Dental Caries and Gingival Evaluation in Children with Congenital Heart Disease

Comparison of dmft and behavior rating scores between children with systemic disease and healthy children at the first dental visit

PURPOSE

To evaluate and compare oral health and behavior scores at the first dental visit and dental treatment need using general anesthesia/sedation (GA/S) of children with systemic diseases (SD) and healthy children.

METHODS

Data were obtained from healthy children (n = 87) and children with SD (n = 79), aged 4 to 6 years, presenting to a hospital dental clinic for a first dental examination. The total number of decayed, missing and filled teeth (dmft), dental behavior score using Frankl Scale, and dental treatment need using GA/S were recorded. Chi-square / Fisher's exact test and Mann-Whitney U tests were used for statistical analyses.

RESULTS

The patients with SD were diagnosed with cardiac disease (61%), renal disease (9%), and pediatric cancers (30%). The median dmft values of the SD group (3.00) were significantly lower than those of healthy children (5.00) (p = 0.02) and healthy children exhibited significantly more positive behavior (90.8%) than children with SD (73.4%) (p = 0.002). The number of patients needing GA/S for dental treatment did not differ significantly between the two groups (p = 0.185). There was no relationship between dental treatment need with GA/S and dental behavior scores of the patients (p = 0.05). A statistically significant relationship was found between the patients' dmft scores and the need for dental treatment using GA/S; and the cut-off value was found to be dmft > 4 for the overall comparisons.

CONCLUSION

The presence of chronic disease in children appeared to affect the cooperation negatively at the first dental visit compared to healthy controls, however, it did not affect the oral health negatively. Having a negative behavior score or SD did not necessitate the use of GA/S for dental treatment.

Oral findings in paediatric patients with severe heart, liver, and kidney failure prior to organ transplantation

PURPOSE

Organ transplantation is an effective treatment for children with severe heart, liver, and kidney diseases. These patient groups may have more oral and dental diseases than healthy controls. It is important to eliminate oral infection foci before transplantation and to maintain good oral health to avoid potential post-transplant complications. The aim of this study was to describe and compare oral health in Finnish paediatric heart, liver, and kidney transplant recipients prior to organ transplantation.

METHODS

Eighty-six children who received a heart (n = 21), liver (n = 19), or kidney (n = 46) transplant in Finland during the years 2014-2018 were included in this study. The inclusion criterion was a pre-transplantation oral examination. Oral hygiene, enamel anomalies, and the number of decayed, missing, and filled teeth (dmft/DMFT) were analyzed retrospectively from medical and dental records and compared between the three patient groups.

RESULTS

Children with liver (p = 0.043) or heart (p = 0.047) disease had higher combined primary and permanent dentition dmft/DMFT scores compared to children with kidney disease. A higher combined dmft/DMFT score was associated with poor oral hygiene (p = 0.005). No significant differences in oral hygiene between the patient groups were found. Furthermore, all patient groups had a high prevalence of developmental dental defects.

CONCLUSION

Children with liver or heart disease seem to have a higher combined dmft/DMFT score, indicating a higher prevalence of caries compared to children with kidney disease. Prevention of dental caries, along with promoting a good oral hygiene routine and regular check-ups, is suggested in these patient groups.

A Comparative Assessment of Dental Caries Experience in Relation to Nutritional Status among 6-12-year-old School-going Children and Those with Congenital Heart Disease in Bhubaneswar City

Aim

To assess the dental caries experience in relation to nutritional status among 6-12- year-old school-going children and those with congenital heart disease in Bhubaneswar city.

Materials and methods

A cross-sectional study was conducted among 6-12-year-old healthy school-going children and those with congenital heart disease for a period of 6 months (October 2019-March 2020) in Bhubaneswar, India. Type III clinical examination was carried out as per American Dental Association (ADA) specifications using plane mouth mirrors and community periodontal index (CPI) probes. Clinical oral examination and measurement of the weight and height of the child were performed by a single examiner. Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0.

