MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS

ORTHODONTIC CONSIDERATIONS IN

MEDICALLY COMPROMISED PATIENTS

BY-

DR JASMINE ARNEJA

MDS II YEAR

CONTENTS• Introduction

• Definition

• Infective endocarditis

• Metabolic disorders

• Diabetes

• Adrenal insufficiency

• Hematological disorders

• Bleeding tendencies

• Malignancies

• Autiommine

• Juvenile rheumatoid arthiitis

• Resiratory disease

• Asthma

• Allergies

• Latex

• Nickel

• Nervous system disorders

• Epilepsy

• Liver disorders

• Immunocompromised states

• Others

• Effect of drugs on orthodontic treatment

• Conclusion

• reference

INFECTIVE ENDOCARDITIS

INFECTIVE ENDOCARDITIS

• Infective endocarditis (IE) is a disease in which microorganisms colonize the damaged endocardium or heart valves.

• The organisms most commonly encountered in IE are alpha -hemolytic streptococci (e.g., Streptococ-cus viridans). However, nonstreptococcal organisms often found in the periodontal pocket have been increasingly implicated, including Eikenella corrodens, Actinobacillus actinomycetemcomitans, Capnocytophaga, and Lactoba-cillus species.

HOW IS ORTHODONTICS RELATED TO INFECTIVE ENDOCARDITIS?

• Most bacteraemia arises from everyday activities such as chewing and tooth brushing. (guntheroth 1894)

• The bacteraemia experienced by the patient maybe increased by plaque accumulation, which increases in the presence of orthodontic appliances.

• The prevalence and magnitude of bacteraemia of oral origin are directly proportional to the degree of oral inflammation present.(pallasch and slots 1996)

• Degling (1972) failed to detect any bacteremia while manipulating orthodontic bands

• McLaughlin et al 1996 reported bacteremia in 10% patients while fitting orthodontic bands

WHO IS AT RISK?

ORTHODONTIC CONSIDERATIONS

• Contact the patient’s cardiologist to asses the risk

• Start the treatment only when the patient exhibits exemplary oral hygiene habits

• 0.2% chlorhexidine 5 min before the orthodontic procedure (khurana and martin 1999)

• Avoid bands. Use bonded attachments when possible

• Regular supportive therapy from a hygienist

WHICH PROCEDURES NEEDS PROPHYLAXIS?

• American Heart Association (AHA) recommends that antibiotic prophylaxis should be given, in all cardiac patients with the highest risk of IE mentioned before, in all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (dajani et al 1997)

• These include probing, extractions, banding procedures (both band placement and band removal) and placement of separators. They do not recommend prophylaxis at the placement of removable orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, and bleeding from trauma to the lips or oral mucosa.

• Resources from British National Formulary suggest supplementation of antibiotic prophylaxis for dental procedures with chlorhexidine gluconate gel 1% or chlorhexidine gluconate mouthwash 0.2%, used 5 min before procedure. It is also recommended to continue antibiotic prophylaxis two days after the dental procedures

METABOLIC DISORDERS

DIABETES

• Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.

• This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (increased hunger).

There are three main types of diabetes mellitus

• Type 1 DM results from the body's failure to produce insulin, and currently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".

• Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".

• The third main form, gestational diabetes, occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 DM.

DIABETIC PATIENT AND DENTAL TREATMENT

• Identify diabetic patients –

• Xerostomia

• Candidiasis

• Glossopyrosis

• Recurrent oral infections

• Ketone breath

• Poor periodontal health

• Multiple carious teeth

Factors responsible for these oral manifestations-

• Abnormal collagen metabolism

• Altered protein metabolism due to hyperglycemia

• Impaired neutrophil chemotaxis and macrophage function

ORTHODONTIC CONSIDERATIONS

• Orthodontic treatment should be avoided in patients with poorly controlled Insulin-dependent DM (HbA1c more than 9%), as these patients are particularly susceptible to periodontal breakdown.

• It is important to stress good hygiene, especially when fixed appliances are used. Daily rinses with 2%chx mouthwash can provide further benefits.

