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Medical disorders and orthodontics

Chesterfield Royal Hospital NHS Foundation Trust, Charles Clifford Dental Hospital, Sheffield, UK

Donald J Burden

Orthodontic Division, The Queen’s University of Belfast, UK

Jonathan Sandler

Chesterfield Royal Hospital NHS Foundation Trust, UK

Address for correspondence: Jonathan Sandler, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield Rd, Calow, Chesterfield, S44 5BL, UK., Email: jonsandler{at}aol.com

	Abstract

Top Abstract Introduction Cardiovascular system Respiratory system Neurological disorders Liver disease Endocrine conditions Renal disorders Musculoskeletal system Side effects of medication Allergies Eating disorders Summary References

 
The orthodontic treatment of patients with medical disorders is becoming an increasing aspect of modern day practice. This article will draw attention to some of the difficulties faced when orthodontic treatment is provided and will make recommendations on how to avoid potential problems.

Key words: Medical disorders, orthodontics, guidelines

	Introduction

Top Abstract Introduction Cardiovascular system Respiratory system Neurological disorders Liver disease Endocrine conditions Renal disorders Musculoskeletal system Side effects of medication Allergies Eating disorders Summary References

 
An increasing number of patients with complicated medical conditions and drug regimes are seeking orthodontic treatment. Progress in medicine, higher expectations of quality of life, increased life expectancy have resulted in a greater demand for elective dental and medical treatment.¹ Orthodontists need to be aware of the possible clinical implications of many of these diseases. In addition orthodontists see their patients every 6 to 8 weeks and rapidly developing medical problems can manifest themselves at any age. Orthodontists must remain vigilant as they may be the only health care professional seen by otherwise fit, young patients on a regular basis.

This article examines aspects of some of the conditions that are of relevance to orthodontic practice. A comprehensive medical history should be taken and regularly updated. Case notes should alert the clinician to the patient’s medical status. All medical conditions should be accurately understood before any treatment is planned and this may involve seeking guidance from the patient’s physician. Patients should be well informed of all the options and made aware that any orthodontic treatment has been planned with their best interests at heart. It should be highlighted they are not being penalized for their medical condition.² The importance of excellent oral hygiene should be emphasized to all patients considering a course of orthodontics.

	Cardiovascular system

Top Abstract Introduction Cardiovascular system Respiratory system Neurological disorders Liver disease Endocrine conditions Renal disorders Musculoskeletal system Side effects of medication Allergies Eating disorders Summary References

 
Infective endocarditis (IE)
IE is a rare condition with a high mortality and morbidity.³ The primary prevention of IE is very important. Antibiotic prophylaxis for such patients prior to an invasive procedure that could generate a bacteraemia has been a founding principle of dental practice for half a century, although the evidence of benefit is limited. Very few cases of IE are now secondary to oral streptococci and Staphylococcus aureus is now the most common pathogen.⁴

The lack of evidence from human models and changing clinical profile of IE has led several authorities to update their guidelines in recent years (Table 1). Most authorities across Europe and from the United States of America recommend the use of prophylaxis prior to invasive procedures in high-risk patients.^5–8

• The efficacy of antibiotic prophylaxis for IE has never been shown in a randomized trial. A Cochrane review concluded that there was no evidence to support the use of penicillin prophylaxis.¹⁰
  
• A direct link between routine orthodontic or dental procedures and IE has never been established conclusively. Although four cases of endocarditis have been reported in patients undergoing orthodontic treatment, no evidence was presented to confirm that orthodontic treatment was a causal factor.^11–13
  
• General dental and skin hygiene are probably more important for the prevention of IE.
  
• The use of antibiotics is by no means risk free.
  

Although prophylactic regimes suggest single dose administration, from which non-fatal side effects are usually minor, there is a risk of fatal anaphylaxis, which affects 12–25 people per million.¹⁴

Orthodontic considerations in patients with cardiovascular disorders

The orthodontist should communicate with the patient’s physician to confirm the risk of IE. The orthodontist should offer people at risk of IE clear and consistent information about prevention including the following factors: The risks and benefits of antibiotic prophylaxis and an explanation of why antibiotic prophylaxis is no longer routinely recommended in the United Kingdom. The importance of maintaining an exemplary standard of oral hygiene and that it is their responsibility to protect themselves. Regular supportive therapy from a hygienist is also advisable. The risk of using electric toothbrushes is poorly defined but a pilot study showed that brushing with a powered toothbrush results in a transient bacteraemia more frequently than brushing with a manual or ultrasonic toothbrush.15 The authors concluded that the resulting bacteraemia might affect patients with congenital heart defects at risk of bacterial endocarditis. However, their results show that vigorous brushing increased bacteraemia from brushing once but do not answer whether bacteraemia incidence would decrease with a program of vigorous daily brushing. Symptoms that may indicate IE and when to seek specialist advice. The risk of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing. The main orthodontic procedure that has been postulated to cause a bacteraemia has been placement of a separator.16 Lucas and co-workers investigated the bacteraemia associated with an upper alginate impression, separator placement, band placement and adjustment of an archwire on a fixed appliance. Blood samples were taken from randomly allocated orthodontic patients immediately before the intervention and then 30 s after the procedure. The mean total number of anaerobic and aerobic bacteria was significantly greater following the placement of a separator, compared with baseline blood cultures. There was no difference noted between baseline and taking an impression or placement of a band. Using similar methodology, Burden and colleagues did not detect a significant difference in the prevalence of pre-debanding (3%) and post-debanding (13%) bacteraemia.17 The authors concluded that this is lower than the prevalence of bacteraemia following toothbrushing and those procedures do not warrant antibiotic prophylaxis. The use of orthodontic bands and fixed acrylic appliances should be avoided whenever possible in high-risk patients with poor oral hygiene. A risk of bacteraemia induced by traction of unerupted, exposed and bonded teeth has been suggested. Lucas and associates studied the prevalence, intensity and nature of bacteraemia following upper arch debanding in 42 patients and gold chain adjustment in seven patients.18 The authors found no significant difference in the prevalence of bacteraemia between baseline and following debanding or gold chain adjustment. Admittedly the sample size for gold chain adjustment was small Any episode of infection in people at risk of IE should be investigated and treated promptly.

Haematology and patients with bleeding problems
Disorders of the blood, whether acquired or inherited can affect the management of orthodontic patients. Mild bleeding disorders are not problematic to the orthodontist but patients with severe disorders may require more care.

A history of a clinically significant episode is one that

• continues beyond 12 h
  
• requires a patient to call or return to their dental practitioner or seek medical treatment or emergency care
  
• results in the development of a haematoma or ecchymosis within the soft tissues
  
• requires blood product support.¹⁹
  

Inherited coagulopathies – deficiencies in clotting factors
Haemophilia is a common example of a clotting factor deficiency. Haemophilia A is a sex-linked disorder due to a deficiency of Factor VIII. When the Factor VIII level is less than 1% of normal, the condition is classified as severe.²⁰ Other bleeding disorders include Haemophilia B or Christmas disease (factor IX deficiency) and von Willebrand’s disease (defects of von Willebrand’s factor).

