Seizure disorders represent the most common serious chronic neurological condition, characterised by episodes of altered sensation, behaviour or consciousness. Epilepsy is a neurological condition characterised by two or more unprovoked seizures. According to a recent meta-analysis, the prevalence of epilepsy in pediatric and adolescent populations in India is estimated at 0.8%. For patients with a history of seizures, a comprehensive medical history, including the age of onset, frequency, duration, triggers and medication history, is essential.

• Risks and limitations : Patients with epilepsy are at risk for various dentofacial injuries, such as trauma to the tongue and buccal mucosa, facial fractures and temporomandibular subluxation during seizure episodes. ^, Parents or caregivers should be informed about these risks before initiating orthodontic treatment. Long-term use of anti-epileptic medications like phenytoin and sodium valproate can lead to side effects such as gingival hyperplasia, recurrent aphthous-like ulcerations, gingival bleeding, hypercementosis, root shortening, delayed eruption and cervical lymphadenopathy. Epileptic patients also tend to have a higher prevalence of carious and missing teeth compared to the general population due to challenges with motor skills that can impair their ability to maintain effective oral hygiene.

• Management precautions : Orthodontic treatment can be safely administered to patients with controlled seizures. Fixed appliances are preferred to minimise the risk of dislodgement and injury during seizures. However, metal appliances may need to be removed prior to magnetic resonance imaging (MRI) scans due to noise distortion, with ceramic or titanium brackets offering viable alternatives. ^, If removable appliances are indicated, high-impact acrylic should be used to prevent breakage and sharp fragment injuries. Bonded retainers should be avoided due to the potential for gingival enlargement, and aligners must have trimmed gingival margins.

Autism spectrum disorder (ASD) is a neurodevelopmental condition typically presenting within the first three years of life, often accompanied by varying degrees of intellectual disability ranging from mild to severe. ^, Individuals with ASD often face challenges in social interaction, deficits in verbal and non-verbal communication and the presence of repetitive and stereotyped behaviours, which can be compounded by an unsupportive environment, leading to behavioural outbursts.

• Risks and limitations : Studies reveal a high prevalence of malocclusions, particularly Angle’s class II and class III, open bite, increased overjet and crowding in ASD patients, often with higher Index of Orthodontic Treatment Need (IOTN) scores than non-ASD children. Moreover, individuals with ASD have higher rates of persistent parafunctional habits, including mouth breathing, biting of various objects and onychophagy. Increased overjet in class II malocclusions is associated with heightened dental trauma risk, emphasising the importance of early orthodontic intervention.

• Management : Orthodontic care for ASD patients requires effective communication, demonstration of trust-building procedures, positive reinforcement and behavioural modification techniques. Orthodontic treatment can be challenging, as it disrupts daily routines and increases the risk of caries due to compromised oral hygiene and plaque retention associated with orthodontic appliances. Treatments under general anaesthesia or conscious sedation have shown positive orthodontic treatment outcomes in ASD patients when tailored to their needs and supported by behavioural management techniques. ^, Saito et al. in 2013 used a resin reinforced removable NiTi springs for maxillary teeth retraction in an autism patient.

Attention deficit hyperactivity disorder (ADHD) is a neurological disorder marked by inattention, hyperactivity and impulsivity, affecting approximately 4% of children globally, with a male-to-female ratio of 3:1. Its prevalence is notably higher among orthodontic patients, ranging from 10% to 16%. ADHD has a multifactorial aetiology, with strong genetic contributions (80% heritability) and environmental factors such as prenatal nicotine and alcohol exposure, low birth weight and socioeconomic challenges. Symptoms often persist into adulthood, resulting in lifelong cognitive, behavioural and functional impairments.

• Risks and limitations : Children with ADHD are shown to exhibit poor oral hygiene, higher plaque scores, more decayed teeth and an increased risk of dental trauma. Non-nutritive sucking habits like nail biting, lip biting, pacifier use and bottle-feeding, as well as bruxism, are also more prevalent. These habits and prolonged pacifier use contribute to narrower dental arches, posterior crossbite, class II malocclusion, increased overjet and anterior open bite.

