Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome

Meghan Sullivan Walsh September 16, 2010 Department of Pediatric Dentistry/LMC -Providence Literature Review

Article Title:

Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome

Author:

Jeffrey M. Karp DMD MD; Gabriela G. Ganoza DDS

Journal:

Pediatric Dentistry

Volume (number), Year, Page #’s:

28:6, 2006, 547-551

Major topic:

Awareness of Long QT syndrome and dental trauma which can occur in these patients.

Overview of method of research:

case report

.

Findings:

Long QT syndrome (LQTS) is a cardiac abnormality which prolongs the ventricular repolarization (QT interval). This effect can promote complex reentry circuits in the heart, loss of a synchronized heart rhythm and torsades de pointes. These dysrhythmias compromise the flow of oxygen to the brain which can intern lead to syncope, seizures and sudden cardiac death. LQTS occurs in 1 out of every 5000 persons and is primarily diagnosed in pediatric patients. There are four main interventions for LQTS; Beta Blockers, pacemakers, cardiac defibrillator implants and left cardiac sympathetic denervation.

A 7 year old white male presented to the ER with dental trauma due to syncope. His medical condition was LQTS, Pierre Robin sequence, ADHD and an implanted cardioverter defibrillator. Three of his maxillary incisors had avulsed and the second lateral was luxated. The patient was diagnosed with PRS as a child due to his clinical presentation of a cleft palate, glossoptosis and mandibular micrognathism at birth. During the surgeries for his cleft they determined he also had LQTS after examining his electrocardiography. He was given an implanted cardiac defibrillator however a malfunction of this device and then a replacement two years after it was placed left this patient on warfarin therapy and was taking this medication the time of admittance to the ER. The patient was also taking aspirin, atenolol and atomoxeine. The patient was watched and admitted while the dental team waited for five days until clearance to asses the patient’s dental condition. They were most concerned with the luxated incisor and recommended extraction due to the system infection originating from the pulpal necrosis, tooth aspiration and complicated endodontic treatment. The physicians and dental team agreed that due to his medical condition the best setting for tooth extraction would be under GA in a hospital OR. The patient was discharged from the hospital with antibiotics and returned a week later to have the tooth extracted. The child tolerated the procedure well and discharged with traditional home care instructions.

Key Points/Summary

Appropriate dental care for LQTS patients under the age of 18 falls on the judgment of the pediatric dentists. Providers must be aware of this disease and the complications which arise from treating these patients. As a general recommendation, these patients should have a consultation with their cardiologist for electrocardiographic evaluation prior to any procedure. Providers should also be aware than many of these patients are given the wrong diagnosis of epilepsy. Dentists should also be aware of the drugs Chloral hydrate and epinephrine which prolong QT interval. While there are no recommendations as of yet for treatment of these patients, the article recommends premeditation and sedation as a manner with which to treat these patients to reduce stress and anxiety. In addition these patients should be treated in an environment where personnel is available to monitor cardiac rhythms. There for GA is the recommendation of the authors for treatment and management of these patients after consultations which a pediatric anesthesiologist. These patients require a multidisciplinary approach to medicine to account for the social, emotional, psychological and financial characteristics.

Assessment of Article

Interesting case report. I was unaware of the disease so it was a great introduction for me. I would assume these patients are an ASA of a II or even a III so I couldn’t imagine treating these patients in a traditional setting, however knowing the main reasons why GA is recommended is always useful.