Results

The overall mean decayed missing filled primary teeth surfaces (dmfs) in primary dentition was higher (5.93 ± 10.224) in subjects with congenital heart disease (CHD) (group I) than in healthy controls (3.41 ± 6.192). The overall mean decayed missing filled permanent teeth surfaces (DMFS) in permanent dentition was 0.33 ± 1.105 in subjects with CHD (group I) and 0.24 ± 0.714 in group II. In group I, the majority of them (58.9%) were underweight, followed by 41.1% who were a healthy weight. However, in group II, 47.9% of the study subjects were healthy weight, 26.1% were underweight, 14.4% were obese, and 11.7% were overweight.

Conclusion

This study concluded that children with CHD have a higher dental caries experience and poor nutritional status as compared to healthy school-going children.

How to cite this article

Hazarika SJ, Jnaneswar A, Jha K. A Comparative Assessment of Dental Caries Experience in Relation to Nutritional Status among 6-12-year-old School-going Children and Those with Congenital Heart Disease in Bhubaneswar City. Int J Clin Pediatr Dent 2024;17(1):1-6.

Comparative Clinical Study on Periodontal Health Status and Early Diagnosis of Periodontal Diseases Quantified through Clinical Periodontal Indices on a Group of Children and Adolescents with and without Cardiovascular Diseases

It is well known that bacterial plaque is the main etiological factor that causes the appearance of periodontal diseases and carious disease. Periodontal diseases can affect children and adolescents and are manifested in the form of gingivitis, but also the early form of chronic periodontitis as well as aggressive marginal periodontitis associated with local or general factors. Early periodontitis is frequently undiagnosed by clinicians due to a lack of knowledge of the specific symptoms. Certain systemic diseases, such as cardiovascular diseases, can create favorable conditions for the appearance and progression of severe manifestations of periodontal disease; also, recent research highlights that individuals with periodontal disease present an increased risk of developing cardiovascular diseases. Children with congenital or acquired cardiovascular diseases are at increased risk for complications resulting from the growth of microorganisms in the oral cavity, presenting a risk of infective endocarditis. The specific aim was to highlight the existing differences between the periodontal health of children with cardiovascular diseases and that of children without these diseases. The analyzed group included 124 patients, represented by children and adolescents, aged between 7 and 17 years, who were divided into four subgroups depending on the presence or absence of cardiovascular diseases and periodontal disease. A specialized clinical examination was performed for each patient, and periodontal clinical parameters were quantified (plaque index, gingival bleeding index, gingival index, community periodontal index of treatment needs) and associated with the diagnosis of general condition. Patients diagnosed with periodontal disease underwent specialized treatment and were called to a control visit 3 months after treatment. Statistical analysis showed significant differences between subgroups with much higher values of clinical parameters for patients with cardiovascular disease. Also, the response to the treatment was better in the case of patients in the control subgroup without cardiovascular diseases. The present study highlighted the interaction of three factors in the progression of periodontal diseases: subgingival microbiota, immune system response and environmental factors.

The impact of pediatric congenital heart disease on primary teeth structure: a histological study

Congenital heart disease (CHD) is an abnormality in the structure or function of the cardio-circulatory system present at birth and the ventricular septal defect (VSD) is the most common CHD in children. This study aimed to determine any differences in the histological structure of primary teeth between both healthy children and those children with ventricular septal defects in Erbil City. Methods enrolled children were divided into two groups. Group I (control) & group II (CHD) aged between 6-10 years old. A total of 44 children were collected, (22 children) in each group. Enamel, dentin, and odontoblast layers were examined histologically. Unpaired t-test used for statistical analysis. Results: The histopathological sections showed a significant difference in enamel, dentin, and odontoblast layer thickness (255.8 ± 41.68- 406.4 ±46.39), (1156 ± 116.0 - 1320 ± 117.4) and (29.74 ± 7.66 -41.38 ± 12.06) respectively, with p values (P < 0.0001) for enamel and dentin layer, and P < 0.0004  for odontoblast layer. A study of the images in the CHD group showed that the tooth tissue lost its integrity and cohesion in some places, and the thickness of the enamel and dentin layer in this group was significantly reduced compared to group I.  Tissue loss in enamel, pulp, and dentin cell were observed. Also, connective tissue layers in the pulp were disrupted. Conclusions: CHD can alter the natural structure formation of primary teeth. Histologically, enamel, dentin, and odontoblasts layer thickness reduction are found in primary teeth in children with ventricular septal defects.