• Management : Orthodontic management of ADHD patients requires addressing their heightened anxiety, limited attention spans and difficulty adapting to new environments. Effective strategies include distraction techniques, behavioural shaping, a reward system and desensitisation to reduce fear. ^, Treatment plans should prioritise quick, efficient procedures and minimise frequent appliance adjustments or high patient compliance.

Cerebral palsy (CP) is a non-progressive neurological disorder resulting from brain damage during development, impairing motor function, posture and movement.

• Risks and limitations : Oral manifestations commonly include malocclusions such as open bite, increased overjet and class II relationships, alongside bruxism, dental trauma and drooling. ^, Variations of CP, including spastic (muscle rigidity, class II division 2 malocclusions), athetoid (involuntary movements, class II division 1 malocclusions), ataxic (coordination issues) and mixed types, pose unique challenges in orthodontic management due to associated physical and intellectual disabilities.

• Management : Orthodontic care for CP patients requires individualised treatment plans that consider motor limitations and cooperation levels. Techniques like the ‘Tell-Show-Do’ method, positive reinforcement and adjunctive therapies such as speech therapy and therapeutic horseback riding improve compliance and function. Multidisciplinary care involving orthodontists, paediatric dentists, speech therapists and caregivers is essential to address intellectual disabilities, persistent reflexes and compliance issues. Ongoing follow-ups, hygiene reinforcement and caregiver involvement further support successful outcomes tailored to the specific needs of CP patients. Comprehensive orthodontic treatment is rather impossible. Orthodontic treatment should focus on the most essential aspects of the problem and design systems that are not demanding and can work with fewer adjustments.

Body dysmorphic disorder (BDD) is a psychiatric condition characterised by obsessive preoccupation with perceived physical flaws, often minor or unnoticeable, classified under obsessive-compulsive disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). BDD prevalence among orthodontic patients ranges from 5.2% to 7.5%, with higher rates in individuals with multiple cosmetic procedures and those with higher educational levels. ^, Factors such as gender, age and marital status influence BDD, with single individuals more commonly affected. BDD is associated with significant psychological distress, social avoidance and dissatisfaction with cosmetic outcomes, often coupled with depression and anxiety.

Orthodontic challenges with BDD patients include unrealistic treatment expectations, dissatisfaction with outcomes and repeated procedure requests. Clear communication about realistic results is essential but may be hindered by mistrust. A multidisciplinary approach involving psychologists is key for addressing underlying issues. Early identification through psychological assessments allows for better management and improved outcomes, supporting patient-centred care.

Diabetes mellitus (DM) is globally prevalent, with the number of people living with the condition rising from 200 million in 1990 to 830 million in 2022. This increase has been particularly pronounced in low- and middle-income countries. Type 1 DM, or juvenile-onset diabetes or insulin-dependent DM, results from autoimmune destruction of pancreatic beta cells, leading to insulin deficiency. It accounts for 5%–10% of diabetes cases and is often diagnosed in individuals under 20, though it can develop later. Type 2 DM accounts for 90%–95% of cases and is characterised by insulin resistance, excessive glucagon secretion or inadequate insulin secretion. It typically develops after the age of 40 and is referred to as maturity-onset or non-insulin-dependent diabetes.

Around 4% of diabetic patients are first diagnosed with diabetes at a dental clinic, often through complications related to the condition. Oral manifestations of DM include xerostomia, frequent ulcerations, delayed wound healing, gingivitis, periodontitis, increased caries risk, altered taste sensation and recurrent infections such as oral candidiasis. A bidirectional relationship exists between diabetes and periodontitis through systemic inflammatory markers like interleukin (IL)-6, IL-1β, C-reactive protein (CRP) and tumour necrosis factor (TNF)-α, leading to periodontal breakdown. Furthermore, reduced bone turnover and density contribute to osteopenia, osteoporosis and altered responses of the periodontal ligament under orthodontic forces, making orthodontic treatment challenging in uncontrolled diabetes. With more and more adults seeking orthodontic treatment, a medical history of diabetes symptoms or a history of known conditions should alert orthodontists to have further investigations and take appropriate precautions.