As well as problems with bleeding, these patients may be infected with HIV or hepatitis viruses because of the transfusion of infected blood or blood products before 1985. The methods of screening and manufacture have improved, but they do not rule out the risk of virus transmission entirely. The UK Department of Health (DoH) carried out a risk assessment concluding that all recipients of UK sourced plasma-derived coagulation factor concentrates used in the period 1980–2001 should be regarded as being at risk of developing variant Creutzfeldt-Jakob disease (vCJD) for public health purposes.²¹ Risk assessments have been carried by both the DoH and the World Federation of Haemophilia which could not identify any person with haemophilia who has developed vCJD.^22,23 Moreover, they concluded that routine dental treatment including minor oral surgery is unlikely to pose a cross-infection risk.

Orthodontic considerations in patients with bleeding disorders

Orthodontic treatment is not contraindicated in patients with bleeding disorders.24 A thorough history and close liaison with the patient’s haematologist, oncologist or physician will help reduce the risk of problems occurring. Patients should be encouraged to maintain excellent, atraumatic oral hygiene.25 If extractions or surgery cannot be avoided, the management of patients with haemophilia relies on careful surgical technique, including an attempt at primary wound closure and the following regimen to: increase Factor VIII production with 1-desamino-8-D-arginine vasopressin (DDAVP) replace missing Factor VIII with cryoprecipitate, Factor VIII, fresh frozen plasma or purified forms of Factor VIII antifibrinolytic therapy with transexamic acid or epsilon-amino caproic acid (EACA)25 Nerve-block anaesthetic injections are contra-indicated unless there is no better alternative and prophylaxis is provided to prevent the risk of a haematoma forming.26 Chronic irritation from orthodontic appliances should be avoided. Fixed appliances are preferable to removable appliances as the latter can cause gingival irritation.27 Self-ligating brackets are preferable to conventional brackets. If conventional brackets are used, archwires should be secured with elastomeric modules instead of wire ligatures.27 Care is required when placing and removing archwires.1 The duration of orthodontic treatment should be kept to a minimum to reduce the potential for complications.28

Sickle cell anaemia
This is a genetic disorder that is characterized by a haemoglobin gene mutation (HbS as opposed to HbA). Deoxygenation, for example during anaesthesia induces the red cells to deform into a sickle shape. This restricts their movement through capillaries and hence deprives the tissues of oxygen and in conscious patients causes intense pain. The disease is chronic and life expectancy is shortened to about 45 years.²⁹

Sickle cell trait is the term given to patients who inherit one of the genes of sickle cell disease but without developing the recurrent symptoms. It is not benign and can also have symptoms due to comorbidity and conditions that can lead to overheating, dehydration and sickling.

Sickle cell anaemia is more common in people of African origin where malaria is common but it also occurs in people of Asian and West Indian descent.³⁰

Treatment ranges from NSAIDs for milder vaso-occlusive crises to IV opioids.³¹ Acute chest crises are treated with antibiotics and blood transfusions to reduce the percentage of HbS in the blood. The risks of blood transfusions have been discussed above. Tetracycline may need to be given as an alternative to amoxicillin or flucloxacillin when the child develops multiple drug sensitivity. Chemotherapy³² and bone marrow transplants have also been advocated and these treatments come with their own list of orthodontic considerations.

Oral manifestations of sickle cell disease include enamel hypoplasia in the form of white spots on the tooth surface, dentinal hypomineralization, delayed tooth eruption, pale lips and oral mucosa and glossitis. Radiographic signs include osteoporosis and parallel trabeculae amidst teeth but not in edentulous areas.³³ Mandibular osteomyelitis in the absence of other problems can occur due to the limited blood supply. Vaso-occlusive crises can predispose the patient to pain and paraesthesia of the inferior alveolar nerve and the lower lip.

Orthodontic considerations in patients with sickle cell anaemia

Orthodontic treatment is not contra-indicated in sickle cell patients, provided the patient has no or very mild complications and the oral hygiene is excellent. Intervention in these patients favours a multidisciplinary approach involving the patient’s physician, haematologist, dentist, and family. Emotional stress should be avoided and care should be taken to ensure the surgery is well ventilated and at an ambient temperature.34 A non-extraction approach to treatment is preferred. If extractions are necessary they are best carried out in a hospital environment.34 General anaesthetics for elective procedures are contra-indicated and hence orthognathic surgery should not be recommended. If a GA in a sickle cell trait patient cannot be avoided careful oxygenation must be ensured. Patients with sickle cell disease itself may require a pre-anaesthetic transfusion so the level of haemoglobin A is at least 50%.35 The orthodontist should be aware of possible pulpal necrosis involving healthy teeth, the changes in bone turnover, mandibular vaso-occlusive crises, and the greater susceptibility to infections.34 It has been recommended that orthodontic forces should be reduced and rest intervals between activations should be increased to restore the regional microcirculation.34

Leukaemia
Leukaemia is divided into acute and chronic forms. Acute lymphoblastic leukaemia (ALL) is the commonest presentation in children accounting for 25% of all childhood tumours. The prognosis in children with ALL is better than that for adults for whom the long-term survival is low. Acute myeloblastic leukaemia (AML) is more common in adults than children and the prognosis is poor. The treatment for acute leukaemia includes chemotherapy or bone marrow transplantation (BMT). Total body irradiation (TBI) and immunosuppression are used to prevent graft-versus-host disease after BMT.

Chronic leukaemia involves the proliferation of more mature cells than those found in acute leukaemia. The prognosis is better and adults are more commonly affected than children. Chronic lymphocytic leukaemia (CLL) is more common and patients tend to be asymptomatic. Chronic myeloid leukaemia (CML) affects adults of a younger age group than CLL. The main signs of the chronic leukaemia tend to be splenomegaly and lymph node enlargement. Treatment is with chemotherapy and radiotherapy.

The sequelae of treatment may be immediate or may occur several months after treatment. These effects can be caused by the malignancy itself, by the treatment including chemotherapy, radiotherapy and supportive care such as transfusions, antibiotics and immunosuppressive treatment. The degree to which an individual is affected is related to the age at which the disease is diagnosed and treated and the type and intensity of the treatment. The growth rate generally declines in children during treatment for leukaemia. Soon after treatment the normal growth rate is resumed and catch up growth is sometimes seen. Growth hormone therapy has the capacity to improve the height velocity.³⁶ Bone density is frequently reduced in long-term survivors of childhood malignancies.³⁷ They also show acute and long-term complications in the oral cavity and in dental and craniofacial development. The most common dental disturbances are arrested root development with V-shaped roots, premature apical closure, microdontia, enamel disturbances and aplasia.³⁸ A common side effect of radiation is salivary dysfunction leading to xerostomia. Craniofacial disturbances were demonstrated by a case controlled study of 17 children treated for ALL with allogeneic BMT and TBI. The ALL group had reduced vertical dimensions of the face, alveolar processes as well as reduced sagittal dimensions of the jaws, characterized by mandibular retrognathism.³⁹

