|Year : 2012 | Volume
| Issue : 3 | Page : 129-137
Orthodontic care of medically compromised patients
Sandhya Maheshwari, Sanjeev Kumar Verma, Juhi Ansar, KC Prabhat
Department of Orthodontics and Dental Anatomy, Aligarh Muslim University, Aligarh, India
|Date of Web Publication||29-Apr-2013|
Department of Orthodontics and Dental Anatomy, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh - 212 001
Source of Support: None, Conflict of Interest: None
Advances in the treatment of medical conditions have resulted in long-term disease-free survival. Consequently, many of these patients are now seeking orthodontic therapy. This article will discuss various systemic diseases, their effect on orthodontic treatment and the recommended methods to avoid the potential problems that may arise.
Keywords: Guidelines, interdisciplinary management, life expectancy, medically compromised patient, orthodontic considerations, orthodontic treatment
|How to cite this article:|
Maheshwari S, Verma SK, Ansar J, Prabhat K C. Orthodontic care of medically compromised patients. Indian J Oral Sci 2012;3:129-37
|How to cite this URL:|
Maheshwari S, Verma SK, Ansar J, Prabhat K C. Orthodontic care of medically compromised patients. Indian J Oral Sci [serial online] 2012 [cited 2017 Mar 27];3:129-37. Available from: http://www.indjos.com/text.asp?2012/3/3/129/111174
| Introduction|| |
As medical science continues to make advances that increase the quantity and quality of life with previously untreatable diseases, dental practitioners are seeing more and more of these patients for routine care.  Thus, orthodontists need to be aware of the possible clinical implications of these diseases. He must have a basic working knowledge of patient's disease process and should inform the general physician about the type of procedures planned.  Treatment plan should be modified according to impact of the particular disease in the oral cavity. This article examines aspects of some of the conditions that are of relevance to orthodontic practice. Medical conditions commonly encounter in orthodontic patients include;
| Infective Endocarditis|| |
Bacterial endocarditis is a relatively uncommon, life-threatening infection of the endothelial surface of the heart, including the heart valves.  The infection usually develops in individuals with underlying structural cardiac defects. It can occur whenever these persons develop bacteremia with the organisms likely to cause endocarditis. Both the incidence and the magnitude of bacteremias of oral origin are proportional to the degree of oral inflammation and infection. 
- Orthodontist should communicate with the patient's physician to confirm the risk of IE. Informed consent requires that a patient is aware of any significantly increased risk. 
- The importance of maintaining an exemplary standard of oral hygiene and that it is their responsibility to protect themselves.
- The main orthodontic procedure that has been postulated to cause a bacteraemia has been placement of a separator. 
- Orthodontics should avoid using orthodontics bands instead use, bonded attachments. If banding is required use of antibiotic prophylaxis is must. 
- Antibiotic prophylaxis is only required in high-risk patients and the drug of choice is penicillin. 
| Hemophilia|| |
Hemophilia is the most common congenital bleeding disorder.  Hemophilia A is a sex-linked disorder due to a deficiency of clotting factor VIII. Other bleeding disorders include hemophilia B or Christmas disease (factor IX deficiency) and von Willebrand's disease (defects of von Willebrand's factor). The normal concentrations of clotting factor are between 50% and 150% of average value and the minimum level of a factor for adequate hemostasis is 25%. 
- Orthodontic treatment is not contraindicated in patients with bleeding disorders. 
- Duration of treatment should be given careful consideration. Lengthier the treatment duration may increase potential complications. 
- Chronic irritation from orthodontic appliances should be avoided. Fixed appliances are preferable to removable appliances as the latter can cause gingival irritation. 
- Self-ligating brackets are preferable to conventional brackets. If conventional brackets are used, archwires should be secured with elastomeric modules instead of wire ligatures.
- If extractions or surgery is to be performed increase factor VIII production with 1-desamino-8-darginine vasopressin (DDAVP). Parentaral DDAVP can be used to raise factor VIII levels 2-3-fold to prevent surgical hemorrhage. 
| Hematological Malignancies|| |
More than 40% pediatric malignancies are hematological either leukemia or lymphoma. Cranial irradiation given to children with acute lymphocytic leukemia (ALL) to eliminate cancer cells in the central nervous system (CNS) can cause growth retardation, most probably through its effect on pituitary function, specifically growth hormone deficiency.  Adults treated for childhood cancer have been shown to have a reduced bone mineral density. Arrested root development with short V-shaped roots and premature apical closure has been reported after cancer therapy. 
