TETRALOGY OF FALLOT: a case report and dental



TETRALOGY OF FALLOT: a case report and dental
ISSN 1807-5274
Rev. Clín. Pesq. Odontol., Curitiba, v. 5, n. 3, p. 289-292, set./dez. 2009
Licenciado sob uma Licença Creative Commons
a case report and dental considerations
Tetralogia de Fallot: relato de caso com considerações dentárias
Prashant Babaji[a]
MDS, Reader, Department of Pedodontics, Darshan Dental College and Hospital, Loyara, Udaipur, India, e-mail:
[email protected]
OBJECTIVE: To present a case of Tetralogy of Fallot, a serious congenital heart disease, which can
have an impact upon the dental tissue and which needs dental care. DISCUSSION AND
CONCLUSION: Successful management of cardiac patients depends upon, knowledge about the
condition. This paper highlights on dental management of Tetralogy of Fallot patients.
Keywords: Tetralogy of Fallot. Cyanosis. Fissured tongue. Gingival bleeding.
OBJETIVO: Apresentar um caso de Tetralogia de Fallot, uma doença cardíaca congênita grave,
que pode causar um impacto nos tecidos dentários, os quais necessitam de tratamento.
DISCUSSÃO E CONCLUSÃO: O tratamento adequado de pacientes com problemas cardíacos
depende do conhecimento do clínico a respeito da condição. Este relato enfatiza o manejo
odontológico de pacientes com Tetralogia de Fallot.
Palavras-chave: Tetralogia de Fallot. Cianose. Língua fissurada. Sangramento gengival.
Rev Clín Pesq Odontol. 2009 set/dez;5(3):289-292
Babaji P.
Cardiovascular diseases represents a wide
spread heterogeneous group of conditions that have
significant morbidity and mortality. The available
data about oral findings and dental management of
patients presenting with Tetralogy of Fallot, even
though a most common form of congenital heart
disease, is scarce. Hence the purpose of the article
is to highlight on the dental aspects.
Tetralogy of Fallot is a serious congenital
heart problem, since it obstructs blood flow from
reaching lungs. It was first described by Dane,
Nichols and Stenson (1). In 1888 a French physician
Etienne Fallot separated it from other forms of
cyanotic heart diseases, hence the name Tetralogy
of Fallot (1). Its overall incidence is 10% of all
forms of congenital heart diseases; males are more
commonly affected than females (2).
The exact aetiology is unknown, but it is
thought to be related to the faulty embryogenesis
during the gestational week 3 through 8 weeks
(3). Risk factors like maternal rubella infection,
thalidomide, phenytoin, warfarin and alcohol
consumption or cigarette smoking during
pregnancy can trigger the condition (4).
FIGURE 1 - Clubbing seen at finger nails
A 4 ½ year old boy was referred to the
Department of Pedodontics, Darshan Dental
College and Hospital, Udaipur, India, with
complain of pain in lower right back tooth. Patient
has a known history of Tetralogy of Fallot. Family
history was non contributory. General physical
examination of patient revealed a undernourished
child with delayed growth and development, along
with cyanosis of extremities and digital clubbing.
There was history of cyanotic attack on exertion.
Intra oral examination revealed a cyanotic
mucous membrane of lips, tongue and gingiva,
fissured tongue and inflamed bleeding gingiva. Teeth
were hypoplastic with multiple carious lesions. The
tooth 85 was carious with acute periapical abscess.
Dental treatment provided to the patient included
oral prophylaxis, restoration and extraction of the
nonrestorable 85, which was carried under local
anaesthesia with antibiotic coverage. Patient was
recalled at regular intervals (Figures 1 to 4).
FIGURE 2 - Cyanotic mucous membrane and gingiva
FIGURE 3 - Cyanotic tongue with fissures
Rev Clín Pesq Odontol. 2009 set/dez;5(3):289-292
Tetralogy of fallot
FIGURE 4 - Carious tooth 85 with gingival abscess
Tetralogy of Fallot is a serious congenital
heart disease, presenting with a tetrad of features:
obstruction of right ventricular
outflow due to pulmonary artery
atresia or stenosis;
ventricular septal defect;
right ventricular hypertrophy;
aorta that straddles the ventricular
septal defect and arises partially from
each ventricle (4-6).
Children afflicted with Tetralogy of Fallot
are prone to hypoxic spells or blue spells during
exertion or anxiety, due to abrupt reduction in
pulmonary blood flow (5). Patients frequently
present with dyspnea, cyanosis and clubbing.
