Management of Children with Heart
Disease
Selected from the topics of Dr. Aseel Haider
Abdulrahman Firas Hashim Kamar
Fifth year
Group C2
Management of children with Heart Disease
Introduction
Heart disease can be divided into two general types congenital and acquired.
Because individuals with heart disease may require special precautions during dental
treatment, such as antibiotic coverage for prevention of infective endocarditis (IE),
a dentist should closely evaluate the medical histories of all patients to ascertain their
cardiovascular status. In April 2007 the American Heart Association presented
recommendations to conserve the use of antibiotics for the prevention of IE to
minimize the risk of developing resistance to current regimens.
CONGENITAL HEART DISEASE
The incidence of congenital heart disease is approximately 9 in 1000 births.
The cause of a congenital heart defect is obscure. Generally it is a result of aberrant
embryonic development of a normal structure or the failure of a structure to progress
beyond an early stage of embryonic development. Only rarely can a causal factor be
identified in congenital heart disease. Maternal rubella and chronic maternal alcohol
abuse are known to interfere with normal cardiogenesis. If a parent or a sibling has
a congenital heart defect, the chances that a child will be born with a heart defect are
about 5 to 10 times greater than average. Congenital heart disease can be classified
into two groups: acyanotic and cyanotic.
Acyanotic Congenital Heart Disease
Acyanotic congenital heart disease is characterized by minimal or no cyanosis and
is commonly divided into two major groups. The first group consists of defects that
cause left-to-right shunting of blood within the heart. This group includes ventricular
septal defect and atrial septal defect. Clinical manifestations of these defects can
include congestive heart failure, pulmonary congestion, heart murmur, labored
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breathing, and cardiomegaly. The second major group consists of defects that cause
obstruction (e.g., aortic stenosis and coarctation of the aorta). The clinical
manifestations can include labored breathing and congestive heart failure.
Cyanotic Congenital Heart Disease
Cyanotic congenital heart disease is characterized by
right-to-left shunting of blood within the heart.
Cyanosis is often observed even during minor exertion.
Examples of such defects are tetralogy of Fallot,
transposition of the great vessels, pulmonary stenosis,
and tricuspid atresia. Clinical manifestations can include cyanosis, hypoxic spells,
poor physical development, heart murmurs, and clubbing of the terminal phalanges
of the fingers.
ACQUIRED HEART DISEASE
Rheumatic Fever Rheumatic fever
is a serious inflammatory disease that occurs as a delayed sequela to pharyngeal
infection with group A streptococci. Rheumatic fever is a commonly diagnosed
cause of acquired heart disease in patients under 40 years of age. The mechanism by
which the group A Streptococcus strains initiate the disease is unknown. The
infection can involve the heart, joints, skin, central nervous system, and
subcutaneous tissue. Although rheumatic fever can occur at any age, it is rare in
infancy. It appears most commonly in children between the ages of 6 and 15 years.
Rheumatic fever is most prevalent in temperate zones and at high altitudes and is
more common and severe in children who live in substandard conditions.
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Infective Endocarditis (IE)
It is one of the most serious infections of humans. It is characterized by microbial
infection of the heart valves or endocardium in proximity to congenital or acquired
cardiac defects. IE has been classically divided into acute and subacute forms. The
acute form is a fulminating disease that usually occurs when microorganisms of high
pathogenicity attack a normal heart, causing erosive destruction of the valves.
Microorganisms associated with the acute form include Staphylococcus, group A
Streptococcus, and Pneumonococcus. In contrast, subacute IE usually develops in
persons with preexisting congenital cardiac disease or rheumatic valvular lesions.
Surgical placement of prosthetic heart valves can also predispose a patient to IE;
heart valve infections occur in 1% to 2% of such patients. The subacute form is
commonly caused by viridans streptococci, microorganisms common to the flora of
the oral cavity. Embolization is a characteristic feature of IE. Microorganisms
introduced into the bloodstream may colonize the endocardium at or near congenital
valvular defects, valves damaged by rheumatic fever, or prosthetic heart valves. The
clinical symptoms of IE include low, irregular fever (afternoon or evening peaks)
with sweating, malaise, anorexia, weight loss, and arthralgia. Inflammation of the
endocardium increases cardiac destruction, and murmurs subsequently develop.
Painful fingers and toes and skin lesions are also important symptoms.
Infective Endocarditis Prophylaxis
Transient bacteremia is an important initiating factor in IE. So, procedures known to
precipitate transient bacteremias in dentistry IE prophylaxis is recommended for.
