Heart disease

1) Dental management in children with Heart disease –

Congenital cardiac anomalies is one of the most common type of heart

disease among children and is more prevalent than rheumatic heart disease.

Congenital heart disease can be cyanotic or acyanotic.

Cyanotic Acyanotic

Tansposition of great vessels Ventricular septal defect

Tetralogy of fallot Atrial septal defect

Tricuspid atresia Coarctaton of aorta

Pulmonary atresia Patent ductus arteriosus

Eisenmenger’s syndrome Pulmonary stenosis

Mitral valve prolapsed

Aortic stenosis

Bicuspid aortic valve

The most striking feature of congenital heart disease is cyanosis. It results

from shunting deoxygenated blood directly from right ventricle to the left side

of the heart and the systemic circulation leading to chronic hypoxaemia.

Severely impaired development and gross clubbing of fingers and toes will be

present.

Tetralogy of fallot – Ventricular septal defect, pulmonary stenosis, right

ventricular hypertrophy and an aorta that overrides both the ventricles are the

features of tetralogy of fallot. Infants with mild degrees of right ventricular

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outflow obstruction may present with heart failure caused by ventricular left to

right shunt. Often cyanosis is not present at birth, but with increasing

hypertrophy of right ventricle and patient growth, cyanosis occurs in the 1st

year of life. Its prominent in the mucous membrane of lips and mouth and in

the fingernails and toenails. When the ductus begins to close in first few days

of life, severe cyanosis and circulatory collapse may occur. As arterial O 2 is

less, these children are more prone to metabolic acidosis. Growth and

development may be delayed in patients with severe untreated tetralogy of

fallot, especially when O2 saturation is chronically less than 70%.5,12

Transposition of great vessels – This is a reversal of the origins of pulmonary

artery and aorta, and causes cyanosis and breathlessness from birth, and early

congestive cardiac failure. Death in infancy is common unless there is

associated defects such as patent interventricular septum or patent ductus

arteriosus, which provide sufficient collateral circulation for oxygenation of

the blood to maintain life a little longer.12

Ventricular septal defect – One of the most common congenital defects, this

ranges from mere pinholes compatible with survival atleast into middle age, to

defects so large to cause death in infancy. There is left to right shunt. There

may eventually be right ventricular hypertrophy, reversal of shunt and late

onset cyanosis.12

Atrial septal defect – Often located near the foramen ovale and is called as

secundum defect. It is one of the most common congenital heart disease

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presenting in adults. However, right ventricular failure usually develops in the

absence of surgical correction.12

Patent ductus arteriosus – A persistent opening between the aorta and

pulmonary artery is common in prematurity and rubella. The shunt is from left

to right, initially acyanotic and the typical complication is right ventricular

failure. Closure of the ductus can be promoted in early infancy by giving

intravenous indomethacin, a prostaglandin inhibitor.12

Coarctation of the aorta – Usually sited beyond the origin of the subclavian

arteries. The blood supply to the head, neck and upper body is normal but the

supply to the lower body is restricted. The classic sign of coarctation of the

aorta is a disparity in pulsations and blood pressures of the arms and legs.

Some children or adolescents complain about weakness or pain (or both) in the

legs after exercise, but in many instances even patients with severe coarctation

are asymptomatic.12

Pulmonary stenosis – A narrowing of the pulmonary valve, the valve cusps are

deformed to various degrees, resulting in incomplete opening during systole.

The main symptoms are breathlessness and right ventricular failure. If the

stenosis is severe, there may be signs of right ventricular failure such as

hepatomegaly, peripheral edema, and exercise intolerance.12

Aortic stenosis – Usually due to narrowing of the aortic valve, it can cause

angina, dyspnoea, and syncope. episodes of syncope in the presence of

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cardiac pathology such as heart block, ventricular tachycardia, and aortic

stenosis are an ominous sign. The incidence of sudden death is increased with

aortic stenosis. Of all the valvular conditions encountered in practice, aortic

stenosis appears to be the most significant. Critical aortic stenosis is generally

defined as an orifice of < 0.75 cm 2 and/or > 50 mm Hg gradient across the

valve during normal cardiac output. These patients do not tolerate increases in

heart rate because of decreased ejection time, filling time, and diastolic

coronary artery perfusion time of the left ventricle. Thus, β-adrenergic

agonists, anticholinergics, vasodilators, hypovolemia, pain, and anxiety are

poorly tolerated, particularly for patients whose end-stage disease involves

angina, syncope, and congestive heart failure.4,5,12

Clinical features –

The most striking feature of some types of congenital disease is

cyanosis. It results from shunting deoxygenated blood from the right ventricle

directly into the left side of the heart and the systemic circulation, leading to

chronic hypoxemia. Chronic hypoxemia causes severely impaired

development and often gross clubbing of fingers and toes.4,5,12

Rheumatic fever –

Rheumatic fever is a serious inflammatory disease that occurs as a delay

sequel to pharyngeal infection with group A streptococci. The infection can

involve the heart, joints, skin, central nervous system and subcutaneous tissue.