• Diabetes related microangiopathy can occasionally occur in the periapical vascular supply resulting in unexplained odontalgia, percussion sensitivity, pulpitis or even loss of vitality. Orthodontist should be aware of this phenomenon and periodical checkups are advised

• The most common dental office complication seen in diabetic patients taking insulin is symptomatic low blood glucose or hypoglycemia. When planning dental treatment, it is best to schedule appointments before or after periods of peak insulin activity. Morning appointment is preferable.

• If a patient is scheduled for a long treatment session e.g. about 90 minutes, he or she should be advised to eat a usual meal and take the medication as usual.

MANAGEMENT OF HYPOGLYCEMIC EPISODE

• Hypoglycemia occurs when blood sugar levels drop below 80 mg/dl and typically becomes more acute in the 20-30 mg/dl range.

• Hypoglycemia can be prevented by making sure the insulin dependent diabetic has eaten before treatment, by scheduling appointments in the morning, and by having a glucose source readily available at chairside.

• If the patient exhibits signs and symptoms of hypoglycemia, administer an oral carbohydrate such as regular cola, table sugar, or even a spoonful of honey or icing to raise blood glucose levels.

• For a patient who becomes unconscious, maintain their airway, turn the patient on their side to prevent aspiration and administer glucose in the dependent cheek. This will usually provide sufficient glucose to allow the patient to regain consciousness. The patient should then drink a liquid high in sugar to increase their blood glucose level.

• keep the patient supine till complete recovery

ACUTE ADRENAL INSUFFICIENCY

• The adrenaline is a neurotransmitter and a hormone that is secreted by the medulla of the adrenal glands and mediate the FIGHT AND FLIGHT reaction to stress.

• Acute adrenal insufficiency is associated with peripheral vascular collapse and cardiac arrest along with severe bronchoconstriction. Therefore, the orthodontist should be aware of the clinical manifestations and ways of preventing acute adrenal insufficiency in patients.

ORTHODONTIC CONSIDERATIONS

• Orthodontic considerations Before treating a patient with a history of steroid use, physician consultation is indicated to determine whether the patient's proposed treatment plan suggest a requirement for supplemental steroids.

• Steroid coverage should be considered for minor oral surgery procedures.

• Use of a stress reduction protocol and profound local anesthesia may help to minimize the physical and psychologic stress associated with therapy and reduce the risk of acute adrenal crisis.

• Hydrocortisone 200 mg (IV/ IM immediately pre-operatively or orally 1 hour preoperatively) and continue normal dose of steroids post-operatively.

RESPIRATORY DISORDERS

ASTHMA

• Asthma is a diffuse chronic inflammatory obstructive lung disease with episodes of chest tightness that causes breathlessness, coughing, and wheezing all of which are related to bronchiole inflammation. It is associated with hyper reactivity of the airways to a variety of stimuli and a high degree of reversibility of the obstructive process.

• Typical oral health conditions in asthma:

Greater rate of caries development than do their non-asthmatic counterparts because of anti-asthmatic drugs-induced xerostomia.

The use of nebulized corticosteroids can result in throat irritation, dysphonia and dryness of mouth, oropharyngeal candidiasis and, rarely, tongue enlargement.

In an asthmatic patient, the common mouth breathing habit and immunological factors will cause gingival inflammation.

ORTHODONTIC CONSIDERATIONSBefore treatment:

• Review the medical history

• As a rule in general, elective orthodontics should be performed only on asthmatic patients who are asymptomatic or whose symptoms are well controlled.

• appointment should be in the late morning or the late afternoon.

• Orthodontist needs to be aware of the potential for dental materials and products to exacerbate asthma. These items include dentifrices, fissure sealants, tooth enamel dust (during interproximal slicing) and methyl methacrylate. Therefore, fixed appliances and bonded retainers without acrylic are preferable.

• Dental local anesthetics with vasoconstrictors should be used with caution in asthmatic patients, as many vasoconstrictors contain sodium metabisulfite, a preservative that is highly allergenic.

• Anxiety is a known ‘asthma trigger', so the orthodontist should reduce the stress level of the patient.

