Dental caries prevalence in children with congenital heart disease – a systematic review

Figures & data

Figure 1. PRISMA Flow Diagram of identification and selection of studies.

Table 1. Quality of the studies included in the systematic review on caries in children with congenital heart disease (CHD) according to the modified Newcastle-Ottawa scale.

	Selection (0–4 points)				Comparability (0–2 points)	Outcome (0–3 points)			Total Score (range 0–9)
Author, year (reference number)	Representativeness: All children with CHD in a defined catchment area = 1 or All children with CHD in a defined hospital or clinic =1	Comparison group: Community controls = 1 or Hospital controls =1	CHD diagnosis: Patient record = 1 or Structured interview =1	Sample size: Sample size calculation provided =1	Comparability: Mean age comparable in both groups = 1 and SES comparable in both groups =1	Assessment of caries: Clinical dental examination with or without BiteWing x-rays =1	Follow-up : Majority of patiens at least 3 years of age = 1	Calibration: Calibration of caries diagnosis performed =1
Pourmoghaddas et al., 2018 (24)	1	0	1	0	1 0	1	1	0	5
Ali et al., 2017 (15)	1	1	1	1	1 1	1	1	1	9
Cantekin et al., 2015 (22)	1	1	1	0	1 1	1	1	0	7
Cantekin et al., 2013 (16)	1	1	1	0	1 0	0	1	0	5
Suma et al., 2011 (18)	1	0	1	0	0 0	1	1	0	4
Siahi-Benlarbi et al., 2010 (21)	1	1	1	0	0 1	1	1	0	6
Da Fonseca et al., 2009 (19)	1	0	1	0	0 0	1	1	0	4
Tasioula et al., 2008 (23)	1	1	1	0	1 1	1	1	1	8
Stecksen-Blicks et al., 2004 (17)	1	1	1	0	1 0	0	1	0	5

SES: socioeconomic status; Representativeness: representativeness of children with CHD in the community; Comparison group: Comparison group derived from the same population as the children with CHD; CHD diagnosis: ascertainment of CHD diagnosis; Sample size: sample size calculation; Comparability: comparability of study groups; Follow-up: follow-up long enough for outcome to occur; Calibration: calibration of the examiner.

Table 2. Age, sample size, meth of caries assessment, and dental caries prevalence in children with CHD compared to a healthy control group.

Author, year reference number)	Age (years), range mean (SD)	Sample size (N)	Method of caries assessment	Dental caries prevalence (dmft/DMFT or dmfs/DMFS)	Mean (SD) or proportion Mean (SD)			P value (CHD vs C)
Pourmoghaddas et al., 2018 (24)	5-10 years CHD:7.4 (1.8) C: 7.8 (2.5)	CHD: 68 C : 74	Clinical examination	DMFT	CHD 6.4 (2.5)		C 5.5 (2.2)	0.14
Ali et al., 2017 (15)	3-12 years 3-7 years CHD: 4.8 (1.4) C: 4.9 (1.4) 8-12 years CHD: 10.0 (1.3) C: 10.1 (1.3)	CHD: 111 C: 182 CHD: 62 C: 101 CHD: 49 C: 81	Clinical examination	dmft dmft > 0 Sic DMFT DMFT > 0 Sic	CHD 3.7 (3.8) 77.4% 8.2 1.3 (1.7) 53.1% 1.8		C 2.3 (3.2) 56.5% 5.9 0.6 (0.9) 34.6% 0.8	0.021 0.007 0.008 0.008 0.038 0.001
Cantekin et al., 2015 (22)	3-14 years CHD: 6.24 (2.9) C 6.73 (3.0) 3-11 years CHD: 5.88 (2.6) C: 5.94 (2.8) 5-14 years CHD: 9.56 (2.8) C: 9.83 (2.8)	CHD: 72 C: 56 CHD: 63 C: 46 CHD: 42 C: 38	Clinical examination	dmft DMFT	CHD 2.80 (3.8) 0.81 (1.6)		C 1.87 (3.3) 0.72 (1.5)	0.36 0.79
Cantekin et. al., 2013 (16)	3-16 years CHD: 8 (3.2) C: 9.4 (3.4)	CHD: 165 C: 165	Dental and radiographical records	dmft DMFT	CHD 2.8 (7.5) 2.0 (2.1)		C 1.4 (3.7) 1.1 (1.7)	0.03 <0.001
Suma et al., 2011 (18)	2-12 years CHD + RHD: 6.5 (3.8) C: 6.5 (3.8) 2-5 years 6-12 years	CHD: 40 RHD: 10 C: 50 CHD + RHD:14 C: 17 CHD + RHD: 36 C: 33	Clinical examination	dmft DMFT	CHD + RHD 2.43 (2.5) 2.14 (2.4)		C 4.18 (2.8) 2.64 (2.5)	0.099 0.354
Siahi-Benlarbi et. al., 2010 (21)	2-16 years CHD: 8 HTx: 8 C: 10	CHD: 24 HTx: 31 C: 23	Clinical examination	dmft DMFT dmft/DMFT	CHD 1.7 0.2 1.9	HTx 0.2 0.3 0.5	C 1.5 2.0 2.0	ns ns ns
Da Fonseca et. al., 2009 (19)	1-6 years CHD: 3.0 (1.3) C: 2.7 (1.4)	CHD: 43 C: 43	Clinical examination	dmft dmft > 0	CHD 1.03 (1.9) 17%		C 1.23 (2.5) 13%	ns
Tasioula et. al., 2008 (23)	2-15 years CHD: 6.88 (3.6) C: 7.02 (4.3) 2-15 years CHD: 6.11 (3.1) C: 5.26 (2.8) 5-15 years CHD: 9.4 (2.8) C: 10.3 (3.1)	CHD: 86 C: 60 CHD: 76 C: 47 CHD: 48 C: 47	Clinical examination	dmft DMFT	CHD 1.57 (3.0) 0.77 (1.4)		C 1.81 (3.6) 0.38 (1.2)	ns ns
Stecksen-Blicks et al., 2004 (17)	2-12 years CHD: 6.5 (2.4) C: 6.5 (2.4)	CHD: 41 C: 41	Dental records and bite-wing radiographs from dental clinics	dmfs DMFS	CHD 4.7 (6.3) 0.6 (1.7)		C 2.1 (3.4) 0.3 (0.6)	<0.05 >0.05

