Orthodontic Strategies to Establish and Maintain a Patent Airway in OSA 235
(a) Management pathway for child History
• habitual snoring
• unusual sleep posture
• behavioral problems
• allergies
Clinical signs and symptoms Cephalometric signs
• obesity • small maxilla and/or mandible
• small maxilla and/or mandible • enlarged adenoids and/or tonsils
• enlarged tonsils and/or adenoids • narrow airway
• mouth breathing
• medical conditions associated with
floppy muscles and/or
• complex craniofacial syndromes
• Refer patient to sleep clinic if the index of suspicion is high
• Manage patient in consultation with pediatric allergist and otolaryngologist
to enlarge airway space by reducing hyperplastic adenotonsillar tissues, or
functional appliances to promote growth of maxilla/mandible; manage with
respiratory physician and maxillofacial surgeon for complex syndromes with OSA
(b) Management pathway for adult History
• habitual loud snoring
• witnessed apneas
• excessive daytime sleepiness
• hypertension
Clinical signs and symptoms Cephalometric signs
• obesity • small maxilla and/or mandible
• small maxilla and/or mandible • low hyoid position
• nasal blockage, mouth breathing • narrow airway
• crowded oropharynx
(Grade III-IV for
Friedman palate togue position)
• collapsible pharyngeal airway
(Müller’s maneuver score 3–4)
• Refer patient to sleep clinic if the index of suspicion is high
• Manage patient in consultation with otolaryngologist, respiratory, endocrine
physician and maxillofacial surgeon; use CPAP or mandibular advancement
splint for sleep-breathing; bimaxillary advancement osteotomies
Figure 13.23 (a) Management pathway for a child with dentofacial deformity and malocclusion suspected of having OSA. (b) Clinical management pathway
for an adult with dentofacial deformity and malocclusion, suspected of having OSA. (Source: National Dental Centre, Singapore.)
236 Integrated Clinical Orthodontics
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14
Acute and Chronic Infections Affecting the Oral
Cavity: Orthodontic Implications
Vinod Krishnan, Gunnar Dahlén, Ze’ev Davidovitch
Summary to the general health status of patients, as if the dentofacial
region exists in isolation from the rest of the body. This
Infectious diseases occur worldwide, posing multilevel challenges to approach can be termed as ‘regional diagnosis’, where an
orthodontists everywhere. Each new patient must be examined thor- emphasis is placed on the face and oral cavity while ignor-
oughly to uncover the possible presence of infections that could be ing the overwhelming evidence on an intimate association
potentially dangerous for others. Recognition of pathological conditions between dentofacial events and a multitude of pathophysi-
in a patient’s orofacial region before or during treatment requires a precise ological developments throughout the rest of the body
diagnostic technique to eliminate all potential health risks to other (Moore, 1939). Such a narrow approach to orthodontic
patients and staff in the orthodontic clinic. In those cases where patients diagnosis and treatment planning, which overlooks basic
have such infections, it is advisable to promptly interact with pertinent biological principles, may not only jeopardize treatment
medical specialists to obtain confirmation of the disease identity, its treat- outcomes but also the wellbeing of the patients. Thus it is
ment, and any bearing of the disease and medications on the orthodontic essential to shift the paradigm of orthodontic patient evalu-
treatment plan and projected outcome. Both infectious diseases and the ation to encompassing all aspects, both medical and dental,
medications taken for their treatment may affect the tissue remodeling in the diagnostic datasheet, with due consideration of all
response to orthodontic forces. This chapter discusses the features of health-related issues.
infectious diseases, both acute and chronic, that may profoundly affect
the diagnosis, course, and outcome of orthodontic treatment. These infec- Orthodontic tooth movement results from profound
tious diseases are caused by bacteria, viruses, fungi, and parasites and remodeling activities of all dental and paradental tissues in
some may be potentially lethal. The goal of this chapter is to stress the response to the application of mechanical forces to the
importance of identifying these diseases during the diagnostic phase of crowns of the teeth. These remodeling activities are per-
orthodontic therapy and of seeking advice from medical specialists to formed by various cells, including cells of the nervous,
prevent the spread of the diseases and achieving optimal orthodontic immune, endocrine, and skeletal systems, providing tooth
outcomes. movement with a noticeable systemic involvement.
Therefore, orthodontics should be considered as an integral
Introduction part of medicine, and aiming to treat and correct maloc-
clusions while weighing the possible effects of each patient’s
Orthodontics, a specialty based on solid scientific founda- systemic condition on his/her orthodontic diagnosis and
tions, is being practiced predominantly as a mechanical art, treatment plan. This definition introduces biological factors
due, at least in part, to its close association with dentofacial into orthodontic practice, and increases the probability of
esthetic dogmas. Orthodontists are keen to correct facial attaining pleasing and durable results (Childs, 1933).
and dental disfigurements, but often little attention is paid
Orthodontists often see patients with acute or chronic
infectious diseases or with adverse reactions to the mech-
anotherapeutics they practice. It is helpful to refer these
Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
Orthodontic Implications of Oral Acute and Chronic Infections 241
patients to competent physicians for advice that will enable primed inflammatory cells reaching the mechanically
the orthodontist to expand the boundaries of the diagnos- stressed periodontal ligament (PDL) are capable of both
tic process, and craft detailed individual treatment plans. accelerating and inhibiting the rate of tooth movement,
Creation of such a communication bridge will augment the depending on the nature of the specific molecules involved.
union between orthodontics and medicine to the benefit of Moreover, patients who have been diagnosed as having
all individuals in need of orthodontic care (Dunning, acute or chronic infectious diseases are usually being treated
1941). with medications that may markedly alter the course and
outcome of orthodontic therapy, primarily by affecting the
The close relationship that an orthodontist should main- patient’s immune system and the paradental inflammatory
tain with other medical and dental specialists depends on process. All these facets of infectious diseases dictate that a
the extent of his or her knowledge base, on which depends consultation with a physician specializing in treating
the ability to identify conditions requiring and/or justifying patients with these diseases is imperative prior to the onset
patient referral to appropriate medical professionals of any orthodontic treatment. This communication
(Weinberger, 1938). An orthodontic practice might encoun- between the orthodontist and the physician must continue
ter patients with oral manifestations of a variety of diseases. throughout the course of treatment in the event of any
Recognizing these signs and symptoms should prompt the change in the health status of the infected patient during
practitioner to perform specific laboratory tests to facilitate this period.
making the correct diagnosis, identifying the course of the
disease process, and assessing its effects on the treatment Bacterial infections
plan and the course of treatment. Such a routine could
include differentiation between infectious and noninfec- The resident and transient microflora of the oral cavity
tious diseases, and aid in deciding whether orthodontic consists of more than 700 bacterial species or phylotypes,
treatment can be provided without further delay, or if a providing a useful defense mechanism against the establish-
referral to a medical specialist for consultation is deemed ment of more pathogenic species (Aas et al., 2005). The
necessary prior to formulating a comprehensive diagnosis. resident oral flora can be divided into the indigenous flora,
Lack of adequate knowledge of infectious diseases can that is, those are found in almost all humans irrespective of
cause unnecessary delays in instituting appropriate therapy, environmental conditions (e.g. species of Streptococcus,
and at the same time lead to failure in implementing proper Actinomyces, Haemophilus, Neisseria, Fusobacterium, and
safety measures for prevention of disease transmission to Prevotella), and the supplemental flora, which have specific
the orthodontic office personnel. This chapter will concen- requirements for adhesion, nutrition, redox potential,
trate on non-odontogenic infections and their possible and pH levels (Dahlèn, 2009). The species of transient
orthodontic implications (odontogenic infections are dis- flora do not permanently colonize the oral cavity, have
cussed in subsequent chapters of this book). Systemic infec- low virulence and live in harmony with the hosts. This
tious diseases with oral manifestations and with a high might include some opportunistic pathogens, such as
degree of microbiological specificity are discussed, provid- Staphylococcus aureus, pneumococci, enterococci, enteric
ing a clear guide to distinguish between bacterial, viral, rods, and yeasts. If the host’s immunity becomes impaired,
fungal and parasitic infections. these bacteria might initiate an infectious process (Kononen,
2000). Moreover , impairment of the host immune response
In many systemic infectious diseases, the salient causative destroys the microbial homeostasis, which allows some
organisms have been identified and characterized as bacte- pathogens to grow in greater numbers and cause an
ria, viruses, fungi, or parasites. The infectious nature of infection characterized by increased pathogen load and
these diseases requires the implementation of strict hygi- inflammation.
enic procedures and disinfection, to avoid any chance of
contamination and transmission of the disease in the Mucosal lesions of uncertain
orthodontic office. To achieve this goal, it is imperative to microbiological basis
identify at the first appointment itself, patients who may be
carriers of such diseases, prior to proceeding with any clini- Mucositis
cal activities. However, in addition to the efforts to elimi- Mucositis is a form of mucosal barrier injury, characterized
nate the risk of spreading an infectious disease to other clinically by oral erythema, ulceration, and pain (Figure
people in the orthodontic office, orthodontists should 14.1). It is a common complication of therapeutic proce-
realize that infectious diseases, with no exception, modify dures involving chemotherapy, radiotherapy, or both, and
the immune system of each infected person. Such modifica- in patients receiving bone marrow transplants, which are
tions may have profound effects on the paradental cellular damaging to the epithelial cells (Scully et al., 2003). The role
and tissue response to orthodontic forces. Inflammation is of microorganisms in mucositis is uncertain as regards
a major part of this response, intimately involved in every whether they have a role in the initiation of the lesion, or
step of the tissue remodeling process that facilitates tooth whether they secondarily infect the damaged area or the
movement. Signaling molecules produced by migratory
242 Integrated Clinical Orthodontics
Figure 14.1 Oral mucositis. (Courtesy of Dr Nathaniel S Treister.)
ulcer. Commonly, the oral manifestation of cancer therapy Figure 14.2 Major aphthous ulceration.
is a generalized stomatitis whose association with the
primary underlying infection is more obvious (For further poor nutrition, infection, hormonal fluctuation, and
details, see ‘Oral mucosal bacterial infections’, p. 243). trauma (McCullough et al., 2007). The disease is usually
Secondary bacterial infections may also arise in bite wounds, self–limiting, and nutritional supplementation, alleviation
and in viral stomatitis and aphthous ulcerations, and lead of stress, and warm saline rinses have been found to help
to streptococcal bacteraemia in any area of the mouth, such in its management. Orthodontic attachments are consid-
as the tongue, buccal mucosa, floor of the mouth, palate, ered to be one among the main reasons for triggering their
and gingiva. appearance. If the ulcers appear following orthodontic
bonding, the irritating attachment can be either covered
In addition, there is increased occurrence of opportun- with orthodontic wax or removed to prevent further irrita-
istic pathogens such as aerobic Gram-negative bacilli tion aggravating the process.
(AGNB) including enterics (Escherichia coli, Enterobacter
spp.) and pseudomonads, as well as yeasts (Candida spp), Burning mouth syndrome
in mucositic lesions. If xerostomia prevails, oral health can
be seriously compromised (Sonis, 2007). Xerostomia can Scala et al. (2003) defined the burning mouth syndrome as
lead to decreased clearance of oral microorganisms, along a chronic pain syndrome that mainly affects middle-aged/
with decreased pH, resulting in increased colonization by older women with hormonal changes or psychological dis-
lactobacilli, Candida albicans, and other opportunistic orders. This disorder reduces the quality of life, especially
microorganisms, such as Staphylococcus aureus, entero- with large psychological implications. Although the etiol-
cocci, and enteric rods (Pajukoski et al., 2001). ogy of this syndrome remains unclear, the presence of sali-
vary gland dysfunction or systemic diseases, such as
Recurrent aphthous stomatitis diabetes, makes a patient prone to it. In addition, patients
with chronic pulmonary diseases, asthma, and rheumatic
Otherwise known as canker sore, this is the most common arthritis can develop epithelial atrophia, glossitis, xerosto-
nontraumatic type of oral ulcer (Figure 14.2). The sore is mia, and the burning mouth syndrome. All these symptoms
often mistaken for a virus infection (herpes simplex), and are due to superimposing fungal and bacterial infections
is differentiated by appearance only in the nonkeratinized that follow adverse reactions to immunosuppressive medi-
mucosa, such as the labial mucosa, buccal mucosa, ventral cations and reduced salivary flow. Chemotherapeutic agents
tongue, and vestibule (Ship et al., 2000). Based on their also have the potential to induce changes in the oral epithe-
clinical appearance, aphthous ulcers can be classified as lium, leading to superinfection (Lopez-Jornet et al., 2010).
minor (<1 cm in diameter), major (>1 cm diameter), and
herpetiform, in which multiple minute ulcers and which
might coalesce to form plaques (Woo and Sonis, 1996).
Most aphthae are of the minor variety, and heal within 10
days. Factors predisposing to this condition include stress,
Orthodontic Implications of Oral Acute and Chronic Infections 243
Oral mucosal bacterial infections condition prevails. A microbiological diagnosis is strongly
recommended since the treatment strategy may be quite
Acute mucosal infections of the oral cavity may appear different, depending on the identity of the involved micro-
locally, or as generalized stomatitis, and can be asympto- organisms. Treatment of these infections is also sometimes
matic or accompanied by mild discomfort or severe challenging due to a combination of infections caused by
pain (Dahlèn, 2009). Patients often neglect these condi- two or more of these opportunists. A brief description of
tions, unless they become bothersome. The most common bacteria commonly producing oral mucosal infections is
symptoms are burning sensations, followed by clinical provided below. Yeasts involved in the process are discussed
signs of redness and epithelial atrophy or desquamation. on page 256–259.
Helovuo et al. (1993) observed an increased prevalence
of E. coli, Enterobacter spp, and Staph. aureus after treat- Staphylococcus aureus
ment with penicillin and erythromycin. Patients with con- Staph. aureus is considered to be a relevant pathogen
ditions causing immunocompromise, such as leukemia in symptomatic oral mucosal lesions. Until then, if isolated,
and other malignancies, are at high risk of developing it was considered to be a part of a transient microbial flora
oral mucosal ulcerations due to drug consumption and that seems to increase with advanced age. This bacterium
development of granulocytopenia. Similar conditions have is frequently isolated from infections of the facial skin
been found in patients with organ transplants and rheu- and lips (Faergemann and Dahlèn, 2009). Angular cheilitis
matic arthritis (Dahlèn, 2009). As a result of decreasing is commonly secondarily infected by Staph. aureus (Figure
general health and increased medication intake, older 14.3), with a particular predilection in young individuals
people are more prone to develop oral mucosal lesions and those with dry skin. If a healthy individual harbors
(Sweeney et al., 1994). Dahlèn et al. (2009) recently con- high numbers of salivary Staph. aureus (>100 000 colony-
firmed that bacterial mucosal infections are more prevalent forming units/mL) over an extended period of time, they
than fungal infections in the oral cavity. They also observed are considered to be healthy carriers (Dahlèn, 2009).
a marked decline in the levels of normal mucosal bacteria, Infected medical and dental professionals pose a risk
such as viridians streptococci (α-streptococci), Neisseria, of transmitting it to other individuals visiting them. A
and Haemophilus spp. serious concern in this regard is the infection caused by
methicillin-resistant Staph. aureus. Treatment of infection
Dentists, more specifically orthodontists, frequently with Staph. aureus typically included penicillinase-stable
ignore such conditions, and/or leave them underdiagnosed. penicillins, such as cloxacillin, dicloxacillin, or flucloxacil-
Infections associated with the oral cavity have a unique lin, because of the risk of developing resistant strains
microbiological base, often a mixed one, making it difficult (Dahlèn, 2009).
to identify a specific, salient microorganism. The best diag-
nostic approach starts with comprehensive history taking, Enterococci
which should be followed by a thorough physical examina- Enterococci, particularly Enterococcus faecalis, are com-
tion. Microbiological laboratory investigations and antibi- monly involved in oral mucosal infections. These infections
otic susceptibility tests should be conducted routinely on occur sporadically in the oral mucosa and around the teeth
orthodontic patients with oral lesions, so that the condi- in healthy individuals but enterococci are a typical oppor-
tions can be effectively and properly managed. An ortho- tunist in immunocompromised patients, often in combina-
dontist accepting patients in this category should emphasize tion with other opportunists such as enterics and yeasts
the importance of maintaining impeccable oral hygiene to (Dahlén, 2009). Enterococci are of particular interest to
postpone or minimize the development of oral mucosal dentists due to their persistence even after treatment of
ulcerations. It is also highly recommended to refer any endodontically involved teeth.
patient with an oral microbiological infection that might
be contagious, for a consultation to a physician. The infec- Enterococci were known as streptococci for a long time,
tions arising in the oral cavity are listed in Table 14.1. and were classified as Lancefield group D. However, owing
to their survival in harsh environments (temperature,
Aerobic infections of the oral cavity dryness, salts, dyes, antiseptics, and antibiotics), they were
classified as a new genus, which normally resides in a sig-
Microorganisms causing oral mucosal infection have a pre- nificant part of the upper intestine and is resistant to bile
dominantly aerobic character, and in the majority comprise salts. It is spread to the oral cavity by vomiting and faecal
staphylococci, enterococci, AGNB, and yeasts. They are all contamination. Enterococci are commonly used in the food
categorized as classical opportunists, and are commonly processing, e. g. cheese, and spread through food cannot be
associated with immunocompromise (Dahlèn et al., 2009), excluded (Templer et al., 2008). It is resistant to penicillin
although they have been noted in healthy individuals. These V and clindamycin, and broad-spectrum penicillins such as
aerobic infections are difficult to treat due to a pronounced ampicillin and amoxicillin remain the drugs of choice
resistance against common antibiotics by these microor- (Dahlén et al., 2009).
ganisms and a low response as long as the compromised
244 Integrated Clinical Orthodontics
Table 14.1 Bacterial infections of the oral cavity
Type of infection Main causative agent Prevalence Prevalence in Treatment
Bacterial infections of the in the the resident
oral cavity and its Staph. aureus diseasea flora of the Cloxacillin, clindamycin, vancomycin
environment Strep. pyogenesc oral cavityb Penicillin V
Oral mucosal infections Enterococcus faecalis ++ Amoxicillin/ampicillin
(including bacterial Aerobic Gram-negative bacilli + + Multi-resistance drugs (ciprofloxacin)
associated lesions) Yeastsd ++ (+) Mucostatins, amphotericin, azoles
Treponema spp. +++ + Penicillin V
Acute necrotizing Anaerobes (Fusobacterium spp., Prevotella spp.) +++ +
ulcerative gingivitis Strep. pyogenesc +++ ++ Penicillin V
Peritonsillar abscess Anaerobes (Fusobacterium spp., Prevotella spp.) ++ + Metronidazole
Lemierre disease F. necrophorum +++ +++ Metronidazole, surgery
Staph. aureus + (+) Cloxacillin, clindamycin
Suppurative parotitis Anaerobes +++ +++ Penicillin V
Allergy + (+) –
Non-infectious rhinitis Primary infection – viral + + Penicillin V, amoxicillin
Rhinitis and sinusitis Secondary infection –Facultative bacteria (Strep. +++ +++ Penicillin V, macrolides
pneumoniae, H. influenzae) and less commonly ++ ?