• Oxygen and bronchodilator should be available during treatment.

During treatment:

• It has been found that improper positioning of suction tips, fluoride trays or cotton rolls could trigger a hyper reactive airway response in sensitive subjects. Eliciting a coughing reflex should be avoided.

• Prolonged supine positioning, bacteria-laden aerosols from plaque or carious lesions and ultrasonically nebulized water can provoke asthma triggers in the dental setting.

• Avoid rubber dam use

• Owing to chances of allergy, offending NSAIDs include ketorolac, ibuprofen and naproxen sodium should be avoided after banding and bonding. In such cases, choice of analgesic is acetaminophen.

ACUTE ASTHAMATIC ATTACK

In case of acute attack, following steps should be taken.

• •Discontinue the procedure and allow the patient to assume a comfortable position.

• •Maintain a patent airway and administer bronchodilator via inhaler/nebulizer.

• •Administer oxygen via face-mask. If no improvement is observed and symptoms are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/kilogram of body weight to a maximum dose of 0.3 mg)

• •Alert emergency medical services. Maintain a good oxygen level until the patient stops wheezing and/or medical assistance arrives

HYPERSENSITIVITY REACTIONS

LATEX ALLERGIES

Type I

• the most serious and rare form of latex allergy,

• Type I hypersensitivity can cause an immediate and potentially life-threatening IgE mediated reaction (angeodema, utricria).

Type IV

• Involves a delayed skin rash with blistering and oozing of the skin.

• May extend beyond the area of contact of irritant

Irritant contact dermatitis

• Contact dermatitis causes dry, itchy, irritated areas on the skin, most often on the hands.

• Anaphylactic shock can be provoked in allergic persons by the previous use of latex in an area: latex is typically powdered to prevent sticking, latex proteins become attached to the particles of powder, and the powder becomes airborne when the latex item is used, triggering potentially life-threatening Type I reactions when the latex-contaminated powder is inhaled by susceptible persons.

ORTHODONTIC MANAGEMENT

• Avoid contact with the product and use of alternative products made of synthetic rubber or plastic

• Substitute 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

• 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

LATEX FREE PRODUCTS

NICKEL ALLERGY

• Nickel typically elicits contact dermatitis, which is a Type IV delayed hypersensitivity immune response.

• Kerosuo et al found the prevalence of nickel allergy in Finnish adolescents to be 30 per cent in girls and 3 per cent in boys.

• It has been suggested that a threshold concentration of approximately 30 ppm of nickel may be sufficient to elicit a cytotoxic response.

• Release rate for full mouth orthodontic appliances is 40 micrograms/day for nickel.

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

COMMON CLINICAL FINDINGS

ORTHODONTIC MANAGEMENT

• In confirmed cases of nickel allergy, NiTi wires should be replaced with SS/ TMA/fiber reinforced composite wires

• If allergy continues even after substituting the wires, fixed treatment should be discontinued and plastic aligners should wherever possible

NERVOUS SYSTEM DISORDERS

EPILEPSY

• Epilepsy is defined as two or more seizures that are not provoked and are not due to an acute disturbance of the brain; it is a sign of underlying brain dysfunction, rather than a single disease. There are many different types of epilepsy; treatment and prognosis varies by type.

I Focal seizures (Older term: partial seizures)A Simple partial seizures – consciousness is not impairedB Complex partial seizures – consciousness is impaired (Older terms: temporal lobe or psychomotor seizures)C Partial seizures evolving to secondarily generalized seizures

II Generalized seizuresA Absence seizures (Older term: petit mal)

1 Typical absence seizures2 Atypical absence seizures

B Myoclonic seizuresC Clonic seizuresD Tonic seizures,E Tonic–clonic seizures (Older term: grand mal)F Atonic seizures

III Unclassified epileptic seizures

CLASSIFICATION OF EPILEPSY

SIDE EFFECTS OF ANTIEPILEPTIC DRUGS

• gingival hyperplasia ( 50% of patients treated with phenytoin, sodium valproate and ethosuximide).