Orthodontic considerations in patients with leukaemia

Dahlöf and Huggare have produced an excellent review on the risk factors to be aware of when planning orthodontic treatment in long-term survivors of childhood malignancy.40 Before diagnosis Significant orofacial complications of leukaemia in children include lymphadenopathy, spontaneous gingival bleeding caused by thrombocytopenia (reduction in platelets), labial and lingual ecchymoses and mucosal petechiae, ulceration, gingival swelling, and infections. The orthodontist may be the first to notice signs of the illness.41 Patients presenting with spontaneous bleeding in the presence of good oral hygiene warrant an immediate referral to a physician.2 After diagnosis Orthodontic treatment should be postponed if the patient requires chemotherapy as the drugs can exacerbate the thrombocytopenia and agranulocytosis. After treatment It has been suggested that orthodontic treatment should be postponed until at least 2 years after BMT.2 By then the risk for relapse of the malignancy has diminished and the patient is no longer on immunosuppressive therapy. Additionally, the growth rate and the need for supplemental growth hormone have been assessed. In view of the fact that TBI can suppress growth, the prognosis for growth modification in skeletal Class II malocclusions is guarded.40 The treatment should be modified to reflect the patient’s medical condition and planned with the patient’s best interests in mind. There are no reports about any adverse effects of orthodontic treatment in these patients.42 Treatment mechanics should be aimed at minimising the risk of root resorption, keeping the forces low and accepting a compromised treatment result. There may be merit in treating the upper jaw only to reduce the risk of undesirable events.40 In patients with short blunt roots, it is wise to monitor the crown to root length after 6 months of fixed appliance treatment. If there is evidence of apical root resorption, treatment should be interrupted for 3 months. The appliance should not be removed but the archwire should be left passive so there can be no active tooth movement.43 Tooth extractions have been implicated in causing osteoradionecrosis (ORN) with a higher incidence in the mandible. There are no reports on the incidence of ORN after tooth extractions in children treated for malignancies. Atraumatic extraction techniques will also reduce the risk of ORN.44 The caries risk may be increased due to salivary dysfunction and as with all patients the oral hygiene should be of a high standard. Topical fluoride application and artificial saliva may be recommended. A further side effect of anti-cancer treatment is a reduced resistance to infections and atrophy of the oral mucosa. Even minor irritation from orthodontic appliances can lead to severe ulceration. Vacuum formed aligners may be the appliances of choice for selected malocclusions. If a patient requires additional chemotherapy or radiotherapy, appliances should be removed to reduce the risk for oral complications. Treatment can be recommenced when the patient is in remission with a good prognosis.27 Both the patient and parent should be counselled that this regime is being followed in the best interest of the patient.2 Removable retainers should fit well with little potential to be a source of irritation, ulceration or infection.2

	Respiratory system

Top Abstract Introduction Cardiovascular system Respiratory system Neurological disorders Liver disease Endocrine conditions Renal disorders Musculoskeletal system Side effects of medication Allergies Eating disorders Summary References

 
Respiratory disorders are common and the use of intravenous (IV) sedation and general anaesthesia (GA) for elective procedures may be contraindicated. The unwanted effects of prescribed drugs can also influence the orthodontic treatment of these patients.

Asthma
Approximately 300 million people around the world have asthma, and it has become more common in both children and adults globally in recent years.⁴⁵ The severity varies from mild to severe. In moderate cases episodes are severe but the patients are symptom free between attacks. In severe asthma the attacks are severe and the child is never asymptomatic and growth and lung function can be affected.

There has been a tentative link between orthodontically induced external root resorption and patients with asthma.⁴⁶ This increased prevalence of resorption was confined to mild root blunting and the researchers concluded that longevity or function of posterior teeth would not be adversely affected. Nonetheless patients should be informed of this risk prior to treatment.

Cystic fibrosis
Cystic fibrosis (CF) is the most common life limiting, childhood-onset, autosomal recessive disorder among people of European heritage. It affects the exocrine glands of the lungs, liver, pancreas and intestines, causing progressive disability due to multisystem failure. The cells are relatively impermeable to chloride ions and thus salt rich secretions are produced. The mucous is viscid and blocks glands of the respiratory and digestive systems. There is a non-productive cough that leads to acute respiratory infection, bronchopneumonia, bronchiectasis, and pancreatic insufficiency. Diabetes mellitus may be a complication and patients may have cirrhosis of the liver.^47,48 There is no cure for CF. Most individuals with CF die young: many in their 20s and 30s from lung failure; however, with advances in medical treatments, the life expectancy of a person with CF is increasing to ages as high as 40 or 50.⁴⁹ Heart and lung transplantation are often necessary as CF worsens. Oral effects include hypoplastic enamel and delayed eruption. In the 1970s there were several reports of tetracycline staining of teeth but alternative medications are now used.⁵⁰ A side effect of antibiotic treatment is the lower prevalence of dental disease.⁵¹

Relevance of drugs in respiratory disorders
The chronic use of corticosteroid inhalers can lead to localized lowered resistance to opportunistic infections. As a result of this oro-pharyngeal candidal infection may occur.⁵² To avoid this complication, patients should be advised to rinse and gargle with water after the use of their inhaler especially if wearing removable acrylic appliances.⁵³ Candidiasis can be treated with topical antifungal agents such as nyastatin. Additionally the regular use of inhaled corticosteroids can predispose the patient to an adrenal crisis if subjected to stress. The need for steroid cover is discussed in the general section on drugs and orthodontic treatment.

Beta-adrenergic agonist bronchodilators such as sal-butamol, antimuscarinic bronchodilators, cromoglycates and antihistamines can all produce dry mouth, taste alteration and discolouration of teeth.

Orthodontic considerations in patients with respiratory disorders

The patient’s physician should be contacted before treatment is commenced to evaluate the severity and prognosis of the problem.27 The orthodontist should ensure the patient has their inhaler nearby.1 Patients may not be comfortable in the supine position if they have difficulty breathing.53 The first objective is to prevent acute asthmatic attacks. Treatment can be deferred in patients with poorly controlled asthma and with a history of multiple emergency room visits. It is best to minimize the factors that precipitate attacks in patients at low or moderate risk. Morning appointments when the patient is rested, short waiting and treatment times all help ease stress and anxiety.1 Orthodontic extractions should ideally be carried out under local anaesthesia (LA) with or without relative analgesia (RA) and not GA. If GA is required the patient must be in optimal health with no evidence of a respiratory infection.53 RA with nitrous oxide and oxygen is favoured to intravenous sedation (IV) since the former can be rapidly reversed.53 CF also affects the salivary glands and hence salivary flow can be reduced. These patients, as well as those with drug-induced xerostomia are at a higher risk of decalcification. Aggressive oral hygiene, supplemental topical fluorides, and vigilance for dental disease are necessary to combat these side effects.28 Patients with asthma should be prescribed non-steroidal anti-inflammatory drugs (NSAIDs) with caution as many asthmatic patients are allergic to aspirin like compounds. A retrospective, cohort study identified that patients younger than 40 years with a history of multiple respiratory reactions and prior reactions associated with aspirin and NSAIDs were more likely to have a positive oral aspirin challenge.54

	Neurological disorders

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It is important that orthodontists have knowledge of the most common neurological conditions as some problems may manifest initially in the orthodontic chair.⁵⁵

Epilepsy
Epilepsy is a common symptom of an underlying neurological disorder. The seizures can take a variety of forms and epilepsy is considered to be active if a person has had a seizure within the last 2 years or is taking anti-epileptic medication.⁵⁶

Brain damage due to injury, infection, birth trauma or a cerebrovascular accident accounts for 25% of cases. The other 75% of cases have no identifiable cause but there is a familial trend. Epilepsy can develop in some genetic syndromes such as Down’s syndrome⁵⁷ or in Sturge-Weber syndrome.⁵⁸

The risk of developing epilepsy is 2–5% over a lifetime. The prevalence of active epilepsy is between 5 and 10 people per 1000 of the population.⁵⁹ The condition is more common in men and the incidence is high in the first two decades of life, and then reduces before increasing after the age of 50 years as a result of cerebrovascular disease.⁵⁶

Hyperventilation, fever, photic stimulation, withdrawal or poor lack of compliance with anticonvulsants, lack of sleep, over-sedation, emotional upset and some medications such as antihistamines can stimulate attacks.