Chronic rhinitis facultative bacteria (Staph. aureus, Strep. pyogenes) + + Cloxacillin, clindamycin
Epiglottitis Third phase infection – anaerobes +++
Staph. aureus +++ Amoxicillin, ceftriaxone, penicillin V,
Chronic infections with H. influenzae +++ ampicillin, chloramphenicol
oral manifestations +++ (nostrils)
Actinomycosis Actinomycosis israelii Penicillin V (long time, high doses)
Gonorrhea Neisseria gonorrhea +++ + Penicillin V
Mycobacterial infections Mycobacterium tuberculosis +++ Rifampicin
Mycobacterium leprae +++ +
Syphilis Treponema pallidum + − Penicillin V
+ −
−
−
aPrevalence: + <10%, ++ <30%, +++ >30%.
bNot isolated, (+) sporadically present in low numbers, + present in <10% and in low numbers, ++ commonly present <30% sparsely or in moderately heavy
growth, +++ usually present and in the predominant flora.
cGroup A hemolytic streptococci.
dCandida spp.
AGNB, including E. coli, Enterobacter spp., Klebsiella spp., and peri-implantitis. They rapidly become drug-resistant,
Proteus spp. and more, are typically involved in human and the drug to be used should be selected only after a
opportunistic infections, including oral mucosal infections. susceptibility test, although the choices are more or less
AGNB are part of the normal resident intestinal flora, fre- exhausted. Quinolones (ciprofloxacin, norfloxacin) are the
quent participants in nosocomial infections, and cause the drugs of choice for the infections with AGNB, but should
classic opportunistic infections affecting the oral cavity. be prescribed only under proper medical supervision.
Transmission of these bacteria to the oral cavity can occur Empirically, it has been observed that it is difficult to harm
through poor personal hygiene, or through food and drink- the bacteria and for the infection to heal as long as the
ing water. They are frequently associated with periodontitis patient is in a compromised state (Dahlèn et al., 2009).
Orthodontic Implications of Oral Acute and Chronic Infections 245
Figure 14.3 Angular cheilitis with Staphylococcus aureus. (Courtesy of Dr 1994). The treatment of this condition is directed towards
Maria Westin.) debridement of affected soft tissues and teeth, along with
antibiotic therapy (Rivera-Hidalgo and Stanford, 1999). A
Figure 14.4 Acute necrotizing ulcerative gingivitis (ANUG). (Courtesy of Dr. referral to a competent periodontist, if an orthodontist
Martin S Spiller.) encounters such a condition, can be of great value in its
management.
Acute necrotizing ulcerative gingivitis
Acute necrotizing ulcerative gingivitis (ANUG) is an infec- Acute pharyngitis
tious disease of the gingiva (Figure 14.4), caused by a mixed
flora consisting of spirochetes, fusobacteria, Prevotella Acute pharyngitis, otherwise known as a sore throat, can
intermedia, Veillonella species, and streptococci (Rivera- have either viral or bacterial etiology. The most common
Hidalgo and Stanford, 1999). This disease often results in bacterium involved is Streptococcus pyogenes (β-hemolytic
gingival bleeding, ulceration, and episodes of severe pain. streptococci or group A streptococci [GAS]) (Peterson and
Factors predisposing to this condition include stress, Thomson, 1999). During the acute phase of the disease,
smoking, malnutrition, and poor oral hygiene (Horning these microorganisms can be detected in the saliva. This
and Cohen, 1995). ANUG is common in patients with disease is among the 20 most common diseases that occur
human immunodeficiency virus (HIV) infection. If it is without any age, sex, or racial predilection. The exotoxins
associated with rapid alveolar bone loss, it is categorized as produced in this infection by the β-hemolytic streptococci
necrotizing ulcerative periodontitis, in which severe deep act as superantigens that up-regulate the T lymphocytes,
aching pain is a characteristic feature (Murayama et al., prompting the release of proinflammatory cytotoxins, and
have synergistic effects along with the lipopolysaccharides
of the extracellular matrix. The superantigens then evade
the pharyngeal immune response, resulting in proliferation
of Strep. pyogenes. The most common symptoms of acute
pharyngitis are sore throat, odynophagia, headache, nausea,
vomiting, and abdominal pain. On physical examination,
the patient may have fever, tonsillopharyngeal erythema,
exudates, beefy red swollen uvula, anterior cervical tender
lymph nodes, petechiae on the palate, and scarlatiniform
rash. The gold standard diagnostic test for acute pharyngitis
is throat culture, but unfortunately this test takes 24–48
hours to be completed (Halsey, 2009). Instead, rapid antigen
detection tests (RADTs) with commercial kits are available
but these are relatively expensive. Samples for throat culture
or RADTs should be obtained from the posterior pharynx
or the tonsils. Imaging studies have no role in the diagnosis
of this disease.
Oral penicillin V is the drug of choice for this disease.
Amoxicillin remains a better alternative, but tetracyclines
or sulfamethoxazole should not be used due to the high
resistance rate. In the case of penicillin allergy, cepha-
losporins, which contain a β-lactam ring, can be used with
caution. In rare cases, the pharyngitis spreads to adjacent
areas, forming abscesses requiring surgical drainage.
Surgery is an option, especially if the history reveals recur-
rent tonsillitis (Brook, 2009). The patient should be allowed
to eat a normal diet and drink warm liquids that provide
symptomatic relief (Halsey, 2009). An otorhinolaryngolo-
gist should be consulted for local suppurative complica-
tions such as peritonsillar abscess and mastoiditis. An
infectious disease expert should be consulted for patients
with immunocompromising conditions, or when HIV
infection is suspected.
A rare but often underdiagnosed form of an oropharyn-
geal infection is the Lemierre syndrome, an infection caused
by Fusobacterium necrophorum (Karkos et al., 2009), which
246 Integrated Clinical Orthodontics
Figure 14.5 Peritonsillar abscess. obstruction, sepsis, toxicity, or other complications. Along
with incision and drainage, analgesics, and throat wash,
occurs in adolescents and young adults as a complication antibiotics are often prescribed for complete resolution
of tonsillitis (‘sore throat’), especially in recurrent forms of PTA. A combination therapy of penicillin and metroni-
(Klug et al., 2009). It is life-threatening if neglected, and dazole is often preferred. Clindamycin is a good choice
should be treated aggressively with antibiotics (metronida- in people with penicillin allergy. Consultation with an
zole) and/or surgery (Ridgway et al., 2010). otorhinolaryngologist should be sought whenever a PTA
is recognized, before, during, or after the onset of ortho-
Peritonsillar abscess dontic treatment, for proper management of these patients.
Peritonsillar abscess (PTA) is a localized accumulation of Help from an anesthetist might sometimes be required if
pus in the peritonsillar tissues, which forms as a result the patient develops difficulty in maintaining airway
of suppurative tonsillitis (Figure 14.5). The peritonsillar patency.
space is bounded by the tonsillar pillars anteroposteriorly,
piriform fossa inferiorly, and the hard palate superiorly. Suppurative parotitis/sialadenitis
The area can be infected with both aerobic (S. pyogenes)
and anaerobic (Prevotella and Peptostreptococcus spp.) bac- Acute suppurative parotitis (ASP) is an infectious process
teria. The infection begins superficially, progresses into of the parotid gland, usually seen in elderly people who are
deep tissues and has no age, sex, or racial predilection. The dehydrated, malnourished, or recovering from surgery
symptoms include sore throat, dysphagia, and change in (Raad et al., 1990). Although the infection is usually con-
the voice, headache, malaise, fever, neck pain, otalgia, fined to the parotid capsule, it can occasionally spread to
and odynophagia. Physical examination reveals mild to cervical fascial planes. Immunosuppression states such as
moderate discomfort, fever, tachycardia, dehydration, diabetes, alcoholism, HIV infection, autoimmune disorders
drooling of saliva, trismus, cervical lymphadenitis, asym- (e.g. Sjögren’s syndrome), poor oral hygiene, decreased sali-
metric tonsillar hypertrophy, inferior and medial displace- vary flow, postsurgical dehydration, sialolithiasis, tumors or
ment of a tonsil, contralateral deviation of the uvula, and foreign bodies in the duct, can increase the risk for ASP. The
erythema and exudates from the tonsils. No investiga most common clinical manifestation of ASP is an indu-
tions are required to diagnose PTA but if a need is assu rated, erythematous, warm swelling of the cheek. The
med, needle aspiration followed by culture of the fluid patient will also have mild fever along with pain. Intraorally,
obtained can be performed (Peterson and Thomson, 1999; the orifice of Stensen’s duct will be red, and pus may be
Mehta et al., 2009). Patients are often managed in the out- expelled while palpating it (Brook, 2009). In rare instances,
patient department, unless they show signs of airway facial nerve dysfunction may be the end result (Noorizan
et al., 2009). Diagnosis can be established by a thorough
clinical examination, along with a complete blood count
and chemistry, and culture and sensitivity. Radiological
evaluation should include CT scanning with an intravenous
contrast medium, ultrasound scanning for detection of
abscesses and also sialography.
Traditionally, the main causative agent of ASP is thought
to be Staph. aureus. However, Brook et al. (1991) have iso-
lated strict anaerobes such as Peptostreptococcus spp. and
Gram-negative anaerobic rods from ASP lesions. The key
treatment for ASP is rehydration and supportive treatment,
which should include intravenous fluids, nutritional
support, a warm compress, sialogogs, good oral hygiene,
and antibiotic therapy. The drugs of choice in ASP are
penicillin, first-generation cephalosporins or clindamycin,
however, more important is the selection of the drug in
relation to the causative agent. Intraductal injections of
antibiotics usually lead to improvement in the condition. If
there is lack of improvement after 3–5 days of antibiotic
treatment, and if there is facial nerve involvement or
involvement of adjacent vital structures, surgical opinion
must be sought; usually incision and drainage via a stand-
ard parotidectomy incision will be the preferred treatment.
Proper follow-up, repeated clinical examinations, fine
needle biopsy, and imaging should be performed on a
Orthodontic Implications of Oral Acute and Chronic Infections 247
regular basis to ensure the absence of any neoplastic changes the anterior tip of the inferior turbinates. Determination
in the gland (Brook, 2009). of specific antibody involvement can be made through
skin testing, which has high sensitivity, and at the same
Rhinitis and sinusitis time is simple, easy, and can be rapidly performed (Wallace
et al., 2008). The main treatment for rhinitis is directed
Rhinitis implies a heterogeneous group of nasal disorders, towards avoidance of the inciting factors, such as allergens
characterized by sneezing, nasal itching, rhinorrhea, and and irritants. A multitude of drugs are available for the
nasal congestion, which can be allergic, nonallergic, infec- management of this disease, including antihistamines,
tious, occupational, or hormonal in nature. Recently corticosteroids, oral and nasal decongestants, leukotriene
Dykewicz and Hamilos (2010) suggested that in approxi- receptor antagonists, etc. For the orthodontist, making
mately 44–87% of patients with rhinitis, the condition a referral to an otorhinolaryngologist is an important
is either allergic or non-allergic in nature. Common aller- step in managing the condition. The specialist will
gens causing the problem include proteins and glycopro- determine an individualized treatment approach for each
teins in airborne dust, mite fecal particles, cockroach patient, based on their responses, preferences, and cost–
residues, animal dander, moulds, and pollens. Within effectiveness of the treatment options (Dykewicz and
minutes of inhalation, these allergens are recognized by IgE Hamilos, 2010).
antibody bound to mast cells and basophils, causing
degranulation and release of preformed mediators, such as Sinusitis or rhinosinusitis is defined as inflammation of
histamine and tryptase, and inflammatory mediators, such the nose and the paranasal sinuses, and is usually infectious
as leukotrienes and prostaglandin D2. These mediators in nature (Meltzer et al., 2004). Typically, sinusitis follows,
cause plasma extravasation from blood vessels, with conse- from a microbiological point of view, a characteristic
quent edema, pooling of blood in cavernous sinusoids, pattern, starting as a viral infection, followed by superinfec-
and occlusion of nasal passages. These developments tion with facultative bacteria after a couple of days and,
are accompanied by active secretion of mucus from glan- after 1 week, showing anaerobes as the predominant organ-
dular and goblet cells, and release of histamine, which isms (Brook, 2009). Acute rhinosinusitis is diagnosed when
manifests as itching, rhinorrhea, and sneezing. In late there is purulent nasal drainage of with up to 4 weeks,
stages, a prominent nasal congestion develops, as these early accompanied by nasal obstruction, facial pain, pressure,
phase reactions set off by around 4–8 hours (Rosenwasser, fullness, or both. The pain is usually described as being dull,
2007). Rhinitis is often accompanied by non-nasal symp- or felt as pressure in the upper cheeks, between the eyes, or
toms, such as allergic conjunctivitis, and it is frequently in the forehead. The most common bacteria isolated from
associated with allergic asthma, pathophysiologically and sites of acute rhinosinusitis are H. influenzae, Strept. pneu-
epidemiologically. moniae, Moraxella catarrhalis and sometimes Staph. aureus.
Disturbances in the sense of smell, which occur in sinusitis,
Diagnosis should include evaluation of all specific symp- can be either partial (hyposmia) or complete (anosmia),
toms and the pattern of occurrence of the symptoms and are usually associated with mucosal thickening or
(infrequent/intermittent, seasonal and perennial) along opacification in the anterior ethmoid sinuses, which can
with identification of predisposing factors, previous be seen a hyperdense areas in an orthopantomograph
responses to medication, and coexisting diseases. A hand- and computed tomography (CT) images (Dykewicz and
held otoscope or head lamp with nasal speculum permits Hamilos, 2010) (Figure 14.6). An initial period of watchful
viewing of the anterior third of the nasal airway, including
(a) (b) (c)
Figure 14.6 (a–c) Radiological appearances of sinusitis in various radiographs. (Courtesy of Akitoshi Kawamata, Asahi University School of Dentistry, Gifu,
Japan.)
248 Integrated Clinical Orthodontics
waiting without initiation of antibiotics is the best treat- such as ceftriaxone or chloramphenicol, either alone or in
ment for acute rhinosinusitis. combination with penicillin or ampicillin, for streptococcal
coverage.
An important aspect of the diagnosis of sinusitis is to
differentiate between bacterial and viral causes, as only bac- Chronic infections with oral manifestations
terial infections respond to antibiotic therapy. Clinical signs
suggestive of bacterial infection include symptoms that last Actinomycosis
for more than 7 days. Patients with more severe forms of Actinomycosis is a chronic disease characterized by forma-
the disease can be treated with antibiotics, and if this tion of abscesses, fibrosis, and draining sinuses (Figure
approach is decided on, amoxicillin is the drug of choice. 14.7). The causative agent is the nonspore-forming anaero-
If the patient is allergic to penicillin, a combination of bic or microaerophilic bacterial species of the genus
trimethoprim and – sulfamethoxazole (not used in Actinomyces (most commonly Actinomyces israelii), which
Scandinavian countries) or macrolide antibiotics can be are normal inhabitants of cervicofacial, thoracic, and
considered. Intranasal decongestants can be prescribed, but abdominal areas (Rivera-Hidalgo and Stanford, 1999). A
for no more than 3 days, to avoid rebound decongestions similar infection, nocardiosis, is caused by the related fac-
(Brook, 2010).In contrast to acute rhinosinusitis, chronic ultative Nocardia spp. Cervicofacial actinomycosis is the
rhinosinusitis (CRS) is defined as an inflammatory condi- most common form of the disease (Laskaris, 1996).
tion involving the paranasal sinuses and nasal passages over Actinomyces get access to the host tissues when there is an
a minimum duration of 8–12 weeks, despite attempts at interruption in the mucosal barrier, caused by procedures
medical management (Meltzer et al., 2004). Superimposed such as tooth extraction and endodontic infection and
bacterial infections further complicate the process. The treatment. Following this initial superficial invasion, the
four major symptoms of CRS are: anterior, posterior, or infection spreads deep into the tissues and a hard, slow
mucopurulent drainage; nasal obstruction or blockage; growing, relatively tender swelling may form with multiple
facial pain, pressure, or fullness; and decreased sense of drainage areas or sinus tracts. The discharge from these
smell (Meltzer et al., 2004). The bacteria can also form a tracts typically contains the visible yellowish colonies of the
biofilm over the sinus epithelium. Sequestration of bacteria microorganisms and are termed ‘sulfur granules’. If left
within biofilms allows the bacteria to resist antibiotic treat- untreated osteomyelitis with extensive bone destruction
ment and persist as a low-grade infection within the sinus will result (Feder, 1990; Brook, 2008). Diagnosis can be
mucosa. Topical corticosteroid nasal sprays are preferred confirmed by isolation of Actinomyces species from clinical
for all forms of CRS, along with antihistamines for underly- specimens. Indirect immunofluorescence can also be uti-
ing allergic causes, and antibiotics (penicillin V, amoxicillin, lized for this purpose (Gohean et al., 1990). The demon-
or cloxacillin) are prescribed when nasal purulence is stration of actinomycotic granules, which consist of tangled
present (Dykewicz and Hamilos, 2010). Functional endo- filaments of organisms, in the exudates or histological sec-
scopic sinus surgery (FESS) is the management of choice of
chronic refractory rhinosinusitis. Figure 14.7 Oral actinomycosis. (Image reprinted with permission from
Medscape.com, 2011.)
