15
Orthodontic Care in the Adult Medically Compromised Patient
Ashok Kumar Jena and Jitendra Sharan
Unit of Orthodontics and Dentofacial Orthopedics, Department of Dentistry, All India Institute of Medical Sciences, Bhubaneswar, India
The United Nations’ “Global population growth and sustainable development report” in 2021 suggested that since the middle of the twentieth century the world’s population has more than tripled, increasing from around 2.5 billion in 1950 to almost 7.9 billion by 2021 (United Nations Department of Economic and Social Affairs, 2021). Part of this stems from increased life expectancy in societies around the world. At the biological level, aging results from the impact of the accumulation of a wide variety of molecular and cellular changes over time. This might lead to a gradual decrease in an aging individual’s physical and mental capacity, resulting in an increased risk of disease (Tosato et al., 2007; Franceschi et al., 2018). These changes are neither linear nor consistent and are only loosely associated with a person’s chronological age. The diversity seen in the mid‐age group is not random.
There has been increasing recognition that the health status, type and level of activity, productivity, and other socioeconomic characteristics of adult persons have changed significantly in many parts of the world over the past years. The adult population is also characterized by the emergence of several complex health conditions such as cardiac issues, endocrinal anomalies, infectious disorders, pulmonary disorders, skeletal disorders, mood disorders, and so on (Tosato et al., 2007; Franceschi et al., 2018). The demand for oral healthcare has also increased over the past few decades among adult patients worldwide (Petersen et al., 2005). Many of these patients need orthodontic care and belong to various ethnic backgrounds and socioeconomic strata (Abu Alhaija et al., 2010). With an increase in the flow of the adult population to orthodontic treatment, it is obvious that an orthodontist will see patients with various systemic disorders (Patel et al., 2009; Batista et al., 2018). The recent advancement in medical and oral healthcare sciences has enabled the complex needs of such patients (medical and dental care) to be met with greater satisfaction. However, this requires orthodontists to have a sound understanding of systemic diseases and their pathophysiology, and in case of doubt they should seek opinions from other medical and dental professionals (Patel et al., 2009).
An orthodontist, who is, in turn, part of the oral healthcare professional community, should focus on the patient’s overall well‐being before treating dentofacial abnormalities. Often patients are unaware of their systemic problems when they report to the orthodontist with dentofacial problems. Also, orthodontists often focus on the “regional diagnosis,” which is more of a local approach and deals with dentofacial issues, rather than looking for a broader or general approach (Kharbanda and Wadhawan, 2012). Regional diagnosis misses the bigger picture of the patient in the form of pathological, medical, mental, or psychological conditions affecting overall well‐being. Thus, a comprehensive or holistic approach to diagnosis is essential for the optimal outcome of comprehensive orthodontic care. This will lead to the best possible oral healthcare delivery to medically compromised adult patients, which is also the primary goal of an orthodontist. The protocol for managing patients with various systemic disorders is broadly outlined in Figure 15.1 (van Venrooy and Proffit, 1985) and considered in more depth in this chapter.
Figure 15.1 Orthodontic treatment protocol for patients with systemic diseases.
Cardiovascular disorders
Infective endocarditis
Infective endocarditis (IE) is a relatively rare disorder with an estimated incidence of 3–10 cases per 100,000 population per year (Khan et al., 2016). The incidence of IE is higher in elderly people, who often are affected by many comorbidities. Such individuals have various clear and observable cardiac changes in the heart’s septum, valves, and walls. Up to one‐third of patients acquire IE in a healthcare‐associated environment, including oral healthcare (Vallejo, 2016). Unexpected fever, common cold symptoms, weight loss, rigor, fatigue, myalgia, joint pain, and back pain are the usual signs and symptoms of IE. Various oral healthcare procedures pose a risk for IE in the individual with structural pathological changes in the heart. Thus, antibiotic prophylaxis is always considered before certain orthodontic or dental procedures that involve the manipulation of gingival tissues (oral prophylaxis), the periapical region of the teeth, or any sort of perforation of the oral mucosa (tooth extraction, banding, interproximal reduction). In individuals with the following cardiac conditions, antibiotic prophylaxis is routinely recommended:
- Prosthetic cardiac valves.
- Hypertrophic cardiomyopathies.
- Prosthetic material used for valve repair.
- Previous episode(s) of IE.
