthodontic considerationsStrategies used by orthodontists in treating this patient group may include: using appliances that minimize the risk of root resorptionlow force applicationaccepting a compromised treatment result by simplistic mechanicsterminating the treatment earlier than normalnot treating the lower jaw It is advised to postpone the start of orthodontic treatment at least 2 years after completion of cancer therapySince radiation therapy has a growth-suppressive effect, especially on cartilage growth , avoid treating a skeletal Class II malocclusion with growth modificationOrthodontic Treatment and ExtractionsThere are no reports on occurrence of osteoradionecrosis after tooth extractions in children treated for malignanciesIn the group of children subjected to orthodontic treatment, healing after extractions was uncomplicatedSince orthodontic treatment should not be started until 2 years after completion of cancer therapy, extractions for orthodontic indications should likewise be deferred until that time

Cardiac Disease, Bleeding Disorders and AsthmaWhile orthodontic therapy has been historically considered to be completely noninvasive, specific orthodontic procedures may place some patients at risk for serious complicationsAmong the most common of these conditions are those associated with cardiac disease, bleeding disorders, and asthma

Orthodontics and BacteremiaAlthough most orthodontic treatment is minimally invasive, the placement and removal of orthodontic bands has been suggested to produce bacteremias. McLaughlin and colleagues studied the incidence of bacteremias after orthodontic banding in 30 healthy adultsElastomeric separators were placed 1 week before the placement of a single band on a permanent first molar.Bacterial cultures revealed that the frequency of bacteremias following banding was 10% compared with 3% in the preoperative sample.The impact of gingival health on bacteremias associated with band placement can be further appreciated when one compares the incidence of bacteremia following matrix band placement between individuals without gingival inflammation (0%) and those who had gingivitis associated with bleeding (32%)the frequency of banding-induced bacteremias appears to be less than that reported for flossing (20%) or toothbrushing (25%)Risk assesmentPatients at HIGH RISK are those with a prior history of endocarditis, those who have prosthetic valves or surgically corrected systemic pulmonary shunts or conduits, or those with complex cyanotic congenital heart disease (tetrology of Fallot)

Patients at MODERATE RISK are those with congenital cardiac malformations, acquired valvular dysfunction (such as that caused by rheumatic fever), hypertrophic cardiomyopathy, and mitral valve prolapse with regurgitation

Patients at NEGLIGIBLE RISK for endocarditits, defined as being no more likely to develop BE than the general population, are those with secundum atrial septal defects, surgical repair of atrial or ventricular septal defects or patent ductus arteriosus, previous coronary artery bypass grafts, mitral valve prolapse without valvular regurgitation, innocent heart murmurs, previous Kawasaki disease or rheumatic fever without valvular dysfunction, cardiac pacemakers, and implanted defibrillators

Prevention of Infective EndocarditisThree management guidelines form the basis for patients at risk of bacterial endocarditis: Communication with the patients physician to confirm that a risk for bacterial endocarditis truly exists

Aggressive pre-treatment and intra-treatment oral hygiene to minimize the presence of gingival inflammation

Prudent use of prophylactic antibiotic therapy

Premedication ProtocolThe current recommendations for endocarditis prophylaxis by the American Heart Association are a single dose of Amoxicillin (2 g in adults or 50 mg/kg in children) administered 1 hour before the procedure For penicillin-allergic patients, Clindamycin (600 mg for adults and 20 mg/kg for children)

If a patient forgets to take his or her premedication, or if unanticipated bleeding occurs, the American Heart Association guidelines suggest that antibiotic given at the time of treatment or up to 2 hours from the time of insult is effective

Bleeding DisordersEffective hemostasis is the consequence of a sequence of events in which platelets and plasma proteins produce clotting.Defects in either may result in a clinically relevant coagulopathy with consequent bleedingBleeding disorders result from qualitative or quantitative platelet deficiencies, or inadequate or insufficient levels of plasma-clotting factors

Etiology of Bleeding DisordersPlatelet deficiencies of interest to the orthodontist are associated with conditions that result in a reduction of platelets (thrombocytopenia). Thrombocytopenia may result from a reduction in the production of platelets caused by disruption of the bone marrowThe most likely sources for this etiology are malignancies involving the bone marrow (leukemia) or autoimmune conditions in which the platelet-producing cells in the marrow are destroyed (aplastic anemia)