• recurrent apthous-like ulcerations,

• gingival bleeding,

• hypercementosis,

• root shortening,

• anomalous tooth development,

• delayed eruption and

• cervical lymphadenopathy.

ORTHODONTIC CONSIDERATIONS

• The appointment should be scheduled at mornings since patient is most stress free

• Orthodontist must ensure that the patient has taken their normal anti-leptic (AEDs) medication, is not too tired before each appointment.

• Gingival growth with phenytoin is widely known complication of antiepileptic medication. Surgical removal of the hyperplastic gingiva is advisable before starting the treatment. For patients with recurrent hyperplasia, the patient’s physician should be contacted to discuss alternative medication

• Stress, Light and sound can act as triggers, so always explain the procedure in advance, perform as painlessly as possible and avoid direct operating light on patient’s eyes.

• Removable appliances are to be used cautiously as they can get dislodged during a seizure.

• Space closing mechanics including nickel titanium closing springs, elastomeric power chain or active elastics can impinge on the hyperplastic gingival tissue. Therefore, they are not used in these patients.

• Small low profile brackets are recommended . Bands are avoided .

• Essix based retainers should be relieved around the gingival margins to maintain alignment. Bonded retainers are avoided in patients at risk of gingival overgrowth

EPILEPTIC EMERGENCIES

• Remain calm

• Remove all dental instruments and removable appliances from the patient’s vicinity

• Remove all tight clothings, tie, shoes, spectacles, rubberdam etc

• Donot try to restrain the patient, instead try to remove all possible things that could harm the patient

• Prevent tongue fall back and aspiration by tilting the patient sidewards

• In most cases seizure activity will last only upto 5 minutes. After recovery, administer oxygen, amd keep the patient supine with legs elevated.

• If the seizure activity lasts beyond 5 minutes it is imperative to seek emergency help.

AUTOIMMUNE DISORDERS

JUVENILE RHEUMATOID ARTHRITIS

• Juvenile rheumatoid arthritis Juvenile rheumatoid arthritis (JRA) is an autoimmune inflammatory arthritis occurring before the age of 16 years.

• The process involves an inflammatory response of the capsule around the joints secondary to swelling of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus) in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints.

• Temporomandibular joint (TMJ) can be damaged up to complete bony ankylosis.

SIGNS AND SYMPTOMS

• RA typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Gentle movements may relieve symptoms in early stages of the disease.

• Classic signs of rheumatic destruction of the TMJ include condylar flattening and a large joint space

ORTHODONTIC CONSIDERATIONS

• It has been suggested by Klellberg that functional treatment for patients with JRA would prevent worsening of TMJ condition by reducing mechanical loads resulting from stabilization of occlusion.

• On the other hand, Profitt states that functional appliances and heavy class II elastics should be avoided in such cases as they Load the TMJ

• Orthopaedic chin cups should be avoided as they load the TMJ

• If the wrist joints are affected these patients have difficulty with tooth brushing.

• Regular professional scaling

• Recommend use of an electric toothbrush

• Sugar-free medicines should be preferred to minimize caries.

HAEMATOLOGICAL DISORDERS

BLEEDING DISORDERS

The main inherited coagulation disorders include hemophilias A and B and von Willebrand's disease.

• Haemophilia A is a recessive X-linked genetic disorder involving a lack of functional clotting Factor VIII and represents 80% of haemophilia cases.

• Haemophilia B is a recessive X-linked genetic disorder involving a lack of functional clotting Factor IX. It comprises approximately 20% of haemophilia cases.

• Two main areas to be considered in treatment of these patients are

• Chances of iatrogenic viral infections

• Risk of spontaneous bleeding

CHANCES OF IATROGENIC VIRAL INFECTION

• Medical treatment of choice in bleeding disorders is administration of various factor concentrates. Transfusion of these concentrates derived from human blood may spread viral infections like hepatitis B, C and HIV. The recent introduction of genetically manufactured factor VIII products has reduced this risk.

RISK OF BLEEDING DURING EXTRACTION.

