Lupine Publishers | Maryland Bridge : A Treatment Option in Children

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

The most common traumatic injury encountered in a pediatric dental set up is avulsion. Loss of permanent anterior teeth at a young age can have an impact on the psychological development of the child. Reimplantation if not possible, the anterior tooth can be restored with either removable or fixed prosthesis depending on the completion of the growth. To overcome the limitations of removable prosthesis, temporary fixed prosthesis can be an option in restoring the esthetics and functions when growth is not completed. Maryland bridge is an ideal option as a fixed temporary prosthesis in such patients.

Keywords: Avulsion; maryland bridge; re-implantation

Introduction

Over the last few decades dentistry has taken its turn towards more conservative and preventive treatment modalities. This has been possible not only because of the improved and advanced materials and techniques but also because of the understanding to preserve the natural tooth as far as possible. Reasons for tooth loss could be congenital absence, caries or trauma. Of these, traumatic injuries resulting in avulsion of the tooth is one of the common causes for tooth loss in the anterior region of the oral cavity. Trauma to the anterior teeth is common in childhood, one study reported that out of 2,100 children (aged 8-14 years) surveyed for teeth fractured due to trauma, 60.74% were aged between 11 and 14 with 13.8% cases involved incisors [1]. This case report presents a case of replacement of missing anterior teeth because of avulsion with direct fiber reinforced resin composite.

Case Report

A 13-year-old boy reported to the Department of Pedodontics and Preventive dentistry with a chief complaint of avulsed tooth in the maxillary front region of the jaw for three weeks. Patient had a fall while riding bicycle. The patient was healthy without any significant medical and dental history. On extra-oral examination no abnormalities were found. On intra-oral examination soft tissues were normal avulsed socket was all healed. Patient had no bruises or scars on his body after the fall. Maxillary right lateral incisor had avulsed was seen with respect to maxillary right lateral incisor (Figures 1&2). Patient had reported to our department after three weeks with his natural avulsed tooth . The avulsed tooth was not stored in any media by the patient and was not in a good condition to be used as pontic as it had become dehydrated and had lost its color from the normal one. As the patient growth was not completed implant was not an option. Patient was very concerned about his esthetics and wanted immediate replacement. An option of conservative and conventional fiber reinforced composite resin bonded pontic was selected for the prosthetic rehabilitation. A composite buildup of maxillary right lateral incisor was done on a diagnostic cast. On the diagnostic cast the length of the FRC fiber (everstick, GC company) was pre-measured from the half the maxillary right canine to the half of the maxillary right central incisor. The fiber was pre-measured in such a way that it followed the contour of the ridge.

Figure 1: Intraoral view showing missing maxillary right lateral incisor.

Figure 2: Radiographic view.

Figure 3 Ever stick fiber placed on palatal Grooves.

Figure 4: Composite build-up pontic.

The palatal surface of the maxillary right canine and the right central incisor was roughened for better adaptability of the fiber for good retention. The surfaces were roughened using coarse flame shaped bur. Then the roughened surfaces of the abutment teeth was etched and bonded and then the fiber was placed starting from the canine to the central incisor and it was well adapted on the surface with a plastic carrying instrument. Then the fiber was bonded using composite in such a way that the fiber was at the center of the bonded tooth and was not in occlusion (Figure 3). Then a groove was made palatally on the composite build up pontic so that the fiber inserts well in the pontic for better retention (Figure 4). The pontic was bonded with composite keeping the arch form and function in harmony (Figures 5&6). The roughened surfaces were smoothened and polished with finishing and polishing kit (Enhance Composite Finishing and Polishing System Dentsply Caulk Dentsply International Inc, Milford, DE). The patient was followed for 6 months and had no complaints with the prosthesis.

Figure 5: Fiber reinforced bridge replacing missing tooth.

Figure 6: Occlusal view with replaced missing tooth.

