MEDICALLY COMPROMISED ORTHODONTIC PATIENTS

MDS, ORTHDONTICS
ORTHODONTIC CLINICAL MANAGEMENTS OF MEDICALLY COMPROMISED PATIENTS

1. MEDICALLY COMPROMISED ORTHODONTIC PATIENTS PRESENTED BY A.GEETHANJALI, II – YEAR – PG, DEPT. OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS

2. There has been an increase in the number of patients seeking orthodontic treatment. Some of them are medically compromised or on medications . Orthodontists need to be aware of these conditions and how to modify their protocol of treatment accordingly. They are obligated to coordinate with their patients' physicians about some orthodontic procedures and whether any modification to the treatment will be needed during the treatment. Orthodontists need to be aware of the possible clinical implications of these diseases. They must have a basic working knowledge of patient’s disease process and should inform the general physician about the type of procedures planned. Orthodontic treatment is not contraindicated in most of these conditions unless it is uncontrolled because the tissues' response to orthodontic treatment is jeopardized during the active or acute phase of an illness. Introduction

3. Cardiovascular Diseases

4. Infective endocarditis Bacterial endocarditis is a relatively uncommon, life-threatening infection of the endothelial surface of the heart, including the heart valves. The infection usually develops in individuals with underlying structural cardiac defects. It can occur whenever these persons develop bacteremia with the organisms likely to cause endocarditis. Both the incidence and the magnitude of bacteremia of oral origin are proportional to the degree of oral inflammation and infection Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

5. The association between IE and orthodontics has not been completely identified The actual data to support this hypothesis are sparse. McLaughlin and colleagues studied the incidence of bacteremias after orthodontic banding in 30 healthy adults. Importantly, the study cohort were in excellent periodontal health as defined as having a gingival/plaque index of less than 1. Elastomeric separators were placed 1 week before the placement of a single band on a permanent first molar. Bacterial cultures revealed that the frequency of bacteremias following banding was 10% compared with 3% in the preoperative sample. The impact of gingival health on bacteremias associated with band placement can be further appreciated when one compares the incidence of bacteremia following matrix band placement between individuals without gingival inflammation (0%) and those who had gingivitis associated was bleeding (32%). From a risk standpoint, it is interesting to note that the frequency of banding-induced bacteremias appears to be less than that reported for flossing (20%) or toothbrushing (25%) Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

6. Orthodontic management Since the risk of bacteremia is strongly associated with gingival bleeding, aggressive oral hygiene is a critical part of the orthodontic management of these patients. The presence of bands, brackets, and wires exaggerates the risk of gingival inflammation, especially in a youthful population for whom dental hygiene is not always a top priority. Hygiene assessment, with plaque disclosure, should be a routine part of adjustment visits. The importance of oral hygiene for oral and systemic health should be explained to the patient and parent. Elastomeric ties are preferable over ligature ties to secure arch wires in place. All sharp edges should be smoothed and polished , such as tubes and hooks. Excess adhesives should be removed and cleaned. Fixed acrylic appliances, like Nance and acrylic rapid maxillary expanders, should be avoided . Antimicrobial rinses such as chlorhexidine gluconate may be of value in temporarily reducing the oral bacterial load before the placement or removal of bands .

7. Before initiating orthodontic therapy in cardiac patients, the patient's IE risk is best determined by referring to the current American Heart Association guidelines and through consultation with the patient's cardiologist . Procedures that can lead to tissue injury or bacteremia should be avoided. Oral hygiene must be reinforced because inflammation influences bacteremia. The American Heart Association's committee found no significant risk for bacteraemia from adjustment of orthodontic appliances. Thus, prophylaxis is not recommended for routine adjustment of removable or fixed orthodontic appliances or placement of orthodontic brackets . Prophylaxis is recommended for any orthodontic procedures that might perforate oral mucosa or manipulate gingival tissues. These include insertion and removal of orthodontic bands, interproximal reduction, and placement of temporary anchorage devices . The antibiotic prophylaxis should be given as one dose before the procedure or up to 2 hours later. It should be prescribed for high risk patients including previous IE, prosthetic valve, valve disease in cardiac transplant recipients, unrepaired or incompletely repaired cyanotic congenital heart disease (CHD), and CHD repaired with prosthetic material for 6 months after the procedure Clinical Implications Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

8. Consultation should be done with the patient's cardiologist to determine the risk level and to arrange for a proper antibiotic prescription based on the orthodontic procedure intended: amoxicillin (2 g orally for adults, 50 mg/kg orally for children) is the first choice . Clindamycin (600 mg for adults, 20 mg/kg for children) can be used in case of allergy to penicillin; strict oral hygiene regimen should be followed during the treatment; bonded brackets are recommended over bands. If a patient forgets to take his or her premedication, or if unanticipated bleeding occurs, the American Heart Association guidelines suggest that antibiotic given at the time of treatment or up to 2 hours from the time of insult is effective. Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

9. Patients with Bleeding Disorders or Risk of Systemic Infection

10. Thrombocytopenia This condition results from a reduction of blood platelet count due to bone marrow disruption. This can be caused by malignancy of the bone marrow ( leukaemia ) or an autoimmune disease (aplastic anaemia ). Spontaneous gingival bleeding in the presence of good oral hygiene is considered to be one of the early signs of leukaemia . Both leukemia and aplastic anemia, not only affect stem cells that produce platelets, but they also eliminate the production of infection-fighting neutrophils, which results in neutropenia. Normal Platelet Count: 150,000 to 450,000 platelets per microliter of blood.  Thrombocytopenia: A platelet count below 150,000 platelets per microliter.  Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

