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Oral and dental management in children with tetralogy of fallot

Arlette Suzy Puspa Pertiwi, Inne Suherna Sasmita and Yetty Herdiati Nonong
Department of Pediatric Dentistry
Faculty of Dentistry, Padjadjaran University
Bandung - Indonesia

abstract
Tetralogy of fallot is one of the congenital cyanotic heart disease that is often found in children. The disorder has four features, a
ventricular septal defect, aortic overriding, infundibulary stenotic, and hypertrophy right ventricular. Like other congenital heart disease,
tetralogy of fallot sometimes related to fatal complications, such as bacterial endocarditis which was related to dental infections. The
correct management of oral and dental conditions is important to prevent bacterial endocarditis. This paper discussed the oral and
dental conditions and its management in two cases of tetralogy of fallot children.

Key words: Oral and dental condition, Antibiotic, Cyanotic heart disease

Correspondence: Arlétte Suzy Puspa Pertiwi, c/o: Bagian Kedokteran Gigi Anak, Fakultas Kedokteran Gigi Universitas Padjadjaran.
Jl. Sekeloa Selatan I Bandung 40132 Indonesia. E-mail: arlettesuzy@yahoo.com, Telp/Fax. 022 253 3031.

introduction

Tetralogy of fallot (ToF) is a congenital cyanotic heart

Like any other cyanotic congenital heart disease, in ToF
disease that is often found in children, approximately
sometimes lead to a fatal complication such as bacterial
around of 7–10% from overall congenital heart disease in
endocarditis. Incidence of bacterial endocarditis in ToF
children. The disorder includes ventricular septal defect,
is 15%.1 Bacterial endocarditis is caused by a bacterial
aortic overriding, infundibullary stenotic, and hypertrophy
infection in heart valve or endocardium. In the field of
right ventricular.1 Defects of ToF describe as a hole in
dentistry, bacterial endocarditis is closely related to dental
the wall between the ventricles (ventricular septal defect)
infection. Poor dental condition mostly found in a child with
which lets oxygen-poor blood mix with oxygen-rich blood.
ToF is due to a disturbance in enamel development. Gingival
An obstruction from ventricle to the lungs (pulmonal
hypertrophy may be present and the tongue shows a map
stenotic) is an important feature cause by the blockade of
appearance of geographic tongue.2 Dentist’s role is highly
blood flow from the right ventricle into the lungs due to a
needed in an attempt to prevent this complication.5
narrowed outlet to the pulmonary artery, usually along with
Invasive dental treatment, such as extraction, scaling,
an abnormal pulmonary valve. Be aside of all, an aorta that
oral surgery, and endodontic treatment may cause
straddles the septum (overriding) between the ventricles
bacteriemia.6 Dental procedures that allow trauma in soft
will lets oxygen-poor blood flow into the aorta and also
tissue or bone may lead to a bleeding which can cause
due to a thickened and enlarged heart muscle tissue in the
transient bacteriemia. The condition in a certain patient
right ventricle.2
may cause endocarditis. Minor dental treatment, such as
Overriding aorta above the ventricular defect and
placing matrix band may lead to transient bacteriemia
pulmonal stenotic allows the blood from the ventricles to
which further lead to bacterial endocarditis.5,6 The attempt
be pump into the body. Together, these defects make the
to prevent bacterial endocarditis is the administration
level of oxygen in the blood low. These allow a bluish
of prophylactic antibiotic. Oral Streptococcus such as
appearance (cyanotic) when oxygen-poor blood is pumped
S. sanguis and S. mitis are the organism which mostly cause
into the body, the fingers, toes, and lip.2 Child with ToF
bacterial endocarditis.6
may feel easily exhausted, short winded, and hyperpnoea
Children with ToF are in a high risk of caries, especially
caused by hypoxia. Sometimes the cyanotic does not clearly
in primary dentition. These are due to a certain medication
appear. Tip of fingers and toes showed a clubbing shape
for heart disease contains a high concentrate of sugar and
and cyanotic. Patient often do a squatting position after a
further on, there is an increase in the prevalence of enamel
certain distance walk or even cry. This position is necessary
mineralization disturbance. Preventive efforts include the
to enhance periphery resistance and restrain the blood flow
dietary counseling, fluoride administration, pit and fissure
from the extremities into the heart.1 Further on, the increase
sealant, and oral hygiene instruction.6,7 These clinical
of systemic resistance from a squatting position may repair
reports discuss two cases of dental management in children
the lungs oxygenation.3–5
with ToF.
Pertiwi: Oral and dental management 43

