1. Orthodontic Management of Medically Compromised Patients

2. INTRODUCTION Numerous conditions require special patient management
The dental professional have to endeavor to treat each patient as an individual with unique needs that may require modifications, additions or deletions to the standard of care
People with special needs are those whose dental care is complicated by a physical, mental, or social disability.

3. Guidelines Regarding Medical Guidance
A medical history should be comprehensive
The medical history should be kept safely with the patient’s record
A patient’s medical history should be updated regularly.
At the first visit of a patient to the clinic.
At the start of any new course of orthodontic treatment.
Before referral to another practitioner or specialist for additional treatment.

4. 1. Infective Endocarditis
Implications For Orthodontic Therapy:
But Bacteraemia Can Be Increased By Plaque Accumulation Which In Turn Increased With Orthodontic Appliances.
Procedures that can cause bacteraemia:
Impression
Separator placements (greatest bacteraemia)
Fitting or removing bands
Surgical exposure of teeth.
2. No Antibiotic Nor Chlorohexidine Mouth Is Given To Dental Patient Except Very High Risk Patients.

5. Management
Informed consent – patient needs to know of any increased risk and should be informed about the uselessness of AB.
Need high standard OH with daily antimicrobial M/W – (eg. chlorhexidene 0.2%) to aid plaque control, particularly for 2 days up to fitting or removal or major adjustment of fixed appliances.
Bonded appliances – preferred to banded – where possible (exceptions are RME, HG, QH)
Un-erupted teeth - avoid bonding with closed eruption.

6. 5. Antibiotic prophylaxis
In medium risk cases AB is not used.
In high risk cases all procedures liable to cause bacteraemia should be covered by antibiotic prophylaxis. Note that antibiotic administration is not without risk and should only be used where a clear indication exists.
Antibiotic prophylaxis regime
No Penicillin allergy
0-5 years Amoxycillin oral 750mg 1 hr pre-op
5-10 years Amoxycillin oral 1.5g 1 hr pre-op
10+ years Amoxycillin oral 3g 1 hr pre-op
Penicillin allergy or penicillin more than once in last month
0-5 years Clindamycin oral 100mg 1 hr pre-op
5-10 years Clindamycin oral 300mg 1 hr pre-op
10+ years Clindamycin oral 600mg 1 hr pre-op
Note - that an additional post-op dose of antibiotic is no longer recommended.

7. 2 . Seizure Disorders: E.g.. Epilepsy (Eg. Grand Mal)
Anti-epileptic drugs should be taken regularly.
Sedation may be indicated in stress induced procedure like surgical exposure.
Avoid removable if epilepsy poorly controlled
If an individual having a class II Division I incisor relationship experiences an seizure, he or she should carry a soft mouth guard with palatal coverage and extending into the buccal sulci to use at such times
Space closing mechanics including nickel titanium closing springs can impinge on the hyperplastic gingival tissue. Therefore, they are not used in these patients.
Small low profile brackets are recommended.
Essix based retainers should be relieved around the gingival margins to maintain alignment.

8. 3. Pregnancy
Avoid X-rays or drug therapy, especially in first trimester.
Avoid supine position in late pregnancy.
Good OH

9. 4. Latex allergy Prevalence: 1% of population Who at risk?
Individuals with allergic rhinitis, Asthma
Patient hypersensitive to certain food
Atopic patient
Pts w urogenital anomalies
Patient with multiple previous operation
Healthcare professional
Latex industry worker
Types of reaction to Latex
Type I hypersensitivity reaction
Type IV hypersensitivity reaction (Allergic contact dermatitis)

10. 4. Appliance design and handling Latex free gloves.
1. Definitive diagnosis
Patch testing
Pin prick testing,
Blood test
Staff training and communication: Staff should be aware of emergency protocols for dealing with anaphylactic reactions and auxiliary staff should be aware of the diagnosis.
Appointment and surgery management:   Appointments should be scheduled for the early morning with use of a latex-screened area to segregate latex-free products to avoid contamination.
4. Appliance design and handling
Latex free gloves.
The use of elastomeric ties could be avoided with use of self-ligating brackets.
Space closure should be undertaken with nickel– titanium coils.
Where inter-maxillary elastics are required, latex-free elastics can be used, although they are subject to greater force degradation.

11. 5. Nickel allergy
Nickel induces a contact dermatitis, which is a Type IV delayed hypersensitivity immune response, cell-mediated by T lymphocytes.
Nickel hypersensitivity has also been found to be higher in asthmatic patients
More serious if contact the skin than mucosa, times the concentration of nickel required
to provoke mucosal lesions compared with skin lesions
Nickel is found in arch wires, bands, brackets and headgear, with stainless steel containing nickel in the ratio of 18:8, with 8 referring to the level of nickel.
Nickel allergy

12. Signs and symptoms of nickel allergy
1. For the gingiva:
Gingivitis in the absence of plaque
Gingival hyperplasia
2. For the tongue:
Burning sensation in the mouth
Metallic taste
Numbness/tingling sensation
Soreness of the side of the tongue
For the lip:
Labial swelling
Angular cheilitis
Labial desquamation
4. Extra-oral signs and symptoms can include localised dermatitis in sites of prolonged skin contact with nickel-containing objects, for example, headgear studs. This can present as a maculopapular skin rash or vasculitis-like skin lesions.