- In these patients intense chemotherapy weakens regenerative capacity of mucosa. Minor irritation can lead to opportunistic infection and subsequent severe complications.
- Use appliances that minimize the risk of root resorption, Use lighter forces, terminate the treatment earlier than normal, choose the simplest method for the treatment needs and do not treat the lower jaw.  The lower jaw is at risk of osteoradionecrosis (ORN) because of its limited blood supply. A group of 104 patients who developed ORN of the jaws were reviewed and treated between 1972 and 1992. The most common affected site was the mandible (99 cases, 95.2%), followed by the maxilla (5 cases, 4.8%). Among all cases, 93 (89.4%) were trauma induced-ORN. 
- Orthodontic treatment may start or resume after completion of all medical therapy and after at least 2-year event free survival when risk of relapse has been decreased. In adults receiving head and neck radiotherapy the incidence of ORN is 8.2%. 
- Atraumatic extraction procedures are reported to reduce the risk for ORN.
| Thalassemia|| |
Thalassemia is an inherited disorder of hemoglobin synthesis. It can be can be classified as α-thalassemia, β-thalassemia, γ-thalassemia and δ-thalassemia indicating which blood hemoglobin chains are affected.  Based on their clinical and genetic orders they are classified into major (homozygous) and minor (heterozygous) types.  β-Thalassemia major (Cooleys anemia) is the most severe form of congenital hemolytic anemia. The most common oral and facial manifestation is enlargement of the maxilla, bossing of the skull and prominent malar eminences due to the intense compensatory hyperplasia of the maxilla. This lead to expansion of the marrow cavity and a facial appearance known as "chipmunk" face. , the overdevelopment of the maxilla frequently result in an increased overjet and spacing of maxilla teeth and other degree of malocclusion. 
- Patient who have undergo splenectomy are at massive risk of infection followed by bacterimia.  Antibiotic prophylaxis must be given during invasive procedures like extraction. Antibiotic of choice is penicillin V 2000 mg or erythromycin 1000 mg taken 30 min to 2 h prior to dental procedure, then 500 mg taken every 6 h for 8 doses. 
- Functional and extra-oral appliances can be used; however, the "skeletal forces" in thalassemia patients must be less than what is used with normal patients because of the thin cortical plates in thalassemic patients. 
- Radiographs at 3 months intervals can be indispensable because the thin cortical plates can complicate orthodontic treatment.
- Regular prophylaxis and fluoride applications are recommended in these patients.
- Extraction should be carried out at the time of admission for blood transfusion, i.e. when hemoglobin level is at its highest, with the administration of antibiotics. 
- Thalassemic patients are at an increased risk of viral hepatitis and AIDS due to repeated blood transfusion and therefore screening test for the same should be carried out at regular intervals.
| Bronchial Asthma|| |
Asthma is a chronic disease that affects the lower airways. It is characterized by recurrent and reversible airflow limitation due to an underlying inflammatory process.  Signs and symptoms of asthma, include intermittent wheezing, coughing, dyspnea, and chest tightness.
- Inhaled corticosteroids are the most widely used and most effective asthma anti-inflammatory agents. 
- Oral manifestations include candidiasis, decreased salivary flow, increased calculus, increased gingivitis, and increased periodontal disease. 
- Schedule these patients' appointments for late morning or later in the day, to minimize the risk of an asthmatic attack.
- Judicious use of rubber dams should be avoided as they reduced breathing capability.
- Care should be used in the positioning of suction tips as they may elicit a cough reflex.
- Up to 10% of adult asthmatic patients have an allergy to aspirin and other nonsteroidal anti-inflammatory agents.  A careful history concerning the use of these types of drugs needs to be elicited. The orthodontist should ensure the patient has their inhaler nearby.
| Epilepsy|| |
Epilepsy is the most common serious chronic neurological condition. It is as a chronic neurological disorder characterized by frequently recurrent seizures.  The risk of developing epilepsy is 2-5% over a lifetime. It affects about 0.5-2% of the population.  Injuries to the tongue, buccal mucosa, facial fractures, avulsion, luxation or fractures of teeth and subluxation of the temporomandibular joint can occur during seizures.  Both the condition and the medical management of condition can affect oral health.