11. The orthodontist might be the first specialist to recognize it and should refer the patient to a physician for consultation . In children, treatment of leukaemia by chemotherapy or radiotherapy reduces their growth rate, which is resumed after treatment. It also disturbs dental and craniofacial development , which can lead to some orthodontic problems including mandibular retrognathism , short vertical facial dimension, reduced height of alveolar processes, root development anomaly, V-shaped roots, and microdontia Orthodontic management The orthodontist must communicate efficiently with the patient's physician to determine the prognosis of the disease: if the diagnosis of leukaemia is confirmed before the orthodontic treatment, orthodontic treatment should be delayed until chemotherapy is complete and at least two years

12. growth modification to treat skeletal class II malocclusion has a questionable diagnosis . This is due to growth suppression as a result of radiotherapy . due to the high risk of root resorption , it is recommended to take an apical X-ray after six months of active orthodontic treatment . If the resorption is confirmed, treatment should be stopped for three months . All appliances should be adjusted to a passive state , and there should be no active orthodontic movement ; nickel-free brackets are recommended for cancer survivors . Stainless steel brackets produce cytotoxicity because of free radical production . This is a major concern for these patients because they are already immunocompromised and less resistant to infection due to anti-cancer therapy. Therefore, stainless steel brackets are not recommended for cancer survivors who need to undergo magnetic resonance imaging (MRI) repeatedly, steel brackets and arch wires distort the image. Thus, the use of aesthetic brackets or clear aligners is recommended since they cause minimal distortion ; for cancer patients in general, orthodontic treatment should start at least 2 years after the anticancer therapy because this period might have risk of cancer recurrence. Simple orthodontic treatment and compromised results should be accepted

13. Haemophilia This condition results from a deficiency of one of the blood clotting factors. Haemophilia A and B are caused by factor VIII and IX deficiency, respectively. Von Willebrand's disease is caused by a defect of Von Willebrand's factor In individuals with hemophilia, oral manifestations can include   frequent bleeding from multiple sites in the mouth, particularly gingival and post-extraction hemorrhages.  This can range from spontaneous bleeding in severe cases to prolonged bleeding after minor trauma or dental procedures.  Other oral manifestations include purpura, ulcerations, ecchymosis, and hematomas in the lips, tongue, and other oral tissues.  Hamad Alqahtani,.Medically compromised patients in orthodontic practice: Review of evidence and recommendations,International Orthodontics,Volume 17, Issue 4,2019,Pages 776-788,.ISSN 1761-7227

14. Orthodontic management Communications need to be shared with the patient's haematologist to minimize the risk of future problems: orthodontic treatment is not contraindicated for these patients strict oral hygiene should be followed; mucosal injury caused by the orthodontist or orthodontic appliances should be minimized . Sharp edges need to be smoothed, and excess wires should be cut. Self-ligating brackets are preferable over the conventional type . Arch wires should be ligated with elastomeric rather than wire ligatures. Treatment time should be as short as possible Removable appliances tend to cause more gingival irritation. Thus, fixed appliances are preferable . A non-extraction treatment plan and bonding over banding are advisable, if possible Hamad Alqahtani,.Medically compromised patients in orthodontic practice: Review of evidence and recommendations,International Orthodontics,Volume 17, Issue 4,2019,Pages 776-788,.ISSN 1761-7227

15. non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended for pain management since they can increase a tendency to bleed. Acetaminophen is a safer alternative. to minimize soft tissue trauma, it is preferable to make an impression with a non-metal tray to minimize trauma . During bonding, a saliva ejector is recommended to be placed on a gauze placed on the mouth's floor. clear aligners should be trimmed carefully to avoid gingival irritation Hamad Alqahtani,.Medically compromised patients in orthodontic practice: Review of evidence and recommendations,International Orthodontics,Volume 17, Issue 4,2019,Pages 776-788,.ISSN 1761-7227

16. Sickle cell anaemia This genetic condition is characterized by a mutation of the haemoglobin gene , which results in abnormal red blood cells. It decreases their plasticity and ability to pass through microcirculation . This increases the viscosity of the blood , obstructs capillaries, limits blood flow to organs, and eventually leads to pain, ischemia, and tissue damage. Common orthodontic problems include delayed tooth eruption, class II malocclusion, increased overjet and overbite, prognathic midface, prognathic maxilla, retrognathic mandible, increased vertical dimension, and convex profile Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

17. Orthodontic management Careful communication with the patient's physician is recommended: orthodontic treatment is not contraindicated; appointments should be scheduled early in the morning, and the patient should be in a chronic phase of the disease. Emotional stress should be minimized ; a non-extraction treatment plan is preferable, if possible; light orthodontic forces should be applied if possible. In the case of clear aligners, teeth movements should be reduced. This can be requested through the Invisalign ClinCheck service rest periods between activations should be included in the treatment plan to allow local microcirculation to be restored . It is recommended that they be worn longer than two weeks per aligne r; bleeding should be avoided during orthodontic procedures. If extra anchorage is needed, extra-oral anchorage is preferred over TADs or mini-plates , and the applied forces should be managed carefully

