Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2005  |  Volume : 23  |  Issue : 1  |  Page : 44--45

Peeping through heart's window: A case report of Fallots tetralogy

R Bhowate, A Dubey 
 Department of Pedodontics, G.D.C. Raipur, Chattisgarh, India

Correspondence Address:
R Bhowate
Department of Pedodontics, G.D.C. Raipur, Chattisgarh


Tetralogy of Fallot is a congenital heart defect. A combination of four abnormalities in heart allow oxygen rich and oxygen-depleted blood to mix. The resulting low-oxygen blood then circulates through the body. A child with the condition tends to develop slowly, eat poorly and grow slowly and may experience DQblueDQ spells on crying and dyspnea on exertion. A 12 year old child with this congenital heart defect and cleft palate with cleft lip is discussed. Details of the latest diagnostic and treatment procedures are also presented.

How to cite this article:
Bhowate R, Dubey A. Peeping through heart's window: A case report of Fallots tetralogy.J Indian Soc Pedod Prev Dent 2005;23:44-45

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Bhowate R, Dubey A. Peeping through heart's window: A case report of Fallots tetralogy. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2020 Sep 19 ];23:44-45
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Full Text

Tetralogy of Fallot (ToF) is the most common form of cyanotic congenital heart disease. It is a combination of four different defects[1] viz. ventricular septal defect (VSD); obstructed out flow of blood from the right ventricle to the lungs (Pulmonary stenosis); a displaced aorta, which causes blood to flow into the aorta from both the right and left ventricles (dextra position or over riding aorta) and right ventricle hypertrophy (RVH). The cause of ToF is unknown. Genotype 22q 11 deletion has been related to faulty development pathway of pulmonary vessels in ToF.[2] Marfan's Syndrome has also been associated with ToF.[3] Intra orally, cyanosis is seen on vermilion border of lips, tongue, buccal mucosa and gingivae.[4] The degree of gingival cyanosis corresponds closely to general degree of cyanosis.[4]-[6] The cyanotic gingiva may be swollen and it is also observed that children with ToF may show periodontal destruction.[1] Insufficient lip seal and geographic tongue are frequently co-existing oral findings.[4]

 Case Report

A 12 years old male child reported for correction of malaligned tooth. Patient gave a history of surgical treatment for congenital heart defect and cleft palate. The child was born out of non-consanguineous marriage, by LSCS for prolonged labour. Patient's mother gave history of viral fever during first trimester. The child was detected to have heart disease on day 1 of life when cyanosis was apparent. Cyanosis worsened every time during cry and on exertion. There was no history of spells or squatting in early childhood. Chest radiograph showed boot shaped heart due to RVH and clear lungs. Hb% level was found to be 25.2 gram % before surgery. 2-D echo cardiographic examination revealed a large paramembranous VSD (0.80 cm), 50% Over riding of aorta, generalized right ventricular hypertrophy, hypoplastic pulmonary artery and dysplastic pulmonary valves. At the age of 8 year, the child was planned for right modified Blalock Taussig shunt (6 mm PTFE Graft). Child recovered well postoperatively. Patient required prolonged pleurocentesis (right side). Prior to surgical treatment of the cardiac defect, cleft palate had been repaired previously in 5 stages.

Clinical examination revealed clubbing and flat foot. Intra oral examination revealed operated cleft lip and closure in palatal cleft region [Figure 1]. Crowding and "v" shaped anterior maxillary arch was present .The maxillary arch was under developed transversely and 12,15,25 were congenitally missing. 55,16,65,26,36,46 were found to be decayed [Figure 2]. Relative macroglossia due to under developed maxillae and cleft palate was present.

Decayed permanent teeth were restored and the child was referred to orthodontist, wherein treatment was planned into 4 distinct but inter related stages:

PHASE I: Expansion of maxillary arch and protrusion of maxillary arch.

PHASE II: Bone grafting in opened up space for arch stabilization.

PHASE III: Arch alignment with orthodontic mechanotherapy and setting of occlusion.

PHASE IV: Cosmetic plastic surgery for lip and palate.


Cardio vascular diseases are common and it is inevitable that any practitioner dealing with patients will encounter it.[7] This underlines the need for correct diagnosis from clinical picture and laboratory findings. Blood studies show polycythemia and high hematocrit.[8] X-ray chest reveals oligemic lung fields (poorly vascularized lungs), a small boot shaped heart with the tip of boot turned up and above diaphragm (because of right ventricular hypertrophy) and concavity of pulmonary artery. ECG[9] demonstrates right axis deviation, an evidence of right ventricular hypertrophy with beaked P-waves. 2-D echocardiographs[10] establishes the diagnosis and provides information as to the extent of aortic over ride on the septum, location and degree of right out flow tract obstruction, size of proximal branch pulmonary artery and the side of aorotic arch. Cardiac catheterization demonstrates a systemic pressure. The number of sub epithelial gingival vessels per square millimeter in patient with ToF is significantly higher than in healthy subjects. After thoracic surgery, the number of gingival blood vessels drops back to normal.[1]

Unless the child's heart is repaired surgically ToF is fatal. Cyanotic spells usually respond to oxygen, morphine and knee-to-chest position. Prostaglandin E[11] is found to be of same use to improve blood flow through lungs. Propanolol is given to prevent hypoxic spells. Open-heart surgery is done to close the defect in the septum, remove extra heart muscle and open/repair the pulmonary valve at early age (less than 1 year).[8],[12] While performing dental procedures, sevoflurane is found to be better alternative than Halothane as an induction agent.[13]

It is stressed that dental treatment plan for patients with ToF must take into account the patients medical status prior to and following corrective surgical procedures Preoperative evaluation of cardiac function is must, lest patient might show Arrythmias.[14] These patient are also susceptible to SABE following minor surgery and dental extractions, hence patient should be put on antibiotic prophylaxis before any surgery or dental work.[1] Pulpectomy is questionable in these patients as ToF patients might suffer from cerebral abscess due to inadequate cleaning of lateral and accessory canals.[15]


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