Epiglottitis
Epiglottitis, or inflammation of the epiglottis, is considered
to be a medical emergency, as it can lead to airway obstruc-
tion and death. It follows oral infection with H. influenzae
(Peterson and Thomson, 1999). This microorganism is
abundant in the oral mucosal surfaces and in dental plaque.
However, certain capsulated strains are considerably more
virulent and are thought to be a major pathogen in the
respiratory tract, causing otitis, sinusitis, and pharyngitis.
The major symptoms are fever, difficulty swallowing, drool-
ing, hoarseness of voice, and stridor. The diagnosis is often
confirmed by examination with a laryngoscope, which will
show cherry-red and swollen epiglottis and arytenoids
(Jenkins and Saunders, 2009). This condition requires
immediate medical attention, with urgent endotracheal
intubation, to protect the airway. This procedure should be
performed by a competent anesthetist, with the help of a
respiratory therapist and otorhinolaryngologist (D’Agostino,
2010). In addition, the patient should be given antibiotics,
Orthodontic Implications of Oral Acute and Chronic Infections 249
tions, confirms the diagnosis. Actinomyces species are disease. Tuberculosis is still among the most life-threatening
susceptible to several antibiotics such as penicillins, tetra- infectious diseases in humans and one-third of the world’s
cyclines, erythromycin, clindamycin, and ciprofloxacin. population comes in contact with the disease at some stage
Antibiotics need to be given at high doses for longer periods in their life (Kakisi et al., 2010). It commonly affects the
(2–6 weeks) for a complete cure. Surgery might be required lungs, but can occur in any part of the body, and is charac-
in some cases to aspirate or surgically drain the abscesses terized by formation of granulomas with caseation necrosis
(Brook, 2008). Consultation with an oral medicine special- caused by cell-mediated response. Primary tuberculosis is
ist and with an otorhinolaryngologist will be of great help seen in patients who have had no previous exposure to the
in managing these patients. disease and initially is predominantly subclinical. Secondary
tuberculosis is seen in previously sensitized patients (Phalen
Gonorrhea et al., 1996). Oral lesions are rare (0.1–5%, Kakisi et al.,
2010), but if they occur, they appear as chronic, painless,
Gonorrhea is the most frequently encountered sexually irregular ulcers, with a vegetative surface covered by grayish
transmitted disease, caused by Neisseria gonorrhea, a non- or yellow exudates. The dorsal surface of the tongue is a
motile spherical oval coccus. The organism is aerobic, common site of secondary tuberculous infection, followed
Gram-negative and cannot penetrate an intact stratified by the palate, gingiva, buccal mucosa, and lips (Hale and
squamous epithelium, such as that of the skin and oral Tucker, 2008). Diagnosis is reached based on the medical
mucous membrane (Rivera-Hidalgo and Stanford, 1999). history, identification of acid-fast mycobacteria in clinical
However, it can directly invade the urethra, cervix, pharynx, specimens, a positive delayed hypersensitivity skin reaction
and conjunctiva, because of the presence of columnar to purified protein derivative, and chest radiograph find-
and transitional epithelium in these areas. From these ings, which includes infiltrates or consolidations and/or
sites, infection may spread readily along mucosal surfaces, cavities in the upper lungs with or without mediastinal or
or systemically, resulting in disseminated disease (Guinta hilar lymphadenopathy. Recent developments in rapid
and Fiumara, 1986). Humans are the only known hosts for detection and identification of tuberculous bacteria are
N. gonorrhea, and the organism has been cultured from reducing the laboratory time in the diagnostic process
saliva of infected individuals. Twenty percent of patients (Ellner et al., 1988). If a patient has tuberculosis, all ortho-
with gonorrhea have oral, pharyngeal, and tonsillar involve- dontic procedures should be carried out under strict
ment. The tonsils are red and swollen, with grayish exu- medical or a pulmonologist’s supervision, in order to
dates. Lesions in the oral mucosa may appear as fiery red prevent the spread of the disease, as well as its
and edematous, and occasionally there may be painful aggravation.
ulcerations. Diagnosis is established by culture and identi-
fication of N. gonorrhoeae (Laskaris, 1996; Bruce and Leprosy
Rogers, 2004). Sugar fermentation tests aid in species dif- Leprosy is a chronic disease caused by M. leprae, and is
ferentiation, and fluorescent antibody techniques have been characterized by damage to the nerves and skin, resulting
used for rapid identification of gonococci. Penicillin is the in deformities and disability. M. leprae is a Gram-positive,
drug of choice for this infection, and in drug-resistant acid-fast, nonspore-forming, nonmotile, pleomorphic
patients ceftriaxone and ciprofloxacin have been used suc- bacillus, which causes four types of leprosy: indeterminate,
cessfully (Chue, 1975). tuberculoid, borderline, and lepromatous (Rivera-Hidalgo
and Stanford, 1999). Oral lesions have been demonstrated
Mycobacterial infections in tuberculoid, borderline, and lepromatous leprosy. The
lesions present as nodules/lepromas that progress to necro-
The most common mycobacterial infections are tuberculo- sis and ulcerations. The ulcers may heal with scarring or
sis, caused by the tubercle bacilli, Mycobacterium tubercu- progress to produce further tissue destruction. Lepromas
losis, and leprosy, caused by Mycobacterium leprae. There are filled with M. leprae, and might occur in the palate,
are also numerous nontuberculous mycobacteria, such as dorsum of the tongue, uvula, and the lips. When left
M. kansasii, M. chelonei, and M. avium – intercellular com untreated, these lesions can cause extensive destruction of
plex (Weg, 1976; Rivera-Hidalgo and Stanford, 1999), the oral tissues (Ghosh et al., 2009). The diagnosis is based
which cause most of the medical infections. These infec- on clinical signs such as anesthetic skin lesions, enlarged
tions are noncommunicable from person to person, and do peripheral nerves, and the presence of acid-fast bacilli in
not require long-term systemic medication as in the case of smears taken from skin lesions.
tuberculosis (Rivera-Hidalgo and Stanford, 1999).
Syphilis
Tuberculosis Syphilis caused by the spirochete Treponema pallidum
Tuberculosis is a chronic infectious disease caused by the is a venereal disease, with a decreasing prevalence rate.
airborne mycobacterium tubercle bacilli, and spreads
almost exclusively via droplets from a person with active
250 Integrated Clinical Orthodontics
Syphilis can be either congenital (when the fetus becomes glycoproteins, participating in viral attachment and infec-
infected in utero), or acquired (contracted by sexual contact, tion of the host. Viral infections have two stages: attach-
direct inoculation, or by transfusion with fresh human ment and penetration. Viruses attach to their host cells by
blood). Early congenital syphilis may manifest itself as the way of cellular receptors, and after getting enveloped,
papulosquamous lesions of the skin and the oral mucous they fuse with the host cell membrane. Receptor-mediated
membranes. The lesions at the commissures of the lips, endocytosis is the process through which enveloped and
angle of the nose, and eyes heal with radiating scars called naked viruses gain entry into host cells. The outcome of
‘rhagades’ (Rivera-Hidalgo and Stanford, 1999). Oral mani- viral infection depends on the viral state. If the virus is in
festations of late congenital syphilis include Hutchinson’s a lytic stage, the host cell is destroyed. In lysogeny, the virus
triad of deafness, interstitial keratitis, and malformed inci- enters and integrates with the host cell, and is reactivated
sors, along with other dental anomalies such as hypoplastic at a later date to become lytic in nature. In latent stage, a
molars with poorly developed cusps, called mulberry form of lysogeny, the viral genome stays in the host cell, but
molars. is not necessarily incorporated. Once the viral gene is
released, early gene transcription begins, the products of
Acquired syphilis has three classic phases. Primary syphi- which are proteins that regulate the transcription of further
lis is characterized by chancre, a centrally ulcerated granu- genes and viral DNA replication (McCullough and Savage,
lomatous lesion with a raised, indurated border; the lesion 2005b). Viral diseases may be the direct result of cell
is painless and resolves within 2–8 weeks. Secondary syphi- destruction by a virus, or a consequence of host immune
lis is the systemic or disseminated phase, and may occur reactions against viral proteins. Viruses may encode
2–12 weeks after contact. Signs and symptoms consist of homologs of host cytokines and decoy receptors capable of
fever, headache, malaise, a symmetrical rash, and mucous binding and neutralizing host-derived cytokines. The rapid
patches in the oral cavity. The oral lesions appear as grayish- rate of mutation in critical viral genes can help viruses to
white, glistening patches on the soft palate, tongue, and overcome adaptive host defenses (Slots, 2009). The most
buccal mucosa, but rarely on the gingiva. After this stage, common viral infections that are relevant to dentists and
the patient enters a latent stage and 30–40% of untreated orthodontists are listed in Table 14.2.
patients develop tertiary syphilis, which includes multior-
gan involvement. Gumma is the characteristic lesion in this Herpesvirus
phase and is seen in the hard palate. This phase is not infec-
tious (Little, 2005). Clinical examination and serological This virus belongs to the family Herpetoviridae, and
tests aid in the diagnosis of syphilis. Dark field microscopy consists of a double-stranded DNA molecule surrounded
can sometimes be useful when serological test results are by an icosahedral capsid, a proteinaceous tegument, and a
negative but there is a high index of suspicion (Seigel, lipid-containing envelope with embedded viral glycopro-
1996). Penicillin is the pharmaceutical agent of choice in teins (Greenberg, 1996). Around 300 different types of her-
this disease. pesvirus have been identified, of which eight human
herpesvirus species with distinct biological and clinical
The three mycobacterial infections, tuberculosis, leprosy, implications have been classified in three groups (Slots,
and syphilis, are highly contagious, posing a serious danger 2009):
to all the people in the orthodontic office, including the
orthodontist, the patients, and the staff. It is, therefore, • Alpha group: includes herpes simplex virus 1 (HSV-1),
essential to identify suspected carriers of these diseases, and the herpes simplex virus 2 (HSV-2) and varicella zoster
refer them promptly to a physician for a definitive diagno-
sis. Failure to recognize and appropriately refer potential • (VZ) virus
carriers and proceeding to address only their malocclusion Beta group: human cytomegalovirus, human herpesvirus
may endanger all personnel and patients visiting an ortho-
dontic office. • 6 and human herpesvirus 7
Gamma group: Epstein–Barr virus (EBV) and human
Viral infections herpesvirus 8.
Oral diseases and infections of viral etiology are common Primary herpetic gingivostomatitis
in dental, as well as orthodontic practices, and awareness of
these can effectively prevent their spread. Viruses contain The primary infection with herpes simplex virus, which
one type of nucleic acid alone, either DNA or RNA. They usually occurs in infants and children, often goes unno-
often require a host, who provides them with ribosomes, ticed, being subclinical in nature (Scott et al., 1997). There
which they need to multiply to produce disease conditions. may be a prodrome of fever, malaise, and nausea. The infec-
Nearly all viruses are icosahedral, and possess a protein tion might also present as vesicles on the mucosa of the
shell or nucleocapsid; protein spikes project from the mouth and pharynx. The vesicles break down to form clus-
surface of the viral nucleocapsids. The proteins are usually ters of small, round or irregular superficial ulcers with yel-
lowish base and red margins. There is a characteristic
widespread inflammation of the gingivae, which appear
Orthodontic Implications of Oral Acute and Chronic Infections 251
Table 14.2 Viral infections of relevance for the dentist and orthodontist
Virus family Virus name Viral disease General clinical or oral appearance Treatment
Herpes viruses Herpes simplex (HSV – 1 and 2)
Varicella zoster (VZ or herpes Primary infection Swollen and red gingiva, sometimes with Aciclovir
Alfa group virus 3) gingivostomatitis ulcers, multiple vesicles in mucosa
Recurrent infection: herpes Lesions on lips (usually unilateral), perioral skin, Aciclovir
Beta group Cytomegalovirus (CMV or labialis and intraoral herpes intraoral ulcer lesions, trigeminal neuralgia
Gamma group herpesvirus 5) Shingles ‘Belt of roses’, rash and neuralgia with pain Palliative
Morbilli virus Epstein–Barr virus (EBV or commonly from the trigeminal nerve (15%), on
Paramyxoma herpesvirus 4) CMV infection one or sometimes both sides of the face Ganciclovir
Papovavirus Morbilli virus Infectious mononucleosis May infect fetus during pregnancy
Retroviruses Mumps virus Measles Palliative
Mumps (parotitis) Tonsillitis
Picorna virus Human papillomavirus (HPV) Vaccine
Picorna virus Papilloma Cough, conjunctivitis, fever, photophobia,
HIV-1, HIV-2 rhinitis, Koplik spots, skin rash Vaccine
Hepatitis virus Acquired immune deficiency Glandular infection especially of salivary
Coxsackie virus syndrome (AIDS) glands, which become swollen and painful – Surgery
Enterovirus Acute and chronic (years) unilaterally or bilaterally
Squamous cell papilloma – cauliflower-like Retarding
Hepatitis B virus (HBV) Herpangina lesions, narrow base, pink, exophytic growth medicine –
Hepatitis C virus (HCV) Hand, foot and mouth Verruca vulgaris – wartlike and broader base highly active
disease Hairy leukoplakia antiretroviral
therapy
Liver infection Candidiasis and other fungal infections (HAART)
Aggressive periodontitis
Kaposi sarcoma Palliative
Frequently mucosal infections
Clustered petechiae in the soft palate that Benign and
becomes ulcerated in a few days heals within
Ulcerations on the buccal mucosa and soft 7–10 days
palate often in conjunction with ulcers on the Aciclovir
hands and feet HBV – vaccine
HBC – no
Jaundice (yellow skin and eye) vaccine,
HBV – acute infections and 5% develop the aciclovir
chronic, benign carrier state
HCV – 60% develop chronic liver disease and
80% of these develops cirrhosis
Adapted from Sällberg (2009) and Slots (2009).
pinkish red and swollen (Figure 14.8). The patient will is compromised. Recurrent infections are observed in 20–
experience difficulty eating and swallowing, and the condi- 40% of individuals after a primary infection. The reappear-
tion, which is self-limiting, heals without scars in about 10 ance of the infection shows regional predilection with
days. The lesion is always accompanied by cervical lym- the type 1 virus (mostly activated from trigeminal ganglia)
phadenopathy, and may be more severe if it occurs in adults producing oral infections, and type 2 (activated from sacral
(Tovaru et al., 2009). ganglia) producing genital lesions. The typical picture
of the intraoral recurrent lesions is a cluster of small ulcers
After primary infection, the virus remains dormant in the attached gingivae, which are initially discrete
in the sensory and autonomic trigeminal or sacral ganglia, and painful and then coalesce at a later stage to form
and is reactivated at a later stage, when host immunity
252 Integrated Clinical Orthodontics
Figure 14.8 Acute herpetic gingivostomatitis. (Courtesy of Professor Mats
Jontell.)
Figure 14.10 Herpetic whitlow affecting the fingers.
Figure 14.9 Herpes labialis. Clinical features are usually sufficient for diagnosis of
herpes infection, the major differential diagnosis of which
larger lesions that heal in 10–12 days (Arduino and Porter, is recurrent aphthous ulceration (p. 242). The diagnosis can
2008). be confirmed with the help of cultures and enzyme-linked
immunosorbent assay (ELISA), polymerase chain reaction
Herpes labialis/cold sores (Figure 14.9) is a common (PCR), or direct immunofluorescence (Rivera-Hidalgo and
recurrent herpes infection. A prickling sensation precedes Stanford, 1999).
blister formation. These blisters enlarge, coalesce, rupture,
and become crusted before healing within 7–10 days. The Aciclovir has been recommended for treatment of this
lesions usually appear on the lips and perioral skin, often condition, but should be prescribed only under strict
triggered by ultraviolet radiation. In some cases, trigeminal medical guidance. It should be supplemented with bed rest,
neuralgia has been described in conjunction with episodes fluids, and soft diet, along with antipyretics for fever reduc-
of herpes labialis, suggesting induction of neurosensory tion (Wilson et al., 2009). Patients should be discouraged
abnormalities (Treister and Woo, 2010). Herpetic whitlow from touching the lesions, in order to reduce the risk of
(Figure 14.10), a herpetic infection of the fingers, is an spreading the infection.
occupational hazard as far as dental professionals are con-
cerned, consisting of severely painful localized lesions, but Varicella zoster infection
which can spread following surgical intervention (Wu and
Schwartz, 2007). The primary infection from varicella virus is chicken pox,
which occurs mainly in children. The virus remains in a
latent state in dorsal root ganglia, and is reactivated, when
host immunity is compromised at a later stage to produce
herpes zoster or shingles. Varicella is a highly infectious
disease, transmitted by inhalation of infective droplets and
by direct contact with the lesions. The pruritic skin rash
progresses through macules, papules, vesicles, drying vesi-
cles and scabs, with healing occurring over 2–3 weeks.