18. Thalassemia This condition is manifested by reduction of synthesis of a or b polypeptide chains that make the normal haemoglobin compound HbA. This reduces the amount of haemoglobin in red blood cells and causes anaemia . b-Thalassemia major (Cooley's anaemia ) is considered to be the most severe type. Orthodontic problems include skeletal class II malocclusion, small teeth size, reduced dental arch dimensions, everted lips, anterior teeth spacing and flaring, open bite, protrusion, maxillary enlargement, and increased overjet . Maxillary bone marrow undergoes hyperplasia more than the mandible, which causes a distinctive "chip munk face'' Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

19. Orthodontic management A haematologist should be consulted before the treatment: due to orthodontic problems that might occur at an early age, orthodontic diagnosis and interceptive treatment are recommended to begin early functional appliances and extra-oral appliances can be utilized to treat dentofacial problems in young patients -. In the case of using high pull headgear , it is recommended to apply a medium force in short intervals. -This is because thalassaemic patients are more prone to pathological fractures due to thin cortical plates. -In the case of a protruded premaxilla, the orthopaedic force should be directed anterior to the maxillary centre of resistance. This will produce a counterclockwise rotational and translatory movement to reduce the prominence of the premaxilla, incisors, and gingiva. -If the mandible is intended to be treated with growth modification, a combined twin block with high pull headgear for vertical control can be utilized

20. due to thin cortical plates, tooth movement must be monitored by the orthodontist for short intervals of time. Lighter forces than usual are highly recommended the distinctive thalassaemic facial appearance is mainly due to a maxillary problem. -Thus, segmental osteotomy is usually recommended to impact and set the premaxilla into an appropriate position. -Presurgical orthodontic treatment can be accomplished to close spaces and align incisor teeth. -These patients have a spongier maxillary cancellous bone . Therefore, they have more tendency to bleed during surgery. - This issue needs to be discussed carefully with the surgeon before starting the treatment. Sonis, Stephen. (2004). Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders, and asthma. Seminars in Orthodontics. 10. 277-280. 10.1053/j.sodo.2004.09.008.

21. Diabetes mellitus

22. Diabetes mellitus This condition is characterized by a persistent elevation in blood glucose (chronic hyperglycaemia ) due to insulin deficiency . Types 1 and 2 are the main types of DM. Type 1 results from insulin secretion deficiency. Type 2 results from insulin resistance and inadequate insulin production . Periodontal problems are the main concern for poorly controlled DM.

23. Oral complications in diabetic patients are considered major complications and can affect patients’ quality of life Oral manifestation: 1. Salivary gland dysfunction (Xerostomia). 2. Fungal infection (Candidiasis). 3. Recurrent oral infections. 4. Oral burning and test impairment (Ketone breath). 5. Poor periodontal health. 6. Multiple carious teeth. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

24. A periodontist should be involved , especially with adult patients, to evaluate periodontal condition before and during orthodontic treatment orthodontists and staff should be trained and ready to deal with any diabetic emergencies , especially sudden hypoglycaemia Orthodontic management Careful communication with the patient's physician is recommended: orthodontic treatment is not contraindicated for well-controlled DM . Thus, communication with the patient's physician is required to determine DM status before and during treatment appointments early in the morning are preferable , and the patient is encouraged to eat a regular meal and take usual medication before the visit light orthodontic forces should be used oral hygiene should be very well maintained and should be reinforced every time the patient is seen at the office. Also, any deterioration in oral health should be monitored at every visit. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

25. Thyroid disorders

26. Thyroid disorders Hyperthyroidism is caused by unregulated thyroid hormone synthesis. In contrast, hypothyroidism results from a reduction in thyroid gland function and its hormone production. Orthodontic problems with hyperthyroidism include high bone turn over and accelerated dental eruption . Orthodontic problems with hypothyroidism include anterior open bite, macroglossia, delayed eruption of teeth, impaction of the mandibular second molars, and low bone turnover Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

27. Orthodontic management The patient's primary physician should be consulted before the treatment to confirm the stability of the condition: a stress reduction protocol should be implemented with hyperthyroidism pain medications should be selected carefully with hyperthyroidism. NSAIDs and aspirin are not recommended, and alternative pain medication should be prescribed patients with hyperthyroidism tend to have an increased amount of tooth movement patients with hypothyroidism tend to have an increased risk of root resorption Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

28. Asthma This condition results from the narrowing of the airways , and occurs episodically. This leads to difficult breathing and wheezing, although these symptoms are usually, reversible. Xerostomia is a common problem with asthmatic patients due to prolonged use of steroid-containing inhalers. This makes them more prone to decalcification and periodontal problems Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

29. Orthodontic management This condition must be well controlled, and communication with the primary physician is crucial: stress and anxiety should be minimized since they might trigger an asthmatic episode . It is advisable to provide the patient with morning appointments and short visits, short waiting times, and avoid the supine position , if possible. the patient's usual medication should be used before the appointment, and an inhaler should be available to the patient during the appointment if needed. asthmatic patients tend to have an increased risk of external root resorption strict oral hygiene is advisable because of xerostomia aspirin and NSAID pain medications are not advisable because of a possible allergy to these medications. Acetaminophen is recommended for asthmatic patients. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

