Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome 1/8/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence

Article title: Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome
Author(s): Karp, Jeffrey DMD. Gabriela Ganoza, DDS.
Journal: Pediatric Dentistry
Year, Volume (number), Page #’s: 2006. 28:6. 547-551
Major topic: How to approach a child with LQTS for dental TX
Minor topic(s): Use of a multidisciplinary approach
Main Purpose: Highlight the potentially malignant course of symptomatic LQTS and emphasize the importance of warning signs and multidisp. Medical management of children with LQTS
Overview of method of research: Review of syndrome, case report

Findings: Syncope occurs in roughly 1 out of every 800 pediatric patients seeking medical attention. Syncope is defined as a loss of consciousness related to decreased cerebral perfusion and can be mediated by several mechanisms. Neurocardiogenic, AKA vasovagal syncope, is the most common and occurs during periods of emotional stress. The prodromal symptoms are1. Lightheadedness2. Dizziness3. Nausea4. Pallor5. diaphoresis6. Visual changesVasovagal syncope is normally benign. The other type of syncope is cardiac syncope, which is a result of cardiac abnormalities in which obstruction to blood flow, myocardial dysfunction, and arrhythmias occur. These conditions can be due to genetic mutations, following a familial distribution. Long QT syndrome is a cardiac electrophysiological abnormality where the QT interval indicative of ventricular depolarization is prolonged on an ECG. LQTS can occur through either autosomal dominant of de novo mutation. It occurs in 1 out of every 5,000-10,000 individuals in the US(wide range???). The prolonged ventricular repolarization can lead to complex reentry circuits within the heart, loss of cardiac rhythm, and V-Tac, known as torsades de pointes(TdP). Tdp can be self-limiting; it can persist, or can cause V-Fib. All of these disarythmias compromise oxygen supply to the brain and other organs, leading to syncope, seizures, and death…, which stinks. Symptoms of LQTS include1. Unexplained syncope2. syncope during exercise in kids3. familial history of unexplained syncope4. seizures5. Sudden death in people <406. Congenital deafness7. QT interval longer than 440ms in males, 450 in females.There are four main treatment options for people diagnosed with LQTS.1. Beta blocker2. pacemakers3. implantable defibs. ICD4. left cardiac sympathetic denervation(LCSD)Success of treatment depends largely on the underlying genetic mutation. The article reviews a case of a 7 year old girl with a medical history of Pierre Robin Syndrome(PRS), ADHD, LQTS, and an implanted cardioverter defibrillator. The child was on 81mg of aspirin, 25mg of atenolol, and 10mg of atomoxetine. The child suffered avulsion of 8 and 9, and lateral luxation of 7. Apart form the initial exam, further dental TX was denied by the ED trauma team because the child developed a TdP rhythm. The child was later admitted. After multiple failed attempts due to cardiac complications, the dental team was finally allowed to render TX on the 5th day of the child’s hospital stay with the use of IV sedation. #7 had +2 mobility, and was deemed to be an aspiration and infection risk, and thus was planned for extraction. Due to the child’s medical status and complication associated with her conditions(glossoptosis, micrognathia), TX in the OR was decided on. The child received consults from her cardiologist, an anesthesiologist, and their PCP before TX under GA. Once in the OR, #7 was extracted and an impression was taken. There were no complications, and the child was discharged later that day.

Key points/Summary: The basic purpose of the case report is to raise awareness on the early signs and symptoms of LQTS and how it should be dealt with in the dental setting. A comprehensive medical history is paramount. A multidisciplinary approach is best. Consults are needed with the child’s cardiologist, neurologist, and PCP. With LQTS, use of choral hydrate and epinephrine are contraindicated because they prolong QT. Treatment under GA is the best option for care due to the necessity of monitoring the child’s cardiac condition by a cardiologist, even for routine dental treatment. In terms of treatment, a definitive restoration should be placed when possible, minimizing the risk of recurrent decay, failed pulpal therapies, and subsequent emergent care. With regards to trauma, the more appropriate treatment is extraction rather than endo. And some form of complex restorative care (in SOME instances). Replacement of lost teeth is assessed on a case by case basis, taking into account the child’s risk factors, health status, etc.
Assessment of Article: Good article. Concise, to the point on how to best treat kids with LQTS. The main points to take away are that a multidisciplinary approach is the only way to properly and safely treat these kids, and that they should be seen in the OR. Werd. Holla back youngin'.

Check out some videos yo...