The pituitary gland, the ‘master endocrine gland’ of the body, is responsible for secreting hormones that regulate growth, development, metabolism and the function of other endocrine glands. Dysregulation in the secretion of growth hormone (GH) can result in either excess or deficiency, affecting both skeletal and dental development. Multiple pituitary hormone deficiency (MPHD) is a condition characterised by the reduced secretion of all the hormones produced by the anterior lobe of the pituitary gland.

Slow growers and dwarfism

Orthodontic management of children with growth delays or dwarfism requires careful evaluation of their growth patterns compared to expected growth milestones for their age and their parents’ growth history. Growth hormone deficiency (GHD) and hypothyroidism can significantly affect craniofacial and dental development, presenting unique challenges for orthodontists.

Children with growth deficiencies often present with a reduced vertical facial dimension, immature facial appearance and midfacial hypoplasia. Radiographic analysis may reveal increased posterior facial height, a short cranial base and reduced mandibular length, particularly in the ramus and corpus, leading to micrognathic appearance. ^,

In hypothyroidism, there is delayed or disrupted eruption of teeth; the children may exhibit enamel hypoplasia, abnormal tooth morphology and delayed tooth development, leading to the need for early orthodontic intervention to manage issues such as anterior open bite or tooth malalignment. Other characteristics can include presence of macroglossia, dysgeusia (altered taste sensation), poor periodontal health and delayed wound healing. Cases presenting with such features must be suspected for hypothyroidism and referred to an endocrinologist for further investigations. A case of a 20-year-old female with diagnosed hypothyroidism and a positive history of gingival bleeding and macroglossia showed multiple unerupted teeth and retained deciduous teeth on orthopantomogram (OPG) investigation ( Fig. 93.1 ).

An OPG of a 20-year-old female, a known case of hypothyroidism, showing multiple unerupted teeth and retained deciduous teeth.

She had a positive history of gingival bleeding and the presence of macroglossia.

Source: Gupta R, Goel K, Solanki J, Gupta S. Oral manifestations of hypothyroidism: a case report. J Clin Diagn Res. 2014 May;8(5):ZD20-2. doi: 10.7860/JCDR/2014/8905.4379. Epub 2014 May 15. PMID: 24995258; PMCID: PMC4080079.

A 12-year-old boy in mixed dentition presented with a delayed eruption of his maxillary lateral incisors. A cephalometric analysis showed that the size of the Sella turcica was smaller than average. An orthopantomogram (OPG) revealed anoodontia of the left lateral incisor, as well as an unusually high positioning of the right lateral incisor. ( Fig. 93.2.i ). The eruption pattern was delayed to the patient’s chronological age. ( Fig. 93.2.ii ).

A 12-year-old boy with mixed dentition presented with a delayed eruption of his maxillary lateral incisors.

(A) An orthopantomogram (OPG) showed anodontia of the left lateral incisor and an unusually high positioning of the right lateral incisor. (B,C) A lateral cephalogram revealed an unusual shape of the sella turcica. The child was suspected of having a growth anomaly and was referred to a pediatric endocrinologist. He is currently undergoing treatment with growth hormone therapy.

The growth assessment by an endocrinologist showed reduced secretion of growth hormone.

The child appeared to have normal intelligence but was shorter in stature than his peers. During a detailed conversation with his mother, she expressed concerns about his short stature and suspected a growth abnormality. As a result, the child was referred to an endocrinologist, who diagnosed him with reduced secretion of growth hormone. He is currently undergoing growth hormone therapy. To facilitate the eruption of the impacted lateral incisor, the tissue obstruction was surgically removed under local anaesthesia.

This case highlights the importance of orthodontists being vigilant about overall growth, thoroughly reviewing X-rays, and analysing eruption patterns to reach a comprehensive diagnosis. It also underscores the vital role orthodontists play as part of the healthcare team.