Both the condition and the medical management can affect oral health. Phenytoin was once the first choice in managing epilepsy in younger people but this has fallen out of favour because of its many side effects. These include nausea, mental confusion, acne, hirsutism, hepatitis, erythema multiforme and gingival overgrowth. However, the orthodontist may still encounter patients taking phenytoin. Alternatives such as carba-mazepine also have oral side effects including oral ulceration, xerostomia, glossitis and stomatitis.⁵⁶

Prevention of oral disease and carefully planned dental and orthodontic treatment are essential to the well being of patients with epilepsy.

Other forms of treatment for epilepsy such as surgery are unlikely to have implications for orthodontic care.

Orthodontic considerations in patients with epilepsy

Most people who have seizure disorders are able to undergo conventional orthodontic care in the primary care setting. Nonetheless, the orthodontist should ensure the patient has taken their normal anti-epileptic medication, is not too tired and has eaten normally before each appointment. The orthodontist should ensure the patient is receiving regular and rigorous preventative dental care to avoid/minimize dental disease. Patients should be aware of and consented for the risk of soft tissue and dental injuries as a result of a seizure.60 Gingival overgrowth associated with phenytoin is the most widely known complication of anti-epileptic medication, with 50% of individuals being affected within 3 months of starting the drug.61 Gingival hyperplasia is greater in those with high plaque scores but there is also a genetic link.62 Gingivectomy is recommended to remove any hyperplastic tissue that interferes with appearance or function. For patients with recurrent hyperplasia, the patient’s physician should be contacted to discuss alternative medication. Gingival hyperplasia resolves spontaneously within 1–6 months of phenytoin withdrawal.63 Removable appliances need to be used with caution as they can be dislodged during a seizure. It is not always possible to avoid the use of removable appliances. Wherever possible removable appliances should be designed for maximum retention and made of high impact acrylic.56 Trauma can also result in subluxation of the temporomandibular joints and tooth devitalization, fractures, subluxation or avulsion. If an individual with a Class II division 1 incisor relationship experiences an aura before a seizure, he or she should carry a soft mouth guard with palatal coverage and extending into the buccal sulci, to use at such times.56 The orthodontic team should be well trained in seizure management. Status epilepticus is a medical emergency and there should be given a benzodiazepine from the emergency drug kit.56

Multiple sclerosis (MS)
MS is a complex neurological condition that occurs as a result of damage to the myelin sheathes within the central nervous system. The damaged areas result in inflammation and interference in both sensory and motor nerve transmission.

MS is the most common cause of severe disability among young adults in the UK. It has an incidence of 0.1% (1 : 1000) in the general population.⁶⁴ The diagnosis of MS is usually made between the ages of 20 and 40 years. It is more common in women than men with a ratio of 3 : 2.⁶⁵ The prognosis depends on the subtype of the disease. The life expectancy of patients is nearly the same as that of the unaffected population, and in some cases a near-normal life is possible.

Subtypes of MS

Benign 20% of people with MS. Mild attacks followed by complete recovery and no permanent disability Relapsing/remitting 25% of confirmed cases. Remissions occur spontaneously, relapses unpredictable, some residual damage Secondary progressive 40% of cases. Follows on from relapsing/remitting phase and then remissions cease to occur. Usually 15–20 years from onset of symptoms Primary progressive 15%. Symptoms worsen and disability progresses.

The aetiology of MS is not understood and various environmental factors such as viruses, climatic factors have been implicated. It is not an inherited condition but there is a familial link.

The main symptoms relevant to oral care include pain and numbness of varying severity in the facial and oral tissues. The arms and hands can also be affected challenging the patient’s ability to carry out effective oral hygiene. Trigeminal neuralgia is atypical in that patients are younger, the pain may be bilateral and unstimulated. Indeed trigeminal neuralgia in people under 40 can be indicative of MS. Orthodontists should be aware of this and refer affected individuals for a neurological assessment.

Transient spasticity occurs when opposing muscles contract or relax at the same time leading to muscle stiffness, lack of coordination, clumsiness, muscle spasm and related pain. This can interfere with the safe delivery of orthodontic treatment and treatment should be delivered until the individual is in remission. Some patients also suffer from a tremor making satisfactory oral hygiene problematic.

There is no cure for MS. The focus of treatment is on the prevention of disability and maintenance of quality of life. Drugs, physical treatments and psychological techniques are used. Steroids are often used to help a person over a severe relapse. A plethora of other drugs can be prescribed, several of which can cause dry mouth, ulceration, gingival hyperplasia amongst other symptoms.⁶⁶

Orthodontic considerations in patients with MS

Treatment should involve a multidisciplinary approach including the patient’s physician, neurologist, MS specialist nurse and care worker.67 Preventative regimes should be based on the nature of the individuals MS. Custom made toothbrush handles to improve grip and the use of electric toothbrushes to compensate for the loss of manual dexterity and coordination have been recommended.67 It is important to discuss with every patient with MS how he or she prefers to manage his or her symptoms. Appointments should be at their convenience, the environment kept at a comfortable temperature. Patients with spasms should be allowed to get out of the dental chair and move around to relieve them. Individuals with dysphagia should be treated in a semi-reclined position. Treatment objectives should be tailored to the patient’s condition. Patients with severe MS may be best treated to a compromised result. Removable appliances may not be tolerated well. In patients with poor coordination the use of intermaxillary traction may be contraindicated.

	Liver disease

Top Abstract Introduction Cardiovascular system Respiratory system Neurological disorders Liver disease Endocrine conditions Renal disorders Musculoskeletal system Side effects of medication Allergies Eating disorders Summary References

 
Liver disease can result from acute or chronic damage to the liver, usually caused by infection, injury, exposure to drugs or toxic compounds, an autoimmune process, or by a genetic defect. For most childhood liver diseases the cause is unknown.

The main effects of liver disease can be categorized into:

• coagulation disorders;
  
• drug toxicity;
  
• disorders of fluid and electrolyte balance;
  
• problems with drug therapy;
  
• infections.³⁵
  

Infections
Viral hepatitis is undoubtedly of importance to the orthodontist. Hepatitis B (HBV), hepatitis C (HCV) and hepatitis D are blood borne and can be transmitted via contaminated sharps and droplet infection. Aerosols generated by dental hand pieces could infect skin, oral mucous membrane, eyes or respiratory passages of dental personnel and patients. The main orthodontic procedures to result in aerosol generation are removal of enamel during interproximal stripping, removal of residual cement after debonding, and prophylaxis.⁶⁸

HBV has an incubation period of 6 weeks to 6 months and a small number of infected persons can progress to the carrier state associated with chronic active hepatitis and eventually cirrhosis. Hepatitis B Surface Antigen (HBsAg) is the first sign of infection. Antibody to HBsAg is associated with protection from infection. Hepatitis B Core Antigen (HBcAg) is detected by the development of an antibody to it. If the person is HBsAg negative but HBcAg positive they are infective. Hepatitis B e Antigen is only found if HBsAg is present and is an indication of infectivity.