- Unrepaired cyanotic congenital heart defect (CHD), surgically repaired CHD, or palliated structural conditions.
- Intravenous drug misuse/abuse.
A recommended antibiotic prophylactic regimen for dental or orthodontic procedures (Wilson et al., 2021) is described in Table 15.1.
Table 15.1 A single dose of an antibiotic can be administered 30–60 minutes before the dental procedure.
| Situation | Medication* | Adult | Children |
|---|---|---|---|
| Oral | Amoxicillin | 2 g | 50 mg/kg |
| Unable to take oral medication | Ampicillin OR cefazoline or ceftriaxone |
2 g IM/IV
1 g IM/IV |
50 mg/kg IM/IV 50 mg/kg |
| Allergic to penicillins or ampicillin – oral regimen | Cephalexin** OR azithromycin or clarithromycin OR doxycycline |
2 g
500 mg 100 mg |
50 mg/kg
15 mg/kg <45 kg 2.2 mg/kg |
| Allergic to penicillin or ampicillin and unable to take oral medication | Cefazoline or ceftriaxone*** | 1 g IM/IV | 50 mg/ kg IM/IV |
* Clindamycin is not recommended for antibiotic prophylaxis for any dental procedure.
** Or other first‐ or second‐generation oral cephalosporins in equivalent adult or pediatric dosage.
*** Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.
IM, intramuscular; IV, intravenous.
Orthodontic implications
- Consultation is necessary with the treating cardiologist/physician before any orthodontic and dental intervention. This will minimize any risk in the future that arises due to orthodontic or dental care, and such a protocol develops a better understanding of the patient’s present and future medical requirements.
- A dental procedure such as routine injection through noninfected tissues, recording dental radiographs, placement of removable orthodontic appliances, adjustment of orthodontic appliances (fixed/removable), and placement of orthodontic brackets does not warrant antibiotic prophylaxis.
- Bonding is preferred over banding. Excessive adhesives around the brackets should be removed.
- For the ligation of archwires, elastomeric ties are preferred over stainless steel ligature ties to prevent any injury to the oral soft tissues.
- All orthodontic appliances or accessories like edges of bands, hooks, and molar tubes should be smoothened and polished to minimize any irritation or injuries.
- Fixed acrylic orthodontic appliances such as rapid maxillary expansion appliances and the Nance button should be avoided, as they tend to increase oral microbial colonization in and around these appliances.
- Patients are encouraged to maintain the highest level of oral hygiene. It is good practice to use 0.2% chlorhexidine mouthwash during orthodontic treatment to reduce the oral microbial load (Jena et al., 2004).
- For more invasive procedures like orthognathic surgery, the patient should be counseled about the risks and benefits of antibiotic prophylaxis and the sign and symptoms of IE.
Thrombocytopenia
Thrombocytopenia is a medical condition related to reduction in the circulating blood platelet count as a result of bone marrow disruption (Lee and Lee, 2016). The bone marrow suppression could be secondary to the malignancy of the bone marrow or an autoimmune condition (Lee and Lee, 2016). Gingival bleeding could be the first or, in many cases, the only clinical sign with which the patient presents (Sugiura et al., 2018; Sharan et al., 2022). Patients with a confirmed diagnosis of thrombocytopenia most often are on chemotherapy or radiotherapy, which might affect their somatic growth, thus affecting stomatognathic growth too. The altered stomatognathic growth can manifest as mandibular retrognathism, a decrease in the vertical facial dimension, microdontia, a V‐shaped pattern of roots, anomalies in root development, and a decrease in the height of alveolar processes of maxillary and the mandibular bone. All these changes have great impacts on the successful outcome of orthodontic care in patients with thrombocytopenia (Patel et al., 2009; Mituś et al., 2015).
Orthodontic implications
- Consultation with the treating oncologist/physician before commencement of orthodontic care is important to know the details of the patient as well as the associated risk factors that can arise during treatment.
- If the patient has been diagnosed with a malignant disorder of bone marrow such as leukemia before the commencement of orthodontic care, the treatment should be delayed until comprehensive chemo‐ or radiotherapy is over and at least two years have elapsed after bone marrow transplantation.
- These patients have reduced resistance to infection, and at the same time there is a decrease in saliva formation. Such a scenario increases the risk of dental caries (Jena et al., 2004).