Discussion

The patients with lost anterior teeth require immediate attention for the restoration of the aesthetics and function. The various treatment options available for restoring missing anterior tooth after avulsion are reimplantation, removable partial denture or fixed prosthesis depending on the case. In the present case the patient reported with the avulsed tooth after 3 weeks so reimplantation of the tooth was not a treatment option. Removable partial dentures are the most easily fabricated and cheapest options available, but they are often unacceptable to the patient because they are bulky, uncomfortable and not very esthetically pleasing [2]. Replacement of missing teeth with conventional fixed partial denture can involve tooth preparation of abutment teeth which can cause hypersensitivity, pulpal injury [3]. Fiber reinforced bridge was opted in this case, in order to provide a single visit, cost effective and a minimally invasive fixed solution to the patient. Clinical studies have shown a substantial clinical performance of the FRC FPDs, with an overall survival rate of 75% after about 5 years, which are higher than that of the FPDs with metal frameworks [4]. Hence high pulp horns of abutment teeth, expected transition in the position of the gingiva and age of the patient were factors that precluded the use of conventional fixed prostheses in this case. The resin material used in this study was GC Ever stick as a bridge for replacement of missing tooth. Accurate bonding between the fibers and composite is the key factor for a successful treatment. The resin fiber used has a unique, interpenetrating polymer network structure (IPN) which leads to superior bonding enabling reliable surface retained applications and perfect handling properties. The use of FRC bridges also allows utilization of a patient’s natural crown as a pontic if the tooth or tooth crown is still intact [5]. In our case the lost tooth was fractured and was not in good condition to be used as a pontic, so the composite build up tooth was used (Figure 4). A study was done involving 358 patients which concluded that the patient’s acceptance was better with resin bonded fixed partial dentures [6]. Maryland bridge is a minimal invasive procedure with less harm to the abutment tooth, minimum chair side time and less cost. It is well accepted by young patients and can be used as a treatment option for avulsion cases.

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Lupine Publishers | Assessment of Dental Neglect and It’s Relation to Oral Health Among School Children Aged 4-12 Years in Sri Ganganagar City, Rajasthan, India

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Background: Dental neglect indicates that parents or guardians fail to give the necessary oral health requirements such that the child can take pleasure in function and free from disease, where reasonable means are accessible to parents or caretaker.

Aim: The aim of the study was to evaluate the dental negligence of parents towards their children aged 4-12 years in Sri Ganganagar city, Rajasthan and to correlate the oral health status of the children.

Materials and Methods: A cross‑sectional study was done involving 1000 school going children and their parents. Questionnaire were distributed among the parents of the children which includes the details of parents and their children . WHO form was used to assess the oral health status of the children i.e. the dental caries and bleeding on probing as per the World Health Organization criteria,2013 index. Statistical analysis was done by using SPSS software version 20.0.

Results: A significant higher dental negligence score was found among those parents who resided in the suburban area and whose educational qualification was higher secondary only and those who had visited the dentist only after the development of symptoms in their children.

Conclusion: Among the parents whose educational qualification was higher secondary only, those who resided in the suburban area and those who went to see dentist only after the development of symptoms in their children have shown poor health status.

Keywords: Dental neglect; dental caries; oral hygiene; parents

Introduction

Dental neglect indicates that how known knowledge of oral health care are not fulfilled which fails to do the proper maintenance of oral cavity. For proper oral health care people need to be aware of the dental problem consequences. In spite of giving so much dental professionals and audio-visual dental care measures, only a small number of people take proper dental home care and they do not go for periodic dental checkup. Oral health is considered as the central importance for our general health and well-being. A healthy oral cavity allows an individual to communicate, have food and participate in social activities without having any disease, discomfort or difficulty. Having oral disease can be expensive in terms of money and also life style can be changed [1]. The World Health Organization has stated that neglect should be differentiated from conditions like poverty, where it shows dental neglect is present only where there are available resources. It was found that there is a great deal of severity of dental neglect worldwide [2].

Materials and Methods

Ethical approval for the study were taken from the concerned authority of the institution. This ensured that participants involved in the study were randomly selected from the schools of Sri Ganganagar city. This study was conducted from January 2019 to August 2019. The age of the children were 4 to 12 years, and the questionnaire were given to the parents of the children to be answered. An informed consent was obtained from the parents earlier. The parents were asked to answer the questionnaire which had details of both parents and children. Consent form from parents were taken for the survey to be done. Oral examination of children was conducted by using disposable mouth mirror, straight probe and CPTIN probe in a natural day light. Oral status was recorded according to the WHO form, 2013. The collected data were tabulated and subjected to statistical analysis using SPSS software version 20.0, (SPSS Inc., Chicago Ill., USA) and levels of statistical significance were set at P < 0.05.