• To prevent surgical haemorrhage, factor VIII levels of at least 30% are needed.

• Parenteral I-deamino-8-D-arginine vasopressin (DDAVP) can be used to raise factor VIII levels 2- to 3-fold in patients with mild or moderate haemophilia.

• Wherever possible a nonsurgical approach should be adopted.

ORTHODONTIC CONSIDERATION

• Excellent oral hygiene is must for preventing gingival bleeding before it occurs. Every effort should be made to avoid any chronic irritation from orthodontic appliance.

• Arch wires should be secured with elastomeric modules rather than wire ligatures, which carry the risk of cutting the mucosal surfaces. Special care is required when placing and removing arch wires.

• Preformed bands should be preferred to avoid unnecessary trauma

• In case of prolonged gingival oozing, 25% zinc chloride can be used. It causes shrinkage and cauterisation of the tissue.

• In painful conditions, aspirin should be avoided (pg inhibition) instead acetaminophen or acetaminophen in combination with codeine can be prescribed

• Bleeding can be managed by replacement of missing clotting factors, so extractions and orthognathic surgery is not contraindicated if managed carefully

HAEMATOLOGICAL MALIGNANCIES

• More than 40% paediatric malignancies are hematological either leukemia or lymphoma.

• Oropharyngeal lesion can be the initial signs in 10% of acute leukemia.

• In the absence of local causative factors, orthodontist should be suspicious of patients who present with gingival redness pain or hypertrophy, pharyngitis and lymphadenopathy. In such cases prompt referral to a physician is necessary to exclude malignancy.

ORTHODONTIC CONSIDERATIONS

• Orthodontic treatment may start or resume after completion of all medical therapy and after at least 2-year event free survival when risk of relapse has been decreased and patient is not on immunosuppressive drugs.

• Patient's physician should be consulted before starting the procedure.

• Those receiving chemotherapy have an increased potential for infection that is the leading cause of morbidity in immune compromised patients. Thus it is imperative to take extreme aseptic measures.

• To counter xerostomia during cancer therapy use of sugar free chewing gum, candy, saliva substitutes, frequent sipping of water, and/or moisturizers is recommended.

• Developing dental tissues are particularly sensitive to radiation. Careful consideration should be given to the patients having severe root shortening, dilacerations etc while planning the tratment

RENAL FAILURE

RENAL FAILURE

• Chronic renal failure may be due to a variety of cause which leads to loss of kidney function. Treatment involves- dietary restrictiom of salt protein and potassium, dialysis and transplant of kidney if required

• The type of treatment that the patient is receiving influences the type of orthodontic treatment.

ORTHODONTIC CONSIDERATIONS

• Those who are not dot dialysis dependant- orthodontic treatment must be started only if the disease is well controlled and after the physician’s consent

• Those who are dialysis dependant- orthodontic treatment should be finished before kidney transplant

• Those who have received their kidney transplant-

• For prevention of graft rejection, these patients are usually under immunosuppressant drugs (cyclosporine, prednisolone etc). Thus these patients exhibit severe gingival hyperplasia

• Hyperplasia is maximum during the 1st 6 months of cyclosporine therapy. Ortho treatment if possible, should be delayed

• Orthodontic treatment should be started only when oral hygiene is exemplary and must be supplemented with 2% chlorhexidine.

• If gingival growth is present, it must be removed surgically before commencement of orthodontic treatment

• Removable appliances should be avoided as they may fail to fit owing to hyperplastic gingiva

LIVER DISORDERS

LIVER DISEASES

• Liver Diseases Liver diseases are very common and can be classified as acute or chronic usually caused by infection (hepatitis A, B, C, D, and E viruses, infectious mononucleosis), injury, exposure to drugs or toxic compounds, an autoimmune process, or by a genetic defect.

• The liver has a broad range of functions in maintaining homeostasis and health: it synthesizes most essential serum proteins (albumin, transporter proteins, blood coagulation factors V, VII, IX and X, prothrombin, and fibrinogen. Liver dysfunction alters the metabolism of carbohydrates, lipids, proteins, drugs, bilirubin, and hormones.