- The orthodontist should ensure the patient is receiving regular and rigorous preventative dental care to avoid/minimize dental disease.
- Gingival overgrowth associated with phenytoin is the most widely known complication of anti-epileptic medication. Gingivectomy is recommended to remove any hyperplasic tissue that interferes with appearance or function.
- Removable appliances should be used with caution as they can be dislodged during a seizure. 
- Wherever possible removable appliances should be designed for maximum retention and made of high impact acrylic.
- The metal in a fixed orthodontic appliance may distort images obtained by magnetic resonance imaging (MRI).  An acceptable MRI may be obtained if arch wires and other removable components are removed before the scan.
| Diabetes Mellitus|| |
DM is one of the most common endocrine disorders. It is characterized by persistently raised blood glucose levels (hyperglycemia), resulting from deficiencies in insulin secretion, insulin action, or both.  Diabetes can be Type 1 (insulin dependent diabetes mellitus or juvenile onset diabetes) results from defects in insulin secretion or Type 2 (non-insulin dependent diabetes mellitus or mature-onset diabetes) develops as a result of defects in insulin secretion, insulin action or both.
- The key to any orthodontic treatment for a patient with diabetes is good medical control. Orthodontic treatment should not be performed in a patient with uncontrolled diabetes. 
- Importance should be given to maintain good oral hygiene, especially when fixed appliances are used. Diabetic related microangiopathy can affect the peripheral vascular supply, resulting in unexplained toothache, tenderness to percussion and even loss of vitality.
- Apply light forces and not to overload the teeth. Uncontrolled or poorly controlled diabetic patients have an increased tendency for periodontal breakdown and these patients should be considered in the orthodontic treatment plan, as periodontal patients.
| Renal Disorders|| |
The most common renal condition to present to the orthodontist is chronic renal failure. Chronic renal failure is a progressive and irreversible decline in renal function. the number of functional units of the kidney or nephrons diminishes, the glomerular filtration rate falls, while serum levels of urea rise. , Up to 90% of patients with renal insufficiency show oral signs and symptoms in soft and hard tissues, some of them being a cause of the disease itself and others deriving from the treatment. Initially treatment is conservative with dietary restriction of sodium, potassium and protein. As the disease progresses dialysis or transplantation are required. Many patients are prescribed steroids to either combat renal disease or to avoid transplant rejection
- Extraction should be done cautiously in such patients. Abnormal bone healing after extraction can result due to alterations in calcium and phosphors metabolism and secondary hyperparathyroidism which result in bone demineralization. 
- Due to the increase in circulating parathyroid hormone. It has been suggested that orthodontic treatment forces should be reduced and the forces re-adjusted at shorter intervals.
- Renal insufficiency is considered a risk condition for IE if the patient does not have a good control of the disease.  Antibiotic prophylaxis should be consider in hemodialyzed patients who were undergoing an invasive dental procedure. 
- During hemodialysis, the patient's blood is anticoagulated with heparin to facilitate blood transit. For this reason, dental treatments with a risk of bleeding must not be performed on the day of hemodialysis. Appointments should be scheduled on non-dialysis days. The day after dialysis is the optimum time for treatment for surgical procedures as platelet function will be optimal and the effect of heparin will have worn off.
- Many antibiotics are actively removed by the kidney, so adjustment of the dosage by amount or by frequency is required.  Penicillin and its derivates are the preferred antibiotics for these patients. In the case of non-narcotic analgesics, paracetamol is the best choice.
- In renal transplant patients corticosteroid are given to minimize the risk of transplant failure. In such patients to minimize the risk of adrenal crisis in patients during surgical procedure, double the dose of corticosteroids on the day of the surgery. 
- Gingival overgrowth secondary to the immunosuppressive therapy is the most studied oral manifestation. Nifedipine increases the prevalence of gingival overgrowth.  Gingival overgrowth can impede tooth movement during orthodontic treatment. Gingivectomy should be considered in such patients.
| Osteoporosis|| |
Osteoporosis is chronic, systemic, degenerative disease characterized by decreased bone mass, a micro architectural deterioration of the bone and consequent increase in bone fragility.  Risk factors that cannot be altered include advanced age, being female, estrogen deficiency after menopause.  Potentially modifiable risk factors include excessive alcohol intake, vitamin D deficiency, and smoking.  Drugs most commonly used in treatment of osteoporosis are bisphoshonate (BP), estrogen, and calcitonins.
