Children with Congenital Heart Defects
Paediatric dentists are required to treat children with heart disease more than any other medically compromised group. Unlike adults most children with heart disease have congenital heart problems. Congenital heart disease (CHD) is seen in 6–8 per 1000 live births with male to female ratio of 1:1. Conditions can be subdivided into cyanotic or acyanotic (Box 49.1). The dental management of this group requires:
- a working knowledge of the various defects and their implications of general health;
- a deep understanding of the impact these have on provision of dental care;
- effective communication with the paediatric cardiology team and paediatric anaesthetist if GA is required;
- a multidisciplinary effort for provision of care.
- Ventriculoseptal defect (VSD)
- Atrioseptal defect (ASD)
- Patent ductus arteriosus (PDA)
- Pulmonary stenosis
- Aortic stenosis
- Coarctation of aorta
- Tetralogy of Fallot (TOF)
- Transposition of great vessels
The dental issues that clinicians should consider centre around the safe provision of dental care. Most important are:
- risk of infective endocarditis;
- increased risk of bleeding;
- management under general anaesthesia if required;
- children who require cardiac surgery.
Infective Endocarditis (IE)
IE is an infection of the lining of the heart chambers and heart valves caused by bacteria, viruses, fungi or other infectious agents. This can cause growths on the heart valves, the lining of the heart or the lining of blood vessels that may form clots that break off and travel to the brain, lungs, kidneys or spleen.
Dental Treatment and IE
Dental treatment is often implicated in the causation of IE. The reason is that although many bacteria can cause IE, Streptococcus viridans, which is commonly found in the mouth, is responsible for approximately half of all cases of bacterial endocarditis. Other common organisms include Staphylococcus and Enterococcus.
Prevention of IE
Opinions have changed recently on the mandatory use of antibiotic (AB) prophylaxis for dental treatment in children with CHD. In the UK for example, the National Institute for Health and Clinical Excellence concluded that there was no evidence of their efficacy; in some countries, including the UK, AB prophylaxis is not used any more for any child with CHD, however “at risk” of endocarditis they might be. In certain countries such as the USA and Australia, there is a move to reconsider the indications and it is used for fewer patients but is still used in children who are believed to be at a greater risk (Box 49.2). The AB prophylaxis protocols that are widely accepted are shown in Box 49.3.