Intraoral vesicles are commonly seen on the tongue, buccal
mucosa, gingiva, palate (Figure 14.11), and oropharynx,
and are generally not painful (Birek, 2000). A number of
predisposing factors can lead to recurrence of the infection
Orthodontic Implications of Oral Acute and Chronic Infections 253
Figure 14.11 Herpes zoster. (Courtesy of Professor Mats Jontell.)
Figure 14.12 Infectious mononucleosis.
in tissues supplied by sensory nerves, such as immunosup- tonsils (Figure 14.12), are the reported oral manifestations
pression with cytotoxic drugs, radiation, internal malignan- (Mendoza et al., 2008). This virus is also implicated in oral
cies, malnutrition, old age, alcohol, and substance abuse. In hairy leukoplakia, which is seen in HIV-infected patients,
immunocompromised patients, including those infected and in malignancies (nasopharyngeal carcinoma, Burkitt
with HIV, the recurrence rate of herpes infection is increased lymphoma, and oral squamous cell carcinoma) and peri-
(Civen et al., 2009). Occasionally, dental manipulation can odontal disease (Mendoza et al., 2008; Hoelzer, 2009). EBV
also lead to recurrence. The first signs are pain and tender- and cytomegalovirus have been associated with multiple
ness in the dermatome corresponding to the sensory gan- autoimmune disorders, such as systemic lupus erythema-
glion, following which vesicles appear on one side of the tosus, rheumatoid arthritis, multiple sclerosis, pemphigus
face or along the distribution area of one branch of the vulgaris, Sjögren syndrome, Wegener granulomatosis, and
trigeminal nerve. The unilateral vesicles form clusters with polyarteritis nodosa (Barzilai et al., 2007). Diagnosis is
areas of surrounding erythema, ending abruptly in the established with a monospot test, and the disease is usually
midline. The lesions often heal with scarring, and areas of self-limiting with bed rest and analgesics. Aciclovir has no
hypo/hyperpigmentation may be seen. When the facial and role in its treatment.
auditory nerves are affected, there is facial paralysis, vesicles
in external ear, tinnitus, deafness, and vertigo, the combina- Cytomegalovirus infection
tion of which is called ‘Ramsay–Hunt syndrome’ (Persson
et al., 2009). A residual complication of herpes zoster infec- This is the least common of the herpes viral infections,
tion is postherpetic neuralgia, which occurs in 10% of as is herpes 6, 7 and 8 viral infections. Human cytomega-
patients, and manifests as unilateral persistent pain in the lovirus infection presents as mainly three syndromes:
affected area (Gilden et al., 2010). Treatment of this infec- perinatal and human cytomegalovirus inclusion disease,
tion is supportive and symptomatic, with topical, as well as acute acquired human cytomegalovirus infection, and
systemic antipruritics and analgesics that do not contain human cytomegalovirus disease in immunocompromised
aspirin. A high dose of aciclovir (800 mg five times daily for hosts (Rivera-Hidalgo and Stanford, 1999). Oral mani
7 days) is recommended. festations are observed in the latter two syndromes, which
are together called heterophil-negative infectious mononu-
Epstein–Barr virus cleosis. Infection often arises after blood transfusion or
sexual contact (Miller, 1996). Sahin et al. (2009) recently
EBV is the causative agent in infectious mononucleosis or identified the saliva of patients with chronic periodontitis
‘kissing disease’ in young adults and children, transmitted as the source for human cytomegalovirus and EBV, from
mainly through blood and saliva (Rivera-Hidalgo and where the reactivation process can start. These viruses
Stanford, 1999). The disease manifestations include fever, become very active in immunocompromised patients and
lymphadenopathy, malaise, and sore throat. Oral ulcers, are often associated with malignancies such as oral squa-
multiple palatal petechiae, gingival ulcerations, and enlarged mous cell carcinoma and cervical carcinoma (Miller, 1996).
254 Integrated Clinical Orthodontics
Palliative treatment is the management choice in these larynx, and the mouth (Dhariwal et al., 1995). The classical
conditions. oral lesions associated with papillomavirus infection are
squamous cell papilloma, condyloma acuminatum, verruca
Measles vulgaris, and focal epithelial hyperplasia (Chaudhary et al.,
2009). Squamous cell papilloma is a slow growing, solitary,
An enveloped virus belonging to the family Morbillivirus painless, exophytic, cauliflower-like, small, pink mucosal
causes measles. This is a highly communicable disease, lesion with a narrow base. It can occur at any age, but is
transmitted by inhalation of infective droplets with an most commonly seen between 30 and 50 years of age, with
incubation period of 10–14 days. It is an acute systemic predilection for the tongue, lip, and soft palate (Carneiro
condition, the prodrome of which consists of cough, con- et al., 2009). Verruca vulgaris or the common wart is a
junctivitis, fever, malaise, photophobia, rhinitis, and Koplik narrow exophytic growth with a wider base, that is sessile,
spots, which appear on the mucosa next to the molars as and firm. Oral lesions arise through autoinoculation, with
bluish-gray specks on a red base. The spots start to appear the labial mucosa, tongue, and gingiva as the preferred
48 hours before the development of the irregular red-brick sites. The most common site is the buccal mucosa, and the
maculopapular rash characteristic of measles, and may last infection is strongly associated with oral habits such as
4 days (Steichen and Dautheville, 2009). Shedding of areca quid chewing and cigarette smoking (Wang et al.,
measles virus starts in the prodromal stage, and continues 2009). Condyloma acuminatum is usually found in the
through the acute stage. Measles remains a major cause of genitalia, with occasional occurrence in the oral cavity. Oral
childhood mortality in developing countries (Rivera- infections are predominantly transmitted through oral–
Hidalgo and Stanford, 1999). However, vaccination can genital sexual contact, and consist of multiple cauliflower-
prevent its occurrence. like lesions; the labial mucosa, lingual frenulum, and
the soft palate are the sites of preferred invasion. Kui et al.
Mumps (2003) traced the occurrence of condyloma acuminatum to
infection by human papillomavirus, and suggested sexual
Mumps, or epidemic parotiditis, is caused by the mumps abuse as the most common route of transmission. Focal
virus, which belongs to the Paramyxoma virus genus. The epithelial hyperplasia, or Heck disease, usually presents
parotid salivary gland infection may appear either unilater- as multiple plaque-like lesions, which are the same color as
ally or bilaterally, and viremia can lead to complications the mucosa and have a smooth surface. Individual lesions
such as orchitis in males, oophoritis in females, pancreatitis, tend to be small (0.3–1 cm), but they coalesce and cluster,
deafness, and aseptic meningitis and encephalitis. Affected giving the mucosa a cobblestone or fissured surface. Lesions
salivary glands will appear swollen, and will be accompa- occur exclusively in the oral mucosa, and often present
nied by swelling of Stensen’s duct, erythema, and pain. It is as asymptomatic papules (Bennett and Hinshaw, 2009).
a highly communicable disease, transmitted by inhalation Other lesions such as erythroplakia, proliferative verrucous
of infective droplets, with an incubation period of 14–21 leukoplakia, candidal leukoplakia, squamous cell carci-
days. Clinical diagnosis is based on the classic parotid swell- noma, and lichen planus have also been associated with
ing, while laboratory diagnosis is based on the isolation of papillomavirus infection (Rivera-Hidalgo and Stanford,
the virus, detection of viral nucleic acid, or serological con- 1999). Most often, the treatment objective is to surgically
firmation with the presence of IgM mumps antibodies. excise the lesion if it causes esthetic problems, or is chroni-
Vaccination can prevent mumps; one dose of vaccine is cally injured.
about 80% effective against the disease (Hviid et al., 2008).
Retroviral infections
Orthodontic treatment should not be carried out during
the infectious stages of these diseases, as inter-personnel Retroviral species, which inhabit almost all vertebrates,
transfer occurs rapidly. If the orthodontist is unaware of the have seven established genera. HIV and T-lymphocytic
disease process, its clinical signs and symptoms, especially viruses are considered to be the human pathogens in this
the initial oral manifestations, he or she might contract the group. The name retrovirus has its origin in its unique
infection and become a carrier. Thus for ethical reasons, an mode of replication. After entering a cell, the viral RNA is
orthodontist, as part of the healthcare system, should be transcribed by viral reverse transcriptase into a DNA mol-
aware of the signs and symptoms of all these diseases along ecule, which is integrated as a provirus into the host chro-
with the methods of identification and management/ mosomal DNA. The provirus DNA serves as a template for
referral strategies, not only to protect him or herself but the formation of viral RNA and the proteins used in the
also their office staff and patients from contacting it. assembly of new virions. The ability of a provirus to remain
transcriptionally inactive enables retroviruses to maintain
Human papillomavirus infections persistent infection despite a functional host immune
system (Slots, 2009). HIV belongs to the Lentivirus genus,
Human papillomavirus is composed of more than 60 sero- and HIV-1 and HIV-2 are its two subspecies. HIV-1 is the
logical types, and produces lesions in many areas of the
body, such as the trachea, esophagus, genitalia, nasal cavity,
Orthodontic Implications of Oral Acute and Chronic Infections 255
most virulent type, and is responsible for the majority of ment, in order to detect those who may have symptoms
HIV infections globally. The most common mode of spread suggestive of these viral infections. Provision of orthodon-
is through the sexual route, followed by blood or blood tic care for patients with these viral diseases requires close
products infusion, and mother-to-child transmission and continuous interaction with the physicians treating
in utero. HIV uses the CD4 receptor and chemokine these individuals.
co-receptor (CCR5) for entry into susceptible cells, and Herpangina
results in selective depletion of CD4+ T lymphocytes Herpangina is an acute febrile illness of sudden onset, char-
by apoptosis or necrosis. This process leads to progressive acterized by the presence of ulcerations, vesicles, and diffuse
loss of cell-mediated immunity (Sallberg, 2009). The course erythema of the soft palate (Figure 14.13), fauces, and ton-
of infection can be primary or acute, or chronic, finally sillar areas. It commonly occurs in children, mainly during
culminating in acquired immune deficiency syndrome the summer, with a sudden onset of malaise, fever, and sore
(AIDS). In the early stages, there is development of oral and throat. The absence of oral lesions on the hard palate, and
vaginal candidiasis along with pneumococcal infections, the acute onset and short period of morbidity, help to dif-
tuberculosis, and reactivation of herpes simplex and vari- ferentiate herpangina from other infectious processes. It is
cella infections. Later stages involve infections caused by more frequently caused by the Coxsackie group A serotypes
Candida, Pneumocystis jiroveci, Histoplasma, Toxoplasma, (Figure 14.14), and less frequently by group B serotypes,
and Cryptococcus species (Reichart, 2003; Slots, 2009).
Malignancies in HIV patients are often viral related, and Figure 14.13 Herpangina. (Courtesy of Dr Peter Johansson.)
EBV lymphomas, human herpesvirus, Kaposi sarcoma, and
papillomavirus sarcomas predominate (Slots, 2009). Figure 14.14 Coxsackievirus infection of the gingiva. (Courtesy of Professor
Mats Jontell.)
Oral hairy leukoplakia presents as a white, vertically cor-
rugated, nonremovable lesion on the lateral or ventral
margin of the tongue. The lesion is caused by EBV and has
no premalignant potential (McCullough and Savage, 2005b;
Gonzalez et al., 2010). Kaposi sarcoma is characterized by
erythematous or violaceous plaque-like lesions that develop
into tumorous growths over time. Large lesions may get
ulcerated and become painful, and interfere with function.
Hairy leukoplakia is predominantly seen in the palate or in
the attached gingiva (Van Heerden, 2006). Other HIV-
related oral lesions include pseudomembranous candidia-
sis, non-Hodgkin lymphoma, linear gingival erythema,
necrotizing ulcerative periodontitis, and necrotizing ulcera-
tive gingivitis (Leao et al., 2009). Current therapy for HIV
infection is termed as HAART, or highly active antiretrovi-
ral therapy, and it includes at least two classes of antiretro-
viral agents. These may be a combination of two nucleoside
analog inhibitors of reverse transcriptase, together with a
protease inhibitor or a non-nucleoside reverse transcriptase
inhibitor. If immune reconstitution had not happened,
there may be a rebound of symptoms, such as oral candi-
diasis and parotid gland enlargement (Ortega et al., 2008).
If the patient is resistant to antiretroviral agents, the newer
classes of drugs such as CCR5 antagonists can be prescribed
(Slots, 2009).
If an orthodontist fails to identify this highly contagious,
globally prevalent viral infection, for which no effective
treatment has yet been developed, this will be considered
highly negligent and dangerous. There is every chance that
infected individuals will request correction of their maloc-
clusion, but treating them without taking proper precau-
tionary measures may lead to transmission of the infection.
It is, therefore, imperative to obtain a detailed medical
history, and to perform a thorough orofacial examination,
in both young and adult candidates for orthodontic treat-
256 Integrated Clinical Orthodontics
echovirus, and enterovirus. Usually the disease is self- Infection with hepatitis B virus has three distinct phases:
limiting (Rivera-Hidalgo and Stanford, 1999; McCullough the first phase is acute, and is either subclinical or shows
and Savage, 2005b; Van Heerden, 2006; Slots, 2009). the classic signs of liver disease. This phase is seen mainly
in adults. Children show the other two stages: chronic infec-
Hand, foot, and mouth disease tion, in which there is a high rate of viral replication, and
later on a latent phase, where the virus maintains a lower
Hand, foot, and mouth disease is a mild exanthematous replication rate. During the infectious phase, the child is
lesion, most commonly seen in children aged 1–5 years, highly contagious and the risk for severe liver disease is
but older children and young adults are not spared. increased (Broderick and Jonas, 2003). The disease can be
Several enteroviruses are thought to be causative, and the easily transmitted via an accidental needle stick injury, or a
most important ones are human enterovirus-71 and bite, through just 1 mL of blood, which contains 105–107
Coxsackievirus serotype (Kushner and Caldwell, 1996). The viral genomes. Dental staff should be vaccinated against
typical feature is exanthematous illness with vesicular hepatitis B, as once infected they can become lifelong car-
lesions, 2–10 mm in diameter, of the hands, feet, and mouth. riers. Treatment for hepatitis B infection requires a combi-
The cutaneous vesicles can resemble chicken pox (Slots, natorial approach, as in HIV-infected patients, and it
2009). Oral lesions appear as ulcerations in the buccal requires drugs that attack the various stages of viral replica-
mucosa (square blisters) and soft palate. Aciclovir has been tion (Sallberg, 2009).
found to be useful in the treatment of hand, foot, and
mouth disease (Shelley et al., 1996). Sometimes the disease Hepatitis C is quite rare in childhood, but can be seen
is self-limiting, with only symptomatic treatment indicated, owing to vertical transmission (from mother to child) or
to alleviate pain and associated fever. Non-aspirin antipy- through a nosocomial route. This virus can also lead to a
retics and topical anesthetics are of great help in these serious liver disorder, and children are often treated with
patients (Rivera-Hidalgo and Stanford, 1999; McCullough interferon gamma and riboflavin combination regimen. No
and Savage, 2005b; Van Heerden, 2006; Slots, 2009). vaccine is presently available for hepatitis C (Fischler, 2007;
Sallberg, 2009).
Viral hepatitis
Fungal infections
Viral hepatitis does not have any oral manifestations, but is
important because it can spread through the oral route. The most common fungal infections affecting the oral
Dentists and orthodontists treating patients with this cavity and of interest to dental surgeons and especially
disease should be aware of its signs and symptoms, so that orthodontists are listed in Table 14.3.
they can prevent the spread of the infection to themselves
and to their patients and clinical staff.
Table 14.3 Fungal infections of relevance to the dentist and orthodontist
Type of fungi Type of fungal infection Common species Clinical manifestations Treatment
Oral yeast infections Candidiasis C. albicans Acute pseudomembranous
Candida-associated lesions C. glabrata Mucostatin
Systemic mycoses by molds C. tropicalis Chronic hyperplastic or erythematous (atrophic) Amphotericin
Aspergillosis C. krusei Azoles
Cryptococcosis C. dublinensis Hyperkeratinized (white) or atrophic (red) mucosal
Blastomycosis lesions from which Candida can be isolated Amphotericin B
Mucormycosis A. fumigates Pulmonary Azoles
Histoplasmosis Amphotericin B
Paracoccidioidomycosis C. neoformans Pulmonary Flucytosine
Sporotrichosis Amphotericin B
B. dermatitidis Pulmonary, cutaneous Azoles
Amphotericin
Mucorales spp. Pulmonary Surgery
Amphotericin B
H. capsulatum Pulmonary, cutaneous Azoles
Amphotericin B
P. brasilisensis Pulmonary Azoles
Amphotericin B
S. schenckii Cutaneous
Adapted from Samaranayake et al., 2009.
Orthodontic Implications of Oral Acute and Chronic Infections 257
Figure 14.15 Acute pseudomembranous candidiasis. (Courtesy of Professor Figure 14.16 Acute erythematous candidiasis. (Courtesy of Dr Bengt Hasseus.)
Mats Jontell.)
