Management of Medically

Compromised Children
Dr: Mohira Ezzeldin Ibrahim
REVIEW SYSTEM
• Cardiovascular system.
• Respiratory system.
• Hematological system.
• Central nervous system.
• Endocrine system.
• Renal and hepatic systems.
• Gastrointestinal system.
• Hospitalization.
• Allergies.
• Current medications.
 Cardiovascular disorders
Can be divided into two main groups:

congenital heart disease (existing before or at birth),

disorders that are acquired after birth.
Congenital heart disease

• Defect in the structure of heart or great vessels present at birth

• Congenital cardiac defect occur in 8-10 in every 1000birth

• There is no sex predilection.

Etiology
• In the majority of cases there is no etiological agent or genetic factor. In
most instances there is a combination of genetic and environmental
influences

• Risk factor of congenital cardiac defect

• Maternal rubella

• Alcoholism

• Diabetes

• Irradiation

• Drugs like(phenytoin.. Thalidomide. Warfarin)

Prevalence of congenital cardiac
disease
Defect Percent
Ventricular septal defect 22
Patent ductus arteriosus 17
Tetralogy of Fallot 11
Transposition of the great vessels 8
Atrial septal defect 7
Pulmonary stenosis 7
Coarctation of the aorta 6
Aortic stenosis 5
Tricuspid atresia 3
All others 14
• Congenital heart disease can be classified into two groups:

• acyanotic

• cyanotic.
Acyanotic Congenital Heart Disease.

• Acyanotic congenital heart disease is characterized by minimal or no

cyanosis and is commonly divided into two major groups:

defects that cause left-to-right shunting of blood within the heart.

 defects that cause obstruction

defects that cause left-to-right shunting of blood within the heart.

• includes :

• ventricular septal defect

• atrial septal defect.

• Clinical manifestations

• congestive heart failure,

• pulmonary congestion,

• heart murmur,

• labored breathing,

• cardio-megaly.
 defects that cause obstruction :include

• aortic stenosis

• coarctation of the aorta.

clinical manifestations

Labored breathing

congestive heart failure.

• Ventricular septal defects (VSDs )

• VSDs are the most common of the cardiac malformations. Small

defects are asymptomatic and may be found during a routine physical
examination. Large defects with excessive pulmonary blood flow are
responsible for symptoms of breathlessness, feeding difficulties, and
poor growth.

• Between 30% and 50% of the small defects close spontaneously,

usually within the first year of life. Larger defects are usually closed
surgically in the second year of life.
• Atrial septal defects (ASDs )
• ASDs are not as common as VSDs in children, but are proportionately
more significant in adults and more frequent in females .

• Even an extremely large ASD rarely produces heart failure in children,

but symptoms usually appear in the third decade. Surgery is usually
carried out before school age.
• Patent ductus arteriosus

• It is a connection between the aorta and the pulmonary artery.

• During fetal life most of the pulmonary arterial blood is shunted through the
ductus arteriosus into the aorta, thus bypassing the lungs.

• Functional closure of the ductus arteriosus usually occurs at birth.

• Virtually all preterm babies weighing less than 1.75kg have a patent ductus
arteriosus in the first 24 hours of life, but this usually closes spontaneously
Symptoms:
Heart murmur.
Poor feeding.
Respiratory distress.
Frequent respiratory infections in infants with heart failure.
• Treatment:

• . Ductus arteriosus patency is mediated by pros-taglandins, and the

administration of inhibitors of prostaglandin synthesis, such as
indomethacin, is effective in closing the ductus.

• . However, surgical ligation is a safe and effective back-up if

indometacin is contraindicated or has not been successful.
• AORTIC STENOSIS ( AS)

• Stenosis possible at the valve, subvalvular or supravalvular.

• This is a more significant and a dangerous lesion compared to PS.

• More common in males.

• A type of subvalvular AS is the commonest cause of sudden death in

children.
Symptoms:

• Mild: None

• Moderate to severe: Chest pain, fatigability, syncope.

• COARTICATION OF THE AORTA

• This is an aortic narrowing, usually sited beyond the origin of the

subclavian arteries.

• It could be : Preductal ( infantile)

Or Postductal (adult).
• Infective endocarditis and left ventricular failure may occur.

