Reviewed by Alex Jacobson
This interesting article, published last year in the Journal of Orthodontics , examines aspects of some of the medical conditions that are relevant to orthodontic practice. Stressed is the need for a comprehensive medical history before any orthodontic treatment is planned. This might involve seeking guidance from the patient’s physician.
Cardiovascular system . Infective endocarditis (IE) is a rare condition, but it has high mortality and morbidity rates. The primary prevention of IE is very important. The National Institutes of 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 prophylaxis should not be used in patients at risk of IE undergoing dental procedures. In addition, NICE advised that chlorhexidine mouthwash should not be offered as a prophylaxis against IE in high-risk patients. The use of orthodontic bands and fixed acrylic appliances should be avoided when possible in high-risk patients with poor oral hygiene.
Hematology . Patients with bleeding problems that continue beyond 12 hours should return to their dental practitioner or seek medical treatment or emergency care. Inherited coagulopathies are deficiencies in clotting factor. Hemophilia A and B are common examples of clotting-factor deficiency. Orthodontic treatment is not contraindicated for patients with bleeding disorders, but a close liaison with the patient’s hematologist, oncologist, or physician is recommended.
Sickle cell anemia is more common in people of African descent but also occurs in people with Asian or West Indian ancestors. Orthodontic treatment is not contraindicated in these patients, but a nonextraction approach to treatment is preferred.
Leukemia has acute and chronic forms. Acute lymphoblastic leukemia is most common in children, whereas acute myeloblastic leukemia is more common in adults. The most common dental and craniofacial developmental disturbances of the condition and the chemotherapy and radiotherapy treatment effects are described in the text, as are the orthodontic considerations for these patients.
Respiratory system . Asthma can range from mild to severe. Children with severe asthma are never asymptomatic, and growth and lung function can be affected. A tentative link has been found between orthodontically induced external root resorption, mild root blunting, and asthma.
Cystic fibrosis is the most common life-limiting childhood-onset, autosomal disorder among people of European heritage. There is no cure for cystic fibrosis, and most patients do no live past their 20s or 30s. The relevance of drugs in respiratory disorders is discussed; the final recommendation is that the patient’s physician should be contacted before treatment to evaluate the severity and progress of the problem.
Neurological disorders . Most people who have epilepsy or seizure disorders can have conventional orthodontic care in the primary care setting. Patients should take their normal antiepileptic medication before appointments, eat normally before appointments, and avoid scheduling appointments when they might be tired.
Patients with multiple sclerosis (MS) will benefit from a multidisciplinary approach to orthodontic treatment that includes the patient’s physician, neurologist, MS specialist, nurse, and caretaker. Electric toothbrushes can help compensate for the loss of manual dexterity.
Liver disease. Hepatitis B, C, and D are blood-borne and can be transmitted via contaminated sharps and droplet infection. All patients should be treated as if they are infected, and universal cross-infection control procedures should be taken. The main orthodontic procedures that result in aerosol generation are removal of enamel during interproximal stripping, removal of residual cement after debonding, and prophylaxis.
Endocrine conditions . Diabetes mellitus, whether insulin dependent (juvenile diabetes) or non–insulin dependent (mature-onset diabetes), if well-controlled, is not a contraindication for orthodontic treatment.
Renal disorders . The condition orthodontists are most likely to see is chronic renal failure. Orthodontic treatment is not contraindicated in patients if the disease is well controlled. Treatment should be deferred if renal failure is advanced and dialysis is imminent.
Musculoskeletal system . Juvenile idiopathic arthritis is a severe disease of childhood. It is more common in Norway and Australia than in other countries. The disease can result in disturbances in growth and developmental anomalies. Treatment is aimed at controlling the clinical manifestations by suppressing the articular inflammation and pain, preserving joint mobility, and preventing deformity. There is remission of the disease in adolescence in about 70% of patients. Oral-hygiene aids including modified toothbrush handles or electric toothbrushes can be recommended to patients with juvenile idiopathic arthritis.
Osteoporosis is a common progressive metabolic bone disease that decreases bone density and causes deterioration of bone structure. It is most common in women after menopause but can also develop in men. In confirmed osteoporosis, bisphosphonate drugs are the first line of treatment in women. Oral bisphosphonates can be poorly tolerated and have been associated with esophagitis.
Side effects of medication . Nonsteroidal anti-inflammatory drugs (NSAIDS) can affect the efficiency of tooth movement. Paracetamol (called acetaminophen in the United States) might be the analgesic of choice for orthodontic patients, but be aware that products from the same class of drugs can have varying effects on orthodontic tooth movement. Corticosteroid drugs are used for many inflammatory and autoimmune diseases. It might be advisable to postpone orthodontic treatment for patients taking acute doses. Orthodontic forces should be reduced and checked more frequently in patients with chronic steroid treatment. Bisphosphonates are commonly prescribed to manage osteopenia and osteoporosis and to treat hypercalcemia caused by bone metastasis in cancer patients. Although the medical effects have been proven, the side effects can include delayed eruption of teeth or inhibited tooth movement. Drug-induced gingival overgrowth affects some patients taking medications for hypertension, epilepsy, and prevention of organ transplant rejection. In some patients, the drug is critical to the control of a serious condition, and intensive periodontal treatment with excision of the hyperplasic tissue is essential.
Allergies . Type I hypersensitivity reactions are an immediate antibody-mediated allergic response occurring within minutes or hours after direct skin or mucosal contact with the allergen. This reaction ranges from contact urticaria to full-blown anaphylaxis with respiratory distress or hypertension. How to deal with anaphylactic shock is outlined in the text. Nickel and latex allergies are also discussed.
Eating disorders . The most common eating disorders are anorexia nervosa and bulimia nervosa. Both are more common in girls. Oral manifestations of eating disorders include dental caries, erosion, dental hypersensitivity, salivary gland hypertrophy, raised occlusal restorations, and xerostomia.
Orthodontic treatment is an elective procedure, and clinicians should consider all treatment options to ensure a satisfactory risk-benefit ratio for each patient. When appropriate, treatment should be postponed until the medical problem is in remission.
The Journal of Orthodontics , the British Orthodontic Society, and Maney Publishing are allowing open access of this article until November 2010 ( jorthod.maneyjournals.org/content/vol36/Suppl/index.shtml ). The article is also featured on the AAO website, www.aaomembers.org/Press/NewsReleases/Medical-Conditions-Impacting-Orthodontics.cfm .