Candidiasis is the most common oral mycotic infection, kia tends to have a tendency towards malignant conversion
and Candida albicans is the organism most commonly asso- (McCullough and Savage, 2005a; Samaranayake et al.,
ciated with it. Other species observed in oral fungal infec- 2009).
tions are Candida tropicalis, Candida glabrata, Candida
krusei, and Candida dublinensis. Clinically, candidiasis can Other conditions caused by Candida species are chronic
be the cause of oral discomfort or pain, dysgeusia, and aver- atrophic candidiasis or denture sore mouth, linear gingival
sion to food (Samaranayake et al., 2009). Oral candidal erythema, secondary oral candidiasis, and chronic muco-
infections are categorized as primary and secondary; cutaneous candidiasis syndromes. In denture sore mouth
primary candidiasis is confined to the oral and peri-oral (Figure 14.19), which can be seen in patients wearing
tissues. If oral candidiasis is a manifestation of systemic removable orthodontic appliances, there is overgrowth of
disease, it is categorized as secondary candidiasis (Axell et C. albicans on the fitting surface of a denture or a removable
al., 1997). Primary oral candidiasis is further subdivided orthodontic appliance. The patient may complain of
into pseudomembranous, erythematous, and hyperplastic angular cheilitis (Figure 14.20a,b), or occasional burning or
types. Pseudomembranous candidiasis (Figure 14.15), oth- tingling sensation beneath the acrylic baseplate. This can be
erwise known as thrush, is characterized by white patches prevented by educating the patient about the importance
on the labial and buccal mucosa, tongue, and soft palate. of oral hygiene measures, and cleaning and proper follow-
The lesions often resemble milk curd, and can be wiped off up of inserted dentures and removable orthodontic appli-
very easily with the help of a tongue blade, to reveal an ances (Coelho et al., 2004).
erythematous, erosive base. The white mass consists of a
tangled mass of fungal hyphae, bacteria, inflammatory cells, Linear gingival erythema is defined as nonplaque-
fibrin, and desquamated epithelial cells. Erythematous can- induced gingivitis, presenting as a distinct erythematous
didiasis (Figure 14.16) occurs as a consequence of persist- band of at least 2 mm along the margin of the gingiva,
ent acute pseudomembranous candidiasis and it is the most with either diffuse or punctate erythema of the attached
common form seen in HIV-infected patients. It consists of gingiva. The lesions may be localized to one or two teeth,
red patches, often in the mid-dorsum of the tongue, palate, or can be generalized, and may or may not be accompanied
and buccal mucosa. Palatal erythematous lesions, otherwise by occasional bleeding and discomfort. C. dubliniensis
known as ‘kissing’ lesions, are a common finding in HIV has been implicated in linear gingival erythema, and is
infection. Motta-Silva et al. (2010) recently concluded that one of the common oral manifestations of HIV infection
oral erythematous candidiasis is more prevalent in patients (Zhang et al., 2009). Treatment of this condition does
with controlled diabetes mellitus type 2. Hyperplastic can- not require antifungal medications, but rather profes
didiasis, or candidal leukoplakia (Figures 14.17, 14.18), is sional periodontal scaling and debridement, along
the least common form, appearing as chronic, discrete, with effective plaque control at home, and twice daily
slightly raised lesions that vary from small palpable, trans- mouth rinses with 0.12% chlorhexidine gluconate for 2
lucent, whitish areas, to large, dense, opaque plaques, with weeks.
hard and rough areas evident on palpation (Sitheeque and
Samaranayake, 2003). Fifteen percent of candidal leukopla- Secondary candidiasis occurs consequent to HIV infec-
tion, hematological malignancies, and aggressive treat
ment with cytotoxic agents. Chronic mucocutaneous
candidiasis syndrome is a persistent candidiasis that
258 Integrated Clinical Orthodontics
responds poorly to topical antifungal agents (Samaranayake
et al., 2009).
Treatment of candidal infections ranges from topical
delivery of polyene agents up to four times a day, to sys-
temic delivery of azole agents ranging from a weekly
single dose, to a single dose per day for a week (Greenspan,
1994; Laudenbach and Epstein, 2009). Two polyenes
are commonly used for antifungal treatment: nystatin
and amphotericin B, of which nystatin is more commonly
used. It has fungicidal and static activity, and is available
as creams, tablets, suspensions, oral gels, rinses, and pas-
tilles. Nystatin is not absorbed when given orally, and is
too toxic for parenteral use. In such cases, amphotericin
B is preferred, but it has a serious systemic adverse effect,
that is, nephrotoxicity. Hypokalemia and anemia are
Figure 14.17 Chronic nodular candidiasis in the buccal mucosa. (Courtesy
of Professor Mats Jontell.)
Figure 14.18 Chronic nodular candidiasis of the lip. (Courtesy of Dr Per-Olov Figure 14.19 Denture sore mouth with secondary Candida infection.
Rödström.) (Courtesy of Dr Ranimol Sreekumar.)
(a) (b)
Figure 14.20 (a) Angular cheilitis due to Candida albicans. (b) Healing lesions in the same patient as in Figure 14.20a. (Courtesy of Professor Mats Jontell.)
Orthodontic Implications of Oral Acute and Chronic Infections 259
also common, along with anaphylaxis, fever, headache, mans (Swe Han et al., 2009). The disease is usually a pul-
vomiting, and anorexia. Amphotericin B is available as monary infection, but oral lesions occur in the disseminated
lozenges, ointment, suspensions, and cream. Azole antifun- form. Oral lesions range from violaceous nodules of granu-
gal agents are imidazoles (clotrimazole, econazole, iso lation tissue, swelling, to ulcers, and are usually seen in the
conazole, miconazole), and triazoles (fluconazole and gingiva, hard and soft palate, pharynx, oral mucosa, and in
itraconazole). Clotrimazole has a broad spectrum of activ- tooth sockets after extraction (Iatta et al., 2009). Diagnosis
ity, and is mainly fungistatic. It is available in the form is confirmed by microscopy, and systemic amphotericin B,
of 1% cream, lozenges, vaginal creams, and tablets. supplemented with flucytosine, is the drug of choice for
Miconazole, which also has a broad spectrum of activity, treatment (Samaranayake et al., 2009).
is also effective against some Gram-positive bacteria,
such as staphylococci (Isham and Ghannoum, 2010). Blastomycosis, caused by Blastomycosis dermatitidis, is a
Fluconazole is the drug of choice in oropharyngeal can relatively uncommon male-predominant disease, present-
didiasis in HIV-infected patients, due to its high syste ing as pulmonary, disseminated or localized cutaneous
mic absorption rate. It is available as capsular and lesions. The disease is initiated upon inhalation of the
intravenous formulations, with a dosage of 100 mg daily for spores, and the clinical and histopathological findings are
7–14 days (Samaranayake et al., 2009; Martinez-Beneyto similar to those of squamous cell carcinoma. Oral blasto-
et al., 2010). mycosis is uncommon, but when present, it is seen as single
or multiple ulcerations, sessile projections, and granulo
Orthodontic appliances, removable, fixed, or functional matous or verrucous lesions (Kruse et al., 2010). Diagnosis
ones, by virtue of preventing proper performance of oral is based on biopsy, smear, and culture. Amphotericin, keto-
hygiene measures can promote candidal overgrowth. conazole, miconazole, and itraconazole are all effective in
Orthodontists should be equipped for management of treating this disease (Samaranayake et al., 2009).
these lesions after appropriate identification, as well as dif-
ferential diagnosis to eliminate serious underlying disor- Mucormycosis, caused by the saprophytic fungus
ders. They should be aware of the available antifungal Mucorales, is often found in the nasal cavity of healthy
preparations and their dosages, so that minor problems can individuals. Infection arises through inhalation of spores
be tackled in the orthodontic office. Major problems should that are deposited in the pulmonary alveoli and spreads to
be identified, followed by referral to an oral medicine spe- different locations, such as the paranasal, rhino-orbital, rhi-
cialist or to a physician, so that the patient’s wellbeing and nocerebral, cerebral, pulmonary, and gastrointestinal areas.
quality of life are not compromised. The fungi erode the arteries, resulting in thrombosis and
subsequent necrosis of surrounding tissues. Auluck (2007)
Some uncommon systemic mycoses with described maxillary erosion (which is rare due to high vas-
oral lesions cularity) by mucormycosis in a patient with uncontrolled
diabetes, outlining its severity. Six cases with mucormycosis
An increasing number of immunocompromised patients affecting the periodontal ligament have been described in
are attending dental as well as orthodontic offices; thus a the literature (McDermott et al., 2010). Oral ulcerations,
number of uncommon mycotic lesions are now being first sinusitis, and facial cellulitis are common with mucormy-
detected by dental surgeons and orthodontists. Aspergillosis cosis, along with blood-tinged nasal discharge, and unilat-
is the second most common opportunistic mycotic infec- eral facial pain or numbness (Tabachnick and Levine,
tion and affects the paranasal sinuses, the nasal cavity and 1975). Diagnosis is confirmed by smear and histological
oral mucosa, as well as the facial skin. It is caused by several demonstration of tissue invasion by hyphae. Treatment
Aspergillus species, of which Aspergillus fumigates is the involves correction of acidosis, antifungal therapy with
most common. It is generally contracted through inhala- amphotericin B, and surgical debridement (Samaranayake
tion of spores, leading to both upper and lower respiratory et al., 2009).
tract infection, and to bronchopulmonary aspergillosis.
Oral aspergillosis lesions are yellow or black in color, with Histoplasmosis, a localized or systemic fungal infection,
a necrotic ulcerated base, typically seen in the posterior caused by Histoplasma capsulatum, appears when microco-
palate or posterior tongue (Iatta et al., 2009). The hyphae nidiae or hyphae are inhaled into the lungs. Clinical pres-
may penetrate the walls of small-to-medium sized arteries entation of this infection includes acute or chronic
and veins and cause infarction, thrombosis, and necrosis, pulmonary cutaneous histoplasmosis, with or without dis-
leading to systemic spread (Sales Mda, 2009). Systemic seminated disease. Oral lesions are mostly chronic, with
amphotericin B is the treatment of choice, along with nodular, indurated or granular masses and ulceration
topical clotrimazole or ketoconazole (Samaranayake et al., affecting the oral mucosa, tongue, palate, gingiva, and the
2009). periapical region of the teeth (Epifanio et al., 2007; Narayana
et al., 2009). Diagnosis is confirmed by microscopy, culture,
Cryptococcosis is a chronic fungal disease involving the and serology. Amphotericin B is the drug of choice, with
lungs, the central nervous system, and occasionally the skin fluconazole and itraconazole as alternatives (Samaranayake
and the mouth. The causative agent is Cryptococcus neofor- et al., 2009).
260 Integrated Clinical Orthodontics
Paracoccidioidomycosis is caused by Paracoccidioides Amphotericin B, itraconazole and terbinafine (Kusuhara,
brasiliensis, which produces a granulomatous disease, 2009).
primarily affecting the lungs and then disseminating to
the nasal mucosa and other organ systems. The disease Parasitic infections
is restricted to south and central America, especially Brazil,
hence the name South American blastomycosis. The source The common parasitic infections of particular interest to
of the organism is the soil, and infection occurs through dentists and orthodontists are listed in Table 14.4.
inhalation or by direct contact (Ramos-E-Silva and Saraiva,
2008). Oral manifestations are common, and the lesions Local protozoan infections, caused by Trichomonas tenax
usually appear as small papules and vesicles, which then and Entamoeba gingivalis, which may occur as harmless
ulcerate to form shallow ulcers with a rolled edge and commensals of the oral cavity, are observed in conditions
a white exudative base studded with small hemorrhagic of poor oral hygiene and in people with a low standard
dots (Jham et al., 2008). In severe cases, infection may pen- of living. The etiological role of these organisms in oral
etrate deep into the bone with perforation of the hard infections is unclear, but they have been isolated from peri-
palate. Lesions can occur anywhere in the oral cavity, odontal tissues of immunocompromised patients with
including the hard and soft palate, tongue, gingiva, and necrotic gingivitis. This finding has led to an assumption
tonsils, and may lead to mobility of teeth due to periodontal that parasitic infections are uncommon in healthy indi-
infection. The face becomes readily swollen (Godoy and viduals and are more frequently observed in immunocom-
Reichart, 2003; Silva et al., 2007). Diagnosis is usually con- promised individuals. Diagnosis is based on microscopic
firmed by histology and culture. Sulphonamide or ampho- examination of tissue scrapings after Giemsa staining, or
tericin B alone, or in combination, is the treatment of after preculture in specific media, such as Kupferberg
choice. Ketoconazole can also be used (Samaranayake et al., Trichomonas broth. In addition, polymerase chain reaction
2009). (PCR) amplification techniques can also be employed.
Metronidazole is the drug of choice in both Trichomonas
Sporotrichosis is a chronic nodular mycotic disease, the and Entamoeba infections, with a dosage of 400 mg three
causative agent of which is Sporotrichium schenckii, a fungus times daily for 1 week. There are no vaccines for these dis-
found in soil and rotting wood. The fungi gain access eases (Bergquist, 2009).
through traumatic ulcerations, and usually affect the skin
(Mahlberg et al., 2009). Proliferation of the organism leads Leishmaniasis, the systemic parasitic infection, is caused
to formation of a nodule or small ulcer. The nodules turn by Leishmania, a protozoan parasite that is found world-
into ‘bumps’ on the skin and after several weeks the initial wide. Transmission relies on the sand fly, which constitutes
lesions heal with scarring, as new nodules and new bumps a vector for the parasite and is part of the life cycle of
develop in other areas. Oral lesions are initially erythema- Leishmania. Leishmaniasis has a spectrum of clinical symp-
tous, ulcerative, and suppurative, but eventually become toms ranging from superficial self-resolving skin patches,
granulomatous, vegetative, and papillomatous. These to systemic mutilating forms resembling leprosy (Motta
lesions are painful, with enlarged and hard regional lymph et al., 2007). The clinical spectrum also includes cutaneous,
nodes, and may resemble aphthous ulcerations, lichen mucocutaneous, and visceral leishmaniasis. Cutaneous
planus, or cutaneous leishmaniasis (Aarestrup et al., 2001). leishmaniasis, often referred to as oriental sore, is a local-
Diagnosis is confirmed by histology and culture. Oral ized skin lesion that does not spread beyond the area of
potassium iodide is the treatment of choice, followed by inoculation. This is the least serious form of the disease
(Reithinger et al., 2007). When the organism invades
Table 14.4 Parasitic infections of interest to dentists and orthodontists
Type of infection Microorganisms involved Clinical manifestation Treatment Comment
Local oral parasitic Entamoeba gingivalis Metronidazole
infection Associated with aggressive periodontitis in Transmitted
Trichomonas tenax immunocompromised patients Metronidazole by a vector
Systemic parasitic (sand fly)
infections Leishmania brasiliensis, Associated with aggressive periodontitis in No efficient drugs available
(leishmaniasis) L. mexicana (in the immunocompromised patients Amphotericin B and antimonite
mucocutaneous form) have some effect
Cutaneous, mucocutaneous and visceral forms
The mucocutaneous forms may have oral
manifestations
Adapted from Bergquist (2009).
Orthodontic Implications of Oral Acute and Chronic Infections 261
mucosal tissues, it is called as mucocutaneous leishmania- blood stream required to cause transient bacteremia is
sis, and has a predilection for oto-nasopharyngeal areas. around 1–10 per mL of blood; this usually lasts for no more
The most common symptom is nasal irritation or stiffness than 15–30 minutes. The bacterial spread is mainly by three
due to infiltration of the parasite into the septum and routes (Gendron et al., 2000):
inferior turbinates. Extension of this lesion can lead to
granulomas in the oral, laryngeal and pharyngeal areas, • Metastatic infection – caused by translocation of
and as the disease progresses, severe facial deformities bacteria
develop, sometimes resulting in total loss of the nose and
upper lip (Di Lella et al., 2006). The involvement of the • Metastatic injury – through microbial toxins
palate, tongue, pharynx, and larynx can lead to dysphagia • Metastatic inflammation – due to immune injury.
or dysphonia. Bacterial superinfections can occur over
these areas, further complicating the problem (Bergquist, Recent studies have confirmed the role of oral micro
2009). Visceral leishmaniasis is otherwise known as kala organisms in focal infections that can lead to coronary
azar, in which there is hematogenous dissemination of heart disease, pre-term low birthweight babies, and aspira-
Leishmania species, which then infect macrophages in the tion pneumonia (Destefano et al., 1993; Offenbacher
liver, spleen, bone marrow, and lymph nodes. This condi- et al., 1996; Scannapieco et al., 1998). The susceptibility
tion usually develops gradually, and the patient becomes of certain groups of individuals, such as older patients and
progressively weak with abdominal distension, nausea, and the immunocompromised (HIV infected, organ trans-
vomiting, followed by lymphadenopathy, petechiae, ecchy- planted), to this process is well established (Gendron et al.,
moses, and edema. The skin becomes dry and scaly, and can 2000).