30. DiGeorge syndrome This syndrome is also known as 22q11.2 deletion syndrome (22q11.2DS). It is a genetic disorder that results from micro deletion in the long arm of chromosome 22. There are five common features associated with this syndrome: immunodeficiency due to thymic hypoplasia or aplasia, congenital heart defects, psychiatric disorders, developmental retardation, and hypocalcaemia due to parathyroid hypoplasia or aplasia . Orthodontic manifestations include a long face, retrognathic jaws, flat profile, open bite, prominent nose with low nasal bridge, small chin, short philtrum, micrognathia, low set of ears, malformed auricles, delayed dental development and eruption, enamel hypoplasia, and high prevalence of caries Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

31. Orthodontic management Orthodontic treatment should be coordinated with other medical and dental specialists to provide the best multidisciplinary treatment : patient's physician should be consulted regarding prophylactic antibiotic . In particular, if heart defects or immune deficiency exist; good oral hygiene is very crucial due to the high risk of caries and enamel defects; these patients tend to have a vertical growth pattern . There fore, well-timed orthodontic intervention is recommended. An open bite should be managed as early as possible by eliminating habits, including thumb sucking altered bone metabolism is caused by corticosteroids, commonly used by these patients. Thus, light orthodontic force is recommended, especially in expansion the bonding durability of brackets and attachments might be challenging due to the wide spread of enamel hypoplasia . More frequent orthodontic visits are recommended many patients tend to have some learning disabilities or mental retardation. Accordingly, orthodontic treatment options and duration should be managed wisely, based on the expected degree of compliance Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

32. HIV/AIDS Human immunodeficiency virus (HIV) is a bloodborne retrovirus which infects the immune system cells ( including T helper lymphocytes (CD4+ cells) and macrophages) resulting in acquired immunodeficiency syndrome (AIDS). Oral lesions are usually detected first in these patients. These lesions include hairy leukoplakia and oral candidiasis , which are associated with a high virus level and a low CD4+ cell number . Depending on the progress and stage of HIV infection, patients with HIV/AIDS may become medically compromised and require special considerations. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

33. Orthodontic considerations Changes in oral health care primarily based on HIV status are not supported. Nevertheless, individual assessment of each patient is required as HIV disease can present with a variety of oral and systemic clinical effects. PLHIV visiting an orthodontic clinic can be grouped into three categories: Patients who don’t know they are HIV positive; (b) HIV-positive but do not wish to disclose their HIV status to the orthodontist; (c) they know their HIV status and disclose it voluntarily. Since the possibility of exposure to unknown HIV patients is present, a general case history form that has a provision for a comprehensive assessment of the patient's health is needed. It helps to screen for medical problems , assess the risks to the patient associated with the provision of orthodontic treatment, and evaluate conditions and diseases that may necessitate modification of orthodontic treatment . Treatment should be prioritized to include alleviation of pain, restoration of function, prevention of further disease and consideration of esthetics. HIV infection is not a contraindication for orthodontic treatment. Patients with undiagnosed HIV infection have received successful orthodontic treatment , suggesting that asymptomatic HIV-infected patients respond to orthodontic treatment in the same manner as non-infected orthodontic patients. Patients’ overall health, stage of disease, presence of other co-infections and co-morbidities and willingness to cooperate influence the treatment planning. Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

34. Pointers in Orthodontic Treatment for PLHIV Unknown/undisclosed HIV-positive status: The practitioner should take a comprehensive patient history that can assess risk factors or risky behaviour for HIV infection. For asymptomatic patients, regular orthodontic treatment can be considered by employing standard precautions and infection control procedures. Treatment is deferred in the case of symptomatic patients. The patients should be advised to undergo HIV testing or to refer to a physician /designated HIV centre for suspected cases showing clinical indicators. Clinical symptoms can range from unexplained weight loss to lymphadenopathy to severe issues like Kaposi's sarcoma, opportunistic infections etc. as classified by WHO Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

35. Known HIV-positive status: For symptomatic patients, orthodontic treatment can be delayed till symptoms reduce and other systemic and oral conditions are treated. For asymptomatic patients, it is necessary to first assess if the patient is under ART . Those who are not on ART should be referred for the treatment of HIV. Coordination with the patient’s general physician will help in customizing treatment to fit the patients' health status. Certain tests may be advised to know patients' health status like CD4 counts for the level of immunodeficiency. The CD4 count should be > 500 per μl . Viral load to ascertain the potential transmissibility of HIV infection should be < 1000 copies/ml. Platelet count, bleeding and clotting time should be checked to look for bleeding tendency, which is a side effect of ART, especially if extraction treatment is planned. Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

36. A low absolute neutrophil count indicates susceptibility to infections. So based on the need, prophylactic or post-treatment, antibiotic therapy may be prescribed. If antibiotic therapy is required, drug interactions with anti-retroviral drugs or other medications that are used should be considered. Acetaminophen and aspirin should be used with caution. In fact, acetaminophen may worsen anaemia and granulocytopenia associated with the use of zidovudine (Retrovir) medication . Antibiotic prophylaxis is not mandatory for all HIV-positive patients. Standard precautions and infection control procedures should be implemented and screening for any developing oral manifestations should be done periodically. Xerostomia can occur due to ART. Artificial salivary substitutes can be given to manage the condition and additionally , fluoride supplementation can be prescribed to prevent caries from dry mouth. Chlorhexidine mouth rinses should be advised for oral hygiene maintenance. Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