Orthodontic considerations in patients with liver disease

General liver disease Care should be taken when prescribing any medication for patients with liver disease. Hepatic impairment can lead to failure of metabolism of some drugs and result in toxicity.69 Patients undergoing liver transplantation will be receiving immunosuppressive drugs that can cause gingival hyperplasia. This effect is discussed in more detail on the section on medication. Haemostasis will be affected and this should be accounted for when planning treatment. Hepatitis All patients should be treated as though they are infected and universal cross-infection control precautions should be taken. Several studies have shown that orthodontists are more complacent than general dental practitioners with regard to cross-infection.70 All members of the team should be immunized against HBV. A booster is required in those with anti-HBs level less than 100.69

	Endocrine conditions

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Diabetes mellitus (DM)
The term DM is characterized by chronic hyperglycaemia. There are two main categories of DM:

Type 1 DM, (insulin dependent, IDDM or juvenile-onset diabetes) results from defects in insulin secretion. The onset is usually before adulthood and accounts for approximately 5–15% of all people with DM. Type 1 DM occurs more frequently in people of European origin than non-European origin. It is life threatening if not treated with exogenous insulin.

Type 2 DM (non-insulin dependent NIDDM or mature-onset diabetes) develops as a result of defects in insulin secretion, insulin action or both. There is a link with being overweight. Type 2 DM usually appears in people over the age of 40, although in South Asian and African-Caribbean people often appears after the age of 25.⁷¹ However, recently, more children are being diagnosed with the condition, some as young as seven.⁷² This form of DM is also more prevalent in less affluent populations. It accounts for 85–95% of all cases of DM. It is not usually life threatening but chronic complications can affect the quality of life and reduce life expectancy.

Gestational diabetes is similar to type 2 DM in that it involves insulin resistance; the hormones of pregnancy can cause insulin resistance in women genetically predisposed to developing this condition. Gestational diabetes typically resolves with delivery of the child, however types 1 and 2 diabetes are chronic conditions.

The prevalence of DM is increasing in the UK and worldwide. The World Health Organisation predicts that the global prevalence of type 2 DM will increase from 135 million in 1995 to 300 million in 2025.⁷³

DM is progressive and has potentially harmful consequences for health. Strict blood glucose control, lowering of blood pressure, together with a healthy lifestyle improves well being and protects against long term damage to the eyes, kidneys, nerves, heart and major arteries.⁷⁴

Oral complications include: xerostomia, burning mouth and/or tongue, candidal infection, altered taste, progressive periodontal disease, dental caries, acetone breath, oral neuropathies, parotid enlargement, sialosis and delayed wound healing. These complications can occur even when the blood glucose is well controlled due to impaired neutrophil function but are all more severe in uncontrolled DM.

Orthodontic considerations in patients with DM

Orthodontic treatment should be avoided in patients with poorly controlled DM as they are more likely to suffer from periodontal breakdown.27 Well-controlled DM is not a contraindication for orthodontic treatment. Rigorous preventative regimes should be put in place. The patient should be made aware of the consequences of poor oral hygiene and the increased risk of periodontal disease. Early morning appointments are least likely to interfere with the diabetes control regime. Patients should be advised to eat a usual meal and take the medication as usual prior to longer appointments. Diabetic related microangiopathy can affect the peripheral vascular supply, resulting in unexplained toothache, tenderness to percussion and even loss of vitality.75 It has been suggested that patients with DM should be treatment planned as periodontal patients. Light physiological forces should be used in all patients to avoid overloading the teeth. The orthodontic team should be trained to deal with diabetic emergencies. Hypoglycaemia is characterized by initial signs of tremor, nausea, sweating, anxiety, tachycardia, palpitations, shivering. The patient may complain of visual disturbance and/ or perioral tingling. If these warning signs are not recognized, a second group of neuroglycopenic symptoms occur. These include impaired concentration or confusion, irrational or aggressive behaviour, slurred speech, and drowsiness progressing to coma if untreated.Treatment in the orthodontic surgery75 Conscious 50 g of glucose as a drink, tablet or gel Unconscious 20 ml of 50% Dextrose IV or 1 mg of glucagon should be administered intramuscularly. When the patient is cooperative oral glucose should be given to prevent recurrent hypoglycaemia. If recovery is delayed, the emergency services should be called.

	Renal disorders

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Patients with kidney disorders are presenting more frequently in orthodontic practice due to improvements in medical care resulting in reduced morbidity and mortality.⁷⁶ The most common renal condition to present to the orthodontist is chronic renal failure (CRF).

CRF occurs after progressive renal damage. The symptoms and signs vary and can affect diverse body systems. Bone disease or renal osteodystrophy is an almost universal feature of CRF. Calcium metabolism is compromised by an elevated parathyroid hormone and by disruption in vitamin D metabolism. This results in secondary hyperparathyroidism. Renal disease also causes anaemia and marrow fibrosis leads to a reduced platelet count and poor platelet function. Haemostasis is impaired to varying degrees in patients with CRF.

Initially treatment is conservative with dietary restriction of sodium, potassium and protein. As the disease progresses dialysis or transplantation are required. Many patients are prescribed steroids to either combat renal disease or to avoid transplant rejection. Immunosuppressant drugs such as cyclosporine and calcium channel antagonists such as nifedipine are also taken to prevent transplant rejection. Immunosuppressants predispose the patients to infections. These drugs can also cause drug induced gingival overgrowth as discussed in the section on drugs and orthodontic treatment.

In children CRF leads to decreased growth and sometimes delayed eruption and enamel hypoplasia.

Orthodontic considerations in patients with renal disorders

Orthodontic treatment is not contraindicated in patients if the disease is well controlled. Treatment could be deferred if the renal failure is advanced and dialysis is imminent. If possible treatment could be carried out prior to transplantation to avoid the risks associated with immunosuppressant drugs. Appointments should be scheduled on non-dialysis days. The day after dialysis is the optimum time for treatment for surgical procedures as platelet function will be optimal and the effect of heparin will have worn off. Surgical procedures are best carried out under local anaesthetic. The anaemia and the potential electrolyte disturbances that can predispose the patient to cardiac arrhythmias can complicate general anaesthesia. Haemostasis is impaired as a result of platelet dysfunction Impaired drug excretion leads to the need for care with drug prescriptions. The value of prophylactic antibiotics in renal transplant patients on prevention of post-operative complications is questionable or unproven, with the Working Party of the British Society for Antimicrobial Chemotherapy (BSAC) stating that there is no need for antibiotic prophylaxis for dental treatment;77 however the decision to give prophylaxis should be made on an individual basis, in conjunction with the patient’s renal physician.78 These patients may be taking or have taken steroids but the use of supplemental steroids in dentistry is controversial and is discussed below in the section on drugs and orthodontic treatment. Animal models have also shown that orthodontic tooth movement is accelerated in rats with renal insufficiency.79 This was attributed to the increase in circulating parathyroid hormone. It has been suggested that orthodontic treatment forces should be reduced and the forces re-adjusted at shorter intervals.79