HEPATITIS B

• Hepatitis B is a worldwide health problem, with an estimated 400 million carriers of the virus. It has been calculated that 1.53% of all patients reporting to the dental clinic are hepatitis B virus (HBV) carriers.

• HBV, hepatitis C virus, and hepatitis D virus 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.

• The main orthodontic procedures to result in aerosol generation are removal of enamel during interproximal stripping, removal of residual cement after debonding, and prophylaxis.

•Infection control protocol should be followed according to the guideline laid down by occupational safety and health administration

All members of the team should be immunized against HBV. Barrier technique such as gloves, eye glasses, and mouth mask should be used.

•HBV can survive on innate subjects for 7 days. Impressions can be one of the links in transmitting the HBV to orthodontics. The impressions must be disinfected by dipping them in glutaldehyde or by spraying sodium hypochlorite and leaving it for 10 min.

•Post-exposure prophylaxis for HBV infection should be given to those who are exposed percutaneously or through mucus membrane to blood or body fluids of known or suspected. If the source individual is Hepatitis B surface antigen (HBsAg) positive and the exposed person is unvaccinated or antibody level is less than 10 mIU/ml, hepatitis B immunoglobulin (0.6 ml/kg) should be administered (preferably within 24 h) along with the vaccine series given at a different site.

•

ORTHODONTIC CONSIDERATIONS

•Liver disease can result in depressed plasma levels of coagulation factors. If extraction is required, special attention should be paid as the risk of bleeding increases; an infusion of fresh frozen plasma may be indicated.

Advanced oral surgical procedures or any dental procedures with the potential to cause bleeding performed on a patient with multiple or a severe single coagulopathy may need to be provided in a hospital setting

• 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. Caution should be used in prescribing medications metabolized in the liver, such as acetaminophen, nonsteroidal anti-inflammatory agents.

ACQUIRED IMMUNODEFICIENCY SYNDROME

• AIDS is an infectious disease caused by the HIV, and is characterized by profound immunosuppression that leads to opportunistic infections, secondary neoplasm and neurologic manifestations.

• Oral manifestations are common and may represent early clinical signs of the disease, often preceding systemic manifestations. This aspect is particularly important as dentists may be responsible for early detection of oral lesions which may indicate HIV infection.

Exposure route Chance of infection

Blood transfusion 90%

Childbirth (to child) 25%[

Needle-sharing injection drug use 0.67%

Percutaneous needle stick 0.30%

ORTHODONTIC CONSIDERATIONS

• HIV infection does not necessitate changes in the orthodontic treatment plan for a child or adolescent. However, effects of HIV infection on the pediatric patient and the patient’s family may alter the clinician’s approach to treatment.

• Many antiretoviral medications (ARV) can cause nausea and vomiting. Frequent episodes of vomiting can affect the oral cavity by increasing acid levels in the saliva and soft tissues. As a result, the oral flora may change due to the overgrowth of bacteria that are not susceptible to acid. This overgrowth can lead to oral conditions such as candidiasis and an increased rate of dental caries.

• Therefore, it is critical that the oral hygiene and health of children and adolescents receiving ARV medications be attended to daily.

• Percutaneous injuries and blood splashes to the eyes, nose or mouth occur frequently during orthodontic treatment.

• On average, dentists in Canada report 3 percutaneous injuries and 1.5 mucous-membrane exposures per year.

• The highest frequencies of percutaneous injuries were reported by orthodontists (4.9 per year) and the highest frequencies of blood splashes to the eyes, nose or mouth were reported by oral surgeons (1.8 per year).

• Universal infection control procedures should be employed for all patients irrespective of their health status. Patients must also be stimulated to use additional auxiliary procedures such as antiseptic mouthwashes

• Xerostomia has been observed in pediatric patients. Clinicians should recommend sugarless gum and frequent consumption of water or highly diluted fruit juices to alleviate xerostomia.

• Post-exposure prophylaxis (PEP) should be given immediately after the accidental occurrence. PEP for HIV exposure is best when started within golden period of <2 h and there is little benefit after 72 h. The prophylaxis needs to be continued for 28 days.