Asthma is a significant non-communicable disease that affects both children and adults, making it one of the most common chronic disease among children globally. The frequent use of β2-agonists and corticosteroid inhalers by asthmatic patients contributes to xerostomia by reducing salivary flow. This, combined with a tendency for mouth breathing, increases the risk of oral health issues, such as dental caries, Candida infections, oral ulcerations and periodontal disease. Chronic asthmatic patients who develop persistent mouth breathing often experience impaired nasorespiratory function, leading to orofacial abnormalities and malocclusion.

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthritis of unknown aetiology that begins before age 16. The condition involves a progressive inflammatory process that leads to the destruction of various joints, including fingers, wrists, elbows, ankles, knees and hips, often affecting them symmetrically. The temporomandibular joint is also commonly impacted, as it serves as a crucial growth centre for the mandible. Damage to the temporomandibular joint (TMJ), particularly the condylar cartilage, can disrupt mandibular development, resulting in micrognathia, retrognathia and facial asymmetry, often accompanied by malocclusion.

Orthodontists play an essential role in the early identification of TMJ arthritis to mitigate joint damage. Warning signs include pain in the pre-auricular region, limited mouth opening and chin deviation. Advanced imaging, such as MRI and cone beam computed tomography (CBCT), is often necessary for further assessment. Patients with JIA frequently exhibit features like condylar lesions, a steep mandibular plane angle, mandibular retrognathia, anterior open bite and altered cephalometric values (e.g., large SNA and small SNB angles). ^, Early recognition and tailored interventions are critical for minimising long-term complications and optimising outcomes.

Management of JIA-related dentofacial deformities focuses on restoring function and preventing joint stress. Mandibular physiotherapy involving exercises for protrusion, opening and lateral movements is recommended. However, the use of functional orthopaedic appliances is controversial, as they may either protect or stress the TMJ. Similar debates exist regarding orthognathic surgery and class II elastics.

Fig. 93.3 shows a case of 15-year-old female diagnosed with JIA in her childhood. She had a mild convex profile and mild mandibular retrognathism, with class III molar and canine relations on the left side and mild crowding in both arches. The treatment was done by camouflaging and extraction of the upper first premolars and lower second premolars. Functional appliances and intermaxillary elastics or maxillary expansion were not considered to avoid undue stress on the TMJ.

Pre-treatment photos of a case of 15-year-old female diagnosed with juvenile idiopathic arthritis in her childhood.

She had a mild convex profile and mild mandibular retrognathism, with class III molar and canine relations on the left side and mild crowding in both arches.

Source: Ruslan AH, Roslan MA. Orthodontic management of a patient with juvenile idiopathic arthritis: a case report. Cureus. 2024;16(8):e66918.

Post-treatment photos.

The treatment was done by camouflaging and extraction of the upper first premolars and lower second premolars. Functional appliances and intermaxillary elastics or maxillary expansion were not considered to avoid undue stress on the TMJ.

Source: Ruslan AH, Roslan MA. Orthodontic management of a patient with juvenile idiopathic arthritis: a case report. Cureus. 2024;16(8):e66918.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disorder that predominantly affects young-to-middle-aged women. The condition presents diverse clinical features, including fatigue, malaise, myalgia, arthralgia (particularly involving the TMJ) and dermatological symptoms such as the classic ‘butterfly rash’ on the face. Orofacial manifestations include desquamative gingivitis, erosive mucosal lesions, oral ulcers and lichenoid plaques. Advanced cases may also involve Sjögren’s syndrome, presenting as xerostomia and dry eyes. These conditions increase the risk of dental caries, periodontal disease and oral infections.

Orthodontic and dental care for SLE patients requires a multidisciplinary approach, involving close coordination with rheumatologists. Comprehensive blood tests, including prothrombin time, platelet count and international normalised ratio (INR), are critical for assessing clotting abnormalities and determining the suitability of anticoagulant therapy in patients with SLE. This is particularly important as SLE patients are often at an increased risk of thrombotic events and bleeding complications. Additionally, given the potential for chronic SLE to cause renal failure, medications prescribed for dental procedures must be chosen in tailored dose especially those metabolised or cleared by the kidneys, such as NSAIDs and specific antibiotics.