acquire a grayish tone, especially on the hands and face
(Gupta et al., 2010). Infective endocarditis
Infective endocarditis is the most common heart disease
Aspirates and biopsy specimens from the raised edges caused by oral bacterial metastasis. Congenital heart dis-
of skin lesions can be used to make a direct diagnosis. eases, presence of valvular defects and a previous history of
Giemsa staining will reveal amastigotes, which tend to congestive cardiac diseases, all predispose patients to infec-
be found in the periphery of infected host cells (Bergquist, tive endocarditis when exposed to surgical dental proce-
2009). Aspirates can be cultured in specialized media dures (Bascones-Martinez et al., 2009). The outcome of
such as Novy-McNeal-Nicolle medium (Limoncu et al., the disease varies from debilitation to death due to valvular
2004). Several rapid and reliable tests are available, such malfunction, congestive cardiac failure, or renal compli
as Montenegro skin test, immunochromatographic test, cation. About 50% of the cases are due to viridans strep
and molecular diagnostic tests using PCR (Bergquist, tococci (alpha streptococci), more particularly the
2009). Pentavalent antimonials, such as sodium stibog polysaccharide-producing Strep. sanguinis, Strep. mutans,
luconate (Pentostam) and methylglucamine antimonite Strep. oralis, Strep. mitis, and Strep. salivarius (Douglas
(Glucantime), are the drugs used in treatment of leishma- et al., 1993). Production of extracellular polys accharide
niasis of all forms. A dose of 20 mg/kg/day is recommended, glucan by these bacteria favors their attachm ent to heart
and should be administered only under medical supervi- surfaces or fibrin-platelet clots. Fiehn et al. (1995) reported
sion. The second line of drugs such as pentamidine, ampho- that bacteria colonizing in the oral cavity may invade
tericin B, and macrolide polyenes can also be used, from through the blood stream and cause infective endocarditis.
which amphotericin B has the highest cure rate (Bergquist, It has been reported that cardiovascular complications are
2009; van Griensven et al., 2010). There is no vaccine avail- more frequent in patients with periodontitis, and studies
able for this disease, and prevention is the only option. Use have provided evidence of a close association between peri-
of insecticide-treated nets is a good method and is recom- odontitis and myocardial infarction, atherosclerosis or
mended as a preventive measure (Bergquist, 2009). stroke, and fatal coronary artery diseases (Scannapieco
et al., 2010). For a more detailed discussion of the subject
The oral cavity as a source for focal infections and the management strategies see Chapter 8 in Biological
Mechanisms of Tooth Movement (Krishnan and Davidovitch
Focal oral infections can be defined as infections occurring (eds), Oxford, Wiley Blackwell, 2009).
in different locations in the human body which are caused
by microorganisms normally inhabiting the oral cavity or Brain abscess
their products. Dental procedures such as tooth extraction, A focal suppurative process in the brain parenchyma can
endodontic treatment, periodontal surgery, orthodontic result from transient bacteremia from oral infections or
separator placement, banding and debonding procedures, dental treatment. Around 0.09–0.84 cases of brain abscess
can introduce oral microorganisms into the blood stream reported per million population per year can be attri
and the lymphatic system. The number of bacteria in the buted to oral infectious causes. In most cases of brain
abscess from oral infections, the lesions are located in the
262 Integrated Clinical Orthodontics
frontal or temporal lobes, and reach the brain via direct reported that 77.3% of their patients treated with com-
extension or cavernous sinus thrombosis through the bined periodontal therapy and triple therapy with antibiot-
hematogenous or anatomical routes (Gendron et al., 2000). ics, antimicrobials, and proton pump inhibitors, showed
Syrjanen et al. (1989) found an increased prevalence of successful eradication of gastric H. pylori infection in
periodontitis, periapical abscess, poor oral hygiene, and comparison with 47.6%, who received only triple therapy.
carious lesions in patients with ischemic cerebral infarction. Oral microorganisms such as A. actinomycetemcomitans,
All types of microorganisms, Gram-positive cocci, Gram- Fusobacterium nucleatum, Prevotella intermedia and
negative cocci and rods, and anaerobic bacteria have been Peptostreptococcus micros (now Parvimonas micra) can
isolated from brain abscess lesions (Schuman and Turner, also cause skin infections following direct inoculation
1994). (Gendron et al., 2000). In the same way, chronic urticaria
can be triggered by pathogenic oral microorganisms that
Chronic meningitis favor release of histamine from mast cells, or formation of
Various oral infections, such as dental abscesses and dental circulating immune complexes (Thyagarajan and Kamalam,
caries, have been implicated in chronic meningitis. Bacteria 1982).
found at these sites can contaminate the cerebrospinal fluid,
and reach the central nervous system. Moreover, the spread Osteomyelitis
of oral infections into the tissues surrounding the oral Osteomyelitis has been reported in association with A.
cavity may give rise to chronic maxillary sinusitis and facial actinomycetemcomitans, P. micros, and E. corrdens. In addi-
plane infections. The extreme form of infection in this tion, fusobacteria and C. albicans have been implicated in
regard is Ludwig angina, which involves life-threatening some cases of osteomyelitis following dental treatment
swelling of the posterior floor of the mouth as it can cause (Hudson, 1993; Navazesh and Mulligan, 1995; Gendron
obstruction of the airway (Gilon et al., 2002; Jimenez et al., et al., 2000).
2004). Oral infections have also been implicated in eye
infections such as uveitis, endophthalmitis, and chronic Pre-term birth
conjunctivitis (Gendron et al., 2000). Approximately 7% of all infants weigh less than 2500 g at
birth, and these infants account for two-thirds of neonatal
Pneumonia deaths. There are many risk factors involved in pre-term
Pneumonia is infection of the pulmonary parenchyma birth, such as maternal smoking, alcohol abuse, drug use,
caused by anaerobic bacteria and a dental source of the and infection. Periodontal disease has also been recently
infection has been demonstrated in the form of dental implicated as a risk factor in this phenomenon. It had been
plaque, associated with periodontitis (Sharma and suggested that periodontal disease provides a chronic sys-
Shamsuddin, 2011). Lung abscesses caused by Streptococcus temic source of lipopolysaccharides, which stimulate the
intermedius, Actinomyces species, and Campylobacter rectus production of interleukin-1β and prostaglandin E2, which
have been reported to originate from oral infectious sources are closely associated with pre-term delivery (Heimonen
and dental treatment-induced bacteremia (Scannapieco et al., 2009; Kumar and Samelson, 2009). Katz et al. (2009)
and Mylotte, 1996). Dental plaque containing Pseudomonas isolated P. gingivalis colonies from the placental tissue of
aeruginosa has been implicated in the development of women delivering pre-term babies. Han et al. (2004) pro-
chronic infection of the respiratory tract in patients with posed F. nucleatum as a cause of pre-term delivery. However,
cystic fibrosis. The mechanisms by which these bacteria further evidence is required to clarify the precise role of this
produce respiratory infections have been described by microorganism.
Scannapieco (1999), who suggests that the host-derived
enzymes in the saliva uncover receptors on the mucosal Conclusions
surface allowing colonization by respiratory pathogens.
From this site,periodontal pathogens such as Porphyromonas Orthodontic care is available to people regardless of age,
gingivalis and A. actinomycetemcomitans, are aspirated into sex, and geographical location. Most orthodontic patients
the lung where they initiate infections. At the same time, are healthy, or have health problems that are of minor sinif-
cytokines derived from periodontal tissues may alter the icance as far as mechanotherapeutics is concerned. However,
respiratory epithelium, promoting infection by respiratory some individuals have pre-existing conditions that may
pathogens. endanger their wellbeing, and sometimes their life. Some of
these diseases may be contagious and spread to other
Helicobacter pylori infection people, who are otherwise healthy. The individuals at risk
H. pylori, which persist in dental plaque even after its eradi- are the orthodontist, the orthodontic office staff, and all
cation with triple drug therapy, may get reactivated in other patients who are being treated in the same clinic.
some instances to produce reinfection. Zaric et al. (2009)
Orthodontic Implications of Oral Acute and Chronic Infections 263
Therefore, it is of prime importance for the orthodontist to Bergquist R (2009) Parasitic infections affecting the oral cavity.
identify patients who carry these diseases, in the initial Periodontology 2000 49: 96–105.
diagnosis. The most important duty of orthodontists is to
protect themselves, their assistants, and all their patients Birek C (2000) Herpes virus induced diseases: oral manifestations and
from being infected by contagious diseases carried by some current treatment options. Journal of California Dental Association 28:
persons who are receiving orthodontic care in the same 911–21.
office.
Broderick AL, Jonas MM (2003) Hepatitis B in children. Seminars in Liver
The orthodontist may be the first to diagnose a conta- Diseases 23: 59–68.
gious disease in a patient before or during orthodontic
treatment. In addition to looking for physical evidence of Brook I (2008) Actinomycosis: diagnosis and management. Southern
specific pathological conditions, many laboratory tests are Medical Journal 101: 1019–23.
available, which can confirm or alter the initial diagnosis.
The orthodontist may prescribe medications for the diag- Brook I (2009) Current management of upper respiratory tract and head
nosed diseases, based on his or her knowledge, but fre- and neck infections. European Archives of Otorhinolaryngology 266:
quently they would benefit from seeking the advice of the 315–23.
infected patient’s physician, or a specialist in contagious
diseases. Brook I (2010) Treatment modalities for bacterial rhinosinusitis. Expert
Opinion on Pharmacotherapy 5: 755–69.
In addition to the external dangers associated with con-
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medications used to treat them may affect adversely the biology of acute suppurative parotitis. Laryngoscope 101: 170–2.
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mineralized tissues, under the control of the nervous, ted diseases. Clinics in Dermatology 22: 520–7.
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treatment, but our knowledge about the nature of these loma virus and its detection in potentially malignant and malignant
diseases and the development of means to cure them effec- head and neck lesions: an updated review. Head and Neck Oncology
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provide the best care, alongside protection from undesira-
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15
Orthodontics and Pediatric Dentistry:
Two Specialties, One Goal
Elliott M Moskowitz, George J Cisneros, Mark S Hochberg
Summary pediatric dentist will be applying therapies to their mutual
patient and in many instances, these therapeutic decisions
The pediatric dentist and orthodontist share many professional interests will impact on the immediate and long-term esthetic and
by virtue of the fact that they both are treating the same patient often on functional status of their patient. It is the authors’
a regular and sustained basis. Furthermore, the treatment delivered by belief that new and more profoundly effective avenues
both specialties often has profound overall effects upon the function and of communication and interaction between the orthodon-
esthetics of these young patients as they approach adulthood. Each clini- tist and pediatric dentist need to be established and
cian has the opportunity to support the other’s therapeutic efforts; maintained if individual patients and the public at large
however, there appears to be a significant ‘disconnect’ in treatment focus are to benefit from modern orthodontic and pediatric
and inter-specialty communication and overall interactivity. Individual dental care. Additionally, achieving meaningful and conse-
patient care suffers as the potential synergistic collaboration of the quential interactivity and communication between both
pediatric dentist and orthodontist is never fully realized. The ongoing specialties will require a re-examination of orthodontic and
sharing of new information between both specialties is critical, as is pediatric dental postgraduate curricula as well as existing
coordination of pediatric dental and orthodontic treatment. This chapter guidelines that have been established by each respective
explores some of the existing problems of communication and inter- specialty.
specialty interactivity. Several commonly encountered clinical scenarios
are presented to illustrate these problems as well as to suggest changes Both specialties need to inculcate core information that
in future pediatric dental and orthodontic education, clinical practice, and crosses traditionally defined borders of academic and clini-
ongoing assessments of respective specialty guidelines. cal interest. Some of these areas might include caries man-
agement, enamel decalcification, fluoride use, ectopic and
Introduction impacted teeth, timing of orthodontic treatment, overall
benefit of extraction strategies in orthodontic treatment,
The pediatric dentist is a unique dental clinician as he or management of third molars, dental trauma, patient man-
she is both a primary care dental health provider and spe- agement, root resorption, and treatment options in cases of
cialist. As such, the pediatric dentist has an extraordinary missing permanent teeth. Additionally, the pediatric dentist
responsibility in treating, triaging, and coordinating dental needs more core information on both evidence-based and
healthcare for infants, children, and adolescents. The pedi- evidence-‘bolstered’ information about a number of initial
atric dentist will most likely interface with the orthodontist orthodontic strategies and midcourse orthodontic treat-
on a daily basis far more than any other dental clinician for ment changes that might become necessary as a result of
the obvious reason that many pediatric dental patients will adverse dentofacial growth and development and/or poor
be under the care of both clinicians during the same and patient compliance. Similarly, the orthodontist should
often extended time period. Both the orthodontist and appreciate the incontrovertible value of faithful routine
pediatric dental recall visits of patients undergoing active
Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
268 Integrated Clinical Orthodontics
orthodontic treatment. Both clinicians require a new think- to observe important developmental changes in the denti-
ing of integrating ‘best evidence’ with clinical experience tion and beyond during orthodontic treatment. It is the
and individual patient or parental values. Finally, the ortho- authors’ belief that the orthodontist should bear responsi-
dontist and pediatric dentist must establish mutually bility in assisting the pediatric dentist in ensuring that all
acceptable and practical communication protocols to patients are receiving regularly scheduled pediatric dental
ensure that any or all of these clinical insights will ulti- appointments during orthodontic treatment.
mately result in a consistently higher level of patient care
for each individual patient. While it would be impossible Figure 15.1 shows a typical orthodontic appointment
for the authors to cover all of the aforementioned clinical schedule in a group orthodontic/pediatric dental practice.
situations that the orthodontist and pediatric dentist will At the bottom of the page there are several columns that
encounter in the mixed dentition stage of dental develop- were derived from scheduling information supplied to the
ment in one chapter, several commonly encountered clini- orthodontist from the pediatric dental section of the prac-
cal entities will be included in an effort to emphasize the tice. The first column at the bottom of the page has a list
importance of clinician interactivity between these two of patients who will be seen by the orthodontist and already
specialties. have pediatric dental appointments scheduled. This section
is helpful in coordinating orthodontic treatment and pedi-
Coordinating orthodontic and pediatric atric dental treatment in the near future. For example,
dental appointments in a group or solo timely prescriptions (removal of primary or permanent
practitioner setting teeth, oral hygiene recommendations and/or concerns, etc.)
can be prepared in advance of the individual patient’s pedi-
In order for the pediatric dentist and orthodontist to be atric dental appointment. The second column has a list of
optimally supportive of each other’s efforts, several condi- patients who will also be seen by the pediatric dentist that
tions need to be met. An understanding of the overall particular day. This information may help overall pediatric
emphasis of comprehensive care for the pediatric dental dental concerns as posterior orthodontic bands can be
and orthodontic patient must be appreciated by both clini- removed, a thorough caries check can be performed, and
cians. Most important is the development and maintenance the bands can be replaced that very same day. Additionally,
of ongoing communication paths, so that each clinician is oral hygiene concerns or any unusual in-treatment findings
maximally apprised of the treatment that might already be can be discussed directly with the pediatric dentist and
in progress and/or will be contemplated for the immediate dental hygienist. The third column shows patients who the
or long-term future. There is a growing trend all over the orthodontist will be seeing, but are overdue for their pedi-
world for the formation of consequential ethical profes- atric dental appointments. It is perhaps, this particular
sional partnerships or group types of practice that include column that is most important, for it identifies patients
the participation of pediatric dentists and orthodontists. undergoing orthodontic treatment and who are not being
One would think that such a consortium or association seen by the pediatric dentist during the course of ortho-
would facilitate streamlining communication efforts dontic treatment. Identifying these potentially ‘high risk
between the orthodontist and pediatric dentist. However, patients’ gives the orthodontist an opportunity to have
unless such group practices develop new and unprece- frank conversations with the parents of these patients about
dented communication avenues, the net result would be no the importance of regular pediatric dental appointments
better than what is observed in other types of traditional during the course of orthodontic treatment, and encourage
treatment settings in which the orthodontist and pediatric them to make pediatric dental appointments while they are
dentist frequently are virtually working independently in being seen that day for their child’s orthodontic appoint-
their own milieu, unaware of each other’s treatment plan ment. This protocol has greatly improved oral hygiene
and its progress. efforts and decreased the incidence of white spot lesions
and any associated liability in our practice during ortho-
A glaring, but rather basic example of this point is the dontic treatment, as the orthodontist, pediatric dentist,
pediatric dental recall visit schedule for patients undergo- patient, and parent are optimally apprised of any adverse
ing orthodontic treatment. It is a frequent complaint of the conditions during orthodontic treatment, and appropriate
pediatric dentist that some patients undergoing orthodon- strategies (bolstered oral hygiene instruction, use of fluo-
tic treatment do not faithfully keep their regular pediatric ride varnishes, etc.) can be administered on a regular and
dental recall appointments during the often-extended thoroughly coordinated basis.
period of orthodontic treatment. The reason for this occur-
rence might be a misunderstanding of parents who mistak- For those solo orthodontic practitioners who might be
enly confuse monthly visits to the orthodontist as substitutes interested in a more proactive method of encouraging their
for semi-annual or annual visits to the pediatric dentist patients to keep routine pediatric dental appointments
while their child is undergoing orthodontic treatment. The during orthodontic treatment, a similar strategy can be
pediatric dentist might therefore be denied an opportunity employed. Figure 15.2 is a chart that the orthodontist sends
to the pediatric dentist along with a note that the listed
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 269
Figure 15.1 Appointment schedule of an orthodontic/pediatric dental group, which faithfully tracks the individual orthodontic patient’s pediatric dental appoint-
ments during orthodontic treatment.
270 Integrated Clinical Orthodontics
Dr. John Doe – Pediatric Dentist screening image, missing, supernumerary or ectopic teeth
and a number of other salient underlying deviations and/
Mary Smith - August 2009 or frank pathology will go unnoticed. Radiographs obtained
Jim Cohen - June 2009 by the pediatric dentist or orthodontist need to be shared
William Burk - Sept. 2008 so that each clinician is maximally informed at each junc-
Andrea Wilks - Feb. 2008 ture of patient assessment efforts. Routine yearly pano-
Simon Grove ramic images obtained by the treating orthodontist should
May 2009 also be sent to the pediatric dentist. The modern age of
digital or electronic capabilities make this a seamless routine
Figure 15.2 A list of orthodontic patients (and their commencement date of for both clinicians and should be faithfully included in each
active orthodontic treatment) who are also being treated by the pediatric other’s basic communication protocols.
dentist, Dr John Doe.