Leukemia and Gingival BleedingLeukemia is among the most common malignancies of patients in the most frequently orthodontically treated age groups. Gingival bleeding caused by thrombocytopenia often heralds the onset of acute leukemiaUnlike most gingival bleeding, which is elicited by some type of provocation, gingival bleeding associated with profound thrombocytopenia is spontaneousSpontaneous gingival bleeding is associated with platelet counts of 20,000 cells/mm3 or less (normal 150,000450,000 cells/mm3)Because orthodontists see patients frequently, they are often in the position of being the first health care provider to recognize this early sign of leukemia

Congenital bleeding disordersIn contrast to platelet-related bleeding disorders, factor-related diseases are most often congenital As a result, the orthodontist should be able to determine the presence of these conditions before the initiation of treatmentThree congenital clotting factor deficiencies account for more than 90% of inherited disorders: Hemophilia A (def of Factor VIII)Hemophilia B (def of Factor IX)Von Willebrands disease (defects of von Willebrands factor ) **most common congenital bleeding disorder***

Bleeding disorder

Orthodontic associated risk: ExtractionsFor patients with a congenital bleeding disorder, probably the biggest orthodontic-associated risk is associated with extractions associated with treatment In these cases, the administration of factor replacement along with Amicar or tranexamic acid is prudentAmicar (aminocaproic acid) and tranexamic acid are anti-fibrinolytic agents that prevent the breakdown of the clot in the extraction site, allowing for better organization, and thereby decreasing the likelihood of postoperative bleeding

Precautions with Bleeding DisordersTo minimize risk and cost to the patient, it seems most reasonable to perform all planned extractions at a single visit It is imperative that this group of individuals be in absolute gingival health before the commencement of treatment Care should be used in the placement and removal of orthodontic hardware to minimize the risk of mucosal injuryElastomeric modules are preferential to wire ligaturesOverall treatment should be performed as expeditiously as possible

Bleeding gums

AsthmaEpisodic narrowing of the airways that results in breathing difficulty and wheezing Asthma is most often the result of an inherited immunologic hypersensitivity (allergic) disorder

PrevalenceAlmost half of cases of asthma develop before age 10Prevalence of the condition was highest in blacks (15.8%), intermediate in whites (7.3%) and Asians (6.0%), and lowest in Latinos (3.9%) These differences were unrelated to income or access to medical care The severity of asthma, based on limitation of activities and need for acute medical care, was most notable among black and Latino children

Management ConsiderationsThe first objective is the prevention of acute asthmatic attacks and the key to this is the identification of patients at riskObtain information regarding the severity of the disease (limitation in activities, emergency room visits, etc.), medications, and factors that precipitate an attackThe orthodontist should assure that the patient has taken his or her medication and, if appropriate, has his or her inhaler present if needed during the appointment

Patients with asthma may be sensitive to several specific medications including the erythromycins, aspirin, antihistamines, and local anesthesia containing epinephrineSide Effects of Asthma TreatmentChronic use of inhalers, especially those containing steroids, may result in a predilection for the development of oral candidiasis and xerostomiaIf noted candidiasis can be treated with topical antifungal agents such as NystatinXerostomia enhances the risk of caries, therefore, aggressive oral hygiene, supplemental topical fluorides are essential.

Oral candidiasis

Asthma and Root ResorptionIt has been suggested that orthodontic-induced external root resorption occurs with greater frequency in patients with asthma than in the non-asthma population

McNab and colleagues compared the incidence and severity of external root resorption following fixed orthodontic therapy between patients with asthma and a healthy population.

They found that while the incidence of external apical root resorption was elevated in the asthmatic population, the severity of resorption was the same between groups

It would seem prudent, therefore, for orthodontists to disclose the heightened risk of external root resorption to patients before initiating treatment

Asthma and Root Resorption: StudyThe objective of this study was to determine whether there is an association between excessive root resorption and immune system factors in a sample of Japanese orthodontic patients

The records of 60 orthodontic patients were reviewed retrospectively.

The pretreatment records revealed that the incidence of allergy and root morphology abnormality was significantly higher in the root resorption group

The incidence of asthma also tended to be higher in the root resorption group

From these results, we concluded that allergy, root morphology abnormality, and asthma may be high-risk factors for the development of excessive root resorption during orthodontic tooth movement in patients

Root resorption

referencesOrthodontic considerations in the pediatric cancer patient: A reviewPages 266-276 Gran Dahllf, Jan Huggare

Prevention of Infective Endocardititis: Guidelines from the American Heart Association Wilson, Walter (et. al) J Am Dent Assoc 2008;139;3S-24S