Orthodontic treatment should proceed cautiously. For example, in one case, a 20-year-old female patient with SLE experienced severe intraoral lesions within days of initiating fixed appliance therapy, necessitating treatment discontinuation and intravenous steroid therapy.

Sjögren’s disease, known as Sjögren’s syndrome, is a chronic systemic autoimmune condition primarily targeting the salivary and lacrimal glands. It can occur in isolation (primary Sjögren’s) or in association with other autoimmune diseases such as rheumatoid arthritis or SLE (secondary Sjögren’s). The hallmark symptoms are dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia), often accompanied by fatigue, chronic pain and oral health complications such as candidiasis, dental caries and periodontal disease.

Orthodontic management approach

Patients should be advised to maintain meticulous oral hygiene and use sugar-free lozenges or xylitol to stimulate saliva production. Topical fluoride application before treatment initiation helps reduce caries risk, while clear aligners are not recommended due to the dry oral environment. Regular dental evaluations and proactive measures to maintain oral health are essential throughout treatment.

A 19-year-old girl has reported experiencing anxiety and pain in her left temporomandibular joint (TMJ), along with ringing in her left ear, tingling sensations in both palms, and a dry mouth. She has a history of recurrent stones in the submandibular duct and has undergone surgery twice for this issue. A CT scan revealed a 4 mm radiopaque shadow in the left submandibular gland duct ( Fig. 93.4 ).

A 19-year-old girl has reported experiencing anxiety and pain in her left temporomandibular joint (TMJ), along with ringing in her left ear, tingling sensations in both palms, and a dry mouth.

She has a history of recurrent stones in the submandibular duct and has undergone surgery twice for this issue. A CT scan revealed a 4 mm radiopaque shadow in the left submandibular gland duct. Note radiopaque shadow in circles. (A) Basilar view (B) , Sagittal view (C) , Coronal View. Based on the clinical history, Sjögren’s syndrome was suspected, and the patient was referred to a rheumatologist. She tested positive for antinuclear antibody (ANA). Orthodontic treatment was delayed, prioritising the treatment of rheumatoid arthritis.

Her occlusion appeared normal, aside from a crossbite involving the left maxillary canine, which caused functional deviation of the mandible during closure and resulted in TMJ pain. An oral examination showed low salivary flow, no caries, and healthy dental structures.

Given the reduced salivary flow, which could lead to recurrent submandibular duct stones and generalized weakness, the patient was referred to a rheumatologist with a suspicion of Sjögren’s syndrome. Her ANA test result was positive. Following further investigations, an expert confirmed the diagnosis, and appropriate treatment was provided.

Subsequently, orthodontic treatment was carried out using fixed appliances, which resolved the TMJ pain and other related symptoms.

This case emphasizes the importance of heightened awareness and a holistic approach by orthodontists in managing malocclusion and associated conditions, which may require referral to a specialist.

Multiple sclerosis (MS) is a chronic, progressive inflammatory disorder of the central nervous system, primarily affecting young adults, with a slightly higher prevalence in males. It involves lymphocytic infiltration, demyelination and axonal damage in the brain and spinal cord, with an autoimmune mechanism, genetic predisposition and environmental factors like viral infections contributing to its development.

Oral manifestations of MS include facial numbness, pain, facial paralysis, dysarthria, dysphagia and orofacial pain. Trigeminal neuralgia and temporomandibular disorders are more common in advanced stages. While dental treatment is not contraindicated, it should be performed during remission to minimise symptom exacerbation. Stress management is crucial as procedures and anaesthesia can worsen MS symptoms. Impaired motor coordination increases susceptibility to dental issues. Metals in orthodontic appliances may interfere with MRI, and medications used in MS management can affect orthodontic outcomes. Careful planning and multidisciplinary collaboration are key in treating MS patients.