- Orthodontic treatment therefore, must include the consideration of problems such as bone loss, retention instability, and temporomandibular dysfunction. 
- Problem associated with medication must also be given consideration. Estrogen decreases the rate of tooth movement.  However, if these drugs are not used during orthodontic treatment in patients with osteoporosis, resorption of alveolar bone and possibly tooth roots could occur.
- Use of BP can affect orthodontic treatment by delaying tooth eruption, inhibited tooth movement,  impaired bone healing, and by causing BP-induced (ORN) of the jaws.
- Extraction protocol and use of temporary anchorage devices should be avoided. 
- BP inhibits osteoclasts, decreases microcirculation and thus impedes tooth movement.
| Thyroid and Parathyroid Disorders|| |
After DM, thyroid disease is the most common endocrine problem.  Thyroid diseases occur more often in women and most often in women older than 50 years of age.
- Orthodontic therapy requires minimal alterations in the patient with adequately managed thyroid disease.
- In hyperthyroidism enlarged tongue may pose problem during treatment.
- The bone turnover can influence orthodontic treatment. High bone turnover (i.e., hyperthyroidism) can increase the amount of tooth movement compared with the normal or low bone turnover state in adult patients.
- Low bone turnover (i.e., hypothyroidism) can result more root resorption, suggesting that in subjects where a decreased bone turnover rate is expected, the risk of root resorption could be increased. 
| Liver Diseases|| |
Liver diseases are very common and can be classified as acute (characterized by rapid resolution and complete restitution of organ structure and function once the underlying cause has been eliminated) or chronic (characterized by persistent damage, with progressively impaired organ function secondary to the increase in liver cell damage).  Liver disease can result from acute or chronic damage to the liver, usually caused by infection (hepatitis A, B, C, D, and E viruses, infectious mononucleosis), injury, exposure to drugs or toxic compounds, an autoimmune process, or by a genetic defect. The liver has a broad range of functions in maintaining homeostasis and health: it synthesizes most essential serum proteins (albumin, transporter proteins, blood coagulation factors V, VII, IX and X, prothrombin, and fibrinogen.  Liver dysfunction alters the metabolism of carbohydrates, lipids, proteins, drugs, bilirubin, and hormones. 
- Hepatitis B is a worldwide health problem, with an estimated 400 million carriers of the virus.  It has been calculated that 1.53% of all patients reporting to the dental clinic are hepatitis B virus (HBV) carriers.  Viral hepatitis is surely of importance to the orthodontist. HBV, hepatitis C virus, and hepatitis D virus are blood borne and can be transmitted via contaminated sharps and droplet infection.
- Aerosols generated by dental hand pieces could infect skin, oral mucous membrane, eyes or respiratory passages of dental personnel. The main orthodontic procedures to result in aerosol generation are removal of enamel during interproximal stripping, removal of residual cement after debonding, and prophylaxis. 
- Infection control protocol should be followed according to the guideline laid down by occupational safety and health administration.  All members of the team should be immunized against HBV. Barrier technique such as gloves, eye glasses, and mouth mask should be used.
- HBV can survive on innate subjects for 7 days. Impressions can be one of the links in transmitting the HBV to orthodontics. The impressions must be disinfected by dipping them in glutaldehyde or by spraying sodium hypochlorite and leaving it for 10 min. 
- Post-exposure prophylaxis for HBV infection should be given to those who are exposed percutaneously or through mucus membrane to blood or body fluids of known or suspected. If the source individual is Hepatitis B surface antigen (HBsAg) positive and the exposed person is unvaccinated or antibody level is less than 10 mIU/ml, hepatitis B immunoglobulin (0.6 ml/kg) should be administered (preferably within 24 h) along with the vaccine series given at a different site. 