Treatment:

• For an infant in shock -PGE1 immediately.

• Surgical vs. transcatheter repair.

 Cyanotic Congenital Heart Disease

• Characterized by right-to-left shunting of blood within the heart.

Cyanosis is often observed even during minor exertion. this include:

• Tetralogy of Fallot,

• Transposition of the great vessels,

• Pulmonary stenosis,

• Tricuspid atresia.
• Clinical manifestations

• cyanosis,

• Hypoxic spells,

• poor physical development,

• heart murmurs,

• clubbing of the terminal phalanges of the fingers

Tetralogy of Fallot

• This classically consists of a combination of:

• an obstruction of right ventricular outflow (pulmonary stenosis)

• VSD

• dextroposition of the aorta (its origin may be overlying the VSD)

• right ventricular hypertrophy.

Clinical feature of Tetrology of Fallot

• Cyanosis is one of the most obvious signs of this condition, but it may
not be present at birth.(The oral mucous membranes and nail beds are
often the first places to show signs of cyanosis)

• Growth and development may be markedly delayed in severe

untreated tetralogy of Fallot.

• puberty is delayed.
 Management:

• Early medical management involves the use of prostaglandins so that

adequate pulmonary blood flow can occur.

• Shunt procedure (usually the Blalock–Taussig shunt) is performed to

anastomose the subclavian artery to the homolateral branch of the
pulmonary artery.

• Later in childhood, total surgical correction is undertaken,

Transposition of the great vessels

• Reversal of the origins of the pulmonary artery and aorta causes

cyanosis and breathlessness from birth, and early congestive failure.

• Death in infancy is common.

• Pulmonary stenosis
• There are usually no symptoms with mild to moderate stenosis of the

pulmonary valve, but severe form result in:

exercise intolerance

 cyanosis.

Treatment is required for the moderate to severe forms; in the

majority of children relief of this obstruction is now carried out by

balloon dilatation rather than surgery.
 Tricuspid atresia
• Is a birth defect of the heart where the valve that controls blood flow from the right upper chamber
of the heart to the right lower chamber of the heart (tricuspid valve) doesn’t form at all.
• Some babies with tricuspid atresia can also have other heart defects, including
transposition of the great arteries (TGA).
• Tricuspid atresia may be diagnosed during pregnancy or soon after a baby is born.
• Symptoms:
• cyanosis, because their blood doesn’t carry enough oxygen.
• Problems breathing
• Ashen or bluish skin color
• Poor feeding
• Extreme sleepiness
• Treatment
• Soon afterbirth, one or more surgeries may be needed to increase blood flow to the lungs and
bypass the poorly functioning right side of the heart.
• Other surgeries or procedures may be needed later.
Dental Signs in children with congenital heart disease:

• Children with congenital heart disease constitute a risk group for

caries development particularly in primary teeth.

• They also have an increased prevalence of disturbances in enamel

mineralization.
ACQUIRED HEART DISEASE
• Rheumatic Fever

• Is a serious inflammatory disease that occurs as a delayed sequel to pharyngeal infection

with group A streptococci.

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

• Environmental factors that increase the prevalence of rheumatic fever is:

• temperate zones

• high altitudes

• children who live in substandard conditions.

• Cardiac involvement is the most significant pathologic sequela of rheumatic fever;(Carditis

develops in approximately 50% of patients)

• Cardiac involvement can be fatal during the acute phase or can lead to chronic rheumatic heart
disease as a result of scarring and deformity of heart valves.
diagnosis

 Done by utilizing Jones’ Modified Criteria.

 Requirement for diagnosis:

a. Two major criteria.

b. One major plus two minor criteria.

c. Plus evidence of previous streptococcal infection

 Treatment

Benzyl Penicillin G 0.6-1.2 million I U for eradication

 Steroids: Prednisone (severe Carditis) 2 mg/kg /d. 2-4 W .

 Treatment of CHF- Digoxin .

Infective Endocarditis
Infective endocarditis (IE) 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.

Classically divided into acute and subacute forms.

Acute infective endocarditis
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 Pneumococcus
Sub-acute IE
occurs when microorganisms of low pathogenicity attack persons with
preexisting congenital cardiac disease or rheumatic valvular lesions.
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.