The Bacterial Oral Microbiome in Children with Congenital Heart Disease: An Extensive Review

Children with congenital heart disease have poorer oral health compared with healthy children. Oral diseases, such as dental caries and gingivitis, are associated with the oral microbiome. The objective of this review was to find evidence of differences in the bacterial colonization of the oral cavity of children with congenital heart disease (CHD) versus healthy children. A literature review was conducted according to predetermined criteria, including the need for controlled clinical trials. Half of the 14 studies that met the inclusion criteria reported significant differences in bacterial colonization in children with congenital heart disease. A variety of influencing factors were discussed. There is some evidence for alterations in the oral microflora as a result of physiopathological and treatment-related factors in children with CHD, but additional research is required to validate these findings.

The Evaluation of Oral Health Condition and Oral and Dental Care in Children with Congenital Heart Disease

Objective: Congenital heart disease (CHD) plays a key role in oral and dental health regarding its own impacts on teeth (i.e., enamel hypoplasia), infective endocarditis and choice of dental treatment. The purpose of this study's comparing the oral and dental health status in children with or without CHD is to contribute to the literature by determining the effects of CHD on oral and dental health. Material and Methods: The present study was conducted using a descriptive and correlational design and consisted of 581 children aged between 6 months and 18 years who were healthy (n = 364) or experienced CHD (n = 217). CHD-impacted children were classified according to their shunt and stenosis and then their saturation values were noted. In the intraoral examination, caries data (dmft/DMFT, PUFA/pufa), oral hygiene (OHI-S) and enamel defect (DDE) indices were recorded. Statistical analyses were performed using SPSS 26.0 at a significance level of 0.05. Results: In our study, caries index scores of children with or without CHD in primary or permanent dentition were found to be similar. The mean OHI-S index (p < 0.001) and gingivitis findings (p = 0.047) of children with CHD had a higher prevalence than the healthy ones. The incidence of enamel defects was determined as 16.5% in CHD-affected children whereas an incidence rate of 4.7% was observed in healthy children. The mean saturation value of the participants with enamel defects (89 ± 8.9) was observed to be significantly lower (p = 0.03) than the patients with no enamel defects (95 ± 4.2). Conclusions: Whereas the caries index scores of CHD-affected children with a history of hypoxia in primary and permanent dentition were found to be similar to the healthy ones, children with CHD were observed to be more prone to enamel defects and periodontal diseases. Furthermore, considering the risk of infective endocarditis resulting from existing carious lesions and periodontal problems, it is highly important for pediatric cardiologists, pediatricians and pediatric dentists to collaborate in a multidisciplinary manner.

Oral health-related quality of life and oral manifestations of Syrian children with congenital heart disease: a case-control study

BACKGROUND

There was an immense need for studies evaluating the oral health status of Syrian children with congenital heart disease (CHD) and its impact on their quality of life. No contemporary data are available. The objective of this study was to investigate oral manifestations and oral health-related quality of life (OHRQoL) of children with CHD and compare them with healthy controls aged 4-12 years.

METHODS

A case-control study was undertaken. A total of 200 patients with CHD and 100 healthy children belonging to the same patient's family were included. Decayed, missed, and filled permanent teeth index (DMFT) and decayed, missed, and filled primary teeth index (dmft), Oral Hygiene Index (OHI), Papillary Marginal Gingivitis Index (PMGI), and dental abnormalities were recorded. The Arabic version of the Child Oral Health-Related Quality of Life Questionnaire (COHRQoL, 36-item) which was divided into 4 different domains (Oral Symptoms, Functional Limitations, Emotional Well-Being, Social Well-Being) were studied. Chi-square test and independent- t-test were used to perform statistical analysis.

RESULTS

CHD patients experienced more periodontitis, dental caries, poor oral health, and enamel defects. The dmft mean was significantly higher in CHD patients than in healthy children (5.245 vs. 2.660, P < 0.05). No significant difference was found between patients and controls in the DMFT Mean (P = 0.731). There was a significant difference between CHD patients and healthy children in the mean of the OHI (5.954 vs. 1.871, P < 0.05), and PMGI (1.689 vs. 1.170, P < 0.05). CHD patients have significantly higher enamel opacities (8% vs. 2%) and hypocalcification (10.5% vs. 2%) than controls. Also, the 4 COHRQoL domains, showed significant differences between CHD children and controls.

