heart disease in paediatric dentistry

8/7/2019 Heart Disease in Paediatric Dentistry

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Infective endocarditis, an infection of the

endocardium that usually involves the valves

and adjacent structures, is caused by a widevariety of bacteria and fungi.


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According to Cameron and Widmer (2003) childrenwith congenital cardiac disease represent one of thelargest groups of medically compromised patients the

paediatric dentist manages. Koch and Poulsen (2001)say that all heart disease in children are congenital inorigin. Risk of subsequent infective endocarditis andall cardiac anomalies require antibiotic cover

(prophylaxis) for certain procedures which accordingto Koch et al. (2001) include; invasive dentalprocedures such as extractions, scaling, oral surgery,and endodontic treatment are likely to induce abacteremia.


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Although uncertain, it is believed that cardiac valves and otherendocardial surfaces become infected after exposure to microemboli from bacteria or fungi circulating in the bloodstream.Dextran-producing bacteria, such as Streptococcus mutans, have a

virulence factor that promotes adherence to endovascularsurfaces. Coagulase-negative staphylococci may produce a biofilmon prosthetic surfaces, which also promotes adherence. Beta-hemolytic streptococci and enteric gram-negative bacteria lackrecognized adherence factors, and appear less likely to causeendocarditis. Endocardial surfaces previously damaged from

valvular heart disease, endocarditis, surgery, or pacemaker wiresprovide a favorable environment for thrombus formation. Overtime, microorganisms proliferate in the thrombus, resulting in aclassic vegetation. Microorganisms are released into thecirculation, usually on a continuous basis, which often results ininteresting findings.


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The disease often begins as a flulike illness with a drycough, body aches, and fatigue, which follows asubacute or chronic course. Low-grade fevers, night

sweats, and weight loss are cardinal manifestations.Surprisingly, most patients, especially younger ones,do not seek medical advice until fatigue or feverbecomes unbearable or they suffer a major

complication, such as an embolic event or heartfailure. Patients who have had heart surgery in therecent past usually seek medical advice earlierbecause of their heightened awareness ofpostoperative complications.


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The penicillins, often in combination withgentamicin, remain the cornerstones of therapyfor endocarditis caused by penicillin-susceptible

streptococci. For penicillin-allergic patients,vancomycin is substituted. IV ceftriaxone, givenonce daily for 4 weeks, is another option, andeven a 2-week course in combination with

gentamicin has proven successful.T

herefore,careful follow-up is essential, especially forpatients who leave the hospital to completeantibiotic therapy at home.


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Heart surgery within the past six months Vascular surgery within the past six months Pacemaker History of rheumatic fever that lead to

rheumatic heart disease. Mitral valve prolapse Previous bacterial endocarditis

Systemic pulmonary shunt Congenital heart defect Acquired valvular dysfunction


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Extractions (single) 51%

Extractions ( lti le) 68-1 %

Peridontal s rgery (fla roced re) 36-88%Peridontal s rgery (gingivecto y) 83%

Scaling and root lanning 8-8 %

Periodontal ro ylaxis - %

Toot br s ing -26%

Dental flossing 2 -58%

Inter roxi al cleaning wit toot icks 2 - %

Irrigation devices 7-5 %

C ewing 17-51%


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Prophylaxis Recommended Prophylaxis NOT Recommended

All dental procedures that involvemanipulation of gingival tissue or theperiapical region of teeth or perforationof the oral mucosa

Routine anesthetic injections throughnoninfected tissueTaking dental radiographs

Placement of removable prosthodonticor orthodontic appliances

Placement of orthodontic brackets

Bleeding from trauma to the lips or oralmucosaOrthodontic appliance adjustment

Shedding of deciduous teeth


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Amoxycillin - PO Kids 50mg/ kg 1 hour pre-op (2g max) Adult 2g (max dose) 1 hour pre-op

Clindamycin - PO Kids 20mg/kg 1 hour pre-op (600mg max) Adult 600mg (max dose) 1 hour pre-op

Intra-muscular - 30 min pre-opIntravenous - immediately before op

Ampicillin IM,IV Kids 50mg/kg 1 hour pre-op (2g max ) Adult 2g (max dose) 1 hour pre-op

Intra-muscular or Intravenous - 30 min pre-op


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According to Robinson , Ford and McDonald(2000) patients with ischemic heart disease orprevious cardiac surgery, as well as patients with

circulatory dysfunction such as cardiac failure,show higher plasma levels of lignocaine whencompared to healthy subjects given the samedose.There fore it is recommended that the

maximum safe dose should be halved in suchpatients. Low plasma potassium levels andacidosis also potentiate adverse effects of localanaesthetics on the myocardium.


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If you are unsure if patient requires

prophylactic cover consult the patients

general practitioner or specialist

heart disease in paediatric dentistry

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