Infective endocarditis (IE) is an inflammation of the endocardium that may affect one or more heart valves, the mural endocardium or a septal defect. This condition can potentially lead to intractable congestive heart failure and myocardial abscesses. Conditions such as ventral septal defect (VSD), patent ductus arteriosus (PDA) and tetralogy of Fallot (ToF) are categorised as high-risk patients for developing IE. One of the main aetiological factors for this condition is bacteraemia, which is often caused by dental procedures such as scaling, extractions and orthodontic banding. According to the American Heart Association (AHA) guidelines for preventing IE in association with dental procedures, prophylactic antibiotics should be administered 1 h before any procedure for patients with a history of bacterial endocarditis, prosthetic valves or cardiac transplants. ^,

Prior to orthodontic treatment, obtaining informed patient consent and a recommendation from the physician is essential. Maintaining excellent oral hygiene is crucial, and patients should be instructed on brushing, flossing and using chlorhexidine mouth rinses during orthodontic treatment. Orthodontic procedures such as separator placement, alginate impressions, mini-implant placement and exposure of impacted teeth may cause bacteraemia and require careful consideration. Bondable attachments should be used to maintain hygiene, and archwires should be tied with elastomeric modules to minimise mucosal irritation or injury. With advancements in orthodontics, clear aligners can be prescribed to the IE patients, on a prerequisite of maintaining a good oral hygiene.

Leukaemia is a malignant condition of lymphoid cells characterised by alterations in the number and form of leukocytes and erythrocytes. It constitutes 30% of all paediatric malignancies. With advancements in combined chemotherapy involving multiple agents, there has been a notable increase in survival rates for children with leukaemia.

Paediatric patients with leukaemia often present with dental developmental anomalies as a side effect of radiation therapy. These anomalies include tooth agenesis, localised enamel defects and root shortening. Additionally, the low regenerative capacity of the mucous membrane frequently leads to ulcerative lesions and infections. Xerostomia is prevalent in these patients, increasing their susceptibility to dental caries, gingivitis and stomatitis.

A physician’s recommendation is crucial before starting any dental or orthodontic procedures. No procedures should be performed during or immediately after chemotherapy. Orthodontic treatment should ideally begin two years post-bone marrow transplantation to allow for immune system recovery. In case of a patient developing fever and a positive history of gingival bleeding during course of orthodontic treatment, the clinician should suspect for leukaemic condition and the patient should be referred to the physician for further investigations.

Given their compromised immune resistance, regular monitoring for oral infections and dental caries is necessary. Developmental anomalies and impaired growth can complicate orthodontic treatment, especially with growth modulation appliances. Bonded attachments and nickel-free brackets are recommended to avoid cytotoxicity from stainless steel. Additionally, many leukaemia patients, due to immunosuppressive medication, may develop gingival hyperplasia, complicating oral hygiene and orthodontic care.

Thalassaemia is a genetic blood disorder characterised by reduced synthesis of either α or β polypeptide chains, leading to abnormal haemoglobin formation. This reduction results in anaemia and poor general growth. Patients with thalassemia are prone to increased bleeding episodes, fractures, hepatomegaly and frequent infections.

β-Thalassaemia can result in four clinical syndromes depending on the mutation on chromosome 11. β‐Thalassaemia minor, where β-globin is defective, but sufficient normal haemoglobin is present, with mild, microcytic, hypochromic anaemia. β‐Thalassaemia major with severe anaemia leading to dependence on blood transfusions. β‐Thalassaemia intermedia where symptoms of severity vary between major and minor; or a silent carrier state, with no clinical manifestation of the disease in spite of genetic changes being present.

Craniofacial deformities can develop in children with thalassaemia due to compensatory extramedullary erythropoiesis, which responds to low haemoglobin and red blood cell counts. Common craniofacial manifestations include frontal bossing, macrognathia of the maxilla, resulting in a ‘chipmunk face’ appearance, skeletal class II malocclusion, spaced dentition, dentinal hypoplasia and intrinsic teeth staining. Currently, no established guidelines recommend routine dental or orthodontic treatment for patients with thalassaemia, making orthodontic intervention elective rather than mandatory.