Figure 15.5 is a panoramic radiograph of a patient
Dr. John Doe – Pediatric Dentist undergoing orthodontic treatment in the mixed dentition.
Despite the less than average quality of this panoramic
Mary Smith - August 2009 radiograph, the pediatric dentist viewing this radiograph
Jim Cohen - June 2009 overdue 4mos. noticed possible developmental caries in the mandibular
William Burk - Sept. 2008 second molars. Further specific periapical radiographs were
Andrea Wilks - Feb. 2008 overdue 8mos. then taken, the parents were apprised of this finding early
Simon Grove on, and the matter was reassessed and managed after the
May 2009 eruption of the mandibular second molars. After confirma-
tion of caries, the teeth were appropriately and conserva-
Figure 15.3 The returned list indicating which patients are overdue for their tively restored (Figure 15.6). Figure 15.7 is an intraoral view
pediatric dental appointments. of a patient, HW, in the mixed dentition, who, after exami-
nation by the pediatric dentist, was considered to have
patients are under the care of the orthodontist, and Figure seemingly unremarkable orthodontic issues that would
15.3 is the returned chart with any of the patients listed who require later rather than earlier (i.e. orthodontic treatment
are overdue for their pediatric dental appointments. The in the permanent rather than mixed dentition stage) ortho-
orthodontist can now speak to the parents at their child’s dontic treatment. The screening panoramic radiograph,
next orthodontic appointment and inform them that one however (Figure 15.8), suggested otherwise. The path of
of the requirements of quality orthodontic treatment is to eruption of the canines and several other teeth was notably
ensure that patient’s overall pediatric oral health needs are altered. There is considerable evidence, not only from the
met during the course of orthodontic treatment. This single authors’ clinical observations, but from other investigators
measure is well appreciated by the referring pediatric as well, to support the supposition that the majority of
dentist and represents the orthodontist’s ‘team’ participa- observed ectopically developing maxillary canines that are
tion in the overall care of the orthodontic/pediatric dental predisposed to becoming frank impactions can be con-
patient. servatively managed by appropriate orthodontic interven-
tion if such treatment is commenced earlier rather than
Identifying orthodontic and pediatric dental later (Leonardi et al., 2004; Baccetti et al., 2009). HW was
problems earlier than later comprehensively treated utilizing maxillary expansion,
removal of the maxillary primary canines, and fixed edge-
The pediatric dentist is often the first clinician to recognize wise orthodontic appliances. Figure 15.9 is an in-treatment
malocclusions in the mixed dentition. Figure 15.4 is a chart panoramic radiographic view and Figure 15.10 is an
that should assist the pediatric dentist and dental hygienist intraoral view of the maxillary canines mid-treatment and
in quickly assessing any deviations from the ideal or norm already well positioned into the dental arch. The overall
and serve as a useful adjunct to the routine overall pediatric pediatric dental and orthodontic management of this
dental examination as well as an important vehicle of com- patient was considerably helped by the recognition of the
munication to the referred orthodontist. The orthodontist, benefits of panoramic ‘screening’ radiographs obtained in
similarly, can utilize this check-off assessment chart to the mixed dentition for pediatric dental patients.
further augment his or her traditional orthodontic exami-
nation and study of current orthodontic diagnostic records. It is the authors’ belief that the pediatric dentist should
The pediatric dentist should obtain a panoramic radio- serve as the most important screening clinician for
graph as an integral part of any initial orthodontic exami- orthodontic problems for children in his or her practice.
nation in the mixed dentition. Without the use of such a The clinical examination (utilizing the aforementioned
orthodontic examination checklist) during a routine pedi-
atric dental appointment and a panoramic radiograph
should be sufficient for identifying many early developing
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 271
Figure 15.4 Orthodontic status assessment chart that can be incorporated into the examination protocol of a pediatric dental practice.
272 Integrated Clinical Orthodontics
Figure 15.5 Panoramic radiograph obtained during the course of orthodontic Figure 15.8 Panoramic radiograph of HW revealed altered path of eruption
treatment suggests developmental caries in the unerupted mandibular second of canine and other teeth.
molars.
Figure 15.6 Removal of caries and restoration of the mandibular second Figure 15.9 In-treatment radiograph of HW with initial orthodontic objec-
molars. tives of redirecting the ectopic path of eruption of the maxillary permanent
canines.
Figure 15.7 Intraoral view of a young patient (HW) undergoing a clinical Figure 15.10 In-treatment intraoral view of the maxillary permanent canines
examination, with what appears to be minor deviations from the expected successfully and conservatively redirected into the dental arch.
‘norms’.
orthodontic problems. The panoramic radiograph should exist with respect to both timing and specific treatment
be considered indispensable to any clinical examination strategy, suffice to say that the early recognition of any
and should be obtained by the age of 7–8 years. Prompt developing orthodontic deviation can and should serve as
treatment (when appropriate) and/or referral to an ortho- the beginning of an important dialog between the pediatric
dontic colleague for an assessment of the need and timing dentist and orthodontic clinician.
of earlier (mixed dentition) rather than later orthodontic
intervention (in the adult permanent dentition) can be Restoring form and function – revisiting the
more proactively managed in many instances prior to the unilateral posterior crossbite with a functional
onset of more serious and sometimes irreversible adverse mandibular shift
developmental problems. While it is generally accepted that
many malocclusions can benefit from earlier rather than The unilateral posterior crossbite is a commonly observed
later orthodontic treatment, some other clinicians think clinical finding in the mixed dentition. Posterior crossbites
that this might not result in an overall benefit to individual in the mixed or permanent dentition represent deviations
patients. And while controversy in some instances might from the normal buccolingual occlusal relationships.
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 273
Figure 15.11 Lingual crossbite of several teeth in a patient in the mixed
dentition.
Posterior crossbites can be caused by malpositions of indi- Figure 15.12 Dental lingual crossbite caused by malpositions of individual
vidual or groups of posterior teeth (dental crossbites), mal- teeth. The maxillary and mandibular dental midlines are coincident.
positions of posterior teeth accompanied by a functional
shift of the mandible (functional crossbites), or transverse Figure 15.13 Functional crossbite resembling a dental lingual crossbite,
disharmonies of the maxilla and mandible (skeletal cross- however, the maxillary and mandibular dental midlines are not coincident.
bites) (Moskowitz, 2005). Posterior crossbites are frequently This situation represents a functional shift of the mandible on closure to the
observed as palatal crossbites (Figure 15.11), but may occur patient’s left side.
in buccal crossbite relationship as well. There is a wide
range of reported prevalence of unilateral posterior cross- Figure 15.14 As a diagnostic aid, placing the midlines in their correct
bites in the primary and mixed dentition – from 7% to 23% coincident positions will reveal the bilateral constriction of the maxilla and
(Kutin and Hawes, 1969; Day and Foster, 1971; Infante, suggest the need for bilateral expansion of the maxillary dental arch.
1976; Kurol and Bergland, 1982; De Vis et al., 1984;
Thilander et al., 1984; Heikinheimo and Salmi, 1987;
Hannuksela et al., 1988). They have been reported to
develop between 19 months and 5 years of age, with
approximately 80% being accompanied by functional shifts
of the mandible (Gottlieb et al., 2004).
Unilateral posterior crossbites with functional shifts of
the mandible should be differentiated from unilateral pos-
terior crossbites without shifts of the mandible. Figure
15.12 is a posterior dental crossbite caused by an individual
tooth malposition of the maxillary left molar. Note that the
maxillary and mandibular dental midlines coincide. This
type of crossbite can be treated by moving the tooth (or
teeth) in crossbite into normal position. However, the situ-
ation in Figure 15.13 is quite different. The observed cross-
bite relationship in the maximum intercuspation position
appears to be identical to the dental crossbite anomaly. A
closer look, however, reveals a notable disparity between the
maxillary and mandibular dental midlines. The mandible
has shifted (to the side of the observed crossbite) as it
encountered prematurities upon closure. If we were to place
the mandible in its normal transverse position (lining up
the true maxillary and mandibular dental midlines), we
would observe the actual transverse relationship between
the maxillary and mandibular posterior teeth (Figure
15.14). It becomes apparent that both the right and left
sides of the maxillary posterior segments are lingually dis-
placed. Consequently, the functional crossbite (even though
it resembles the dental posterior crossbite in the maximum
274 Integrated Clinical Orthodontics
(a) (b) (c)
(d) (e) (f)
(g) (h)
Figure 15.15 (a–h) Patient EH has a unilateral posterior crossbite with a functional shift of the mandible to the right side on closure and dental midline
disharmony.
intercuspation position) is a result of a bilateral constric- Undoubtedly, orthodontic treatment can often signifi-
tion or narrowness of the maxillary dental arch and, there- cantly improve both dental and facial esthetics. Quantifying
fore, requires bilateral expansion. functional benefits of orthodontic treatment outcomes has
been a difficult task for the orthodontic specialty for spe-
The patient EH is a young female in the mixed dentition cific types of orthodontic problems. The unilateral poste-
with a unilateral posterior crossbite (Figure 15.15). rior crossbite with a functional shift is one opportunity,
Note the disparity between the maxillary and mandibular however, for the orthodontist and pediatric dentist to
dental midlines which is reflective of the mandibular shift restore function and balance within the dentofacial
to the right side upon closure and resultant facial asym- complex. There is evidence that untreated unilateral poste-
metry (Figure 15.16). Maxillary expansion (Hyrax palatal rior crossbite accompanied by transverse functional shifts
expander) as part of a ‘Phase I’ type of treatment in the of the mandible in still growing patients may result in mor-
mixed dentition was used to accomplish the goal of bilateral phological asymmetries in addition to translational dishar-
maxillary posterior expansion (Figure 15.17). Phase I treat- monies (Pinto et al., 2001). Such transverse translational
ment resulted in the normal transverse relationship of the and morphological disparities may further result in notable
mandible in relation to the maxilla and improvement in facial asymmetries as well as predispositions to temporo-
facial symmetry and extended approximately 12 months mandibular joint-related pathology (Sonnesen et al., 2001;
(Figure 15.18).
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 275
Figure 15.17 Maxillary bilateral posterior expansion achieved with a fixed
palatal expanding appliance.
Figure 15.16 Patient EH displays a facial asymmetry from the frontal view growth years. It would be interesting and beneficial for
as a result of the imposed improper position of the mandible in centric future investigations to determine if there is an identifiable
occlusion. timeline threshold beyond which individual patients are
incapable of such a dramatic reversal in condylar and ramal
Moskowitz, 2003). Figure 15.19 shows an adult patient, GL, asymmetry corrections via conventional orthodontic/
with an obvious facial asymmetry as a result of a longstand- dentofacial treatment.
ing and untreated unilateral crossbite. Figure 15.20 shows
the crossbites on the left side and mandibular shift on Congenitally missing maxillary lateral incisors
closure to the patient’s left side. Note that the maxillary and – who does what, when, and how?
mandibular dental midlines do not coincide. This long-
standing inter-dental arch occlusal condition has contrib- The congenitally missing lateral incisor either unilaterally
uted to profound morphological differences on the left and or bilaterally presents a unique challenge to the orthodontic
right sides as evidenced in both the frontal facial photo- clinician in many respects. First, a decision needs to be
graph and the anteroposterior cephalometric radiograph made as to whether or not the maxillary permanent canines
(Figure 15.21). The distance from the condylar to ante- will be used as a substitute for the missing lateral incisors
gonial areas (ramal length) is remarkably different on the or whether the treatment plan will dictate creating adequate
two sides. Although orthodontic treatment at this juncture space for an implant and subsequent implant-supported
for this patient could improve some of the translation or restoration. It should be appreciated that decisions made
positional issues associated with a deviated mandible as a with respect to the appropriate treatment plan for indi-
result of prematurities of the occlusion, it is obvious that vidual patients with missing maxillary lateral incisors will
establishing a fully symmetrical mandible with equal ramal indeed impact on the esthetics and function of the young
length would involve a coordinated orthodontic and patient as he or she matures into and beyond the adult
orthognathic surgical procedure. permanent dentition. Second, utilizing the modern implant
modality requires exquisite coordination between several
The earlier dentofacial orthopedic possibilities rather clinicians other than the pediatric dentist.
than those employed in later stages for patients exhibiting
unilateral posterior crossbites with functional shifts might Figure 15.23 is representative of a typical young patient
be analogous to our orthopedic medical colleagues who who may be referred to the orthodontist by the pediatric or
choose to treat scoliosis (Figure 15.22) in a growing child general dentist. The patient has a malocclusion caused in
quite differently from patients who have already completed great measure by a congenitally missing maxillary left
their growth. In the former situation, patients are treated lateral incisor, undersized maxillary right lateral incisor,
with an orthopedic brace for the spine and in the latter situ- and resulting shifting of the maxillary central incisors. This
ation, surgery is often performed. Pinto et al. (2001) have seemingly routine and frequently encountered type of
demonstrated that orthodontic patients exhibiting mor- malocclusion requires a considerable degree of treatment
phological differences in cases of unilateral posterior cross- planning prior to orthodontic treatment, during orthodon-
bite with functional shifts have a remarkable capacity to tic treatment, and following orthodontic treatment in order
rebound to normal as a result of treatment during the active to provide comprehensive care consistent with modern
276 Integrated Clinical Orthodontics
(a) (b) (c)
(d) (e) (f)
(g) (h)
Figure 15.18 (a–h) Phase I orthodontic treatment completed with the elimination of the functional crossbite and restoration of normal mandibular position.
Figure 15.19 Patient GL has a significant facial asymmetry due to a long- orthodontic, pediatric dental, periodontal, prosthodontic
standing and untreated unilateral crossbite with a functional shift. and restorative requirements. The specific needs of this
young patient at each juncture of their chronological and
developmental age should dictate which clinician makes the
appropriate decision impacting on the immediate and
long-term needs of the patient. The orthodontist will need
to coordinate orthodontic treatment, as some of the salient
considerations beyond the usual orthodontic requirements
include the precise amount of space to be left between the
maxillary permanent left central incisor and permanent
maxillary canine at the coronal, gingival, and apical levels,
the amount of space to be created in the area of the existing
undersized maxillary right lateral incisor, the selection of
the most effective type of esthetic and functional retentive
device, the timing of the implant placement in the area of
the missing maxillary left lateral incisor, and the choice of
implant and implant-supported restoration, which are all
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 277
(a) (b) (c)
(d) (e)
Figure 15.20 (a–e) Intraoral views of the malocclusion of patient GL. Note the definite lingual crossbite of the maxillary left canine and first premolar as well
as the dental midline discrepancy.
Figure 15.21 The disparity in ramal lengths in patient GL as a result of a Figure 15.22 Scoliosis of the spine, representing an orthopedic developmen-
longstanding imposed mandibular malposition during the many growth cycles tal anomaly.
of development.
278 Integrated Clinical Orthodontics
Figure 15.23 Pediatric dental patient with a congenitally missing maxillary
left lateral incisor and undersized maxillary right lateral incisor, who will be
undergoing orthodontic treatment.
Pediatric
dentist
Orthodontist
Periodontist Oral surgeon Restorative
dentist
Figure 15.24 Interaction between different specialties is needed when long- Figure 15.26 The missing maxillary right lateral incisor was replaced by a
term treatment plans are formulated for pediatric dental patients. cantilever bridge due to the lack of space for a conventional implant.
Figure 15.25 Orthodontics completed in the patient in Figure 15.23, with Figure 15.27 Radiograph showing the inadequate space for an appropriate
appropriate space created for the future implant-supported restoration. implant due to the convergence of the roots of the adjacent teeth.
important details to satisfying modern caveats of esthetics, had received orthodontic treatment in which little to no
function, and stability. consideration was given to the size of the resulting space
requiring future replacement, as well as the lack of diver-
Figure 15.24 depicts the interaction sequence that might gence of the roots of teeth adjacent to the missing maxillary
follow an initial referral of a young patient with a congeni- right lateral incisor. A cantilever bridge intended to replace
tal missing maxillary lateral incisor to an orthodontist and the missing maxillary right lateral incisor was deemed the
several other clinicians who might be consulted during the only long-term solution to this clinical dilemma. As an
orthodontic treatment period. Figure 15.25 shows the same alternative to the existing situation, further orthodontic
patient discussed above immediately following fixed appli- treatment was planned to re-create the appropriate space
ance removal, and Figures 15.26 and 15.27 illustrate the needed, respecting the caveats of modern implant place-
consequences of the lack of such coordination. The patient
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 279
(a) (b)
(c) (d)
Figure 15.28 (a–d) Sequential radiographs of patient requiring orthodontic treatment to accommodate future implants.
ment and implant supported restorations (Figure 15.28).
The orthodontic objectives included diverging the roots of
the maxillary right central incisor and maxillary right
canine to accommodate an appropriate implant and
implant supported restoration. The implant placement
(Figure 15.28d) and final restorations (Figure 15. 29) were
coordinated with the orthodontic treatment to assure that
implant and prosthodontic needs were properly met. This
type of coordination, once again, should have taken
place during the earlier pediatric/orthodontic treatment
experience of this patient, thereby avoiding orthodontic
re-treatment in adulthood.
Figure 15.29 Final implant-supported restorations and veneers placed after Retention considerations and beyond
orthodontic treatment.