Dentist should consider the use of antibiotics in patients with underlying cardiac
conditions for all dental procedures that involve manipulation of gingival tissue,
involvement of the periapical area or perforation of oral mucosa. The recent AHA
revision concluded that only a small number of cases of IE might be prevented by
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antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were
100% effective.
Antibiotic Prophylaxis
Previously, the 1997 guidelines recommended prophylactic antibiotics for patients
in high-risk aid moderate-risk categories. The 2007 guidelines now recommend that
only patients in this high-risk category require coverage. Amoxicillin remains the
first choice as the prophylactic antibiotic. In 1997, amoxdcillin was to be
administered 1 hour before the procedure. The 2007 guidelines recommend
administration of amoxicillin (and any other recommended antimicrobial) 30 to 60
minutes before the procedure. According to the revised guidelines by AAPD (2011),
minimal use of antibiotics is indicated to avoid the risk of developing resistance due
to antibiotic usage. It will also be worthwhile to mention that medically
compromised patients with noncardiac factors may also have a compromised
immune system and may not be able to tolerate transient bacteremia following any
invasive dental procedure. This category may include diseases secondary to
immunosuppression such as AIDS, HIV, autoimmune diseases, post radiotherapy,
prolong use of steroid and metabolic disorders such as diabetes by AHA for
prevention of infective endocarditis.
Any dental patient who has a history of congenital heart disease or rheumatic heart
disease or who has a prosthetic heart valve should be considered susceptible.
Heart conditions are associated with the highest risk of adverse outcomes from IE:
1- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair.
2- Previous infective endocarditis.
3- Congenital heart disease (CHD).
4- Unrepaired cyanotic CHD, including palliative shunts and conduits.
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5- Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
6 months after the procedure.
6- Repaired CHD with residual defects at the site or adjacent to the site of
prosthetic patch or prosthetic device (which inhibits endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy.
Dental management
Parents of patients with cardiac risks typically lack knowledge about IE even
after being informed during routine cardiology visits. Before initiating care,
the dentist should obtain a thorough medical and dental history, perform a
physical examination, formulate a complete treatment plan, and discuss the
treatment with the child’s physician or cardiologist. Behavior management
techniques are useful, and conscious sedation and nitrous oxide–oxygen
analgesia have also been proven beneficial in reducing anxiety in such
patients. Conscious sedation monitoring and cardiopulmonary resuscitation
equipment should be readily available during the appointment. If general
anesthesia is indicated, the dental procedures should be completed in a
hospital setting, where adequate supportive care is available if needed.
Important considerations in treating patients who are susceptible to IE
1. Pulp therapy is not recommended for primary teeth with a poor prognosis
because of the high incidence of associated chronic infection.
2. Endodontic therapy in the permanent dentition can be accomplished
successfully if the teeth selected carefully and the endodontic therapy is
adequately performed.
3. A dentist who feels uncomfortable in treating patients who are susceptible
to IE has a responsibility to refer them to someone who will adequately
care for them.
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References
1. Wilson W, et al.: Prevention of infective endocarditis: guidelines from
American Heart Association, Circulation 116: 1736–1754, 2007.
2. Hayes PA, Fasules J: Dental screening of pediatric cardiac surgical patients, J
Dent Child 68:255–258, 2001.
3. Marwah, N., 2014, Textbook of pediatric dentistry, third edition.
4. Jeffrey A. Dean, 2015, Mcdonald and Avery`s Dentistry for the child and
adolescent, tenth edition.
5. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P,
Poole-Wilson PA, et al. ESC guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008: The task force for the diagnosis and
treatment of acute and chronic heart failure 2008 of the European Society of
Cardiology. Developed in collaboration with the Heart Failure Association of
the ESC (HFA) and endorsed by the European Society of Intensive Care
Medicine (ESICM) Eur J Heart Fail. 2008; 10:933–89.
6. Hsu DT, Pearson GD. Heart failure in children: Part I: History, etiology, and
pathophysiology. Circ Heart Fail. 2009; 2:63–70.
7. Kay JD, Colan SD, Graham TP., Jr Congestive heart failure in pediatric
patients. Am Heart J. 2001; 142:923–8.
8. Rossano JW, Kim JJ, Decker JA, Price JF, Zafar F, Graves DE, et al.
Prevalence, morbidity, and mortality of heart failure-related hospitalizations
in children in the United States: A population-based study. J Card Fail. 2012;
18:459–70.
9. Towbin JA, Lowe AM, Colan SD, Sleeper LA, Orav EJ, Clunie S, et al.
Incidence, causes, and outcomes of dilated cardiomyopathy in children.
JAMA. 2006; 296:1867–76.
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‫عبدالرحمن فراس هاشم قمر‬