Results

Graphs 1&2: Shows the address and parental education level.

A total of 1000 pair of parents and children participated in the study, of which female and male parents were of 631 and 369, respectively. Table 1 illustrate the comparison of key background variables and dental service used in previous two years and Table 2 shows the p value for the oral status with respect to key background variables (Graphs 1&2). It is showed that with respect to dental neglect scores, a significant higher dental neglect score was reported among the people who resided in the suburban location, parents whose educational qualification was higher secondary only, parents whose visit to the dentist were only after the development of symptom, parents those who used only school dental services and those who used dental service only once in previous two years.

Table 1: Comparison of key background variables with respect to given demographic status.

Table 2: .

*P value is statistically significant, **P value is statistically highly significant.

Discussion

Oral health occupies a very significant role for the wellbeing of individuals, and parents’ behavior and way of thinking influence the oral health of their children [3]. Prevention is always better option than cure. People should be very thoughtful and particular to maintain oral health for the prevention of oral disease. Dental professionals and audio-visual media provide the essential dental care measures [4]. But the fact is that only few people take adequate regular home dental care and do not go for periodic/yearly dental check to the dentist to keep their oral cavity healthy [5]. It has been seen that dental neglect is mostly related to the illiteracy amongst low socio-economic class and the prevalence of oral diseases are highest amongst them [6]. Child neglect is a very important subject in terms of prevalence and severity–it is the most common cause for a child to be made subject to a child protection plan in the UK - and there is indubitable evidence and facts that it is harmful and damaging to children [7-10]. There is very scarce literature regarding the estimate of child dental neglect worldwide [11]. Hence, in this study, in addition to recording the caries status, the gingival status i.e. bleeding on probing was also evaluated which interprets the degree of failure to seek dental treatment. Out of 1000 children maximum number of the participants were 7 years with 596 male and 404 females. Majority of the children were in 1st standard and from private school. The caretakers who responded to the questionnaire were mostly mothers of the children. Hence, it helped us to know the complete home and professional dental care the child receives as the child is mostly with the mother. The results of the present study showed that dental neglect was found more in parents who have done only higher secondary education which showed lesser levels of positive dental attitudes which is in contrary to the result of Gurunathan D et al. [12] where it was stated that parents who have done secondary education showed lesser levels of positive dental attitudes which is similar to studies done by Freeman et al. and Williams et al. [13,14]. In the present study, a significant difference was observed in the dental neglect scores among parents residing in the suburban areas in comparison with parents of urban areas. This is essentially due to not much awareness of oral health, availability, and usage of dental services [15]. The dental neglect among children is higher among parents’ whose last dental visit was once or twice in previous 2 years, those who used only school dental services and were symptom driven which is similar to the findings in South Australia and Chennai [16]. The dental neglect is reflected in the poor oral health of these children with significantly higher caries prevalence and untreated carious lesions. This suggests that the knowledge of parents regarding oral health and utility of dental services is limited as the frequency of dental visits suggests the oral health awareness among parents [17].

Conclusion

Inadequate dental care by parents can be observed as dental neglect in children and therefore is a sign of child neglect. Health care workers involved in the care of children are thus in a unique and a very important position to understand early symptoms of child abuse and neglect. We believe and accept that the occurrence of dental caries is an important sign to this diagnosis. From this study it is concluded that, the dental neglect among school going children aged 4-12 years regarding oral hygiene is still far from satisfactory in certain respects in our population, but it is also seen that oral hygiene status can be improved after sessions of oral health education to the children and most importantly the parents.

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Lupine Publishers | Newer Insights in Early Childhood Dental Caries

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Early dental caries is a common devastating disease of early childhood but can be prevented easily by simple methods. It is more common in developing countries and poor socioeconomic status but can be found in all settings. Different bacteria interacting with host salivary molecules, play a role in the development and aggravation of these lesions. Newer techniques for diagnosis, bacterial isolation, as well as treatment are coming up. Clinicians and researchers should be abreast with new developments to ensure proper diagnosis and treatment of these cases.