- If the medical issue is diagnosed during orthodontic treatment, it is advisable to get in touch with the treating medical oncologist/physician and discuss in detail the need for future orthodontic treatment and progress of treatment. Most cases require removing all existing orthodontic appliances to prevent any soft tissue irritation or injury (Sheller and Williams, 1996). Comprehensive orthodontic treatment can only be commenced when all treatment is over and the patient has had a minimum two years of event‐free survival. Before commencement of orthodontic treatment, orthodontists should consult the treating physician and get clearance about patient fitness.
- Orthodontic treatment and mechanics should be kept simple, and the applied force should be gentle and mild to prevent any side effects during comprehensive treatment. Orthodontic appliances should be nonirritating and patients should be advised to use relieving wax. Patients are advised to meticulously keep the highest possible level of oral hygiene to prevent gingivitis and other related issues.
- In growing patients, growth modulation might have a questionable prognosis, as this medical condition might affect stomatognathic growth.
- Imaging of tooth and craniofacial structures is a regular norm in such patients as they have an increased incidence of root resorption, which might affect the orthodontic treatment (Sheller and Williams, 1996; Dahllöf and Huggare, 2004).
- Stainless steel brackets should be avoided as the cytotoxicity is more due to the release of corrosion products (free radicals).
Endocrine disorders
Diabetes mellitus
Diabetes mellitus (DM) is a medical condition that is characterized by a group of metabolic diseases with hyperglycemia resulting from defects in insulin secretion, insulin action, or both (American Diabetes Association, 2018). Periodontal issues are most commonly seen in an individual with uncontrolled DM, which might compromise the tooth‐supporting tissues such as the periodontal ligament, gingiva, mucosa, and alveolar bone. In such a scenario, the normal or enhanced loading of the tooth and supporting structures might pose a risk. The current classification of DM is highlighted in Table 15.2 (Baymest, 2015).
Table 15.2 Current classification of diabetes mellitus (DM).
Adapted from Baymest (2015).
| Type 1 DM | Insulin‐dependent DM Most common among children and young adults Strict insulin management is a must or severe ketoacidosis might result |
| Type 2 DM | Non‐insulin‐dependent DM Usually seen in individuals >40 years Caused by insulin resistance and inadequate insulin secretion |
| Type 3 DM | Due to pancreatic beta‐cell destruction (chronic pancreatitis or pancreatic surgery) Due to decreased insulin production and simultaneous development of insulin resistance |
| Gestational diabetes | Usually seen during pregnancy Typically resolves postpartum |
Orthodontic Implications
- Well‐controlled DM is not a contraindication to orthodontic treatment. The orthodontist should be in touch with the patient’s treating physician/endocrinologist, and regular blood glucose levels should be monitored.
- Early‐morning orthodontic appointments are preferred. The patient should have a regular meal and take usual medications before the visit to the orthodontist (Patel et al., 2009).
- Orthodontists and the supporting team should be trained and in a state of readiness to deal with emergencies, such as hypoglycemia (Patel et al., 2009).
- Orthodontic force should be kept light and continuous (Patel et al., 2009).
- Faster orthodontic tooth movement may be due to the upregulation of osteoclast migration and activity and the downregulation of osteoblast differentiation (Braga et al., 2011).
- Patients should be kept on a strict oral hygiene protocol. They should be educated and encouraged to maintain the highest possible level of good oral hygiene. The importance of maintaining good oral hygiene is to be enforced pretreatment and during subsequent appointments. A periodontist may often be involved while treating adult patients with DM, for pretreatment and subsequent periodontal evaluation when the treatment progresses.
Table 15.3 Clinical manifestations of thyroid disorders.
| Hypothyroidism | Hyperthyroidism |
|---|---|
| Salivary gland enlargement Mouth breathing and thick lips Delayed bone resorption and tooth eruption Macroglossia and glossitis Anterior openbite Enamel hypoplasia in primary and permanent dentitions |
Increased bone turnover and accelerated tooth eruption Increased susceptibility to dental caries Increased susceptibility to periodontal disease Maxillary and mandibular osteoporosis Enhanced risk of development of connective tissue disorders such as Sjögren syndrome or systemic lupus erythematosus (SLE) |
Thyroid disorders
Hypo‐ and hyperthyroidism are caused by unregulated thyroid hormone synthesis by the follicular cells of the thyroid gland. The orthodontist often sees patients with thyroid disorders who present with various clinical manifestations (Pinto and Click, 2002; Chandna and Bathla, 2011; Table 15.3).