CONCLUSIONS

Evidence about the oral health and COHRQoL of children with CHD was provided. Further preventive measures are still required to improve the health and quality of life of this vulnerable group of children.

Oral health status and dental anomalies among children with congenital heart disease in contemporary times

AIMS

The aim of the study was to assess the oral health, hygiene status, and prevalence of dental anomalies in children suffering from congenital heart disease (CHD).

MATERIAL AND METHODS

The study was conducted on 300 children, aged 2-16 years, diagnosed with CHD.

RESULTS

Overall, the oral health status of the children with CHD was found to be poor in this study. The prevalence of caries was found to be 56.7%. It was significantly higher in children with acyanotic CHD compared to cyanotic CHD. Mean DMFT was 0.6 ± 1.6. Mean Debris index was 0.8 ± 0.9. Mean calculus index was 0.3 ± 0.6. The prevalence of dental anomalies was 9%. Most common anomaly was enamel opacities/hypoplasia (8.0%) followed by hypodonita (0.7%) and fusion (0.3%). The mean dmft score and Calculus Index were found to be significantly higher in cyanotic CHD group compared to acyanotic CHD group. Prevalence of caries, Debris Index, Calculus Index, and Oral Health Index were found to be increasing with increasing age (> 5 vs. < 5 years).

CONCLUSION

Overall, the oral health status of the children with CHD was found to be poor in this study.

Congenital Heart Diseases and Periodontal Diseases—Is There a Link?

An understanding in the field of periodontal medicine explains the fact that the oral cavity serves as a niche for numerous pathogenic microorganisms. When these microorganisms or their by-products disseminate to the various parts of the body, they are capable of triggering diseases characterized by an altered host immune-inflammatory response in the anatomically distinct organ. This mechanism is reported in the propagation of cardiovascular diseases with respect to periodontal medicine. Abundant amount of literature suggests an association between atherosclerotic cardiovascular disease and periodontal diseases. However, there is very less data available to highlight the association between periodontal disease and non-atherosclerotic cardiovascular disease, such as congenital anomalies of the heart. This review outlines the relationship between periodontal diseases and congenital heart diseases and also helps us understand whether the presence of periodontal disease can worsen the preexisting congenital cardiac disease.

Dental Treatment under General Anesthesia in Pre-School Children and Schoolchildren with Special Healthcare Needs: A Comparative Retrospective Study

The aim of this retrospective study was to evaluate the dental treatments received under general anesthesia (GA) in pre-school children and school children with special healthcare needs (n = 263) compared with healthy controls (n = 62). In order to analyze the impact of pre-existing cofactors on oral health, children were divided into the following groups: heart disease, cancer, syndromic disease, and other diseases as well as in- and outpatient healthy children. Caries experience (dmf-t/DMF-T) before GA (impulse 1), waiting time, and dental treatment under GA (impulse 2) were determined. Pre-school children showed a higher caries experience (mean ± standard deviation; 8.3 ± 4.8) compared to schoolchildren (6.9 ± 4.3). Predominantly, early childhood caries (ECC) of type 1 were detected. From all groups with special healthcare needs, children with cancer revealed the highest Significant Caries Index (17.0 ± 2.0), followed by other diseases (14.6 ± 2.6), syndromic disease (14.3 ± 1.8), and heart disease (13.8 ± 2.7). Overall, 2607 dental procedures were performed under GA with a mean of 8.0 ± 6.5 dental measures per child. Within the limitations of this study, the data exhibited independent of pre-existing cofactors and age high caries risk in all patient groups showing a high need for treatment.

Dental caries prevalence in children with congenital heart disease - a systematic review

AIM

Poor oral health is related with bacteraemia that may lead to endocarditis in children with congenital heart disease (CHD). The aim of this study was to conduct a systematic literature review to compare caries prevalence in children (<18 years of age) with CHD with healthy children.