Keywords: Caries; sugar; cariogenic; streptococcus mutans

Introduction

 Dental caries is a clinical challenge, especially in young children [1]. In fact, it is the commonest chronic infectious disease of childhood, and caused due to interaction or oral bacteria like Streptococcus mutans with sugary foods and saliva [1].  Of all dental caries, Early Childhood caries or ECC can be defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing teeth (due to caries), or filled tooth surfaces in any primary tooth in a child 72 of months age or younger [1]. ECC is also called baby bottle-fed tooth decay, early childhood dental decay, comforter caries, nursing caries, maxillary anterior caries and rampant caries [1]. In children younger than 3 years of age, in addition, any sign of smooth-surface caries indicates severe early childhood caries (S-ECC) [1]. Early dental caries is frequently encountered in children of less than 71 months of age. Poor oral hygiene or insufficient dental plaque removal can lead to the rapid progression of ECC [2]. As regards bacterial etiology of dental caries, some strains, such as Streptococcus sanguinis, are reportedly associated with healthy teeth, while others, such as S. mutans, other oral Streptococcus spp., Veillonella spp., Actinomyces spp., Bifidobacterium spp., and Lactobacillus fermentum, were associated with caries [3]. There is also enough evidence that Gram positive bacteria like Actinomyces gerencseriae and other Actinomyces spp. play an important role in caries initiation [3]. In a study by Munson et al, in addition to S. Mutans and Lactobacillus spp., Rothia denticariosa and Propionibacterium acnes have also been found in caries lesions [4].

Epidemiology

ECC affects infants and preschool children worldwide, and its prevalence, though variable, can be up to 85% in disadvantaged groups [5]. Prevalence of ECC also varies widely, depending several variables like race, culture, and ethnicity, socioeconomic status, lifestyle, diet and oral hygiene practices and also according to the regional factors from country to country and from area to area [6]. A review of the literature suggests that in most developed countries the prevalence rate of ECC is between 1 and 12% [6]. In less developed countries and among the disadvantaged or poorer groups in developed countries, the prevalence of ECC has been shown to be as high as 70% [6]. However, it is not restricted to children with low socioeconomic status [2]. Recent data, for example, from Australia show a prevalence of ECC of more than 50% in 6-year-old children with caries on deciduous teeth [7]. Milsom et al. found that children with an already existing caries lesion have a 5–6 times higher incidence of developing new caries lesions compared to previously caries-free children [8]. Sleeping problems and insufficient sleep has also been identified as risk factor for ECC, because sleeping problems lead to more frequent use of night-time bottle use containing sugar-sweetened beverages [9]. There is a relationship with gender, since according to studies, the highest prevalence of ECC is found in the 3- 4-year-old age group; also, boys are significantly more affected than girls, aged between 8 months and 7 years [10].

Risk factors

Many risk factors have been identified like

a) Most of the studies have shown significant correlation between ECC and bottle-feeding and sleeping of the baby with a bottle [1].
b) There is substantial evidence that prolonged and nocturnal breastfeeding is associated with an increased risk of ECC, particularly after the age of 12 months [1].
These aggravate caries due to less saliva production at night and less bacterial clearing.
c) Fermentable carbohydrates are a major factor in the development of dental caries. The small size of these sugar molecules allows salivary amylase enzyme to split the molecules into components that can then be easily metabolized by the bacteria in the plaque [11]. This process leads to bacteria producing acidic end products with subsequent demineralization of teeth.
d) Enamel hypoplasia due to premature birth, low birth weight or malnutrition is also a very important risk factor for caries development [12].

Clinical features

In the initial phases, ECC appears as a dull, white demineralized enamel that quickly progresses to obvious decay along the gingival margin [13]. Primary maxillary incisors are usually afflicted earlier than the four maxillary anterior teeth which are often involved simultaneously [1]. Carious lesions can be found on either the labial or lingual surfaces of the teeth and, sometimes on both [1]. The decayed hard tissue is clinically apparent as a yellow or brown cavitated area [1].

Diagnosis

Diagnosis is clinical. Culture of the bacteria can be carried out in Mitis-Salivations agar, from where colonies can further be identified [14]. However, S. mutans may be slightly inhibited in this medium and S. mitis may need longer incubation [14].