37. Orthodontic management General orthodontic planning should include minimizing blood exposure, conservative and short duration of treatment (non-extraction treatment if possible), or less frequent appointments , removable appliances to permit oral hygiene and reduce gingival inflammation, emphasis on good oral hygiene and meticulous care of retainers and appliances . Removable appliances are made with polymethylmethacrylate ( PMMA) material, which has porosities due to the release of residual monomer after polymerization. These porosities provide areas for Candida to adhere to and form a biofilm. HIV-infected individuals are more susceptible to Candida infection because of their immune deficiency. This problem is exaggerated by orthodontic therapy. Therefore, the use of newer less porous thermoplastics in removable appliances [ PEEK ( Polyetheretherketone )] , and good oral hygiene maintenance will reduce Candida adhesion and colonization Bonded attachments can be preferred instead of bands during fixed appliance treatment and the use of stainless steel ligatures can be reduced to prevent ligature pricks. Composite and ceramic brackets show greater colonization of fungi because of the porosity and roughness of the material compared with metal brackets. Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

38. Studies to ascertain the prevalence rate of percutaneous injuries in orthodontists in the United States revealed less than one injury per orthodontist per year. The majority of the injuries happened outside the mouth, during archwire changes and involved the index finger and thumb. The rate of injury was less among practitioners with more experience. Sharp attachments/appliance surfaces and sharp wire ends should be avoided to prevent nicks and cuts in the patients' oral cavity as well as to the clinician. The use of self-ligating brackets will be beneficial in avoiding steel ligature ties . The above guidelines are not absolute and usually, the treatment has to be customized according to the patients' individual requirements. Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

39. Standard precautions according to the Centers for Disease Control and Prevention (CDC), USA include: antisepsis of hands; (2) use of gloves, masks, eyewear, face shields (PPA: personal protective equipment); (3) respiratory hygiene/cough etiquette; (4) safety protocols for working with sharp objects and their disposal; (5) safe injection practices; (6) sterilization of instruments, equipment and devices; (7) disinfection of surfaces and surrounding environments Saritha Madham , J Visshishta , Haritha Dasagari Vinod , Ojass Kumar S , Vishnu Priya Cherukuri A Review of Basic Knowledge of HIV Infection for Orthodontic Management of HIV Patients; Open Access Review Article,Cureus 2023

40. Post-exposure prophylaxis (PEP) First aid should be given immediately after the injury: wounds and skin sites exposed to blood or body fluids should be washed with soap and water, and mucous membranes flushed with water The need for PEP is decided by a scoring system that takes into account the type of exposure, whether the source is suspected or confirmed positive for HIV, and the stage of HIV infection. PEP is effective if taken immediately or within 72 hours of exposure . PEP must be taken for four weeks (28 days). PEP is started after taking informed consent. Psychological support and counselling are provided so that adherence to drug protocol is maintained. After exposure, HIV testing is done to establish a ‘baseline’ for comparing later results. Post-exposure follow-up is done with or without PEP to check for possible infections and to provide psychological support. The number of positive conversions after six months is negligible so no further test is advised after a negative test at six months. Anyone with PEP requirements should be evaluated for signs of positive HIV infection within 3-6 weeks of exposure. During the phase of PEP blood donation, breastfeeding and pregnancy should be avoided and measures to prevent cross-infection should be followed. Counselling on the necessity to complete the PEP regimen is provided.

41. Organ transplantation Transplant procedures can be performed for patients with advanced liver disease, complicated heart problems, and end-stage renal disease. Patients who undergo dialysis or trans plantation are susceptible to premature bone loss, defective bone trabeculae, demineralization, fracture of the maxilla and mandible, and resorption of periapical tissues . Chronic renal failure (CRF) can cause enamel hypoplasia and loss of non carious teeth Transplant patients use certain medications that might compromise their immunity and increase their susceptibility to oral and systemic infections. In particular, immunosuppressants are used more frequently by these patients to reduce host rejection, which affects bone metabolism and tooth movement. For instance, Cyclosporine can cause gingival enlargement, which can result in anterior diastema formation, traumatic occlusion, and impediment of the normal eruption of teeth . Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

42. Orthodontic management Communication with the medical team is crucial to identify the stage of the disease , the kind of organ transplant, and the medications used. This will help in determining the best time to start orthodontic treatment and aid in deciding whether medications can be altered or adjusted to control the gingival enlargement if the patient is seen before transplantation , he or she must be referred to the general dentist to treat and control all active dental problems ; in the case of chronic renal failure (CRF), orthodontic treatment can be executed in well-controlled patients . In the case of advanced renal failure and possible dialysis, orthodontic treatment should be postponed Orthodontic Treatment Should Not Be Initiated In The First Six Months Following The Transplantation . This is a very sensitive period for these patients since they receive the highest dose of immunosuppressants to oppose the transplant's rejection. Orthodontic treatment can be initiated after six months when the patient is in a stable condition, and there is no sign of transplant rejection Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

