Dental Care for Children and Adults with Heart Problems and Down's Syndrome
Why is dental care important?
Everyone has bacteria in their mouth which can enter the bloodstream in small numbers, but with dental disease the number of bacteria can increase and in someone with a heart defect they can cause an infection inside the heart (Endocarditis) which is a rare but life-threatening condition. Anyone who has a congenital heart defect (a hole, abnormal valve or blood vessel) is more at risk of getting Endocarditis if they have tooth decay or gum inflammation, so good dental care should be a priority. Even those who have had corrective surgery may be at risk so it is important to listen to any advice given by the cardiologist, particularly in relation to the use of antibiotic cover for dental treatments.
How can Endocarditis be prevented?
Endocarditis can be prevented by keeping a clean healthy mouth and taking action to prevent tooth decay as well as taking precautions such as taking antibiotics prior to some types of dental and medical treatments if the type of heart defect is considered to increase the risk of it occurring.
Up until March 2008, antibiotic cover was recommended for nearly everyone with a congenital heart defect, whether or not it had been repaired, if they needed certain types of medical or dental procedures. Following an investigation by NICE (National Institute for Health and Clinical Excellence) the recommendation has been changed so that antibiotics will only be offered for those who are considered at higher risk of getting endocarditis or where the procedure is at a site where there is already suspected infection.
There are a number of patients who are considered at increased risk due to the nature of their heart defect so it is important that you obtain advice from your cardiologist for your individual situation.
Generally, for the type of defects people with Down’s Syndrome commonly have, the risk is increased for those who:
- have had valve replacement
- were born with a heart defect (excepted an isolated ASD, repaired VSD or repaired PDA)
- have had infective endocarditis before
Those who are not considered at increased risk are those who:
- have a pacemaker
- have an arrhythmia
You can read the NICE guidelines here (NICE guideline CG64).
Accidents involving the mouth
It is not uncommon for children to have accidents which result in minor injuries to the mouth and teeth which will not require any treatment. However it is always best to check with your dentist or GP about any such injury, even if you think treatment is not required, as antibiotic cover may be recommended.
Preventing Tooth Decay
- Diet is an important factor in preventing tooth decay and it is a good idea to encourage a healthy and balanced diet with reduced sugars from an early age. When sugar is eaten, bacteria in the mouth turn it into acid and if this acid is present in the mouth for long periods it breaks down the tooth enamel and decay begins. It is best to avoid sweets and sugary foods between meals, but if they are given it is preferable if it is straight after a meal and then if possible brush the teeth with fluoride toothpaste to help neutralise the acid
- Fluoride is absorbed into the enamel of the teeth helping strengthen them. It can be given as toothpaste, tablets, drops, mouthwash, gel or in the water (you may need to ask your dentist if the water in your area is fluoridated.) As the adult teeth are already forming long before eruption, some dentists may recommend fluoride drops from as early as 6 months of age.
- Fissure sealants are plastic coatings which can be used by the dentist to coat the biting surfaces of the permanent molars, thus blocking the deep fissures where decay often starts and making the teeth easier to clean. It is important that fissure sealants are applied as soon as the permanent molars erupt before any decay can begin
- Oral hygiene plays an important part in preventing decay and gum disease. Regular brushing prevents plaque sticking to the teeth allowing bacteria to convert sugars in to the acid which attacks the enamel. Plaque also irritates the gums making them red and swollen which in turn often causes bleeding which can allow bacteria into the blood stream. To improve brushing, provide better control over the toothbrush by using one with a small head and a handle that is easy to grip, and check the effectiveness of brushing using disclosing tablets. Remember that teeth have three surface to clean - the back, front and biting surface - and the gums should also be brushed. Brushing after meals and at bedtime is important to limit the time plaque is present on the teeth - bedtime obviously being the MOST important
- Prevention is better than treatment so regular dental "check-ups" should be started from an early age
Dental Development in Children with Down's Syndrome
Children with Down's Syndrome may have delayed development of the teeth and jaw with the first (baby) teeth not appearing until the age of two and it may take another two to three years for them all to be present. Similarly the eruption of the permanent (adult) teeth may be delayed with baby teeth still being present at fourteen years; teeth may also present in an unusual order. It is very common for some of the baby and adult teeth to be missing, and for teeth to be smaller than normal.
Problems associated with Dental Treatment in people with Down's Syndrome
There are a variety of problems that need consideration by the dentist when treating someone who has Down's Syndrome:
- People with Down's Syndrome may be less compliant at the dental surgery so visits need to be carefully planned and the dentist and staff need a clear understanding of what level of communication should be used with the patient. More time should be allowed so that each procedure can be fully explained and demonstrated first; many will respond well to the use of rewards. Ideally checkups should begin at an early age so as to promote familiarity with the surroundings and procedures
- Often the tongue appears to protrude from the mouth, usually due to the mouth being smaller than normal and less able to accommodate it. This can make it more difficult to clean the teeth because the tongue gets in the way. It can also make treatment more awkward for the dentist
- Poor manual dexterity may make cleaning and flossing difficult for people with Down's Syndrome - electric toothbrushes and floss holders may assist
- Reduced muscle tone in the mouth may result in less efficient chewing with more food being left on the teeth after eating
- A small percentage of people with Down's Syndrome will have Atlanto-axial Instability (an increase in mobility between the C1 and C2 cervical vertebrae) which is diagnosed by x-ray. Careful positioning in the dental chair is required for these patients to avoid any potential damage to the spinal cord
- Small nasal passages may cause mouth breathing which results in a dry mouth and fissuring of the tongue and lips. This can be a contributory factor in bad breath (halitosis), so patients should be advised to brush their tongue at the same time as their teeth
Additional sources of information