Etiology and Pathogenesis

It has been depicted by Corby et al that some bacteria are associated with healthy or caries –free teeth, like Streptococcus parasanguinis, Abiotrophia defectiva, Streptococcus mitis, Streptococcus oralis, and S. sanguinis [15]. The same group also showed that Actinomyces species, S. mutans, and Lactobacillus spp. were consistently associated with disease [15]. S. mutans and S. sobrinus have been recognized over the years as the main culprits behind development of Early childhood Dental caries [16]. They damage the dental enamel in presence of fermentable carbohydrates like Glucose, sucrose and fructose. In fact, S. mutant is present in about 30% of the plaques in carious teeth compared to 0.1% in healthy teeth [17]. Nowadays, it is well studied that not only bacteria, but also fungi, such as Candida albicans and the interactions between several different microbes, can enhance the progression of caries [18] . Bacteria and other microbes degrade sugars and lead to acid production which causes demineralisation of teeth and caries development [1]. Enamel of deciduous teeth is more vulnerable to acid-mediated damage than permanent teeth because it is thinner and built quickly in about 24 months by ameloblasts than that of permanent teeth which takes about 16 years to be built [19].

Implications

If left untreated, ECC, also called rampant caries, can lead to rapid and complete destruction of the crown [5]. Hence there is need of rapid and accurate diagnosis of the condition and adoption of suitable preventive measures.

Newer developments

New research has unearthed new mechanisms of pathogenesis in ECC. Bacterial biofilms are rapidly produced and are made of exopolymer matrix or EPS. This EPS is formed more on exposure to sucrose and fructose, and lead to further adhesion and colonization by cariogenic bacteria on surface of damaged teeth. This increased formation of biofilm biomass or “visible plaque”, often found on the smooth surfaces of the children at risk of ECC shows the importance of EPS in the pathological process [20]. Research has also demonstrated a few biomarkers or host salivary molecules that affect ECC development. For example, host CSP-1 helps in adhesion of cariogenic bacteria to the enamel [20]. There are 2 types of Proline-rich glycoproteins in human saliva: acidic PRP and basic PRP. Basic PRP helps in ammonia production and neutralise sugar acids, whereas acidic PRPs bind strongly to teeth and enhance adhesion of the cariogenic bacteria [20]. These molecules can be biomarkers to help in assessing prognosis of ECC.

Newer bacterial and other agents

Atopobium vaginale has been found significantly in ECC in those cases that also grow Streptococcus mutans [3]. Bifidobacterium species have been associated with deep caries lesions [21]. In case of severe ECC, Porphyromonas catoniae has been found very commonly in the plaques [22]. Novel techniques like The Human Oral Microbe Identification Microarray (HOMIM) can be used for this type of assessment [22]

Newer options for treatment

Usually Children at low risk generally do not need any restorative therapy [1]. Children at moderate risk may require restoration of the progressing and cavitated lesions, while white spot and enamel proximal lesions should be treated by preventive techniques and then monitored for progression [1]. Children at high risk, however, may need earlier restorative interventions of enamel proximal lesions, and intervention of the progressing and cavitary lesions to minimize continual caries development [1]. Sometimes stainless-steel crown following pulpotomy and pulpectomy may be needed in cases of severe ECC [1].

Prevention

Prevention of ECC should focus on educating the parents about no nocturnal feeding and dietary modification [5]. Parents also should be advocated to maintain optimal dental health during pre- and postnatal periods [5]. Child health professionals, like physicians, assistants of physician, nursing practitioners, and nurses can play a very significant role in reducing the burden of this disease through monitoring, prompt diagnosis and health promotion activities [1]. Prevention of the progress of ECC can be carried out with the help of restorations, diet counselling, educating parents regarding decay-promoting feeding habits, maintenance of good oral hygiene, and the use of preventive agents like topical fluorides [5].

Discussion

ECC is a very common chronic disease of childhood and easily preventable by simple measures [5]. The associated pain from dental caries has got a negative impact on the child’s emotional status, sleep patterns, and ability to learn or perform usual daily activities. A wide range of risk factors are linked with ECC in children from underprivileged and low socioeconomic status [5]. Oral health has been recognized as an essential prerequisite for general health and quality of life. Therefore, both oral disease prevention and oral health promotion should be included as integral components of chronic disease prevention and general health promotion programmes [5].