43. a minimal duration of orthodontic treatment is preferable. All orthodontic attachments and appliances should be removed immediately after they accomplish their objective during orthodontic treatment, pain medications should be selected carefully based on the physician's recommendations and the type of transplant long-term use of immunosuppressants may accelerate orthodontic movement . Therefore, orthodontic forces should be minimized, and the adjustment of orthodontic appliances should be performed more frequently cyclosporine-induced gingival overgrowth can interfere with orthodontic treatment . For instance, it can block tubes, deflect loops made by the arch wire changing force direction, and cause impingement of the springs. Thus, gingivectomy must be planned before and during the orthodontic treatment. Furthermore, this overgrowth can be exacerbated by chronic external factors such as mouth breathing, plaque, and orthodontic appliances. Therefore, strict oral hygiene protocol is required all the time Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

44. because of the gingival overgrowth, small low-profile brackets and bonded tubes are preferred over cemented bands. All composite should be cleaned thoroughly around the brackets and tubes. Moreover, all orthodontic attachments and appliances need to be seated away from the gingiva. Removable orthodontic appliances are prone to fitting problems because of the gingival overgrowth, which might interfere with retention clasps. For retention, fixed bonded retainers should be avoided. The Essix retainer can be used but needs to be relieved around the gingival margins the treatment plan should be simple, and a non-extraction treatment option is preferable because space closure can be difficult due to gingival overgrowth Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

45. The orthodontist may frequently encounter patients that require prolonged immunosuppressive therapy and orthodontic treatment. Usually, patients in the initial stage of these medications usage may be advised to delay orthodontic treatment, as there would be less bone remodeling , or orthodontic activation appointments should be scheduled at longer intervals. On the other hand, long term medication therapy may accelerate tooth movement , thus orthodontic appliances must be adjusted customarily, or with greater frequency. Medical follow-up with clinical and densitometry periodic exams are necessary in order to obtain more predictable and satisfactory orthodontic results. Santos RL, Lacerda MCM, Gonçalves RT, Martins MA, Souza MMG. Immunosuppressants: Implications in Orthodontics. Dental Press Journal of Orthodontics. 2012 Mar-Apr;17(2):55–61.

46. Seizure disorders These conditions result from involuntary, temporary, and sudden changes in neurologic function due to abnormal electrical signals generated by cerebral neurons . They can present as altered consciousness, behaviour , or sensation. Epilepsy occurs as a result of two or more seizures that are not due to acute brain dysfunction, neither provoked . Orthodontic problems include possible facial fractures, dental trauma, gingival hyperplasia due to anticonvulsant medications, facial asymmetry, and temporomandibular joint sub luxation. well-controlled seizure is not considered a contraindication to orthodontic treatment. Patients with poorly controlled seizures who have episodes of falling or uncontrolled movement of body parts are contraindicated to receive orthodontic treatment Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

47. Orthodontic management The patient's physician should be consulted about the stability of the condition, type of medication used, and history of the disease. This is to identify the type of seizure disorder to determine the extent of the orthodontic intervention it is crucial to explain the possibility of oral soft tissue lacerations and dental injuries that might happen during orthodontic treatment if seizure episodes occur Appliance Type Recommendation Fixed Appliances Preferred — safer during seizures; less risk of dislodgement or aspiration. Removable Appliances Use with caution — must have high-impact acrylic and extra retention to avoid breakage or aspiration. Clear Aligners Acceptable — should be carefully trimmed around gingival margins to reduce irritation. Bonded Retainers Avoided — may cause complications during seizures or imaging (e.g., MRI). Bracket Material Choice Plastic, ceramic, or titanium brackets preferred — to minimize MRI distortion and improve safety Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

48. ● Seizures occur in 5-10% of children with Down syndrome (Cooley et al., 1991). Generalized tonic clonic seizures are the most common. Seizures are diagnosed and treated similarly in children with and children without Down syndrome. ● Impressions using quick‑set materials with fun flavors should be used as these may reduce the tendency for activation of the more sensitive gag reflex frequently experienced with Down syndrome patients. ● High-memory wires allow a longer activation interval between appointments. Self-ligating brackets allow a more patient-friendly activation appointment. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

49. 🔷 Seizure Observed ↓ 🛑 Stop Procedure • Remove all instruments from mouth ↓ 🛏️ Position Patient • Place in supine position ↓ 🌬️ Airway Support • Head tilt–chin lift (if possible) • DO NOT place anything in mouth ↓ ❤️ Assess Vital Signs • Confirm breathing • Check for strong pulse ↓ 🛡️ Protect from Injury • Clear area around patient • Gently guide movements ↓ 👥 Engage Caregiver (if present) • Ask if seizure is typical → If yes: Monitor & support → If no/prolonged: Call EMS ↓ 📞 Contact EMS if seizure is atypical/severe SEIZURES IN DENTAL OFFICES Reed, K. L. (2010). Basic management of medical emergencies: Recognizing a patient’s distress . Journal of the American Dental Association , 141 (5 Suppl), 20S–24S.