cases 74, 84, 85, 64, 65 and pulp hyperemia in teeth no 54, 53,
62, 63. Oral hygiene was in mild condition.
First case: R, nine year old boy was referred to Special Second case: Rz, four year-old boy also referred to
Dental Care clinic in Hasan Sadikin Hospital from his Special Dental Care clinic by his pediatric cardiologist to
pediatric cardiologist to search for focal infection prior search for focal infection and it’s management prior to heart
heart surgery. Patient was diagnosed as ToF since the age surgery. Patient showed the sign of heart disease since the
of eight, but the clinical signs such as fatigue, short winded, age of 5 months. Diagnosis from pediatric cardiologist is
and often make a squatting position was already exist since diagnosis of function (DF): compensated heart disease,
toddler. At the moment, the patient is unable to walk and diagnosis of anatomy (DA): variant ToF + bacterial
have to be carried by his parents. endocarditis, and diagnosis of etiology (DE): congenital
Diagnoses from the pediatric cardiologist were heart disease cyanotic type. Physical examination showed
diagnosis of function (DF): compensated heart disease, failure to thrive. Patient was unable to walk. Skin was pale
diagnosis of anatomy (DA): ToF, and diagnosis of etiology and bluish with clubbing fingers and toes (Figure 3).
(DE): congenital heart disease cyanotic type. Physical Intra oral examination showed poor oral hygiene and
examination showed a delayed growth and development generally chronic marginal gingivitis. Lips, tongue, gingival
compare to a normal child at his age. Patient looked fatigue and buccal mucosa were cyanotic. Dentine caries at teeth
and bluish. Fingers and toes showed clubbing shape (Figure 1). no 55, 53, 63, 65, 73, 72, 71, 81, 82, 83. Caries that reach
Intra oral examination showed cyanotic in lip, buccal, and the pulp in teeth no 54, 64, 75, 74, 84. Radix in teeth no
gingival mucosa. Diagnosis of necrotic pulp in teeth no 75, 52, 51, 61, 62.

Figure 1. Clubbing and cyanotic fingers and toes.

Figure 2. Patient was monitored by pulse oxymetry and administred oxygen inhalation.
44 Dent. J. (Maj. Ked. Gigi), Vol. 40. No. 1 January-March 2007: 42–45

Figure 3. Clubbing and cyanotic fingers and toes.

Figure 4. Patient’s profile.

cases management percent (normally, he have oxygen saturation of 60–70

percent, normal child should have the value of 100 percent).
Dental treatments for the first case consist of preventive Considering the dental treatment will harm the patient, so
and curative efforts. Preventive treatments were carried out he was scheduled to the dental treatment under general
by oral hygiene instruction and topical fluoride application. anesthesia. Laboratory and radiographic examination were
Curative treatments are extraction of the teeth with necrotic carried out and the case was discussed in a join conference
pulp and glass ionomer cement fillings in hyperemia pulp with pediatricians and anesthesiologist. Thorax photo
teeth. To prevent bacterial endocarditis, patient was given showed an enlarged heart of increase vascular marking,
a prophylactic antibiotic 50mg/kg body weight one hour no sign of active specific process, and an opaque round
prior before treatment. During the dental procedure, patient shadow in the right par tracheal.
was monitored by pulse oximetry to monitor the oxygen The join conference concluded that the dental treatment
saturation and heart pulse. Patient was also inhale oxygen under general anesthesia can not be carried out at Hasan
(Figure 2). Patient was very cooperative, so the dental Sadikin Hospital because this patient is in a high risk due to
treatment was done after two months periods. a severe condition of ToF. Patient was referred to undergo
As for the second case, dental management was different mouth preparation under general anesthesia at Harapan
than the first case. Patient was extremely uncooperative. Kita Hospital.
Treatment plan were extraction of teeth no 52, 51, 61, 62,
54, 64, 75, 74, 84 and filling in teeth no 55, 53, 63, 65, 73,
72, 71, 81, 82, 83. Antibiotic prophylactic (Amoxicillin) discussion
was considered to be given 50mg/kg body weight 1 hour
before the procedure. Oral and dental treatment in a child with congenital
In the first visit, patient was very uncooperative, he heart disease is very important. Main point which have to be
revolted and cried so the oxygen saturation drop to 10 noticed is that patient with this disorder is highly susceptible
Pertiwi: Oral and dental management 45

to bacterial endocarditis. In the first case, the history of uncooperativeness. Patient was scheduled to undergo mouth
bacterial endocarditis was not yet exists. But in the second preparation under general anesthesia, but considering that
case, the bacterial endocarditis was already exists. This was this patient has severe ToF, the procedure can not be carried
due to poor oral hygiene in the second patient. out in Hasan Sadikin Hospital.
Every dental procedures which may lead to a damaged Oral and dental treatment is important to be carried out
of soft tissue can cause transient bacteriemia and thus in a in children with the risk of bacterial endocarditis. Patient in
certain condition cause to bacterial endocarditis.5 Transient a good general condition can receive every dental treatment
bacteriemia may exists after physiological activities which as long as covered by prophylactic antibiotic. The important
involves the mouth, such as mastication and tooth brushing. aspects of dental treatment are dental health education,
According to Guntheroth, transient bacteriemia that happens preventive dental treatment, and maintenance after dental
after physiological activities is 1000 fold higher than after treatment. Dental health education can be delivered since
dental procedures. However, the risk of bacteriemia in a the child showed heart disorder considering congenital
patient with a clean and healthy oral cavity is lower than heart disease mostly showed the clinical signs in infancy.
patient with poor oral hygiene.5 Early dental health education can minimize oral and
Bacterial endocarditis that caused from oral bacteria dental disease which may risk the existence of bacterial
has to be prevented with the administration of prophylactic endocarditis.
antibiotic. Antibiotic can prevent endocarditis by killing
the bacteria or damage it so it can be destroyed by host
defense. The effect may occur in oral cavity, blood flow, references
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