Orthodontic Implications
- The treating physician/endocrinologist should be consulted before the commencement of orthodontic care.
- The risk of root resorption is high in patients with hypothyroidism, so regular radiographic evaluation is a must before and during comprehensive orthodontic treatment (Maheshwari et al., 2012).
- In patients with hyperthyroidism, an effective stress reduction protocol must be followed. Early‐morning appointments are preferred.
- For pain management during orthodontic care, nonsteroidal anti‐inflammatory drugs (NSAIDs) and aspirin are usually avoided; instead, other groups of analgesics are preferred (Pinto and Click, 2002).
- In hyperthyroid patients the rate of tooth movement is increased, so judicious application of orthodontic force and selection of mechanics are musts (Maheshwari et al., 2012).
Infectious diseases
Human immunodeficiency virus and hepatitis B and C
The most relevant infectious diseases an orthodontist comes across are blood borne and include human immunodeficiency virus (HIV) and hepatitis B (HBV) and C (HCV). The risk of viral transmission after percutaneous exposure is highest for HIV, followed by HCV and HBV (Laheij et al., 2012). The risk of transmission through saliva is minimal in most cases unless the saliva is contaminated with blood.
Orthodontic implications
- The orthodontist and his/her support team should be immunized with the HBV vaccine, and postvaccination blood tests should be done at regular intervals for assessment of the adequate level of immunization.
- Universal cross‐infection precautions should be followed at the orthodontic office for every patient, irrespective of health status.
- Implementing a sharp equipment disposal protocol and infection control policy should align with the best practice guidance of infection control agencies.
- All instruments and equipment should be sterilized adequately.
- In the case of percutaneous exposure, incidence should be reported to the appropriate authorities, and follow‐up should be done as per the established guidelines.
COVID‐19
Recently, COVID‐19 infection has caused havoc worldwide and is caused by a nonsegmented positive‐sense RNA virus (SARS‐CoV‐2) encapsulated by a lipid bilayer envelope. This virus tends to affect the cells of the nasopharynx, alveolus, and gastrointestinal tract. Transmission of SARS‐CoV‐2 among humans is predominantly from the respiratory tract via droplets or, indirectly, fomites, and to a lesser extent via aerosol. By the nature of their profession, orthodontists are always at high risk of infection from patients, mainly the asymptomatic ones. Therefore, it is imperative to have details of travel history along with the details of medical history to rule out COVID‐19 infection. Patients who present with any of the symptoms of COVID‐19 must be advised to get the appropriate test done. Apart from that, patients’ COVID‐19 vaccination details must be recorded, and if they have not taken the full course of the vaccine they should advised to complete it (Sharan et al., 2020).
Orthodontic Implications
- During the active phase of COVID‐19 infection, the patient and treating orthodontist should use teledentistry for supervision of the ongoing orthodontic treatment and guidance in minimizing any complications (Sharan et al., 2022).
- Short‐term management of various orthodontic emergencies under the guidance of a treating orthodontist is mentioned in Table 15.4.
Table 15.4 Short‐term management of various orthodontic emergencies under the guidance of a treating orthodontist.
| Orthodontic emergency situations | Things for the patient to do under the supervision of the orthodontist |
| Ulcer of the lip/cheek from orthodontic wire and brackets | Apply a small amount of rolled soft orthodontic relief wax over the bracket/wire Apply local anesthesia/antiseptic gel over the ulcer Avoid oily, spicy, and hot food for a week or till the ulcer has healed |
| Loose or broken brackets, bands, and wires | If the band or bracket is broken yet still attached to the wire, it is better to leave it like that if it is not causing any discomfort until the next orthodontic appointment If it is causing irritation/discomfort to the adjacent soft tissue, put relief wax on the loose bracket Do not put any elastic on the broken band or bracket If the bracket or band is broken off, keep it in a safe place and bring it to the orthodontic clinic for the next appointment |
| Elastic “O” ring/ligature came out during brushing or eating | The elastic “O” ring/ligature can be placed back on the bracket using clean tweezers Or it can be removed with the help of tweezers if the patient thinks he/she cannot place it back |
| Stainless steel ligature become loose and/or is irritating soft tissues | A loose ligature can be removed with clean tweezers if it is not coming out, or using nail clippers it can be cut and taken out |
| Loose/broken elastic chain | This can be taken out with clean tweezers or cut with nail clippers |
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