50. Autism Spectrum Disorder (ASD) It is a neurodevelopmental syndrome which starts before three years of age and continues for life. This spectrum presents with Asperger Disorder (AD), autism, Pervasive Developmental Disorder, and Childhood Disintegrative Disorder (CID). This results in repetitive and limited behaviours in addition to impairments of communication and social interaction and responsiveness. Some other features include attention abnormalities , limited eye contact, limited speaking skills, abnormal sensory responses, reduction in visual attention to external stimuli, use of unconventional gestures, and limited ability to explore objects. Orthodontically, these patients have more malocclusion than normal people. In particular, they have a higher prevalence of class II malocclusion, increased overjet, high and narrow palate, posterior crossbite, open bite, and severe maxillary crowding. These traits might be attributed to persistent parafunctional habits, including bruxism, lip biting, pacifier use, and tongue thrusting. Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

51. Orthodontic management Due to reduced patient cooperation and lack of communication, orthodontic treatment needs tremendous effort to be executed: communication with the patient's caregiver is recommended to identify the child's educational approaches and implement them accordingly ; the orthodontist needs to work efficiently to gain the patient's confidence and compliance. For instance, the presence of parents, giving short and clear sentences, voice control, Tell-Show-Do technique, behaviour modification, and positive reinforcement can be utilized to improve communication and acceptance . This must be done over several visits before starting the orthodontic treatment desensitization techniques can be used to deal with autistic patients. In this approach, the patient is gradually introduced to the items used in the orthodontic office. This can be done over many visits to reduce the patient's anxiety and facilitate a successful approach

52. orthodontic procedures need to be evaluated regarding how procedures can be performed. In particular, some procedures can be conducted using behaviour management and protective stabilization (restraint). Others might need sedation, or even general anaesthesia ; since these patients have repetitive behavioural traits, this can help in orthodontic treatment. For instance, the use of removable appliances can be shown and incorporated into the patient's repetitive behavioural schemes. Thus, the patient can use these appliances, and the orthodontic result can be attained efficiently. This technique is called visual pedagogy . Therefore, removable orthodontic appliances are recommended for autistic patients. They should be as small as possible and be reinforced by wires

53. Mood disorders These disorders include bipolar and major depressive disorder (MDD). Common symptoms associated with MMD are hopeless ness, severe depression, lack of interest, loss of appetite, guilt, suicidal thoughts, gloom, and difficulty sleeping. Bipolar disorder (manic-depressive disorder) is characterized by alternating long episodes of mania and depression. Bipolar disorder can manifest with symptoms of MMD in addition to manic episodes, psychotic symptoms, mood swings, tantrums, distractibility, pressured speech, grandiose thoughts, racing thoughts, decreased sleep, irritability, and appetite changes Orthodontically, these patients tend to miss appointments, behave poorly at appointments, lack compliance, lose interest in treatment, and do not maintain good oral hygiene . Therefore, orthodontists should be vigilant about the psychological well being of their patients since orthodontists can detect early symptoms of some psychiatric disorders Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

54. Orthodontic treatment of children diagnosed with ADHD is challenging and requires the involvement of the patient's psychiatrist: due to poor compliance, some orthodontic tasks, including activation of appliances and placement of elastics, need more follow-ups and the involvement of parents and other family members. Strict oral hygiene is mandatory short appointments scheduled early in the morning are recommended. Frequent breaks during the appointment are beneficial to gain compliance and attention. Instructions should be simple and clear. The Tell-Show-Do method has a great impact on behaviour modification in these patients ; orthodontic treatment plans that require high compliance should be avoided

55. Disinfection For Various Impression Materials Mantena, S. R., Mohd, I., Dev, K. P., Sajjan, M. C. S., Ramaraju , A. V., & Rao, B. (2019). Disinfection of impression materials: A comprehensive review of disinfection methods . International Journal of Dental Materials, 1 (1), 7-16.

56. Numerous researchers have developed self-disinfecting impression materials by incorporating different antimicrobial nanoparticles in to impression materials. It was suggested that the silver nanoparticles with the average particle size of 80–100 nm impart superior antimicrobial property to the alginate hydrocolloid in a concentration-dependent manner than the finer nanoparticle size. the addition of greater than 1.0wt% of silver nanoparticles affected the flow, gelation time and strength of alginate impression materials . efficacy of Zinc oxide and Copper oxide nanoparticles were also proved to be effective self-disinfecting agents for alginate impression materials with no significant negative effect on physical and mechanical properties. METHODS THAT CAUSE DIMENTIONAL DISTORTION OF ALGINATE MATERIALS Steam autoclave Ethylene oxide gas autoclave Microwave disinfection Uv light disinfection Mantena, S. R., Mohd, I., Dev, K. P., Sajjan, M. C. S., Ramaraju , A. V., & Rao, B. (2019). Disinfection of impression materials: A comprehensive review of disinfection methods . International Journal of Dental Materials, 1 (1), 7-16.

57. Eating disorders Bulimia nervosa (BN) and anorexia nervosa (AN) are the most common eating disorders. BN is characterized by binge eating interspersed with compensatory behaviours , voluntary purging, enemas, laxative use, and excessive exercise. AN is characterized by excessive fear of becoming overweight and the inability to keep weight higher than 85% of expected weight Dental manifestations include teeth erosion, dental caries, raised occlusal restorations, dentinal hypersensitivity, xerostomia, and salivary gland hypertrophy Orthodontic management The orthodontist can be the first care provider who identifies signs of eating disorders. Thus, appropriate referral and confidential discussion are recommended. Cognitive-behavioral therapy  helps individuals change the unrealistically negative thoughts they have about their appearance and change their eating behaviors. Interpersonal psychotherapy  helps individuals improve the quality of their relationships, learn how to address conflicts head-on and expand their social networks. Nutritional rehabilitation, anti-psychotics and anti-depressants Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