- Liver disease can result in depressed plasma levels of coagulation factors. If extraction is required, special attention should be paid as the risk of bleeding increases; an infusion of fresh frozen plasma may be indicated. Advanced oral surgical procedures or any dental procedures with the potential to cause bleeding performed on a patient with multiple or a severe single coagulopathy may need to be provided in a hospital setting. ,
- Care should be taken when prescribing any medication for patients with liver disease. Hepatic impairment can lead to failure of metabolism of some drugs and result in toxicity.  Caution should be used in prescribing medications metabolized in the liver, such as acetaminophen, nonsteroidal anti-inflammatory agents. 
| Down Syndrome|| |
Down syndrome is one of the most common genetic syndromes, occurring in one of 800-1000 live births.  John Langdon Down who published an accurate description of a person with Down syndrome discovered Down syndrome in 1866, although he did not know the cause of the syndrome. He was then termed the "father" of the syndrome. 
The primary skeletal abnormality affecting the orofacial structures in Down syndrome is an underdevelopment of the midfacial region. The bridge of the nose, bones of the midface and maxilla are relatively smaller in size.  In many instances this causes a prognathic class III occlusal relationship, which contributes to an open bite.  Individuals with Down syndrome have delayed eruption pattern. There is usually some sort of enamel defect affecting the teeth. There is usually congenitally missing teeth and they can have unusually shaped teeth.
- Congenital heart defects are present in 40-60% of infants with Down syndrome. Children with heart defects who are undergoing dental procedures should be given antibiotic prophylaxis against subacute bacterial endocarditis. 
- Reduced muscle tone causes less efficient chewing and natural cleansing of the teeth. More food may remain on the teeth after eating due to this inefficient chewing.  hence oral hygiene instruction should be given in every visit.
- It is ensure that patient is vaccinated for hepatitis before starting dental treatment. This is necessary because persons with Down syndrome are at increased risk of developing the carrier state if they are infected with HBV. 
- Seizures occur in 5-10% of children with Down syndrome.  Generalized tonic clonic seizures are the most common. Seizures are diagnosed and treated similarly in children with and children without Down syndrome.
- Impressions using quick-set materials with fun flavors should be used as these may reduce the tendency for activation of the more sensitive gag reflex frequently experienced with Down syndrome patients.
- High-memory wires allow a longer activation interval between appointments.
- Self-ligating brackets allow a more patient-friendly activation appointment.
| Autism|| |
Autistic disorder is a pervasive developmental disorder defined behaviorally as a syndrome consisting of abnormal development of social skills (withdrawal, lack of interest in peers), limitations in the use of interactive language (speech as well as nonverbal communication), and sensorimotor deficits (inconsistent responses to environmental stimuli.  The typical presenting symptoms of autistic disorder are delayed speech or challenging behavior before 3 years of age.  Indications for formal developmental evaluation include no babbling, pointing, or other gestures by 12 months of age, no single words by 16 months of age, no two-word spontaneous phrases by 24 months of age, and loss of previously learned language or social skills at any age.  The reported incidence of autistic disorder ranges from about 5 per 10,000 to 20 per 10,000 persons.  No single cause has been identified for the development of autism. Genetic origins are suggested by studies of twins and a higher incidence of recurrence among siblings.  Some reports have suggested a possible association with Down syndrome.  In addition to the implication of neuro-transmitters, such as serotonin, in the development and expression of autism.  While use of behavior modification programs is often the primary method of managing challenging behaviors in autistic children, supportive medication use has been found to help reduce behavior problems.
- The main challenge to the orthodontic team may be the reduced ability of autistic patients to communicate and relate to others.
- The first several visits are directed towards raising the patient's confidence and determining the maximum level of compliance that is achievable.
- At the same time, an estimate of the most suitable way (behavior management, sedation or general anesthesia (GA)) to perform the more difficult procedures, such as impressions or bracket bonding may be made. 
- The spectrum of methods used for pain and anxiety control during orthodontic treatment of the autistic child may be divided into conscious methods (such as oral, intramuscular, inhalation with nitrous oxide and oxygen, and intravenous sedation) and unconscious methods which include intravenous or inhalation deep sedation and GA with endotracheal intubation. 
- Jackson was the first to suggest using GA for the placement of orthodontic bands. 
- Patient should be treated in a quiet, shielded single operatory versus an open-bay arrangement, with reduced decoration and dimmed lights. 
- Procedures such as tell-show-do, voice control, and positive reinforcement are effective with children. 
