Introduction

Oral health care for children with heart problem presents a challenge to the dental team. Oral health is often put aside to accommodate more immediate health problems. Therefore it is not surprising if studies have found that many children with heart problems have been shown to have a high prevalence of oral diseases and unmet treatment needs.

Causes of Tooth Decay

Proper and continuous oral health care is important to ensure healthy gums, teeth and fresh breath. If teeth are not properly clean, a sticky, yellowish substance called plaque will form on the tooth surface. Plaque contains bacteria responsible for acid formation. Bacteria acts on sugar from the child?s diet to form acid which attacks the enamel and dissolves it. This is the onset of caries formation. If not checked the caries will progress to the inner layer of the tooth and break it down to form a cavity. Bacteria in the carious cavity can continuously spread and infect the pulp tissues containing blood vessels and nerves. If this happens, the affected child will have toothache and the tooth will eventually become non vital or dead. Without further treatment, bacterial infection soon forms an abscess at the root and finally ends in ‘facial cellulitis’ when the infection spreads to involve the surrounding soft tissues.

Effects of tooth decay on children with heart disease.

For healthy children, dental plaque and untreated caries normally will not cause serious problems. However this situation is different for children with congenital heart disease. Bacteria in the dental plaque and caries can spread to the damaged heart valve via the blood vessels and cause a serious condition called infective endocarditis. This is an infection to the inner layer of the heart muscle that can cause death.

Prevention is the answer

As we know, dental diseases are diseases emerging from unhealthy lifestyle; neglected or ineffective care and unhealthy diet that can lead to dental caries. Therefore it cannot be denied that prevention is important in the context of preventing dental diseases. Diseases like these will require continuous understanding and commitment from parents / carers and the dental team towards achieving healthy oral condition.

Try to reduce consumption of sugars, like avoiding sweet foods and drinks in between lunch and dinner time. You can try to replace these sugary foods with non sugary foods or foods with less sugar like crisps, peanuts or fruits.

Another important factor in preventing caries effectively is the use of fluoridated toothpaste twice daily. Vigorous rinsing after brushing is to be avoided as this can reduce the fluoride content transferred recently to the teeth and thereby minimising its effect. However the use of fluoride too frequently and in abundance can cause fluorosis especially if it is swallowed by children less than 6 years old. Fluorosis is a defect of the tooth substance on the outermost surface or the enamel layer. Mild fluorosis will cause white lines or patches on the enamel that might not be easily seen. Severe fluorosis will cause notches on the enamel and stains it brown. To reduce risk of fluorosis and at the same time retaining the advantages of fluoride, studies advocate the use of fluoridated toothpaste the size of a green pea and parents are to supervise every tooth brushing of children 6 years below.

1. Toothbrushing

After cleaning, dental plaque can form back in less than 24 hours. Therefore teeth must be brushed thoroughly at least twice a day especially at night before bed. Make sure teeth are brushed for at least 2 minutes every session. There are several tooth brushing techniques that are effective in removing plaque, resulting in cleaner teeth and fresh breath. You can ask your dentist or dental nurse about these techniques when you visit the dental clinic. Briefly, you can divide all the teeth in the mouth into 6 segments, upper anterior segment, upper posterior right and left segments, lower anterior and lower posterior right and left segments. At each segment,make sure the tooth surfaces near the tongue and cheeks are carefully clean. One effective technique of tooth brushing is to angulate the toothbrush near the gum margin and move it in a circular, up and down movement and making sure the bristles reach in between teeth. The biting surfaces are then brushed in the forward and backward movements.

2. Diet

Most of us are well informed that sugary food, like biscuits, cakes, sweets, carbonated drinks and so forth are the main cause of tooth decay or dental caries. Within a few minutes of taking a sugary diet, acid is formed near the tooth surfaces and contributes to the formation of tooth decay. Studies have shown that the amount of sugar taken is not the only factor that contributes to caries development but the frequency of eating sugary food in a day is the key contributing factor to caries. Sugary food taken in little amount but frequently can cause more problems than taking the same amount but taken only once. Children?s teeth can easily get carious when exposed to acid that continually forms from continuous sugary food intake.

3. Toothpaste

The use of a suitable toothpaste is important to prevent tooth decay. Many products sold in the market provides help in tooth brushing procedures but do not prevent tooth decay. Therefore it is important that parents get a suitable toothpaste that contains fluoride for their children. Children with heart problems are categorized as high risk of getting caries. The suitable toothpaste for them are the ones containing 1000 ppm (parts per million) fluoride ions. You can read the labeling on the toothpaste like ‘ ………..contains sodium monofluorophosphate or sodium fluoride 1000 ppm’. Fluoro in this context means fluoride.

Visit to the Dental clinic

It is very important for parents and carers to take their children to the dental clinic before they reach the age of 1 or better still when the babies are at 6 to 8 months old when the first milk teeth begins to erupt. Other than familiarising the child to the clinic environment and staffs, the dentist or dental nurse can advice on the ways of attaining good oral health care, good diet for healthy teeth, the use of fluoridated toothpaste and timing of necessary treatment.

When the first permanent molar starts to erupt at the age of 6 or 7 years old, the dentist or dental nurse can provide fissure sealants to seal the fissures of the molars. The sealants act as a shield to prevent the accumulation of plaque on the tooth surface , thus preventing tooth decay. According to studies , the technique is found to be effective in preventing decay in the high risk group of children. Children tend to be cooperative at simple procedure treatment like fissure sealants and small cavity restorations. However if carious lesions has reached 1/3 rd tooth size , most invariably the carious lesions have reached the pulp cavity. In this case , it is advisable to extract the affected tooth to prevent the occurrence of infective endocarditis. Your dentist will be able to tell you if your child require further referral to the Pediatric Dental Specialist.

Conclusion

Always remember to inform your dentist that your child has heart disease be it congenital or acquired when you go to visit them. Effective involvement and early care through knowledge, awareness and continuous commitment from all parties especially parents and carers can ensure good oral health care for these children.