58. Treatment Planning Considerations Minimize appliance-induced trauma : Use low-profile brackets and gentle force systems to reduce mucosal irritation, especially in patients with vomiting history. Avoid esthetic triggers : Be cautious with treatment goals that emphasize facial aesthetics, as this may exacerbate body image concerns. Shorter treatment phases : Consider segmental or phased treatment to reduce overall duration and improve compliance. During Treatment Enhanced oral hygiene protocols: Due to increased plaque and gingival inflammation risk, implement rigorous hygiene education and frequent professional cleanings. Salivary support: Recommend saliva substitutes or stimulants if hyposalivation is present. Nutritional monitoring: Maintain communication with the care team to monitor for signs of relapse or nutritional compromise. Koukou M, Javed F, Michelogiannakis D. Is there an association between fixed orthodontic treatment and initiation of eating disorders? A review of currently available evidence. Front Oral Health . 2021;2:707040

59. Allergies Latex allergies Allergy to latex is a common in dental office Atopic individuals are at increased risk of allergy. Allergic history should be evaluated during taking of case history. Two types of latex allergy are important; Type IV: is a late and localized reaction between 48 and 96 hours after the contact, skin rash with blistering and oozing of the skin , may extend beyond the area of contact of irritant. Type I: The most serious and rare form of latex allergy. It occurs from 2 to 3 minutes after contact and is caused by NRL proteins, rather than to chemical additives . Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

60. Orthodontic considerations ● In orthodontic treatment Self-ligating brackets to avoid elastomeric ties. Early morning appointments can reduce patient exposure to airborne natural rubber latex particles. Elastomeric separators can be replaced with self-locking separating springs. ● Some authors suggest administering prophylactic antihistamines, such as diphenhydramine, or corticosteroids, such as prednisone , before dental treatment to those at known risk ● Type IV allergy may be managed with topical corticosteroids. Mild type I reactions without respiratory distress can be treated with topical steroids and antihistamines (50 mg diphenhydramine 4 times a day until swelling resolves) while Severe type I required to emergency treatment . ● In latex allergy cases, use of powder free and low free latex protein gloves substitute with alternative ones made of other components such as nitrile, neoprene, vinyl, polyurethane, and styrene-based rubbers

61. Nickel allergies Nickel is the most common component of the super-elastic nickel-titanium (Ni-Ti) arch-wires used during the initial leveling and aligning phase of orthodontic treatment with a concentration of 47-50% . It is also a component in stainless steel (present in both arch-wires and brackets), representing approximately 8% of the alloy. Re-exposure to nickel can results in contact dermatitis or mucositis and develops over a period of days or rarely up to 3 weeks. Oral clinical signs and symptoms of nickel allergy can include the following: a burning sensation, gingival hyperplasia, angular chelitis , labial desquamation, erythema multiforme, periodontitis, stomatitis with mild to severe erythema, loss of taste or metallic taste, numbness, soreness of the side of the tongue Alqahtani H. Medically compromised patients in orthodontic practice: Review of evidence and recommendations. Int Orthod . 2019 Dec;17(4):776-788. doi : 10.1016/j.ortho.2019.08.015. Epub 2019 Aug 27. PMID: 31471239.

62. Orthodontic considerations ● In the rare event that the patient continues to manifest an allergic reaction, all stainless-steel arch-wires and brackets should be removed. If any severe allergic reaction develops, the patient should be referred to the physician. ● If diagnosis of nickel hypersensitivity is established, the nickel titanium arch wire should be removed and replaced with a stainless-steel arch-wire which is low in nickel content or preferably a titanium molybdenum alloy (TMA) and Resin coated Ni-Ti wires are also an option. ● Alternative nickel free bracket materials include ceramic, polycarbonate, titanium and gold. Fixed appliances may be substituted with plastic aligners in selected cases . ● Patients with a defined history of atopic dermatitis to nickel containing metals should be treated with caution and closely monitored during orthodontic treatment

63. COVID-19 infection Screening Patients: A questionnaire should be used to identify potential COVID-19 infection before a patient visits the dental office. Emergency vs. Urgency: Only non-deferrable urgencies should be managed in person (e.g., abscesses or severe pain), while orthodontic emergencies can often be handled remotely via messaging or video calls Virtual Assistance: WhatsApp and similar platforms are recommended for triaging emergencies and guiding patients remotely. Caprioglio et al. (2020). Management of orthodontic emergencies during 2019-NCOV. Progress in Orthodontics, 21:10 . .

64. Orthodontic Emergencies - Removable appliances (aligners, retainers): Patients should continue using them as advised unless broken. - Fixed appliances (brackets, wires): If loose or poking, patients can use wax, reposition with tweezers, or cut wires with disinfected tools. - Non-removable, patient-activated appliances (headgear, elastics): Use should be suspended to avoid complications. - Pre-activated appliances ( Forsus , Pendulum): Monitoring with photos every few weeks is suggested, with in-office visits only if pain or swelling occurs. Patient Communication: Reassuring patients and providing clear instructions remotely can reduce unnecessary in-office visits. Caprioglio et al. (2020). Management of orthodontic emergencies during 2019-NCOV. Progress in Orthodontics, 21:10 . .

65. high efficiency particulate air, HEPA filters

66. Conclusion Medically compromised patients can be seen and treated in the orthodontic clinic if their conditions are well-controlled. Communication with their physicians is very important before commencing orthodontic treatment. Orthodontists and staff are encouraged to have basic knowledge about these conditions and be prepared to handle any emergencies that might occur during orthodontic appointments.