Orthodontic problems typically emerge early in life for these patients, and it is crucial to consult with a haematologist before starting treatment. β‐Thalassaemia major patients are dependent on transfusions and extreme care must be taken for their treatment. Conservative and minimal orthodontic treatment for efficient social and aesthetic purposes is enough in such cases. β‐Thalassaemia minor patients are considered as normal patients with mild reduction of haemoglobin. Growth modulation appliances can be effectively used to address dentofacial deformities during the initial phase of treatment. In cases of severe craniofacial deformities, segmental osteotomy may be required to reposition the premaxilla and correct the ‘chipmunk face’ appearance. Due to the spongy nature of maxillary cancellous bone in these patients, there is an increased risk of bleeding during surgery.

Thrombocytopenia is characterised by a reduction in blood platelet count, often caused by bone marrow disruption due to malignant or autoimmune conditions. A key oral manifestation of this condition is spontaneous gingival bleeding, which may occur even in individuals with good oral hygiene. Such symptoms should be taken seriously, and prompt referral for medical evaluation is essential. In children undergoing radiation therapy, thrombocytopenia can lead to stunted growth and craniofacial deformities. Commonly observed abnormalities include mandibular retrognathism, short vertical facial dimensions, reduced height of alveolar processes, root development anomalies, V-shaped roots and microdontia. ^,

During treatment, low-force mechanics should be employed to reduce the risk of root resorption. Lower arch treatment should be approached cautiously or avoided entirely, as the lower jaw is more susceptible to osteoradionecrosis due to its limited blood supply. Non-irritating clear aligners are the preferred choice for appliances, as they minimise the risk of mucosal irritation. Also, relief wax can protect the mucosa and ensure patient comfort. ^,

Although haemophilia patients present with normal bleeding time and platelet counts, their prothrombin time is prolonged, resulting in delayed coagulation. Haemophilia often presents with bleeding from multiple oral sites, including gingival and post-extraction haemorrhages, along with oral ulcerations and ecchymosis. Poor oral hygiene and iatrogenic factors can worsen bleeding tendencies, increasing the risk of periodontal issues. Patients may also face hepatitis risk due to frequent blood transfusions, necessitating strict infection control measures in dental settings, such as protective gear and sterilisation protocols. Invasive procedures should be performed with physician consultation, and extractions or surgeries are best done in a hospital with clotting factor administration. Pain management involves acetaminophen and avoiding NSAIDs due to bleeding risks.

Sickle cell anaemia (SCA) is a hereditary blood disorder caused by a mutation in the haemoglobin gene, producing haemoglobin S (Hb-SS) and causing red blood cells to adopt a sickle shape. This results in chronic anaemia, tissue hypoxia and vaso-occlusive crises. When the sickling gene is inherited in its heterozygous form, it is known as sickle cell trait, which is asymptomatic unless triggered by low oxygen levels. In its homozygous form, it manifests as SCA, a chronic haemolytic condition.

Patients with SCA often exhibit severe periodontitis, hypomaturation, hypomineralisation of enamel and dentin, pale oral mucosa, and delayed tooth eruption and dental development. Atrophy of tongue papillae and mandibular osteomyelitis are also common findings. ^, Additionally, muscular imbalance, absence of a labial seal and skeletal changes can lead to malocclusion. Radiographic findings may show intact lamina dura with areas of osteoporosis and a characteristic ‘step-ladder’ trabecular bone pattern in dentulous regions, absent in edentulous areas. Medullary hypoplasia may cause frontal bone thickening and increased maxillary growth, resulting in maxillary protrusion.

Elective procedures, such as extractions, should be undertaken cautiously, with preoperative medical evaluations and possible blood transfusions if haemoglobin levels are low. Antibiotic prophylaxis is recommended to prevent infections. General anaesthesia is best avoided due to its potential to lower blood oxygen saturation, making orthognathic surgery contraindicated. Vaso-occlusive episodes caused by sickled red blood cells, low oxygen saturation and ongoing haemolysis can lead to life-threatening complications. These systemic issues necessitate careful monitoring during dental and orthodontic care.

