PAEDIATRIC DENTISTRY - 3rd Ed. (2005)

(John Hannent) #1

Rheumatic fever follows a group A streptococcal infection of the upper respiratory
tract, especially in developing countries, and may occur at all ages but usually
between 5 and 15 years. Environmental factors, such as overcrowding, promote the
transmission of streptococcal infections and the incidence of rheumatic fever is higher
among lower socio-economic groups. The clinical onset is usually acute and occurs 2-
3 weeks after a sore throat. Joint pains are common and of a characteristic migratory
polyarthralgia or polyarthritis. Carditis is the most serious manifestation, occurring in
40-50% of initial attacks, especially in young children. Fever is usually present, but in
an insidious onset of the condition it may be low grade. Most of the carditis resolves
except the lesions on the cusps of the heart valves which become fibrosed and
stenotic. Rheumatic heart disease is the most important manifestation of rheumatic
fever and may affect mitral, aortic, tricuspid, and pulmonary valves.


Diseases of the myocardium and pericardium


Major diseases involving the myocardium and pericardium include bacterial
infections such as: diphtheria and typhoid; tuberculous, fungal, and parasitic
infections; rheumatoid arthritis; systemic lupus erythematosus; uraemia; thalassaemia;
hyperthyroidism; neuromuscular diseases, such as, muscular dystrophy; and glycogen
storage diseases. They are relatively rare in children in developed countries.


Other cardiovascular problems


There are several other important conditions that are common in adults but not in
children. These include coronary artery disease (ischaemic heart disease), cardiac
arrhythmias, and hypertension. In children, secondary hypertension is more common
than essential hypertension and is associated with renal abnormalities in 75-80% of
those affected.


16.2.3 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 commenced to include dietary
counselling, fluoride therapy, fissure sealants, and oral hygiene instruction. Regular
monitoring, both clinically and radiographically, with reinforcement of the preventive
advice is essential. Active dental disease should be treated before cardiac surgery is
undertaken.


Treatment planning


If the child and parent(s) are seen in infancy and effective preventive dental
procedures are instituted, then, theoretically, operative dentistry should be
unnecessary. In practice, the situation may be very different. If invasive operative
procedures are required then antibiotic prophylaxis will be necessary, which
influences treatment planning. Ideally, treatment in children should be carried out
during short appointments so that co-operation is maximized. However, if
prophylactic antibiotics are required it is important to carry out as much treatment as

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