Medical Disorders and Orthodontics

Medical disorders and orthodontics

Anjli PatelChesterfield Royal Hospital NHS Foundation Trust, Charles Clifford Dental Hospital, Sheffield, UK

Donald J BurdenOrthodontic Division, The Queen’s University of Belfast, UK

Jonathan SandlerChesterfield 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 ortho-

dontic treatment. Progress in medicine, higher expecta-

tions 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.

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

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 Staphylococcusaureus 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 prophy-

laxis 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 The efficacy of antibiotic prophylaxis for IE has never

been shown in a randomized trial. A Cochrane reviewconcluded that there was no evidence to support the

use of penicillin prophylaxis.10

N 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 orthodon-

tic treatment, no evidence was presented to confirmthat orthodontic treatment was a causal factor.11–13

N General dental and skin hygiene are probably more

important for the prevention of IE.

N The use of antibiotics is by no means risk free.

Although prophylactic regimes suggest single dose

Journal of Orthodontics, Vol. 36, 2009, 1–21

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 Kieferorthopaedie 2009; 41: 23–41.

Republished here by permission of Georg Thieme Verlag kG Stuttgart. New York DOI 10.1179/14653120723346

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2 Patel et al. Clinical Section JO December 2009

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

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 orthodon-

tist but patients with severe disorders may require more

care.

A history of a clinically significant episode is one that

N continues beyond 12 h

N requires a patient to call or return to their dental

practitioner or seek medical treatment or emergencycare

N results in the development of a haematoma or

ecchymosis within the soft tissues

N requires blood product support.19

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 defi-

ciency) 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

Orthodontic considerations in patients with cardiovascular

disorders

N The orthodontist should communicate with the patient’s

physician to confirm the risk of IE.

N 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 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 The use of orthodontic bands and fixed acrylic appliances

should be avoided whenever possible in high-risk patients with

poor oral hygiene.

Orthodontic considerations in patients with cardiovascular

disorders

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

N Any episode of infection in people at risk of IE should be

investigated and treated promptly.

JO December 2009 Clinical Section Medical disorders and orthodontics 3

(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 con-

cluded that routine dental treatment including minor

oral surgery is unlikely to pose a cross-infection risk.

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

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 vaso-

occlusive 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 trans-

plants 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.

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-D-

arginine 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 epsilon-

amino 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 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 Care is required when placing and removing archwires.1

N The duration of orthodontic treatment should be kept to a

minimum to reduce the potential for complications.28

Orthodontic considerations in patients with sickle cell anaemia

N Orthodontic treatment is not contra-indicated in sickle cell

patients, provided the patient has no or very mild

complications and the oral hygiene is excellent.

N Intervention in these patients favours a multidisciplinary

approach involving the patient’s physician, haematologist,

dentist, and family.

N 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


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 long-

term 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 immunosup-

pression 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 immunosup-

pressive 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

capacity to improve the height velocity.36 Bone density

is frequently reduced in long-term survivors of child-

hood malignancies.37 They also show acute and long-

term complications in the oral cavity and in dental and

craniofacial development. The most common dental

disturbances are arrested root development with V-

shaped 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 demon-

strated 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

Orthodontic considerations in patients with sickle cell anaemia

N General anaesthetics for elective procedures are contra-

indicated 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

Orthodontic considerations in patients with leukaemia

Dahlof and Huggare have produced an excellent review on the risk

factors to be aware of when planning orthodontic treatment in long-

term 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


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 casesepisodes 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 orthodonti-

cally induced external root resorption and patients with

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

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, bronch-

iectasis, 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 infec-

tions. 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 orthodon-

tic treatment.

Beta-adrenergic agonist bronchodilators such as sal-

butamol, antimuscarinic bronchodilators, cromogly-

cates and antihistamines can all produce dry mouth,

taste alteration and discolouration of teeth.

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 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 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 Removable retainers should fit well with little potential to be a

source of irritation, ulceration or infection.2


Neurological disorders

It is important that orthodontists have knowledge of themost common neurological conditions as some pro-

blems may manifest initially in the orthodontic chair.55

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

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, withdra-

wal 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 over-

growth. However, the orthodontist may still encounter

patients taking phenytoin. Alternatives such as carba-

mazepine 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 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 anti-

inflammatory 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

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.

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


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 diag-

nosis 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.

The aetiology of MS is not understood and various

environmental factors such as viruses, climatic factors

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 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

Subtypes of MS

Benign 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.

Orthodontic considerations in patients with MS

N Treatment should involve a multidisciplinary approach

including the patient’s physician, neurologist, MS specialist

nurse and care worker.67

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

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.