It appears most commonly between the ages of 6 and 15 years. Cardiac

involvement is the most significant pathologic sequela of rheumatic fever.6,12

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The acronym HACEK refers to a grouping of gram-negative bacilli;

Haemophilus species (Haemophilus parainfluenzae, Haemophilus

aphrophilus, and Haemophilus paraphrophilus), Actinobacillus

actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and

Kingella species. These organisms share an enhanced capacity to produce

endocardial infections. They are responsible for 5-10% of cases of infective

endocarditis (IE) involving native valves and are the most common cause of

gram-negative endocarditis among persons who do not abuse intravenous

drugs. All are part of the normal oropharyngeal flora. Sixty percent of cases of

HACEK IE are associated with various types of dental pathology.27,28

Dental management –

- These children are vulnerable to infective endocarditis and hence require

antimicrobial prophylaxis before any dental surgery.

- Bleeding tendencies may be caused by platelet dysfunction and excessive

antifibrinolytic activity.

- Problems which can affect dental management include Down’s, Turner’s or

William’s syndrome.

AHA guidelines for endocarditis prophylaxis

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Cardiac conditions associated with the highest risk of adverse outcome from

endocarditis for which prophylaxis with dental procedures is reasonable.

- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

- Previous infective endocarditis

- Congenital heart disease (CHD)

- Unrepaired cyanotic CHD, including palliative shunts and conduits

- Completely repaired congenital heart defect with prosthetic material or

device, whether placed by surgery or by catheter intervention, during the first

six months after the procedure†

- Repaired CHD with residual defects at the site or adjacent to the site of a

prosthetic patch or prosthetic device (which inhibit endothelialization)

- Cardiac transplantation recipients who develop cardiac valvulopathy.

Except for the conditions listed above, antibiotic prophylaxis is no longer

recommended for any other form of CHD.

- Endocarditis prophylaxis is reasonable for patients undergoing all dental

procedures that involves the manipulation of gingival tissue or periapical

region of teeth or perforation of oral mucosa.

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Regimen for a dental procedure29

Situation Agent Regimen single dose 30 -60 mins before

Adult dose Child dose

Oral Amoxicillin 2gms 50mg/kg

Unable to Ampicillin 2g IM or IV 50mg/kg IM or IV

Allergic to Cephalexin 2g 50mg/kg

Azithromycin 500mg 15mg/kg

Allergic to Cefazolin or 1 g IM or IV 50 mg/kg

Summary of major changes in updated prophylactic gudielines.29

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- Bacteremia resulting from daily activities is much more likely to cause

infective endocarditis (IE) than bacteremia associated with a dental procedure.

- An extremely small number of cases of IE might be prevented by antibiotic

prophylaxis even if prophylaxis is 100 percent effective.

- Antibiotic prophylaxis is not recommended based solely on an increased

lifetime risk of acquisition of IE.

- Antibiotic prophylaxis is reasonable for all dental procedures that involve

manipulation of gingival tissues or periapical region of teeth or perforation of

oral mucosa only for patients with underlying cardiac conditions associated

with the highest risk of adverse outcome from IE.

Individuals with heart disease require special precautions during dental

treatment for the risk of causing bacterial endocarditis. Infective bacterial

endocarditis is one of the most serious infections of humans. It is

characterized by microbial infection of the heart valves and endocardium in

proximity to congenital and acquired cardiac defects.

- The primary management goal for the patient with cardiovascular disease

during dental therapy is to ensure that any hemodynamic change produced by

dental treatment does not exceed the cardiovascular reserve of the patient.

This is best achieved by minimizing any hemodynamic alterations during

treatment that is, by maintaining the patient’s optimum blood pressure, heart

rate, heart rhythm, cardiac output and myocardial oxygen demand.

- A stress-reduction protocol is frequently suggested for patients with

significant cardiovascular compromise, which includes the following: shorter

appointments, preferably in the morning when the patient is well-rested and

has a greater physical reserve; use of profound local anesthesia to minimize

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discomfort; preoperative or intraoperative conscious sedation or both;

excellent postoperative analgesia.

- Permanently implanted cardiac pacemakers have been used extensively for

the treatment of cardiac rhythm disturbances. Electromagnetic radiation in

the dental office is potentially strong enough to interfere with normal

pacemaker function. Sources of electromagnetic radiation may include

electrosurgery or electrocautery units, ultrasonic devices, induction

casting equipment, electronically controlled timers, microwave oven,

electric spot welders, wireless communication systems, electric pulp

testers, and ultraviolet light curing unit.

- However many modern pacemakers are now equipped with sufficient titanium

shielding to prevent electromagnetic radiation interference in the ranges found

with these devices. But if in case of an accidental interference the

following procedures should be carried out –

 Turn off all possible sources of interference.

 Place the patient in position for cardiopulmonary resuscitation.

 Begin oxygen administration or resuscitation and pulse the heart

externally.

- Sedation premedication is frequently a successful method for reducing

apprehension/ anxiety in the cardiovascular disease patient, especially the

young child.

- Cautious use of any respiratory depressant must be done. Caution should

be used in administering analgesics, narcotics, barbiturates and sedative

agents since these can potentiate and prolong the effect of

antihypertensive agents and lead to hypotension and syncope.