Haemangioma is a benign tumour characterised by the proliferation of blood vessel tissue. It commonly manifests in the buccal mucosa, lips and tongue but is less frequently observed in the masseter muscle and parotid gland and rarely in the maxillary and mandibular bones. Malocclusion associated with haemangioma in the jaw bone can arise from the degeneration of the alveolar bone, periodontal ligament and vascular supply to the pulp, leading to eruptive problems with permanent teeth.

A thorough clinical assessment is crucial before initiating orthodontic treatment for patients with haemangiomas, including the size, location and symptoms. Imaging studies, such as MRI or computed tomography (CT) scans, are often necessary to assess the extent of the lesion and its impact on surrounding structures. Hypertrophy of oral tissues caused by poor oral hygiene can complicate orthodontic treatment, requiring special precautions to avoid bleeding episodes, which may be life-threatening. The orthodontist should be very careful during clinical examination and treatment as any accidental injury by the probe or any fixed appliance component may result in uncontrollable bleeding. Haemostatic agents must be readily available during treatment, and materials that cause chronic irritation to the oral mucosa should be avoided.

Removable appliances can make oral hygiene maintenance difficult, increasing the risk of dental caries and infections. Fixed appliances, on the other hand, may cause ulcerations and bleeding episodes. Additionally, banding of the teeth can lead to plaque accumulation, gingivitis and occasional bleeding episodes, and should therefore be avoided.

Patients such as haemangioma of face should receive no or minimal surgical interventions. The treatment approach should consider non-extraction approach and minimal duration of treatment with appliance which are not likely to cause injury leading to uncontrolled bleeding. Fig. 93.5 represents a case of a 21-year-old female with haemangioma of the face undergone non-surgical and non-extraction treatment approach for orthodontic correction with acceptable social results at the end of the treatment.

A 21-year-old female with haemangioma of right side, centred on the right cheek and extended to the forehead, nose, upper lip and the angle of the mandible.

Intraorally, the right palate and alveolus presented swelling of the corresponding gingival tissue. Molar occlusion on right side had Angle’s class II relationship and left side had Angle’s class III relationship. She had a deep bite, and a highly placed left maxillary canine.

Source: Okayama A, Toshihiko F. A case of malocclusion caused by hemangioma. Orthod Waves. 2010; 69(3):123–8.

Post-treatment occlusion showing acceptable occlusal results done in short time period with minimal orthodontics, no surgical extractions and without intrusion of anterior teeth.

Source: Okayama A, Toshihiko F. A case of malocclusion caused by hemangioma. Orthod Waves. 2010; 69(3):123–8.

Table 93.1 summarises the common haematologic conditions, its diagnostic considerations and basic management strategies.

TABLE 93.1

Haematologic conditions, diagnostic considerations and basic management strategies

Condition	Diagnostic/pre-orthodontics considerations	Management strategy
Leukaemia	Obtain physician recommendation prior to orthodontic treatment.Avoid orthodontic treatment during or within two years of chemotherapy.	Growth modulation appliances and stainless steel (SS) brackets to be avoided. Gingival hyperplasia may cause difficulty in space closure.
Thalassaemia	Haematologist must be considered before starting the orthodontic treatment.	Growth modulation appliances can be used. Segmental osteotomy may be required to correct the skeletal deformity.
Thrombocytopenia	Physician consent must be taken. If the bone marrow transplant is done within two years, do not initiate orthodontic treatment	Orthodontic treatment must be discontinued, if the condition is diagnosed during the treatment.
Haemophilia	Record comprehensive medical history about the condition and medications. Obtain the latest blood reports and consult with physician.	Avoid chronic irritation that occurs by removable appliances and keep the orthodontic treatment for short duration.
Sickle cell anaemia	To get haemoglobin and oxygen saturation levels investigated.	Plan orthodontic treatment of limited duration. Avoid tissue irritation. Avoid procedures requiring general anaesthesia such as orthognathic surgery.
Haemangioma	Thorough clinical assessment must be done, including MRI and CT imaging to know the extent and location of the lesion.	Hypertrophy of oral tissues can make orthodontic space closure difficult. Haemostatic agents must be kept handy for bleeding emergency.

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