C: control group; CHD: congenital heart disease; DMFS: number of decayed, missed or filled permanent tooth surfaces; dmfs: number of decayed, missed or filled primary tooth surfaces; DMFT: number of decayed, missed or filled permanent teeth; dmft: number of decayed, missed or filled primary teeth; HTx: heart transplantation; RHD: rheumatic heart disease; SD: standard deviation; Sic: Significant caries index (mean dmft/DMFT of the one-third of the participants with the highest dmft/DMFT scores). p Value denotes a comparison between CHD and controls caries prevalence measures, ns: non-significant.

Table 3. Publication year, geography, study design, CHD severity and type, syndromes and other diagnoses of the studies included in the analysis.

Author, year (reference number)	Geography	Study design	CHD severity	CHD type	Syndromes and other diagnoses
Pourmoghaddas et al., 2018 (24)	Iran	Cross-sectional	Grade 2 and 3 n = 44 Grade 4 n = 38	Operated CHD Cyanotic CHD	No information
Ali et al., 2017 (15)	Sudan	Cross-sectional	Grade 2 and 3	Mostly operated VSD, ASD, PDA, PS and TOF	Syndrome patients included Critically ill children and use of medication other than for CHDs were excluded
Cantekin et al., 2015 (22)	Turkey	Cross-sectional	No information		Not included
Cantekin et. al., 2013 (16)	Turkey	Cross-sectional	Grade 1 n = 36 Grade 2 n = 55 Grade 3 n = 63 Grade 4 n = 11	Mostly non-operated minor VSD Operated ASD, VSD, PDA Operated TGA, CoA, TA, Shone’s complex etc Operated unbalanced AVSD, PA, UVH	Not included
Suma et al., 2011 (18)	India	Cross-sectional	Grade 2 n = 28 Grade 3 n = 12	Operated ASD, VSD, PDA, Congenital heart block Operated TOF, AS, MVP	No information
Siahi-Benlarbi et. al., 2010 (21)	Germany	Cross-sectional	Grade 3-4	Operated CHD with endocarditis prophylaxis, including HTx	No information
Da Fonseca et. al., 2009 (19)	USA	Cross-sectional	No information		Not included
Tasioula et. al., 2008 (23)	UK	Cross-sectional	Grade 3-4	Operated CHD with endocarditis prophylaxis	Not included
Stecksen-Blicks et al., 2004 (17)	Sweden	Cross-sectional	Grade 2 n = 20 Grade 3 n = 12 Grade 4 n = 9	Operated AS, AS + CoA, PS + PDA, TGA + VSD, AVSD, PS, TGA, VSD, ASD, MI Operated PA + VSD, simple ccTGA, TOF, AS + CoA + VSD, PA + IVS + ASD, IAA + VSD Operated TCPC, VSD + PHT, HTx	Not included

Grade 1: mild CHD (no surgery); Grade 2: simple CHD with complete surgical repair; Grade 3: complex CHD withcomplete surgical repair likely requiring reintervention; Grade 4: complex CHD without complete surgical repair; AS: aortic stenosis; ASD: atrial septal defect; AVSD: atricoventricular septal defect; ccTGA: congenitally correctedtransposition of the great arteries; CHD: congenital heart disease; CoA: coarctation of aorta; HTx: heart transplantation;IAA: interrupted aortic arch; IVS: intact ventricular septum; MI: mitral valve insufficiency; MVP: mitral valveprolapse; PA: pulmonary atresia; PHT: pulmonary hypertension; PDA: patent ductus arteriorus; PS: pulmonary valvestenosis; TA: truncus arteriosus; TCPC: total cavopulmonary connection; TGA: transposition of the great arteris; TOF: tetralogy of Fallot; UVH: univentricular heart; VSD: ventricular septal defect.

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