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- Atropine and its prototypes that are saliva inhibiting agents should be used

with caution because of their vagolytic effect on the heart, which may

produce tachycardia.

- Patients receiving a monoamine oxidase inhibitor should not be given a

local anesthetic containing epinephrine and the use of vasoconstrictors

for gingival retraction is not recommended.

- Antiplatelet and anticoagulation agents are extensively used in the prevention

and management of arterial and venous thrombosis as well as in cases were

capillary and small vessel occlusion are seen in cyanotic congenital heart

disease. Hence the patients receiving this therapy are associated with an

increase in the bleeding time and risk of post operative hemorrhage.

- An International Normalized Ratio (INR) was introduced in the year

1983 by the WHO committee on biological standards to assess the

patients receiving anticoagulation therapy more accurately rather than

using the usual BT, PT & PTT.

- The INR is calculated from the ratio of the patient’s PT and control PT,

raised to the power of international sensitivity index value (ISI).

INR = (patient PT/mean normal PT)ISI .

- It is a more reliable and sensitive value for determining the level of

anticoagulation because it depends on the patient’s blood and on the

sensitivity of the thromboplastin reagent and the assigned ISI value.

- A patient with a normal coagulation profile would have an INR of 1. It is

recommended that patient undergoing invasive treatment should have a PT

within 1.5 – 2 times the normal value, and this corresponds to an INR of 1.5 –

2.5 when the ISI is 1.

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- In patients with anticoagulation therapy, an INR between 2 and 3 is

recommended for most indications. Thus , an INR of 2.5 (2-3) minimizes

the risk of either hemorrhage or thromboembolism.

- Patients are more at risk of permanent disability or death if they stop

antiplatelet or anticoagulation medications prior to a surgical procedure than

if they continue it. It has been concluded that most dental patients can

undergo procedures without stopping their therapies provided that local

hemostatic measures are used to control bleeding.

- The most common antiplatelet drugs are acetylsalicyclic, clopidogrel and

dipyridamole. Patients taking anti platelet medications will have a prolonged

bleeding time, but this may not be clinically relevant because postoperative

bleeding after dental procedures can mostly be controlled using local

haemostatic measures.

- Warfarin is the most common drug used in anticoagulation therapy. It is a

antagonist of Vit K, an element necessary for synthesis of clotting factors II,

VII, IX and X. Warfarin has 2 functions : anticoagulant activity and

antithrombotic effect. Therapeutic doses of warfarin reduce the production of

functional Vit K dependent clotting factors by approximately 30 -50%. A

concomitant reduction in the carboxylation of secreted clotting factors yields

a 10-40% decrease in the biologic activity of the clotting factors. As a result

the coagulation system becomes functionally deficient.

- Lockhart et al suggested that post operative bleeding is considered to be

significant if it conforms to the following four criteria :

a) The bleeding continues beyond 12 hours,

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b) It causes the patient to call or return to the dental practice or emergency

department,

c) Results in the development of large hematoma or ecchymosis within the

oral soft tissues,

d) And requires a blood transfusion.

- The INR should be measured prior to dental procedures, ideally it should

be done within 24 hr before the procedure, but, for patients who have a

stable INR, an INR measured within 72 hrs before the procedure is

acceptable.

- Patients who have an INR greater than 4 should not undergo any form of

surgical procedure, including dental without consultation with the

clinician who is responsible for maintaining their anticoagulation.

- Minor oral surgical procedures, such as simple extraction of up to 3 teeth,

gingival surgery, crown and bridge procedures, supragingival scaling and the

surgical removal of teeth can be safely carried out without altering the

anticoagulation or anti platelet medication dose.

- If more than 3 teeth need to be extracted then multiple visits will be required

and the extractions may be planned to remove 2-3 teeth at a time, by quadrant,

or one at a time in separate visits.

- Scaling and gingival surgery should initially be restricted to a limited area to

assess if bleeding is problematic.

General anesthesia consideration for heart disease

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- Systemic air emboli is a constant threat in children with CHD, regardless of

their usual shunting pattern, because of the dynamic nature of shunts during

anesthesia and surgery. Air traps are advisable for all IV lines but are not a

substitute for meticulous attention and constant vigilance and purging of air

bubbles.

- Prevention of infective endocarditis is an important consideration in patients

undergoing non cardiac surgery.

- Clear fluids can be ingested up to 2 hrs preoperatively, and an extended

period of fasting should be avoided where possible, particularly in cyanotic

patients.

- IV induction of anesthesia should be used for all patients with severely

limited hemodynamic reserve, particularly those with severe ventricular

failure or pulmonary hypertension.

- Cooperative child with adequate cardiac reserve with morbid fear for needles

can have anesthesia induced cautiously with inhaled anesthetics even if the

patients are cyanotic.

- The use of nitrous oxide in children with CHD and shunts is controversial

because of its potential for enlarging systemic air emboli and increasing

pulmonary vascular resistance. It may also exaggerate the effect of other

anesthetics on the circulation.

- Nitrous oxide has been reported to decrease the cardiac output, systemic

arterial pressure and heart rate and it increases the pulmonary vascular

resistance.

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