	Musculoskeletal system

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Juvenile idiopathic arthritis
Juvenile idiopathic arthritis (JIA) is a severe disease of childhood. It comprises a diverse group of distinct clinical entities of unclear aetiology. JIA is more common in Norway and Australia than in other countries. In Norway, the prevalence is 148.1 cases per 100,000 population and the incidence is 22.6 cases per 100,000 population.⁸⁰ A cross sectional, community based, point prevalence study reported a prevalence of 4.0 per 1000 in 12-year-old children in urban Australia.⁸¹

JIA is classified according to the type of onset of the disease and the number of joints affected during the first 4–6 months: pauciarthritis or oligoarthritis denotes four or less joints being involved and polyarthritis when five or more joints are involved. JIA can be of varying severity with localized and/or systemic complications, including functional impairment of the affected joints. This may result in disturbances in growth and developmental anomalies. There is remission of the disease in adolescence, which happens for 70% of patients.⁸²

The temporomandibular joint (TMJ) is affected in 45% of cases with JIA.⁸³ The diagnosis of TMJ involvement is more difficult than the other joints as the signs and symptoms are missing or weak.⁸⁴ Hence patients are most often seen when extensive changes have occurred. This can lead to the development of condylar hypoplasia, restricting mandibular growth resulting in mandibular retrognathism. JIA patients commonly present with skeletal Class II and open bite malocclusions.⁸⁵ Mandibular asymmetry is seen in cases with unilateral TMJ involvement.

Early orthodontic intervention facilitates both the skeletal and the occlusal rehabilitation. The prevalence of dental caries and periodontal disease is higher in adolescents with JIA cases. This has been credited to a combination of factors including difficulties in executing good oral hygiene, unfavourable dietary practices and side effects from the long-term administration of medication.⁸⁶ There are common human leucocyte antigen associations between periodontal disease and JIA which explains their similar inflammatory effects.

Treatment is aimed at controlling the clinical manifestations by suppressing the articular inflammation and pain, preserving joint mobility and preventing deformity. NSAIDs are used in the early stages. More severe cases are prescribed a variety of medicaments such as gold, methotrexate, corticosteroids and antimalarial drugs. These drugs have their own adverse effects which must be reflected on during orthodontic treatment planning.

Orthodontic considerations in patients with JIA

The main aim is to allow the child to live as normal life as possible. The functional ability of the TMJ in JIA children should be monitored closely in order to start medical treatment as soon as inflammation begins in the joint. The TMJ in a growing child has immense potential for structural changes and growth can normalize, provided the inflammation is controlled early and mandibular growth is supported.87 There is remission of the disease in adolescence for 70% of patients.88 There are no controlled human studies studying the efficacy of steroid injections on reducing the inflammatory activity in the TMJ; however, a study on rabbits with antigen induced TMJ arthritis did not show any positive long-term benefit of intra-articular steroid injections.89 Oral hygiene aids including modified toothbrush handles and electrical toothbrushes can be recommended to patients with JIA.90 A bite splint can be provided to unload the joint during any acute periods of inflammation. A distracted splint has also been suggested to modify mandibular growth in the same way as conventional functional appliances.87 The use of functional appliances in patients is a controversial area. It has been argued that functional appliances and class II elastics put increased stress on the TMJs and should be avoided;91 however, it has also been suggested that functional appliances protect the joints by relieving the affected TMJ, the aim being to move the mandible into the normal anterior growth rotational pattern thus correcting the skeletal Class II relationship.92 Surgery can be considered if the problem cannot be treated orthodontically; however, it has been suggested that mandibular surgery should be avoided and instead a patient with severe mandibular deficiency should have maxillary surgery and a genioplasty.28

Osteoporosis
Osteoporosis is a common progressive metabolic bone disease that decreases bone density and deterioration of bone structure. Osteoporosis can develop as a primary disorder or secondarily due to some other factor. It is most common in women after menopause, but may develop in men. Risk factors that cannot be altered include advanced age, being female, oestrogen deficiency after menopause,⁹³ and being of European or Asian origin.⁹⁴ Potentially modifiable risk factors include excessive alcohol intake, vitamin D deficiency, smoking,⁹⁵ low body mass index,⁹⁶ malnutrition, physical inactivity⁹⁷

Osteoporotic bone loss affects cortical and cancellous (trabecular) bone and animal studies have shown this process can result in decreased oral bone density and alveolar bone loss.⁹⁸ Both bone resorption and formation are accelerated and excessive bone resorption leads to loss of attachment. This theoretically can affect the rate of tooth movement.

Treatment modalities include medication, exercise, a diet sufficient in calcium and vitamin D and lifestyle changes⁹⁹ In confirmed osteoporosis, bisphoshonate (BP) drugs are the first-line of treatment in women. Oral BPs are poorly tolerated and are associated with oesophagitis. The chronic nature of osteoporosis necessitates long-term administration of BPs and therefore their safety is clinically important and requires some attention. A recent review of the literature identified 26 cases of osteonecrosis of the jaws (ONJ) in patients on oral BPs for the treatment of osteoarthritis.¹⁰⁰ This prevalence is relatively low compared with the 190 million patients with osteoarthritis and osteopenia on oral bisphosphonates.¹⁰¹

The main implications on orthodontic treatment are due to BP use and hence these are discussed in the section below.

	Side effects of medication

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Non-steroidal anti-inflammatory drugs (NSAIDs)
Pain control during orthodontics is an important aspect of patient compliance. In addition patients may be on pain relievers for a chronic illness. The effects of these medications on tooth movement have been studied.

Prostaglandins are important mediators in tooth movement and it has been suggested that the use of over-the-counter NSAIDs can affect the efficiency of tooth movement. A study to determine the effect of aspirin, acetaminophen (paracetamol) and ibuprofen on orthodontic tooth movement in rats showed acetaminophen did not affect movement whereas there was a significant difference between the control group and the aspirin and ibuprofen group. The authors suggest paracetamol may be the analgesic of choice in orthodontic patients.¹⁰² Their results suggested that NSAIDs reduce the number of osteoblasts by inhibiting prostaglandin synthesis. This led to the use of cyclooxygenase-2 inhibitors (COX-2) drugs, but the effects of these drugs on tooth movement can be very variable. The effects of three different COX-2 inhibitors on tooth movement in Wistar male rats showed that tooth movement was inhibited in rats treated with Rofecoxib. There was, however no significant difference in tooth movement between the control group (saline) and the other two COX-2 inhibitor groups; Celecoxib and Parecoxib.¹⁰³ Fortunately rofecoxib is now withdrawn from the market due to its cardiotoxicity. Orthodontists should be aware that products from the same class of drugs may have varying effects on orthodontic tooth movement.