• PEP is available as either

• basic regimen (2 nucleoside reverse transcriptase inhibitor (NRTI)) or

• expanded regimen (2 NRTI and 1 Protease inhibitors (PI) drugs).

• NACO recommend zidovudine/stavudine + lamivudine (basic regimen) and zidovudine + lamivudine +

lopinavir/ritonavir.

OTHERS

PREGNANCY

• Pregnancy as such is not a contraindication for orthodontic treatment. Care should be taken to minimize the potential exaggerated inflammatory response related to pregnancy-associated hormonal alterations. Meticulous plaque control and oral hygiene should be maintained during treatment.

• Avoid X-rays or drug therapy and extractions particularly in the first and third trimester. The second trimester is the safest time to perform extractions.

• Avoid supine position in late pregnancy. Supine hypotensive syndrome may occur due to obstruction of the vena cava and aorta. This may result in reduction in return cardiac blood supply with decreased placental perfusion; this can be prevented by placing the patient on her left side or simply by elevating the right hip 5 to 6 inches during treatment.

• Long, stressful appointments and surgical procedures should be avoided

• Analgesics, antibiotics, local anesthetics, and other drugs required during pregnancy should be reviewed for potential adverse effects on the fetus.

EHLER DANLOS SYNDROME

• Ehler danlos syndrome is an inherited disorder of the connective tissue. It is characterised by extensive elasticity of the skin and laxity of joints.

• Skin in this syndrome is stretchable, velvet like readily bruisable and slow to heal.

• Joints are hypermobile and dislocation is a recurring problem

• PROBLEMS WITH ED PATIENTS

• Tissue repair is abnormal

• Slow healing after extraction

• Problem in achieving proper cusp fossa relationship due to abnormal tooth morphology

• 40% ED patients show TMJ dislocation during treatment

ORTHODONTIC CONSIDERATIONS

• Appliance should be simple and smooth so that tongue and buccal mucosa are not abraded

• Duration of retention must be longer because of added dental mobility, slow repair and poor organisation of collagen fibers of PDL

• Strict oral hygiene instructions must be given

• Abnormal or excessive pressure on the TMJ must be avoided to prevent subluxation.

INFLUENCE OF DRUGS ON ORTHODONTIC TREATMENT

• ASPIRIN-

• It is a NSAID that blocks the cyclooxygenase pathway, thus inhibits the prostaglandin synthesis. Prostaglandins are required for orthodontic tooth movement Thus aspirin should be avoided in orthodontic patients

• BISPHOSPHONATES-

• It is a potent blocker of bone resorption it inhibits the formation and validity of osteoclast. In experimental animals, bisphosphonates caused significant dose-dependant reduction of tooth movement and inhibits relapse. Thus bisphosphonates are beneficial in anchoring and retaining teeth during orthodontic treatment

• CORTICOSTEROIDS-

• It is an anti-inflammatory and immunosuppressant drug. At low doses (1mg/kg body wt) corticosteroids decrease orthodontic tooth movement by suppressing osteoclastic activity .At high doses, (15 mg/ kg body wt) cortcisteroids increases osteoclastic activity and produces significantly more orthodontic tooth movement and subsequent relapse

• ALCOHOL

• Alcohol inhibits the hydroxylation of vitamin D in the liver and interferes with calcium metabolism, thus increases root resorption.

• CYCLOSPORINE

• It increases gingival hyperplasia. The greatest change occurs in the 1st 6 months Removable appliances, brackets, wires that imping on the gingiva and dental calculus plaque and mouth-breathing aggravates gingival hyperplasia.

CONCLUSION

• An orthodontist needs to recognize various medical conditions and their impact on treatment procedures. Treatment should where appropriate be postponed until the medical problem is in remission or the side effects of the drug therapy are minimized. Comprehensive treatment may not always benefit the patient. Treatment procedure should be modified according to need. Consent before treatment, Good patient cooperation and constant monitoring of the progress of the treatment are necessary to minimize physical damage and to maximize treatment outcome.

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