MATERIAL AND METHODS

A literature search of studies from two online databases (Pubmed (MEDLINE) and Scopus) published from January 2000 to October 2019 using Medical subject heading terms Congenital Heart Disease, Congenital Heart Defect, and Caries was done, and manual search from the reference lists of selected publications. PICO (Patient/Population, Intervention, Comparison group, and Outcome) criteria was applied. Quality of the publications was assessed with the modified Newcastle-Ottawa scale.

RESULTS

The search resulted in 151 articles of which nine fulfilled the inclusion criteria. Caries prevalence was significantly higher in children with CHD compared to healthy children in three out of nine studies. Information on predisposing background factors was limited but difference in caries prevalence was not attributed to SES. The quality of the studies varied.

CONCLUSIONS

Although evidence is limited, the current literature indicates that children with CHD experience a higher caries prevalence compared to healthy children.

Evaluation of the Effectiveness of an Interdisciplinary Preventive Oral Hygiene Program for Children with Congenital Heart Disease

It is recognized that children with congenital heart disease (CHD) are predisposed to having poorer oral health. Therefore, the purpose of this study was to evaluate the effectiveness of an interdisciplinary preventive oral hygiene program (POHP) for children with CHD. The aim was the reduction of the incidence of dental caries, as well as improvement of oral hygiene. The total number of participants in this study was 107 children with CHD aged between two to six years. At baseline, these children were compared to a healthy control group (HCG) of 101 children of similar age from five preschools in Giessen, Germany. All examinations were carried out before the introduction of a standardized POHP. The Quigley/Hein Plaque- (QHI), Silness/Loe Gingival- (GI) and Gingival Hyperplasia Index (GHI) were determined. Starting with baseline, the described procedures were repeated in the CHD group during two follow-ups after three and six months. In the first examination, compared to controls, CHD children showed a significantly (p < 0.05) poorer oral hygiene (QHI: 2.6; GI: 0.3; GHI: 0.2). All oral hygiene parameters (QHI, GI, GHI) of the CHD group improved significantly over the whole period of the preventive program (p < 0.05). These results demonstrated an improvement in CHD children involved in a standardized POHP. The data with regard to the general health of these risk patients, including prevention of endocarditis, demonstrate the necessity of an interdisciplinary approach between pediatric cardiologists, pediatricians and dentists.

Dental caries and attendance to dental care in Finnish children with operated congenital heart disease. A practice based follow-up study

PURPOSE

Oral health of children with congenital heart disease (CHD) is of utmost importance. This study aimed to investigate the prevalence of dental caries and attendance to dental care in Finnish heart-operated CHD patients born in 1997-1999.

METHODS

The cohort of children born in 1997-1999 was selected using a national register on all heart-operated children in Finland. Gender, general health problems, diagnosis, type of the heart defect (shunting, stenotic and complex defects), and number of operations were available and included in the analyses. Dental records from primary health care were collected from municipalities with their permission. The data comprised of the number of dental examinations and data on caries status (dt, DT, dmft, DMFT) at the age of 7 (grade 1), 11 (grade 5) and 15 (grade 8) years and at the most recent examination. The control group consisted of dental data on patients born in 1997-1999 provided by the City of Oulu, Finland (n = 3356).

RESULTS

Oral patient records of 215/570 children were obtained. The difference between the defect types was statistically significant both for DT (p = 0.046) and DMFT (p = 0.009) at the age of 15 (grade 8). The prevalence of caries did not differ between the study population and the controls. High present and past caries experiences were not associated with higher number of visits to oral health care, especially to oral hygienist, or with oral health promotion. National obligations concerning dental visits were not implemented in all municipalities.

CONCLUSION

There seems to be a need for oral health promotion and preventive means implemented by oral hygienists among those with CHD.