Conclusion

Early childhood caries should be diagnosed and treated early. New research is showing new avenues of diagnosis and aetiopathogenesis study.

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Lupine Publishers | Cardiovascular Diseases in Children –Oral Findings and Dental Treatment Approaches

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Oral and dental health is of vital importance in children with cardiovascular system disease. Congenital and acquired heart diseases make oral treatment complicate in children and increase the risk of infective endocarditis [1]. The dentists main aim in children with heart disease should be to prevent infective endocarditis, to maintain periodontal health and to ensure a well oral hygiene. In these children, medical history should be taken in detail before dental treatment. Consult with the pediatrician and inform about the condition of the disease and the drugs used recently. Consideration should be given, and antibiotic prophylaxis should be evaluated consultation to in the treatment planning of children with heart disease. In these children, dental treatments should be performed quickly and effectively, and family awareness should be given importance [1-3]. In this review, common oral findings related to cardiovascular system diseases will be discussed and the precautions and treatment approaches of dentist will be mentioned [4].

Keywords: Endocarditis, heart diseases, intraoral findings, pediatric dentistry

Review

Almost all of the heart diseases seen in children are congenital. The most common structural congenital heart diseases are; ventricular septal defect, patent ductus arteriosus, atrial septal defect, fallot tetralogy, pulmonary stenosis, aortic coarctation, aortic stenosis and transposition of the great arteries. Large defects are surgically closed in the first years of life, and some defects may require complex surgical treatment and eventually transplantation. Acquired heart diseases such as myocarditis and infected endocarditis are the cause of disability and death in children [5]. Oral and dental health may be insufficient in children with congenital heart disease. The reasons for this; chronic vomiting in children up to one-year, dry mouth due to drugs used, neglect of oral care due to cardiac problems as the primary priorities of families [1]. Poor oral hygiene in children with heart disease may pose a risk for bacteremia. Infective endocarditis can result with severe valvular dysfunction, dehiscence, congestive heart disease and various embolisms leading to death. In the long term, it may cause cardiac valve damage and prosthetic regeneration of the heart valve [1,6-8].

Oral findings

Oral findings in children with cardiovascular disease include cyanotic gingivitis, stomatitis, glossitis, mucositis, cleft lip and palate, clefts in the tongue, the fungiform and filiform papilla of the tongue becoming dark red [5,9]. In addition, enamel hypoplasia, high incidence of caries, delays in teeth exfoliation, periodontal diseases and intrinsic discolorations are observed [5,9,10]. In particular, discolorations in permanent teeth occur due to the ingestion of blood and blood products by drugs, increased caries activity and poor oral hygiene [5]. Poor oral hygiene, use of drugs, inadequate food and mineral consumption are effective risk factors for the onset of periodontal disease in children with congenital cardiovascular disease [11,12]. Pourmoghaddas et al. [12] reported that children with congenital heart disease had significantly higher periodontitis than healthy children and that periodontal disease caused endocarditis risk. Al Alousi et al. [13] reported that the rate of development of enamel defects was high in patients with ventricular septal defect and was observed due to malnutrition. The researchers stated that nutrient elements may affect the epithelial cell function and mineralization process and prepare the ground for defect formation in enamel hypoplasia [13]. In Fallot Tetralogy, wrinkled tongue is observed as an oral finding [1].

Infective endocarditis

Infective endocarditis is a rare disease that results in high morbidity and mortality, with an annual incidence of 0.05- 0.12/1000 in children [3,14,15]. Turbulent blood flow observed in heart diseases leads to endothelial injury, resulting in storage of platelets and fibrin on the endothelial surface [15]. As a result, non-bacterial thrombotic endocarditis occurs and bacteremia results in the adhesion of bacteria to this injured endocardium and proliferation in vegetation leading to infective endocarditis. Therefore, some heart diseases pave the way for the development of infective endocarditis [14,15]. Invasive dental procedures, gastrointestinal and genitourinary systems related operations may cause bacteremia and infective endocarditis [15].