13. Patch testing using 5% nickel sulphate in a petroleum jelly substrate.
Management
1. Definitive diagnosis:
History
In case of doubt, a trial appliance can be placed which may include two to four brackets with a Ni-Ti archwire and the patient monitored carefully to assess a reaction.
Patch testing using 5% nickel sulphate in a petroleum jelly substrate.

14. 2. Appliance design and handling
Nickel free brackets
SS because it release less nickel than niti
Ceramic brackets
Polycarbonate brackets
Titanium brackets
Gold brackets
Plastic aligners
Nickel free archwires
Titanium Molybdenum alloy (TMA) archwires
Fibre-reinforced composite archwires
Pure Titanium archwires
Gold plated archwires
Extra oral appliances
For nickel sensitive patients, exposed metalwork should be covered with tape or plasters or headgear use discontinued. Plastic coated headgear studs are also available.

15. 6. Diabetes mellitus
Diabetes mellitus (DM) is a metabolic disorder diagnosed
The disease is characterized by chronic hyperglycemia caused by a deficient insulin management.
Two main types of DM exist: type 1 DM, being a total deficiency in insulin secretion, and type 2 DM, which is a combination of resistance to insulin action and inadequate compensatory insulin secretion
Orthodontic considerations in patients with DM
Orthodontic treatment is avoided in patients with poorly controlled DM
Morning appointments are preferable
If longer sessions are scheduled then patient is advised to take meal and medication
Orthodontic forces are kept to minimum because there is weakening of periodontal ligament and osseous regeneration; Diabetic related peripheral microangiopathy can affect the peripheral vascular supply, resulting in unexplained toothache, tenderness to percussion and even loss of vitality.
The orthodontic team should be trained to deal with diabetic emergencies

16. 7.Rickets 8. Osteoporosis sis
Rickets in children and osteomalacia in adults are the classic manifestations of profound vitamin D deficiency.
The child has retarded growth.
Impaired growth may influence our treatment plan in case of functional appliances.
Orthodontic forces are kept to minimum.
8. Osteoporosis sis
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.

17. Orthodontic considerations in patients with Osteoporosis
Use of bisphosphonates
Osteoporosis in post-menopausal women
Paget’s disease and bone resorption caused by malignant osteolytic lesions
Childhood malignancy
Potential future use of BP
Reinforce anchorage
Reduce their relapse potential after alignment or maxillary expansion
Decrease the tendency for root resorption during orthodontic treatment
Orthodontic considerations in patients with Osteoporosis
Treatment should initially be on a non-extraction
Compromised treatment preferred
Short treatment
Complex orthodontic treatment plans should only be initiated after the response to orthodontic forces has been established.
Treatment should be discontinued if teeth respond poorly to orthodontic force application. Signs of poor response to orthodontic force application include slow or no movement of teeth, excessive mobility, as well as radiographic evidence of sclerosis around teeth or other abnormal radiographic changes in the periodontal ligament space.

18. 9. Inherited Coagulopathies – Deficiencies In Clotting Factors
Implication
Bleeding tendency,
Infection risk,
Anaemia risk
Orthodontically:
Self-ligating brackets are preferable to conventional brackets.
Archwires are secured with elastomeric modules instead of wire ligature
A Vacuum formed aligners may be the appliances of choice for selected malocclusions.

19. Orthodontic considerations for patients with respiratory disorders -
10. Asthma
Episodic narrowing of the airways passages that results in breathing difficulties and wheezing.
Orthodontic considerations for patients with respiratory disorders -
The patient’s physician is contacted before the treatment is commenced.
First goal is to prevent acute asthmatic attacks so that, the orthodontist must ensure that patient is carrying inhaler with them and avoidance of the trigger factors
Patients with a history of asthma seem to be at a high risk for developing excessive root resorption during treatment .This emphasizes the prescription of low forces for these patients.
Pt who use oral inhaler might develop candidial infection and recommendation to gargles after inhaler is requested.

20. If orthodontic treatment has been already started -
11.Malignancy
Patient currently suffers from malignancy: As orthodontic treatment is an elective procedure, orthodontic treatment is not advisable.
If orthodontic treatment has been already started -
The orthodontist should contact the patient's physician possible for prognosis.
As the time of diagnosis of malignancy is very stressful for the patient and family, orthodontist should be aware of its psychological implications.
Consider the effect of chemotherapy which can lead to opportunistic infection and subsequent severe complications. It is advisable to remove all orthodontic fixed appliances before starting chemotherapy as a safety procedure.