• These vegetations, composed of microorganisms and fibrous exudate, may

separate and, depending on whether the endocarditis involves the left or
right side of the heart, be propelled into the systemic or pulmonary
circulation.
Diagnosis

Symptoms

• Constitutional symptoms

• Endocarditis should be considered in patients with vague or

generalized constitutional symptoms such as fever, rigors, night
sweats, anorexia, weight loss, or arthralgia.
• Cardiac lesion

- Congenital heart defect

- Rheumatic heart disease

- Prosthetic heart valves

- Other cardiac diseases

• Skin lesions

• Endocarditis is indicated by:

• Osler's nodes – tender lesions found on finger pulps and thenar/hypothenar

eminences .

• Janeway lesions – transient, nontender macular papules on palms or soles

• splinter hemorrhages

• petechiae (embolic or vasculitic)

• clubbing – in long-standing disease

Splinter hemorrhage petechiae
• Eyes
• Roth spots (boat-shaped hemorrhages with pale centers, in retina)

• conjunctival splinter hemorrhages may be found.

• Splenomegaly
• Splenic infarction may occur as a result of emboli. In this case, splenic
palpation may be painful and tender.
• Neurological
• An acute confusional state is common in patients with infective endocarditis (IE).
• Cerebral emboli, which usually affect the middle cerebral artery, result in hemiplegia
and sensory dysfunction.
• Mycotic aneurysms also affect the middle cerebral artery, where rupture may cause a
subarachnoid hematoma.
• Mycotic aneurysms can occur several years after endocarditis has been treated.
• Renal
• Infarction causes loin pain and hematuria.
• Immune complex deposition may result in glomerulonephritis.
• Treatment of IE

• Optimal treatment of IE is based on the combination of prolonged and

adapted antibiotic treatment with surgical excision of all the infected
tissues in about 50% of patients

• Surgery may also be needed if your heart valves have been damaged.
considerations are especially important in treating patients who are
susceptible to bacterial endocarditis:
• •Pulp therapy is not recommended for primary teeth with a poor prognosis because
of the high incidence of associated chronic infection. (Extraction of such teeth
with appropriate fixed-space maintenance is preferred).
• Endodontic therapy in the permanent dentition can usually be accomplished
successfully if the teeth to be treated are carefully selected and the endodontic
therapy is adequately performed.
• A dentist who feels uncomfortable in treating patients who are susceptible to
infective endocarditis has a responsibility to refer them to someone who will care
for them.
Dental care for children with cardiovascular
disorders
• The most important consideration in planning dental care for children with cardiovascular
disorders is the prevention of dental disease.

• As soon as a child is diagnosed as having a significant cardiac problem, they should be referred for
dental evaluation and an aggressive preventive regimen,including :

 oral hygiene instruction.

dietary counselling,

 fluoride therapy,

fissure sealants,

Regular monitoring, both clinical and radiographic, with reinforcement of the preventive advice is
essential.

Active dental disease should be treated before cardiac surgery is undertaken.

Patients who are known to be at risk should carry a Warning
Card. This should indicate:

1. The precise type of cardiac lesion present.

2. The degree of risk of developing Infective Endocarditis.

3. Whether or not the patient is allergic to Penicillin and the antibiotic

prophylaxis that would normally be given to that patient.

4. The name and telephone number of the Cardiologist who can be

contacted for advice.
American Heat Association : Endocarditis Prophylaxis
Information 2010
The Journal of the American Dental Association -- Wilson et al_ 139 (1) 3S Table 3
PROCEDURES NOT NEEDING ANTIBIOTIC
PROPHYLAXIS
• Restorative dentistry with or without cord.
• Local anesthetic (non-PDL).
• Taking radiograph
• Placement of removable prosthodontic or orthodontic.
• Placement of orthodontic bracket.
• Root canal therapy (not beyond apex).
• Impressions.
• Placement of the rubber dam.
• Shedding of deciduous teeth
• Bleeding from trauma to the lips or oral mucosa
Antibiotic Prophylaxis Regimen

 Following current guidelines give the antibiotic 30 -60 minutes

before procedure.

 The dose can be given 2 hours after the procedure if it was

accidentally not given.

 Select an antibiotic from a different class if the pt already take

antibiotic