Bacteremia in dental procedures

In children, oral flora changes and streptococci (alpha hemolytic streptococci), actinomyces and privately species increase after infancy and begins to resemble adult flora. Healthy children have streptococci, staphylococci, neissera and haemophilus species, while older children have bacteria such as capnocytophaga and aggregatibacter actinomycetemcomitans, which cause periodontal disease [15]. The host’s response to dental plaque due to poor oral hygiene is gingivitis. When this inflammation develops, bacterial colonies may become involved in the gum capillary circulation due to thinning and ulceration. Therefore, there is a risk of bacteremia even in minimal procedures such as daily tooth brushing The frequency of bacteremia after toothbrushing and flossing has been reported to be 20-68%, 20-40% after tooth cleaning with toothpicks, 7-50% after mouth rinsing, and 7-51% after chewing food [3]. In addition, 10-100% after tooth extraction, 36-88% after periodontal surgery, 8-80% after removal of dental plaque, 9-32% after plastic matrix placement, 20% after endodontic procedures have been reported to develop bacteremia [3]. Good oral hygiene and prevention from diseases (such as gingivitis, tooth decay) are important to minimize the risk of bacteremia [15]. The use of amoxicillin in the selection of antibiotics in dental procedures has been shown to have a statistically significant effect on reducing the incidence and duration of bacteremia.

While previous American Heart Association (AHA) guidelines recommend antibiotic prophylaxis for all dental interventions that may cause bleeding, this recommendation has been altered since there is no evidence that this is a predictive symptom of bacteremia when bleeding occurs during dental procedures [3]. In the latest guidelines published by AHA, it was decided to administer prophylactic antibiotics only to the highest-risk group before invasive dental procedures [3] (Table 1). Prophylactic antibiotic administration is recommended only if high-risk patients are scheduled for an operation to the gingival tissue or the periapical region of the tooth, or if there is a risk of mucosal perforation. Routine injections of anesthetic agents, x-rays, removable dental prostheses, orthoses, orthodontic material placement, prosthesis matching, primary tooth extraction, antibiotic prophylaxis are not recommended in uninfected tissue [3]. Antibiotic prophylaxis should be given 30-60 minutes before the procedure. However, it can be given within 2 hours after the procedure if it is not given before the procedure [3]. In patients using oral anticoagulants, intramuscular injection should be avoided, and oral antibiotics should be preferred. Clindamycin, clarithromycin, azithromycin should be given to patients who routinely use antibiotics as they may be resistant to penicillin and ampicillin [3]. These patients should receive dental treatment 10 days after antibiotic treatment to normalize oral flora. In patients receiving intravenous antibiotic therapy, the antibiotic dose should be adjusted 30-60 minutes before dental intervention [3,16] (Tables 1&2).

Table 1: High-risk patients in whom infective endocarditis prophylaxis is recommended [16].

Table 2: Antibiotic prophylaxis recommended before dental procedures [16].

Dentist approach

Patients with cardiovascular disease should be consulted with their doctors. Deciding on premedication, preoperative antibiotic requirements, anesthetic selection and surgical procedures should be decided in accordance with the recommendations of the physician of patient. In children diagnosed with cardiovascular disease, a preventive program including nutritional advice, fluoride therapy, fissure sealants and oral hygiene should be applied [1]. Arrhythmia due to endogenous catecholamines triggered by stress, fear and pain may develop during dental procedures, and patients who are prone to arrhythmia should be closely monitored [3]. Antibiotic prophylaxis should be performed in high-risk patients if a procedure is planned for the gingival tissue or the periapical region of the tooth, or if there is a risk of mucosal perforation [3]. Dental procedures in high and medium risk groups should not exceed the treatment of deep dentine caries. Direct pulp capping, pulpotomy and root canal treatments are not indicated because they increase the risk of bacterial endocarditis. In very deep decayed teeth, the treatment option should be extraction [1].

Conclusion

In children with cardiovascular disease, the risk of infectious endocarditis and bacteremia due to the risk of fatal outcome of the heart valve is very important in terms of oral and dental health in these patients. It is very important for dentists to consult with their physician before dental procedures in children with heart disease, and to take prophylaxis needs and stress tolerances of their patients by writing. These children and their families should be adequately informed about oral hygiene. In this way, the risk of bacteremia, even in oral cleaning procedures such as chewing and brushing, can prevent infective endocarditis [1].

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