Cyanosis is prominent in finger nails, toe nails and
mucous membrane. Growth and development of
child is delayed. In an attempt to compensate for
low arterial oxygen concentration, the body
responds with an increased production of red
blood cells and polycythemia. Red blood cell
precursor may replace platelet stem cells in the
bone marrow, leading to a thrombocytopenia,
bleeding tendency and iron deficiency anaemia (57). There is an increased risk of cerebral abscess in
these patients because infectious material is not
filtered in lung (3-7). In Tetralogy of Fallot heart
is often enlarged and may be boot shaped (2).
Oral findings like stomatitis, glossitis,
cyanotic mucous membrane, gingiva and tongue
are commonly seen. These children may show
delayed eruption of both dentition with an increased
frequency of positional anomalies and enamel
hypoplasia. Gingival bleeding is seen because of
thrombocytopenia. There is higher incidence of
caries and periodontal disease activity because of
poor oral hygiene and lack of dental attention (6).
Dental management of patient with
Tetralogy of Fallot must be coordinated with
medical management. Medical management is
primarily directed towards the prevention of the
disease and the treatment of complications.
Definitive management includes relief of the
pulmonary stenosis and closure of the ventricular
septal defect. Iron deficiency anaemia is treated
with iron supplements. The following points
should be considered in dental management (8).
Thorough history should be taken
along with physician concern;
Treatment should be done in a stress
free condition along with application
of behaviour management techniques;
Premedication with anti-anxiety drugs
is necessary to reduce anxiety;
Uncooperative child can be managed
with conscious sedation or general
Antibiotic prophylaxis is indicated
for procedures like deep scaling, minor
surgical procedures and restorative
procedures involving clamping and
Before procedure, patient mouth should
be rinsed with 0.2% chlorhexidine
gluconate to reduce bacterial count;
During hyper cyanotic attack, place
the patient in knee-chest position,
administer oxygen of 0.2 mg/kg body
wt or refer to physician;
Extraction fallowed by space
maintainer is preferred over pulpotomy or pulpectomy procedures due
to risk of bacteraemia;
Endodontic procedures should be
confined to permanent teeth which have
high success rate, straight canals and
closed apex; as a single visit procedure;
Rev Clín Pesq Odontol. 2009 set/dez;5(3):289-292
Babaji P.
Ideally treatment in children should
be carried out during short
appointment with 2-4 weeks intervals
between appointments;
Child should be instructed to avoid
vigorous brushing to prevent
Active dental diseases should be treated
before cardiac surgery is carried out;
Prevention of dental disease is of utmost
important for children with cardiac problems, as
simple dental problem may severally compromise
a child’s medical management; hence, knowledge
of cardiac conditions and their management is
essential for effective delivery of dental care.
1. Becker AE, Anderson RH. Pathology of
congenital heart disease. London: Butter
Worths; 1981.
4. Cameron A. Medically compromised
children. In: Cameron A, Widmer R.
Handbook of Pediatric dentistry. 2nd ed.
London: Mosby-Wolfe; 1997. p. 221-4.
5. Bernstein B, Kliegman RM, Arvin AM. The
transitional circulation. In: Berstein B. Nelson textbook of paediatrics. 15th ed.
Philadelphia: WB Saunders; 1995. p. 12831315.
6. Scully C, Cawson RA. Congenital heart
disease. In: Scully C, Cawson RA. Medical
problems in dentistry. 4th ed. Mumbai: K M
Varghese; 1998. p. 69-71.
7 . Ro ck m a n R A . Te t r a l o g y o f f a l l o t :
characteristcs, dental implications and
case study. ASDC J Dent Child.1989;
8. Show L, Welbur y RR. Cardiovascular
disorders. In: Welbury R. Paediatric dentistry.
New York. Oxford medical publications;
2000. p. 354-8.
Received: 05/15/2009
Recebido: 15/05/2009
2. Moller JH, Neal WA. Fetal, neonatal and
infant cardiac disease. Norwalk: Appleton
and Lange; 1990.
Accepted: 07/28/2009
Aceito: 28/07/2009
3. Schoen FJ, Catron RS, Kumar V, Robbins SI.
Robbins pathologic basis of diease. 5th ed.
Bangalore, India: Prism books PVT, LTD; 1994.
Reviewed: 11/26/2009
Revisado: 26/11/2009
Rev Clín Pesq Odontol. 2009 set/dez;5(3):289-292

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