Corticosteroids
These drugs are used for many inflammatory and autoimmune diseases. There are two main issues to consider when patients present with a history of corticosteroid use. Firstly, the use of supplemental steroids prior to dental surgery in patients at risk of an adrenal crisis is a contentious issue. The theoretical basis to this practice is that exogenous steroids suppress adrenal function to an extent that insufficient levels of cortisol can be produced in response to stress, posing the risk of acute adrenal crisis with hypotension and collapse. The UK MHRA (Medicines and Healthcare Products Regulatory Agency) and CSM (Committee of Safety of Medicines) together published recommendations in which appear not yet to have been superseded, that include ‘Patients who encounter stresses such as trauma, surgery or infection and who are at risk of adrenal insufficiency should receive systemic corticosteroid cover during these periods. This includes patients who have finished a course of systemic corticosteroids of less than 3 weeks duration in the week prior to the stress. Patients on systemic corticosteroid therapy who are at risk of adrenal suppression and are unable to take tablets by mouth should receive parenteral corticosteroid cover during these periods.’¹⁰⁴

In contrast various authors have suggested modified guidelines for the management of patients on steroid medications.¹⁰⁵ These authors reported on a number of studies confirming the low likelihood of significant adrenal insufficiency even following major surgical procedures. Patients on long-term steroid medication do not require supplementary ‘steroid cover’ for routine dentistry, including minor surgical procedures, under LA. Instead the blood pressure should be monitored throughout the procedure with IV hydrocortisone available in the event of a crisis.¹⁰⁶ Patients undergoing GA for surgical procedures may require supplementary steroids dependent upon the dose of steroid, duration of treatment and severity of the planned surgery.¹⁰⁵

The second factor to be aware of is that glucocorticoid therapy is known to affect bone turnover. Kalia and coworkers studied the effect of acute and chronic corticosteroid treatment in rats.¹⁰⁷ Their results indicate that bone turnover is reduced in subjects on acute corticosteroid treatment and increased in patients on chronic corticosteroid therapy. The authors postulated that it may be wise to postpone orthodontic treatment on patients on acute doses. They also suggested that orthodontic forces should be reduced and checked more frequently in patients on chronic steroid treatment.

Bisphosphonates (BPs)
These drugs are commonly prescribed to manage osteopenia and osteoporosis or to treat hypercalcaemia caused by bone metastasis in cancer patients (see Table 2). About half of the BP that is resorbed is excreted unchanged by the kidneys; the remainder has a high affinity for bony tissues and a reported half-life of 10 years. BPs inhibit the resorption of trabecular bone by osteoclasts and hence preserve bone density. Although their medical benefits have been proven, there are increasing numbers of side effects that can affect orthodontic treatment including delayed tooth eruption, inhibited tooth movement,¹⁰⁸ impaired bone healing, and BP-induced osteoradionecrosis (ONJ) of the jaws. The risk of side effects is greater if the dose is administered intravenously and on a long-term basis.¹⁰⁹

The pathogenesis of BP associated ONJ is not fully known. One suggestion is that hypodynamic and hypovascular bone is unable to meet an increased demand for repair and remodelling due to physiological stress (mastication), iatrogenic trauma (tooth extraction) or due to odontogenic infection. This can be exacerbated by the following factors:

• corticosteroid treatment;
  
• chemotherapy;
  
• medical co-morbidities such as diabetes mellitus;
  
• the presence of dental disease;¹¹¹
  
• dental extractions;
  
• oral bone surgery;
  
• poorly fitted dental appliances;
  
• smoking;
  
• alcohol abuse.
  

Radiographic signs include widening of the periodontal ligament space at the molar furcation areas and mottled bone consistent with osteolysis.¹¹¹

Orthodontic considerations in patients taking BPs

Amend the medical history form to identify patients who are taking BPs.112 Orthodontic treatment can only be considered after discussion with the patient’s physician and other medical specialists they may be under the care of. Ascertain why the patient is on BPs. Assess the risk of osteoradionecrosis via the route of administration, duration of treatment, dose and frequency of use.113 If possible treatment should be carried out prior to BP treatment. In patients at high risk of ONJ, it may be better to accept the malocclusion and consider the benefits of cosmetic dentistry.114 Discontinuing the drug prior to treatment may not be effective because of its long half life (risedronate, 480 h; alendronate, 10 years +; pamidronate, 300 days; zoledronate, 146 h).115 Patients on oral BPs are at a lower risk of ONJ or osteoclastic inhibition. Patients should be counselled about inhibited tooth movement, ONJ and impaired bone healing with elective surgery procedures. If orthodontic treatment is indicated, it should be planned to minimize risks including a non-extraction protocol favouring interproximal stripping to limit the treatment time and the degree of tooth movement and so treatment can be discontinued early if needed. Informed consent should outline all the risks associated with orthodontics and BPs.113 The clinician should look for signs of ONJ and the patient should be advised to have regular dental check-ups. Some clinicians suggest that one should try to avoid invasive laser therapy or temporary anchorage devices in treatment plans;112 however a recent study of implants placed in 61, female patients taking oral BPs for longer than 3 years, revealed no untoward postoperative sequelae. This suggests that patients who take oral BPs are no more at risk of implant or temporary anchorage device failure than other patients.

Drug induced gingival overgrowth (DIGO)
DIGO affects a proportion of patients on medication for hypertension, epilepsy and the prevention of organ transplant rejection. The clinical signs can vary in severity from minor overgrowth to complete coverage of standing teeth. These effects are compounded by poor oral hygiene but can occur in the absence of plaque.¹¹⁶ Drifting of teeth can also occur resulting in further aesthetic and functional problems for the patient.⁷⁸ The main drugs that cause DIGO are phenytoin, cyclosporine and calcium channel blockers including nifedipine, diltiazem, and amlodipine.⁷⁸

There are a few alternatives for reducing gingival overgrowth.¹¹⁷ One possibility is to have the patient placed on a different drug. There is usually spontaneous regression of the gingival hyperplasia provided the oral hygiene is excellent.¹¹⁸ Non-surgical techniques can limit the occurrence of DIGO, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. In some patients, however the drug is critical to control either their epilepsy, transplant, cardiac condition. In these cases intensive periodontal treatment with excision of the hyperplastic tissue is necessary.

Orthodontic considerations in patients with DIGO

Patients at risk of DIGO require a team approach with the patient, his or her physician, GDP, periodontist, hygienist and the orthodontist.76 Early liaison with the patient’s physician is recommended to investigate whether an alternative drug can be prescribed. Treatment should be aimed at reducing the risk of DIGO occurring or at least preventing the DIGO worsening. The recurring message is to ensure patients have excellent oral hygiene in order to reduce the risk of DIGO.117 A rigorous oral hygiene programme should be instigated from the outset and reinforced during treatment. A non-extraction approach is preferred in case treatment has to be terminated due to medical problems or exacerbation of the DIGO.76 Additionally, space closing mechanics including nickel titanium closing springs, elastomeric power chain or active ties can impinge on the hyperplastic gingival tissue. Archwire loops could have a similar effect and be displaced buccally, altering the direction of force.76 Small low profile brackets are recommended and the excess composite around the margins should be removed. Bands should be avoided if possible as they have been associated with significantly more gingival inflammation than bonded molars.119 Essix based retainers should be relieved around the gingival margins to maintain alignment. Bonded retainers should be avoided in patients at risk of DIGO.76

	Allergies

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Two key allergic reactions have been described in the literature. Type I hypersensitivity reactions are an immediate antibody mediated allergic response, occurring within minutes or hours after direct skin or mucosal contact with the allergen.¹²⁰ This reaction ranges from contact urticaria to full-blown anaphylaxis with respiratory distress and or hypotension.