Symptom-orientated oral hygiene for children after heart transplantation: Effectiveness of a standardized prophylactic program

Children with CHD, especially heart-transplanted patients, are predisposed to have caries lesions, gingivitis and other oral findings like gingival hyperplasia. The aim of the study was the implementation of a specific oral hygiene program in these patients and its effect on the improvement of oral health, especially gingival overgrowth. For this, we used a newly developed systematic GHI to evaluate and describe this gingival alteration. Thirty-three children, aged 6 to 15 years with cardiac transplants (9 girls, 24 boys), were examined and introduced into a specific oral hygiene program. Each child showed evidence of gingival hyperplasia. They were randomly divided into three groups with the following oral care measurements: Group ZZ tooth brushing, Group ZZS tooth brushing and mouth rinsing, Group ZZSS tooth brushing, mouth rinsing and the use of an additional single and sulcus toothbrush. A significant decline of all oral health parameters could be proven in all groups. Gingival hyperplasia (GHI) improved as well as plaque accumulation (QHI). The children who used in addition to toothbrushing rinsing solutions and/or additional miniature toothbrushes showed better parameters of the gingival hygiene indexes from the baseline examination until the end of the study. The results show that any infant with cardiac transplant has to be introduced into an individualized oral hygiene program underlining the need of comprehensive dental care in cooperation with pediatric cardiology.

Significance of oral health in adult patients with congenital heart disease

Due to improved diagnosis and treatment life expectancy of patients with congenital heart disease is steadily increasing resulting in a growing portion of adult patients. When entering, adulthood patients commonly show a shift in their specific needs for medical care. Since the treatment is mostly not curative many patients have life-long cardiovascular anomalies, among others, entailing high risk for the development of infective endocarditis. Several oral diseases, i.e., caries, apical periodontitis and periodontitis show a very high overall prevalence. These entities are primarily initiated by bacterial infections. Hence, they cause an inherent risk for bacteremia and subsequently for infective endocarditis in patients with congenital heart disease during professional dental care and various daily activities. Conversely congenital heart disease seems to be inevitably associated with considerable impairment of oral health resulting in a tight interrelation between both entities. Different preventive strategies are available to address the elevated risk for infective endocarditis due to oral diseases in patients with congenital heart disease during professional dental care and routine daily activities. This review delineates the current evidence regarding the issue of oral health in adult patients with congenital heart disease.

Oral Health in Adults with Congenital Heart Disease

Oral bacteria and odontogenic oral infections are responsible for a high portion of cases with infective endocarditis. Hence, oral health in patients with congenital heart disease (CHD) gains particular importance. This case-control study compared the oral health status in 112 adults with CHD and 168 healthy control subjects. In addition, the patient group was stratified according to the complexity of the heart defect and the recommendation for antibiotic prophylaxis during invasive dental procedures. Considering caries experience, a significantly lower mean DMFT (decayed missing filled teeth) score (7.91 ± 6.63 vs. 13.6 ± 8.15; p < 0.0001) was found in patients with CHD compared to healthy controls. Healthy controls had a higher average number of decayed teeth (0.33 ± 0.76 vs. 1.76 ± 2.61; p < 0.0001). In female subjects a significant lower relative amount of teeth with apical periodontitis was found among CHD patients (3.4% ± 0.9%) as compared to healthy controls (5.6% ± 1.9%) (p = 0.053). Regarding periodontal health, patients with CHD had lower rate of sulcus bleeding (0.32 ± 0.65 vs. 0.71 ± 0.60; p < 0.0001) and less alveolar bone loss than heart healthy individuals (% root length: multi rooted teeth: 8.97 ± 10.64 vs. 23.22 ± 20.70; p < 0.0001; single rooted teeth: 5.59 ± 6.25 vs. 17.30 ± 17.17; p = 0.003). On the contrary, CHD patients presented with higher amount of plaque in comparison to healthy controls (Quigley & Hein index: 2.22 ± 0.67 vs. 1.25 ± 0.72; p < 0.0001). Based on the current results, it can be concluded that adults with CHD have better oral health than heart healthy individuals.

Dental treatment and recommended management in patients at risk of infective endocarditis

Infective endocarditis (IF) is found in high-risk groups with congenital or acquired cardiac defects. It is caused by episodes of short bacteraemia. The magnitude and duration of bacteraemia caused by dental procedures are decreased by using antibiotic prophylaxis (AP). The aim of this study is to describe and discuss all clinical implications related to IF and dental procedures, and AP before invasive dental procedures. Maintenance of optimal oral health and hygiene is more important than AP in decreasing the risk of IF. Routine daily activities are associated with a similar risk of bacteraemia. It is estimated that antibiotics use in dentistry may represent up to 10% of total antibiotics use, and the risk of developing bacterial resistance should be taken into account.