- The effectiveness of reinforcers can vary among children with autism spectrum disorder (ASD).  Many children may find reinforcing value in typical, age-appropriate reinforcers such as praise, stickers or video clips while other children's behavior might be reinforced by engaging in self-stimulatory behaviors (for example, hand flapping, or self-talk) or obsession with unusual objects Hung DW. Using self-stimulation as reinforcement for autistic children. 
| Tuberculosis|| |
TB is a chronic infectious disease that is worldwide in distribution. TB continues to occur in epidemic proportions and is estimated by the World Health Organization to infect approximately nine million people annually.  TB primarily affects the lungs but is also capable of involving almost any site in the body including the oral cavity. In dentistry, the incidence of exposure to an active TB patient is quite low. Oral lesions of TB are uncommon, with most cases appearing as a chronic painless ulcer. 
- Patients with a medical history or symptoms indicative of undiagnosed active TB should be referred promptly for medical evaluation to determine possible infectiousness.
- Elective dental treatment including orthodontics treatment should be deferred until a physician confirms that a patient does not have infectious TB.
- TB is not a common occurrence in orthodontic offices but the orthodontic team should be aware of its potential and the issues now associated with the occurrence of active TB in patients who have immune disorders, particularly those with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS).
- The challenge to orthodontics is to be prepared for all infectious diseases that may affect the practice.
| Acquired Immunodeficiency Syndrome|| |
AIDS is an infectious disease caused by the HIV, and is characterized by profound immunosuppression that leads to opportunistic infections, secondary neoplasm and neurologic manifestations.  Oral manifestations are common and may represent early clinical signs of the disease, often preceding systemic manifestations. This aspect is particularly important as dentists may be responsible for early detection of oral lesions which may indicate HIV infection. 
- HIV infection does not necessitate changes in the orthodontic treatment plan for a child or adolescent. However, effects of HIV infection on the pediatric patient and the patient's family may alter the clinician's approach to treatment.
- Many antiretoviral medications (ARV) can cause nausea and vomiting. Frequent episodes of vomiting can affect the oral cavity by increasing acid levels in the saliva and soft tissues. As a result, the oral flora may change due to the overgrowth of bacteria that are not susceptible to acid. This overgrowth can lead to oral conditions such as candidiasis and an increased rate of dental caries. Therefore, it is critical that the oral hygiene and health of children and adolescents receiving ARV medications be attended to daily.
- According to the Public Health Laboratory Service,  as of June 1999, there were 319 reports of occupationally acquired HIV among health care workers worldwide. Of these, 102 cases were confirmed. Of the 217 possible or probable cases, 9 were dental workers.
- Percutaneous injuries and blood splashes to the eyes, nose or mouth occur frequently during orthodontic treatment. On average, dentists in Canada report 3 percutaneous injuries and 1.5 mucous-membrane exposures per year.  The highest frequencies of percutaneous injuries were reported by orthodontists (4.9 per year) and the highest frequencies of blood splashes to the eyes, nose or mouth were reported by oral surgeons (1.8 per year).
- Universal infection control procedures should be employed for all patients irrespective of their health status.
- The potential for allergic reactions and drug resistance increases over time with increased usage and may increase with decreased immune function; therefore, the judicious use of antibiotics is warranted.
- During the visits the patient must be stimulated to recognize their fundamental importance in maintaining oral health. Patients must also be stimulated to use additional auxiliary procedures such as antiseptic mouthwashes. 
- Xerostomia has been observed in pediatric patients. Clinicians should recommend sugarless gum and frequent consumption of water or highly diluted fruit juices to alleviate xerostomia.
- Post-exposure prophylaxis (PEP) should be given immediately after the accidental occurrence. PEP for HIV exposure is best when started within golden period of < 2 h and there is little benefit after 72 h. The prophylaxis needs to be continued for 28 days. PEP is available as either basic regimen (2 nucleoside reverse transcriptase inhibitor (NRTI)) or expanded regimen (2 NRTI and 1 Protease inhibitors (PI) drugs). NACO recommend zidovudine/stavudine + lamivudine (basic regimen) and zidovudine + lamivudine + lopinavir/ritonavir. ,,
| Summary|| |
An orthodontist needs to recognize various medical conditions and their impact on treatment procedures. Treatment should where appropriate be postponed until the medical problem is in remission or the side effects of the drug therapy are minimized. Comprehensive treatment may not always benefit the patient. Treatment procedure should be modified according to need. Consent before treatment, Good patient cooperation and constant monitoring of the progress of the treatment are necessary to minimize physical damage and to maximize treatment outcome.
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