PUBLISHED IN DUBAI www.dental-tribune.me November-December| No. 6, Vol. 8 We have an enormous influence on children’s overall health By Dental Tribune International Parents of children with systemic disease often wonder in the den- tist’s office what oral health prob- lems they can expect for their child. Depending on the type of systemic disease, there can be complications in terms of the child’s oral health. In this context, Dr Karolin Höfer, senior physician at the University Hospital of Cologne, studies oral disease in children with chronic renal insuf- ficiency or congenital heart defects. In her presentation at the Oral-B Up-to-Date event, she spoke about the typical oral health problems of paediatric kidney and heart patients based on her own research and com- pared these with current systematic reviews. She then, in a very personal interview gave helpful suggestions for the support and treatment of these children in everyday life. Dr Höfer, why do you like working with children? Dr Karolin Höfer: My passion lies in working with children and young people; that’s why I specialised in paediatric dentistry, with a special focus on children with systemic dis- ease. In dentistry, we say: one either loves it or leaves it. With every one of my young pa- tients, whether they have a medical history or are healthy, I have to gain their confidence on an emotional level first, aside from the dentistry challenge. Working with children who are traumatised and have medi- cal histories in particular requires sensitive handling in order to build trust, which is the foundation of suc- cessful treatment. Intuition, taking sufficient time, patience and empa- thy are essential here. Successful treatment of children with cancer or severe heart problems or others at high risk is achievable by using special techniques, such as ritualised behaviour management. After a difficult treatment, having a child smile and ask when he or she can come back is the best endorse- ment in daily practice. What patients do you work with? Most of my patients have a systemic disease and are with me from birth up to age 25. The period between ages 18 and 25 is considered a tran- sition phase; from child to adult. After careful paediatric treatment, a deterioration of the condition is frequently reported during the tran- sition phase. For example, we treat patients with cystic fibrosis, con- genital heart defects, chronic kidney disease and immunosuppression, for example, after a transplant or during cancer treatment. Every day, we ask ourselves: Are there correla- Dr Karolin Höfer, Germany tions between these systemic dis- eases and oral disease and/or disease that affects tooth development? As dentists, we should know how these systemic disease can affect oral health. We are already aware of the well-known interactions with some chronic diseases, such as congeni- tal heart disease, diabetes mellitus, arthritis and chronic diseases of the bowel and kidney. What questions do dentists have to ask when treating these patients? First of all, it is important to identify the child’s dental problem. Secondly, it should be determined whether the child has certain diseases and whether there are interactions with oral disease. And thirdly, which spe- cialists in other disciplines should be consulted before dental work com- mences must be established. How do you see your position as a dentist within the holistic therapy of these children? I am not responsible for the patient’s entire medical recovery. However, I see myself as a physician, mediator and member of a team of paediatric specialists. When we treat patients with systemic disease, we need to be in contact with specialists from all disciplines. As experts in oral health, we have an enormous influence on children’s overall health. Every den- tist should consult with the treating paediatricians of children with pre- existing conditions. It’s about the overall well-being of the child. Even a tooth cleaning can take on another meaning for these children. Healthy people associate it with health, well- being and aesthetics. For children with systemic disease, however, an intensive prophylaxis can have major implications for their general health, for example, should patho- genic bacteria enter the bloodstream of a child, say, with immunosuppres- sion. You work with children who have congenital disease. You have con- ducted interesting studies on the prevalence of caries and gingivitis. What have your results been? If one considers the tooth decay pro- cess of healthy children in Germany 20 years ago, about five teeth were affected by tooth decay, while today, only one tooth on average is affect- ed. Up to 85 per cent of 3-year-olds have no caries; however, the remain- der may have up to four carious teeth. As I said, these figures involve healthy children. For children with systemic disease, the situation is different. Children with heart disease have a demon- strably higher prevalence of caries. On average, four to seven teeth are affected. Children with kidney dis- ease have a risk of caries comparable to that of healthy children; however, this group presents a much higher risk of developing gingivitis. Gingi- vitis could thus be understood as enabling bacteria to enter the blood- stream. Children with cystic fibrosis also have a very low caries preva- lence, but owing to the frequent in- take of antibiotics, the composition of their saliva is altered, so in this patient group, frequent enamel hy- poplasia has been determined. Why should paediatric dentistry be interested in such interactions? If there are potentially about 700 different species of bacteria in the mouth, and children with heart dis- ease have an increased risk of caries, the danger actually exists that these bacteria will reach the bloodstream via the mouth. We are speaking here of bacteraemia. Bacteraemia is not a disease in itself and is not a risk for a healthy patient; the immune system automatically fights the invading bacteria. For patients with systemic disease, the starting point is differ- ent. It is therefore not surprising that, with bacteraemia, oral strep- tococci, in particular the viridans streptococci, can be detected. Blood cultures reveal, for example, that vir- idans streptococci, as part of the oral cavity, are also responsible for 50 per cent of infectious endocarditis cases. Of course, bacteraemia does not au- tomatically lead to endocarditis. As I said, a healthy body can normally deal with such bacteria. Patients with pre-existing conditions like heart disease, however, have a higher risk of endocarditis. Ideally, children with a serious heart disease should have their teeth cleaned prior to upcom- ing heart surgery. How frequently does bacteraemia develop after dental procedures? Occult bacteraemia can result from routine activities such as tooth- brushing, but of course also through different dental procedures. Bacte- raemia develops most frequently after surgeries like tooth extrac- tions. Here, the frequency is usually 100 per cent. These bacteria can be released during periodontal proce- dures, such as scaling and root plan- ing, and even during professional tooth cleaning, bacteria enter the bloodstream in around 40 per cent of patients. It is very interesting that, even after brushing and interdental care, the frequency of bacteraemia is about 68 per cent. As I said, a healthy body normally deals with such bacte- ria, but the picture is different for pa- tients with systemic disease, particu- ÿPage C2