Dentists Information Section: Dental care in children at risk of Infective Endocarditis
Advice for dentists during COVID 19 Pandemic
We appreciate that during such unprecedented times you may be concerned about providing advice and/or care for any of your paediatric patients who are at risk of infective endocarditis.
We wish to reassure you that dental care pathways for all children at risk of infective endocarditis have been updated and are under continuous review to ensure such patients will be able to access appropriate dental care if and when they need it.
Fiona Willcoxson (Consultant Paediatric Cardiologist and Clinical Lead at Leeds Children’s Hospital), has advised that COVID 19 infection, based on current evidence available, is often a mild disease with a low complication rate reported in children especially the under 9 year olds.
The morbidity and mortality of infective endocarditis continues to be important. Given this, if any such patients have dental pain/infection they should contact you as their usual dental care provider and over the phone triage completed as per your local protocol. This triage should include not only the dental symptoms but also COVID 19 symptoms of both the patient and those in their household.
Where appropriate, advice/ analgesia/ antibiotics should be prescribed, however where clinical judgement indicates there is likely to be a high need for a clinical care then a discussion should initially take place between the clinician and child’s cardiologist to determine the individual patients risk of infective endocarditis in addition to the risk/benefit of dental care v’s COVID 19 risk. This will be cardiac diagnosis dependent.
If you are unable to ascertain who the child’s cardiologist is/unable to contact them easily then the on-call cardiologist can easily be reached through Leeds General Infirmary switchboard (0113 2432799)
Pending this, a discussion with the child/ carer should then take place to advise of the risks and benefits and appropriate care then provided i.e. referral to an appropriate Urgent Dental Care Centre for face-to-face care or otherwise. Contact information regarding local Urgent Dental Care Centre’s will be available shortly. In the interim, you can also still contact your local specialist/ consultant led paediatric dentistry services for advice; please see the list below.
Stay safe and stay well.
Advice for general dental practitioners
What is infective endocarditis?
• Endocarditis is a rare infection of the inside of the heart or the main arteries.
• It most commonly affects one or more of the heart valves but may also occur around holes between the heart chambers, at the site of abnormalities in the walls of arteries or at the site of previous heart or arterial surgery.
• It is a serious condition and can cause major damage to the heart valves and may even cause stroke or death.
• Most endocarditis occurs in patients already known to have heart abnormalities.
• Most patients with congenital heart disease are at increased risk of getting endocarditis. The only exceptions being isolated atrial septal defects or patients who have had completely curative treatment.
How can I recognise infective endocarditis?
• Patients with endocarditis develop a temperature and feel generally unwell, with symptoms very similar to having the flu.
• Flu is very common and usually resolves after about a week.
• Flu like symptoms with a temperature which persist for longer than a week should be reported to the child’s cardiologist, not just to their GP, so that specialist tests can be carried out to check for endocarditis.
When should a child at risk of infective endocarditis have their first dental check- up?
The British Society of Paediatric Dentistry recommends that all children should start to see a dentist as soon as their first teeth come through, and before their first birthday. Parents of children at risk of infective endocarditis are strongly encouraged by the Cardiology team to seek oral health care with their local general dental practitioner in the first instance.
Children at risk of infective endocarditis should be considered high risk and reviewed on a three monthly basis, as per National Institute for Health and Care Excellence (NICE) recall guidance.
What modes of care can I employ for dental care in children at risk of infective endocarditis?
The safest way for any dental care to be carried out is generally using local anaesthetic. Sometimes sedation, usually inhalation sedation, can also be used to help children and young people to have dental care completed. If dental care cannot be carried out with the child awake then a general anaesthetic will be necessary.
For a small number of patients, treatment under local anaesthetic in a primary care setting is not appropriate e.g. long QT syndrome, and advice from the patient’s cardiologist should be sought in the first instance .
Should antibiotic prophylaxis be given prior to dental care in children at risk of infective endocarditis?
NICE guidance on antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures was updated in 2016. This guidance advised that antibiotic prophylaxis is not routinely recommended for individuals at risk of infective endocarditis who are undergoing dental procedures.
The Scottish Dental Effectiveness Programme (SDCEP) has produced a supporting document around the implementation of the NICE guidance (http://www.sdcep.org.uk/published-guidance/antibiotic-prophylaxis/).
The Consultants at Leeds Children’s Hospital have reviewed both the NICE and SDCEP guidance documents above and have advised that they do NOT recommend antibiotic prophylaxis for any patients under their care.
It is nonetheless necessary for the dentist providing oral health care to discuss antibiotic prophylaxis with the patient/ carer and their agreement, or otherwise, regarding this; these discussions should be clearly recorded in the patient’s record.
My patient has a pacemaker, is there any dental care that I should avoid?
There is a low risk, if following safety precautions, of use of apex locators and ultrasonic scalers in patients with pacemakers. Electrocautery equipment should be avoided.
Where there are any doubts about the use of such dental equipment in a patient with a pacemaker, the manufacturer of the dental equipment should be contacted for further guidance in the first instance.
What if my patient requires dental care under general anaesthetic?
Any patients who require a general anaesthetic for their dental care should initially be referred by their family dentist to the local specialist/ consultant led paediatric dentistry service. Here is a list of the local specialist/ consultant led paediatric dentistry services in Yorkshire and Humber that such children can be referred to:
Geographical area Specialist/Consultant led paediatric service
Barnsley, Doncaster and Rotherham: Community Dental service, The Rotherham NHS Foundation Trust
Bradford and Airedale Community Dental Service, Bradford District Care NHS Foundation Trust
Halifax, Huddersfield, Batley, Dewsbury, Cleckheaton Community Dental Service, Locala Dental Care
Hull Community Dental Service , City Health Care Partnership CIC
Leeds Community Dental Service, Leeds NHS Community Healthcare Trust Or Leeds Dental Institute, Leeds Teaching Hospitals Trust
Sheffield Community And Special Care Dentistry OR Charles Clifford Dental Hospital, Sheffield Teaching Hospitals NHS Foundation Trust
York, Harrogate and North Yorkshire Community Dental Service, Harrogate and District NHS Foundation Trust
Advice for dental practitioners providing dental care under general anaesthetic
For patients who require dental care under general anaesthetic, patients with simple cardiac lesions can have their treatment performed in the local District General Hospital- please see flow chart below for more detailed information.
If the patient has a more complicated cardiac condition, the advice as to whether the patient can be treated locally or at the specialist centre will have to be given on an individual basis based on the patient’s up to date medical condition- please see flow chart below for more detailed information.
If you require advice about elective dental treatment then please contact Dr J Scheffczik, Paediatric Cardiac Anaesthetist based at Leeds General Infirmary for advice:
Dr J Scheffczik email: firstname.lastname@example.org
If the patient requires urgent dental treatment with general anaesthetic please contact the paediatric cardiac anaesthetist on call or the paediatric cardiologist on call via the hospital switchboard at Leeds General Infirmary. Tel 0113 2432799