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 coagulation disorders;

N drug toxicity;

N disorders of fluid and electrolyte balance;

N problems with drug therapy;

N infections.35

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 ofenamel 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.

Endocrine conditions

Diabetes mellitus (DM)

The term DM is characterized by chronic hyperglycae-

mia. There are two main categories of DM:

Type 1 DM, (insulin dependent, IDDM or juvenile-

onset 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 complica-

tions 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

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.

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


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.

Renal disorders

Patients with kidney disorders are presenting more

frequently in orthodontic practice due to improvements

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 metabo-

lism 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 cyclospor-

ine and calcium channel antagonists such as nifedipine

are also taken to prevent transplant rejection.

Immunosuppressants predispose the patients to infec-

tions. 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.

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 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 Conscious 50 g of glucose as a drink, tablet or gel

N Unconscious 20 ml of 50% Dextrose IV or 1 mg of glucagon

should be administered intramuscularly.

N When the patient is cooperative oral glucose should be given to

prevent recurrent hypoglycaemia. If recovery is delayed, the

emergency services should be called.

Orthodontic considerations in patients with renal disorders

N Orthodontic treatment is not contraindicated in patients if the

disease is well controlled.

N 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.

N 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.

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.


Musculoskeletal system

Juvenile idiopathic arthritis

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 develop-

mental 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

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 mani-

festations by suppressing the articular inflammation and

pain, preserving joint mobility and preventing defor-

mity. 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.

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

Orthodontic considerations in patients with JIA

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


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 forma-

tion 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 neces-

sitates 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

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 ibuprofenon orthodontic tooth movement in rats showed acet-

aminophen 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 ortho-

dontic patients.102 Their results suggested that NSAIDs

reduce the number of osteoblasts by inhibiting prosta-

glandin synthesis. This led to the use of cyclooxygenase-2 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; Celecoxiband Parecoxib.103 Fortunately rofecoxib is now with-

drawn 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 ofcortisol 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 recommenda-

tions 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 ofadrenal insufficiency should receive systemic corticos-

teroid 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

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


tablets by mouth should receive parenteral corticoster-

oid 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 co-

workers 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.

Bisphosphonates (BPs)

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.

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 softtissue, 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 extrac-

tion) or due to odontogenic infection. This can beexacerbated by the following factors:

N corticosteroid treatment;

N chemotherapy;

N medical co-morbidities such as diabetes mellitus;

N the presence of dental disease;111

N dental extractions;

N oral bone surgery;

N poorly fitted dental appliances;

N smoking;

N alcohol abuse.

Radiographic signs include widening of the periodontal

ligament space at the molar furcation areas and mottled

bone consistent with osteolysis.111

Table 2 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) 70 mg per week

Risedronate (Actonel, Aventis) 35 mg per week

Ibandronate (Boniva, Roche) 2.5 mg per day

IV bisphosphonates – cancer Pamidronate (Aredia, Novartis) 90 mg per month

Zoledronate (Zometa, Novartis) 4 mg per month

Orthodontic considerations in patients taking BPs

N 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


Drug induced gingival overgrowth (DIGO)

DIGO affects a proportion of patients on medication

for hypertension, epilepsy and the prevention of organtransplant 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, cyclospor-

ine 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 ofplaque-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, occur-

ring 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 respira-

tory 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

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 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

N The clinician should look for signs of ONJ and the patient

should be advised to have regular dental check-ups.

N 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.

Orthodontic considerations in patients with DIGO

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.

N 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.

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

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


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 tita-

nium (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 firstphase 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

Figure 1 Anaphylaxis treatment algorithm – adapted from Resuscitation Council UK guidelines 2008

Orthodontic considerations in patients with a nickel allergy

N A dermatologist should confirm a true nickel allergy.

N 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.


Latex allergy

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 inter-

maxillary 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 profes-

sionals. 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 cross-

reacting 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.

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 combina-

tion of body image distortion and restricted eating.135

Binge eating and purging are also characteristics of BN.

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

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.

Orthodontic considerations in patients with latex allergy

N 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 Latex free goods should be stored in a ‘latex-screened’ area to

avoid prior contamination with latex products.

N 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


Patients with eating disorders rarely present with

problems of compliance. Oral manifestations of eating

disorders include dental caries, erosion, dentinal hyper-

sensitivity, salivary gland hypertrophy, raised occlusal

restorations and xerostomia.136

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 remissionor the side effects of the drug therapy are minimized.

Patients should always be involved in the treatment-

planning phase so that true informed consent can be

obtained.

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