The retention of the corrected malocclusions of individual
Figure 15.30 Post-orthodontic patient requiring implants to replace congeni- patients who will be receiving implants for missing anterior
tally missing maxillary lateral incisors. teeth needs to be coordinated as well. Patients receiving
implants immediately following orthodontic treatment,
such as the patient depicted in Figure 15.30 might fare well
with either a conventional Hawley type of retainer (Figure
15.31) or a typical ‘flipper’ type of removable appliance
which provides for the maintenance of beneficial tooth
movements achieved during orthodontic treatment, pontic
replacement of the missing maxillary lateral incisors, and
some function. However, removable appliances with tradi-
tional labial bows are not esthetic and present long-term
issues such as interference with settling of the occlusion and
tissue irritation (Figure 15.32), hygienic issues, and, when
280 Integrated Clinical Orthodontics
used, simple ‘flipper’ types cannot prevent the reconver- ultimately direct this patient to a general dentist or pros-
gence of the adjacent roots in the implant site. Short-term thodontist who is capable of fabricating a bonded resin
esthetic retention alternatives include the use of thermo- type of bridge. A bonded resin bridge was used to replace
plastic (Essix-type) removable devices with a pontic the maxillary right lateral incisor with some esthetic
replacement in the area of the missing teeth (Figure 15.33). bonding with composite of the maxillary left peg shaped
Long-term retention in post-orthodontic patients who will lateral incisor (Figure 15.36). This type of more sophisti-
not be receiving implants until clinicians are reasonably cated prosthesis/retainer will serve this patient well until an
assured of the cessation of any significant dentofacial implanted supported restoration can be placed for the
growth, however, requires a more sophisticated type of missing maxillary right lateral incisor and a veneer is placed
retentive device. on the maxillary left lateral incisor. As can be appreciated,
these seemingly ‘routine’ types of cases indeed require a
The patient ID (Figure 15.34) underwent orthodontic considerable degree of coordination and interactivity
treatment for a malocclusion complicated by the absence among the orthodontist, referring pediatric dentist, and
of the maxillary right lateral incisor and peg-shaped maxil- several other specialists.
lary left lateral incisor. Figure 15.35 shows the completed
treatment with appropriate space left for the implant and Enamel demineralization during
subsequent implant-supported restoration as well as needed orthodontic treatment – who takes
space for the peg-shaped maxillary left lateral incisor res- responsibility for prevention?
toration. However, this patient will not be receiving an
implant for approximately 2–3 years. Once again, the Orthodontic treatment with fixed appliances offers many
orthodontist and pediatric dentist need to interact on distinct advantages to the patient and orthodontic clinician.
behalf of this patient so that the most appropriate retentive
device can be planned. Such interaction might very well
Figure 15.31 Removable retainer with a labial bow to maintain space for Figure 15.33 Essix-type thermoplastic retainers are excellent short-term
future implants in the maxillary lateral incisor area. retentive devices for patients missing maxillary lateral incisors.
Figure 15.32 Long-term removable appliance wear for post-orthodontic/preimplant patients pose hygienic issues as well potential areas of palatal tissue
irritations.
Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 281
(a)
Figure 15.34 Patient ID: appropriate space being created for an implant-
supported restoration of the maxillary right lateral incisor and a veneer for
the peg-shaped maxillary left lateral incisor.
Figure 15.35 Patient ID, post-orthodontic treatment, requiring planning for (b)
an appropriate retainer prior to implant placement.
Figure 15.36 (a,b) The bonded resin bridge replacing the maxillary right
lateral incisor and bonded composite resin restoration on the maxillary left
lateral incisor will serve as excellent long-term (2–3 years) transitional reten-
tive devices until the patient is ready for an implant and veneer.
These advantages include a broad capability in the manage- (a)
ment of inter- and intra-arch tooth movements during
orthodontic treatment. Regrettably, however, one disadvan- (b)
tage is that fixed orthodontic appliances can present signifi- Figures 15.37 (a,b) A teenage patient with notably poor oral hygiene during
cant oral hygiene challenges to the young orthodontic orthodontic treatment and resulting enamel demineralization with both non-
patient. Consequently, increased plaque retention around cavitated and cavitated white spot lesions.
orthodontic brackets can contribute to enamel deminerali-
zation, resulting in unsightly white spot lesions with or
without cavitation. Figure 15.37 depicts a teenage patient
with notably poor oral hygiene during orthodontic treat-
ment and resulting enamel demineralization with both
noncavitated and cavitated white spot lesions. The patient
had missed his monthly orthodontic visits for 6 months
and failed to keep his regular pediatric dental examination
appointments. Such adverse occurrences seriously question
any perceived benefit (esthetic or otherwise) of the ortho-
dontic service itself. Clinician-prescribed fluoride rinses
and gels, although remarkably effective for orthodontic
patients with scrupulous oral hygiene, are predictably inef-
fective for patients who demonstrate poor oral hygiene
compliance.
282 Integrated Clinical Orthodontics
Geiger et al. (1988, 1992) found poor compliance with a intersecting paths together in harmony with the singular
preventive fluoride rinse program occurred in 50% of the
patients. Along with other orthodontic and pediatric purpose of providing the most modern, evidence-based,
dental colleagues, the authors have utilized fluoride var-
nishes for patients undergoing active orthodontic treat- and practically high-quality oral healthcare to our mutual
ment with fixed orthodontic appliances in an effort to
either completely prevent or at least minimize the occur- patients.
rence of white spot lesions during orthodontic treatment.
Duraflor (Pharmascience Inc., Montreal, Canada) is a fluo- References
ride varnish that contains 5% sodium fluoride by weight in
a natural colophony base. An ex vivo study by Todd et al. Baccetti T, Mucedero M, Leonardi M, et al. (2009) Interceptive treatment
(1999) as well as a recent in vivo investigation by Farhadian of palatal impaction of maxillary canines with rapid palatal expansion:
et al. (2008) have reported a measureable benefit of fluoride a randomized clinical trial. American Journal of Orthodontics and
varnish to significantly minimize white spot lesions in the Dentofacial Orthopedics 136: 657–61.
orthodontic population with fixed orthodontic appliances.
Coordinating the use of these new varnishes between the Day AJ, Foster TD (1971) An investigation into the prevalence of molar
pediatric dentist and orthodontist remains a notable chal- crossbite and some associated etiological conditions. Dental Practice 21:
lenge to attain the maximum benefit and avoid any possible 402–10.
overdosing of fluoride. This is yet another example of the
need for a smooth and continual interaction between the De Vis H, de Boever JA, van Cauwenberge P (1984) Epidemiologic
pediatric dentist and orthodontist so that therapeutic com- survey of functional conditions of the masticatory system in Belgium
pounds can be judiciously prescribed at optimal efficacy children aged 3–6 years. Community Dentistry Oral Epidemiology 12:
levels. Our orthodontic group has been using such var- 203–7.
nishes at 3-monthly intervals and this protocol needs to be
transmitted to the pediatric dentist to avoid unnecessary Farhadian N, Miresmaeili A, Eslami B, et al. (2008) Effect of fluoride
overlapping and duplication of effort. varnish on enamel demineralization around brackets: An in-vivo study.
American Journal of Orthodontics and Dentofacial Orthopedics 133:
While the pediatric dentistry specialty has vast experi- S95–8.
ence with fluoride compounds and their uses, this area is
relatively new to the orthodontic specialty. In the absence Geiger AM, Gorelick L, Gwinnett AJ, et al. (1988) The effect of a
of acceptable bond strength associated with fluoride- fluoride program on white spot formation during orthodontic
releasing orthodontic bonding resins, orthodontists should treatment. American Journal of Orthodontics and Dentofacial Orthopedics
consider routinely incorporating fluoride varnishes in their 93: 929–38.
clinical protocols. Finally, both the orthodontist and pedi-
atric dentist need to take responsibility for recognizing Geiger AM, Gorelick L, Gwinnett AJ, et al. (1992) Reducing white
orthodontic patients at risk for developing white spot spot lesions in orthodontic populations with fluoride rinsing.
lesions and take appropriate and coordinated proactive American Journal of Orthodontics and Dentofacial Orthopedics 101:
measures to minimize such occurrences. 403–7.
Conclusions Gottlieb E, Cozzani M, de Harfin JF, et al. (2006) JCO roundtable, stability
of orthodontic treatment, Part 2. Journal of Clinical Orthodontics 40(2):
We conclude this chapter by revisiting our original inten- 83–94.
tion – that is, to emphasize the profound need for a greater
interactivity and communication between the orthodontist Hannuksela A, Laurin A, Lehmus V, et al. (1988) Treatment of crossbite
and pediatric dentist in order to optimize the treatment in early mixed dentition. Proceedings of Finnish Dental Society 84:
of individual patients. Each specialist must be educated 175–82.
to appreciate the goals and objectives of each other, and
when necessary, be prepared to call on the expertise of Heikinheimo K, Salmi K (1987) Need for orthodontic intervention in
other medical and dental specialists, as required for the five-year-old Finnish children. Proceedings of Finnish Dental Society 83:
specific needs of each individual patient. We recommend a 165–9.
reassessment of respective postgraduate curricula, re-
examination of each specialty’s clinical ‘guidelines’, and Infante PF (1976) An epidemiologic study of finger habits in
increased effort of each specialty association to encourage preschool children as related to malocclusion, socioeconomic status,
ongoing interdisciplinary forums, so that orthodontists and race, sex, and size of community. Journal of Dentistry for Children
pediatric dentists will continue to travel along parallel and 1: 33–8.
Kurol J, Bergland L (1982) Longitudinal study and cost-benefit analysis of
the effect of early treatment of posterior crossbites in the primary denti-
tion. European Journal of Orthodontics 14: 173–9.
Kutin G, Hawes RR (1969) Posterior crossbites in the deciduous and mixed
dentition. American Journal of Orthodontics 56: 491–504.
Leonardi M, Armi P, Franchi L, et al. (2004) Two interceptive approaches
to palatally displaced canine: a prospective longitudinal study. Angle
Orthodontist 74: 581–6.
Moskowitz E (2003) Orthodontics in the progressive dental practice. In:
R Edwab (ed.) Essential Dental Handbook. Tulsa, OK: PennWell Corp,
pp. 387–430.
Moskowitz E (2005) The unilateral posterior functional crossbite, an
opportunity to restore form and function. New York State Dental Journal
Aug/Sept: 36–9.
Pinto AS, Buschang PH, Throckmorton GS, et al. (2001) Morphological
and positional asymmetries of young children with functional unilat-
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Orthopedics 20: 513–20.
Sonnesen L, Bakke M, Solow B (2001) Bite force in pre-orthodontic chil-
dren and unilateral crossbite. European Journal of Orthodontics 23:
741–9.
Thilander B, Wahlund S, Lennartsson B (1984) The effect of early intercep-
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Orthodontics and Dentofacial Orthopedics 116: 159–67.
16
Dental Caries, Tooth Fracture and Exposed
Dental Pulp: The Role of Endodontics
in Orthodontic Treatment Planning
and Mechanotherapy
Neslihan Arhun, Ayca Arman-Ozcirpici, Mete Ungor,
Omur Polat Ozsoy
Primum non nocere Introduction
Hipoccrates (c.460 to c.377 bc) An increased desire towards improved facial esthetics and
dental appearance is the key motivating factor for ortho-
Summary dontic treatment in every population. These appearance-
conscious patients and/or their families request esthetic
For the past 15–20 years, social scientists and observers of contemporary treatment plans that usually require a comprehensive inter-
life have been commenting on the dramatic change in the way business active approach. Coordinated orthodontic, endodontic,
is done in both the public and private sectors. The change that has and restorative treatments, with careful consideration of
attracted so much attention and commentary is a significant increase in patients’ and their families’ expectations and requests are
teamwork and collaborative efforts: people with different views and per- critical for successful outcomes and patient satisfaction
spectives are coming together, putting aside their narrow self-interests, (Vitale et al., 2004). Clearly, it is the orthodontist’s respon-
and discussing issues openly and supportively in an attempt to solve a sibility to take a proactive role in forming close cooperation
larger problem or achieve a broader goal. Teams come together for a between the disciplines to reach the ultimate goal of
number of different reasons, but their goals are the same – to achieve achieving healthy esthetics and function, while at the same
peak performance and experience success. We as dental specialists share time limiting undesirable consequences and risks of
the same goal. We want to have happy and satisfied patients with accept- mechanotherapeutics.
able, even better, facial and dental esthetics with healthy, functional, and
stable occlusions. In a beauty-addicted society where a good smile is a Optimized treatment outcomes necessitate close collabo-
powerful weapon, the demand for orthodontic treatment is increasingly ration between the disciplines to evaluate, diagnose and
rising, and in challenging situations, input from a number of dental dis- resolve problems at the following stages of the treatment
ciplines is required to construct detailed treatment plans. life cycle:
This chapter comprises a comprehensive review of topics requiring • Pretreatment evaluation and the early stages of the
interactive cooperation or teamwork between the orthodontist, endodon- orthodontic treatment
tist, and/or conservative dentistry specialist. Topics such as enamel
demineralization around orthodontic attachments, pulpal reactions, root • Orthodontic treatment
resorption or invasive cervical resorption due to orthodontic treat • Emergency orthodontic treatment in trauma cases
ment, and special considerations about dental trauma will be discussed • Immediate post-orthodontic period and during ortho-
in detail.
dontic retention.
Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
284 Integrated Clinical Orthodontics
This chapter reviews and summarizes the need and benefit restoration and the remaining tooth structure contribute to
of interactions between orthodontists, endodontists, and/ the true prognosis. Whenever the decision has to be made
or conservative dentistry specialists according to the stages about whether to perform endodontic treatment or to
of orthodontic treatment mentioned above. extract a tooth, orthodontists should consult with endo-
dontists taking into account pre-, intra-, and postoperative
Pretreatment evaluation and early factors, such as the patient’s age, socioeconomic class, vital
orthodontic treatment or necrotic pulp, and presence of periapical infections
(Travassos et al., 2003). It is important to realize that the
Successful orthodontic therapy relies on the accurate assess- presence of periapical lesions, increased age, and the pres-
ment of the pretreatment dental and gingival health status ence of irregular canal anatomies especially in molars may
with the aid of other dental disciplines. The assessment compromise the endodontic outcome. Moreover, proce-
should include a determination of systemic and/or local dural errors during canal instrumentation, rinsing with
factors, and obtaining a detailed history of previous trauma irrigation solutions, and medicaments and fillings may play
to the oral tissues. The initial clinical examination should a crucial role in long-term prognosis. These factors should
precede basic radiographic evaluation, which will help the be evaluated based on good clinical judgment along with
clinician to decide on precautions to minimize the undesir- input from endodontists, so that the patient is provided
able effects of orthodontic mechanics. It should not be with an optimized treatment plan, which is at the same time
forgotten that every patient is unique, and demands and cost-effective.
merits a unique treatment plan customized for his/her spe-
cific needs. Endodontically treated teeth can be moved orthodonti-
cally as readily as teeth with vital pulps. If teeth require root
Endodontically treated teeth canal treatment during orthodontic movement, it is recom-
mended that the root canals be cleaned, shaped, and an
The decision of whether or not to extract tooth/teeth is an interim dressing of calcium hydroxide be placed. Canal
important step in designing concrete orthodontic treat- obturation is accomplished after orthodontic treatment
ment procedures. If the orthodontist judges a case as one (Hamilton and Gutmann, 1999). If orthodontic treatment
requiring extraction, the next step will be the decision might take too long to finish, a gutta-percha filling should
regarding which tooth/teeth to extract (Yagi et al., 2009). be placed in-treatment, because the calcium hydroxide
There may be multiple options and choosing one of the filling may make the tooth prone to fracture during this
potential teeth requires consideration of parameters that period.
might require a consultation with specialists from other
disciplines. For example, a history of root canal treatment Cariogenic potential and white spot lesions
or the presence of periapical lesions, restorations, and
carious teeth complicates the decision about the site of After the decision about the final treatment plan, before the
extraction. In such cases, the decision should be the one full bond-up appointment, the clinician should take meas-
that optimizes the orthodontic treatment prognosis with ures against cariogenic challenge. Dental caries in the
less invasive operative intervention. enamel is unique among other infective diseases in the
human body, as enamel is both acellular and avascular; thus
Successful root canal treatment relies on adequate enamel cannot heal itself by a cellular repair mechanism
removal of microorganisms and prevention of re- (Zero, 1999). In orthodontic patients, caries starts as decal-
colonization or re-infection through the placement of a cification areas adjacent to fixed orthodontic appliances.
root canal filling that obliterates the canal space and a res- Earlier studies demonstrated increased cariogenic risk asso-
toration with good coronal seal (Briggs and Scott, 1997). ciated with a rapid increase in the volume of dental plaque,
The benefits of root canal treatment are: retention of the which has a lower pH and significantly elevated levels of
natural tooth in the dental arch and facilitation of the res- acidogenic bacteria such as Streptococcus mutans around
toration to conserve the remaining crown and root struc- orthodontic attachments than in nonorthodontic patients
tures, preservation of the alveolar bone and accompanying (Chatterjee and Kleinberg, 1979; Gwinnett and Ceen, 1979).
papillae, and maintenance of pressure and tension percep- These acidogenic bacteria produce byproducts of organic
tion by paradental mechanoreceptors. However, such a acids in the presence of fermentable carbohydrates,
retained tooth may be at risk of a future root fracture and further lowering the pH of the plaque. As the pH drops
development of caries or periodontal disease after ortho- below the threshold for remineralization (pH = 4.5),
dontic treatment (Torabinejad et al., 2007). Epidemiological enamel demineralization/decalcification occurs. The first
radiographic surveys have revealed a relatively low fre- clinical evidence of this demineralization is visualized as a
quency of high-quality root canal fillings, ranging from white spot lesion (WSL), which has been defined as ‘sub-
14% to 65% (Eriksen et al., 2002). surface enamel porosity from carious demineralization’
that represents itself as ‘a milky white opacity’ caused by the
Endodontic outcomes are difficult to predict since non-
endodontic factors such as the quality of the subsequent
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