Orthodontic diagnosis begins with determining the patient or parent’s chief complaint. Basic orthodontic records include a medical history, extraoral and intraoral exam, facial and intraoral photographs, study models, and panoramic and lateral cephalometric radiographs. All of the records are now most commonly in digital format. If a CBCT is indicated to provide additional information, the panoramic and lateral cephalometric films should be extracted from it. In addition to their diagnostic value, the pre-treatment records are used as a baseline to evaluate treatment results.
As in general dentistry, collecting medical history provides the orthodontist with an idea of a patient’s overall medical status. Some medical conditions, such as need for antibiotic prophylaxis and diabetes could affect a patient’s ability to undergo orthodontic treatment. Patients should be asked if they have any cardiovascular problems or total joint replacements that may require pre-medication before any dental procedure. Patients with growth disorders may present with more complex treatment needs. It is also important to understand what medical conditions may have sequelae in the craniofacial complex and dentition and to deduce if this might have an effect on orthodontic treatment.
There are few drugs that may complicate treatment, including chronic use of non-steroidal anti-inflammatories (NSAIDs), phenytoin, estrogen supplementation and bisphosphonates. Chronic use of NSAIDs inhibits COX-1 and COX-2 and prevents the synthesis of prostaglandins and the generation of inflammation, resulting in slowed tooth movement.7 Anti-epileptic drugs such as phenytoin (Dilantin) may produce gingival hyperplasia, which may slow tooth movement. Although the mechanism of action of bisphosphonates is not fully understood, these drugs tend to slow down bone turnover. Tooth movement has shown to slow proportional to the dosage amounts of bisphosphonates administered.7 A young patient taking medication for Attention Deficit Hyperactivity Disorder (ADHD) may have social-behavioral problems. This could be an indication of potential compliance issues in treatment. Some reports also suggest that Ritalin affects growth rates.
Lastly, any allergies should be noted. The most common allergies that may complicate orthodontic treatment are to nickel, since it is found in most wires, and latex, which is found in some elastic materials. Most nickel allergies, unless very severe, do not generate any allergic reaction as the saliva dissipates the intraoral concentration. For patients that do experience an allergic reaction, options such as nickel-free titanium and ceramic brackets are available. In the case of a latex allergy, latex-free elastics and nitrile gloves should be used. When indicated, one should consult with the patient’s physician regarding the medical condition and its implications for orthodontic treatment.
One should inquire if the parents or siblings received orthodontic treatment, and if so, what the nature of their malocclusion was. There are some indications that there are genetic influences in many dental and occlusal characteristics, including missing and displaced teeth and certain growth patterns.8 It is important to ask if the patient is receiving regular dental care. It is essential for all orthodontic patients to be caries free and in good oral health prior to beginning treatment. This also provides the opportunity to determine the family’s awareness of dental health. A question should be asked about whether the patient ever had any traumatic injury involving the teeth or jaws. Trauma to permanent teeth can result in devitalization or root fracture, which should be addressed by an endodontic or general dentist prior to beginning treatment. It could also result in ankylosis of the tooth which would render it unable to move. Traumatized teeth may also be subject to greater rates of root resorption. Trauma to the jaws (for example, a blow to the chin) could also cause asymmetric condylar growth and thus facial asymmetries. Any past or present habits the patient may have should also be discussed including finger habits, mouth breathing, snoring, nail biting, and several other habits. These habits can generate certain malocclusions or wear patterns on the teeth which can affect treatment and result in skeletal changes if gone untreated for extended periods of time.