A delayed hypersensitivity reaction (Type IV) usually presents with localized allergic contact dermatitis. It presents with diffuse or patchy eczema on the contact area and may be accompanied initially by itching, redness, and vesicle formation. The reactions are not life threatening but can cause permanent damage if not treated. The face, especially the lips and mouth, is more commonly affected in dental patients who develop a latex allergy.

Orthodontic staff should be trained in how to deal with an anaphylactic shock. Figure 1 illustrates the sequence of steps that have been outlined by the Resuscitation Council (UK).¹²¹

View larger version (44K): [in this window] [in a new window]   Figure 1 Anaphylaxis treatment algorithm – adapted from Resuscitation Council UK guidelines 2008

The immune response to nickel is usually a type IV cell mediated delayed hypersensitivity reaction. The first phase or sensitization to nickel is increasing with the increasing use of jewellery containing the metal. The prevalence of nickel allergy is estimated 11% of all women and 2% of men.¹²² Re-exposure to nickel can results in contact dermatitis or mucositis and develops over a period of days or rarely up to 3 weeks.¹²³ Fortunately most individuals with nickel allergy do not report reactions to orthodontic appliances containing nickel. A study by Bass and colleagues of 29 subjects (18 female and 11 male) revealed an initial positive skin patch test to nickel sulphate in five female patients only.¹²⁴ All 29 patients were followed over their fixed appliance treatment. None of the subjects including the positive test patients demonstrated an inflammatory reaction or discomfort as a result of orthodontic treatment. It is postulated that a much greater concentration of nickel in the oral mucosa than the skin is necessary to elicit an immune response. Nickel leaching from orthodontic bands, brackets, stainless steel or Ni–Ti archwires has been shown in vitro to occur within the first week and then decline thereafter.¹²⁵ Oral fluids, certain foods and fluoride media can corrode and accelerate the leaching process.¹²⁶ Concerns about sensitising orthodontic patients to nickel are not supported by the literature but there are a few case reports of localized allergic responses attributed to nickel containing orthodontic appliances.^127,128

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.¹²⁸

Orthodontic considerations in patients with a nickel allergy

A dermatologist should confirm a true nickel allergy. Patients with a defined history of atopic dermatitis to nickel containing metals should be treated with caution and closely monitored during orthodontic treatment.129 In patients with diagnosed nickel hypersensitivity and where intra-oral signs and symptoms are present the orthodontist should replace Ni-Ti archwires with one of the following: stainless steel archwires with a low nickel content; titanium molybdenum alloy (TMA) which is nickel free; fibre reinforced composite wires; pure titanium or gold plated wires. If the allergic reaction continues, all SS archwires and brackets should be removed. If the allergic reaction is severe the patient should be referred to a physician. Alternative nickel free bracket materials include ceramic, polycarbonate, titanium and gold.129 Fixed appliances may be substituted with plastic aligners in selected cases.

Latex allergy
The increase in allergic reactions to natural rubber latex over the past two decades has been accredited to the increased use of latex based gloves and universal precautions. Disposable medical gloves, particularly powdered gloves are the main reservoir of latex allergens. Orthodontic elastics used to apply inter-maxillary forces are another potential source of the latex protein. Both type I and type IV hypersensitivity reactions can occur. The prevalence of potential type I hypersensitivity to latex is lower than 1% in the general population and between 6–12% among dental professionals. For the purpose of this review only risks to patients will be discussed.

Patients at risk of allergy are those with a history of atopy such as hay fever; asthma; eczema; contact dermatitis and those with spina bifida.¹³⁰ Allergies to certain fruits such as banana, avocado, passion fruit, kiwi and chestnut can also indicate a potential latex allergy. They have proteins that are capable of cross-reacting with latex proteins and hence help sensitize the person to latex.¹³¹

Clinical tests, of which the skin prick test is considered most accurate, can determine the presence of circulating antibodies to latex. Multiple testing is recommended for increased accuracy of diagnosis.

Definitive diagnosis should be based on the medical history, and a positive skin reaction to specific chemicals present in natural rubber latex.

Orthodontic considerations in patients with latex allergy

Pre-diagnosis If a reaction to latex is suspected, patients should be referred to an allergist, clinical immunologist or dermatologist for testing. Post-diagnosis The orthodontic team including radiographers should be aware of the implication of treating latex allergy patients. The goal is to significantly reduce exposure to patients routinely. This can be done by cleaning the surgery more frequently with a protein wash, cleaning or changing the air filter more regularly.132 Latex free goods should be stored in a ‘latex-screened’ area to avoid prior contamination with latex products. Patients with a diagnosed allergy can be offered early morning appointments to reduce the exposure to airborne latex particle. The diagnosed patient should be monitored for signs of adverse reactions. The team should be capable of instigating prompt emergency care. The emergency drugs and resuscitation equipment should be free from latex.133

Latex free orthodontic materials

There are a number of latex free alternatives to commonly used orthodontic materials. Natural rubber latex is found in gloves, elastics, separators, elastomeric modules, elastomeric power chain, polishing rubber cups, band removers and masks with latex ties. Synthetic non-latex gloves made from nitrile, polychloroprene, elastyren and vinyl, are readily available for clinical use. Both latex free and latex gloves have to meet the European standard for single use medical examination gloves. Russell and coworkers reported that latex free elastics demonstrated greater hysteresis than latex elastics (40% force decay compared with 25% over 24 h).134 The range of forces produced by the non-latex elastics was larger in vitro, but this difference was not deemed to be clinically significant. Elastomeric separators can be replaced with self-locking separating springs.132 Manufacturers can provide alternatives such as latex free power chain, ligature chain, rotation wedges, headgear components, and masks. It is wise to check with retailers that the product they are marketing is latex free.132

	Eating disorders

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The most common eating disorders are anorexia nervosa (AN) and bulimia nervosa (BN). Eating disorders are more common in females and generally have their onset during the teen years but often continue as a chronic illness. AN is an important cause of mortality in adolescent females. Patients with AN have a combination of body image distortion and restricted eating.¹³⁵ Binge eating and purging are also characteristics of BN.

Patients with eating disorders rarely present with problems of compliance. Oral manifestations of eating disorders include dental caries, erosion, dentinal hypersensitivity, salivary gland hypertrophy, raised occlusal restorations and xerostomia.¹³⁶

Orthodontic considerations in patients with eating disorders

The orthodontist is likely to notice these features and should be suspicious of these illnesses and deal with them sensitively.137 The first referral should be to the patient’s physician. However, it is important to maintain confidentiality and gain consent.138 Referral to another healthcare professional, such as a physician may be a breach of confidentiality if the patient did not give their consent. These patients are less likely to discuss their illness as they tend to be embarrassed and secretive. Diet advice is vital as this cohort of patients may drink an excessive quantity of acidic or carbonated drinks to as an alternative to normal food.139 Patients should be counselled not to brush their teeth immediately after vomiting. They should be given advice on how to increase the intra-oral pH by chewing gum, or rinsing the mouth with water or milk.139

	Summary

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Orthodontic treatment is an elective procedure and clinicians should consider all the treatment options to ensure a satisfactory risk-benefit ratio for each and every patient. Comprehensive treatment may not always benefit the patient. Treatment should where appropriate be postponed until the medical problem is in remission or the side effects of the drug therapy are minimized. Patients should always be involved in the treatment-planning phase so that true informed consent can be obtained.

	References

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