Oral and Dental Late Effects after Pediatric Stem Cell Transplantation

Dental caries and dental developmental defects as adverse effects of antineoplastic treatment in childhood cancer survivors

PURPOSE

To evaluate the prevalence of dental caries and dental developmental defects (DDD) in childhood cancer survivors (CCS) and identify disease and treatment-related risk factors.

METHODS

CCS aged up to 21 years, diagnosed with a malignancy before the age of 10 years and in remission for at least one year were included. Data were collected from patients' medical records and through a clinical examination where presence of dental caries and prevalence of DDD were recorded. Fisher's exact test was used to assess possible correlations and multivariate regression analysis to determine risk factors for defect development.

RESULTS

Seventy CCS with a mean chronological age of 11.2 years at the time of examination, mean age at cancer diagnosis of 4.17 years, and a mean post-treatment follow-up time of 5.48 years were included. Mean DMFT/dmft was 1.31, with 29% of survivors presenting with at least one carious lesion. Younger patients on the day of examination and patients treated with higher radiation dose, showed significantly higher prevalence of dental caries. The prevalence of DDD was 59%, with demarcated opacities being the defect most commonly observed (40%). Age at dental examination, diagnosis, age at diagnosis, and time that have elapsed since the end of treatment were the factors significantly affecting its prevalence. Regression analysis revealed that age at examination was the only factor significantly associated with the presence of coronal defects.

CONCLUSION

A great number of CCS presented with at least one carious lesion or a DDD, with the prevalence being significantly associated with various disease-specific characteristics, but age at dental examination the only significant predictor.

Long-term effects of chemotherapy and radiation received during early childhood on the developing dentition of pediatric cancer patients

INTRODUCTION

The short-term effects of chemotherapy and irradiation are well documented; however, there is paucity regarding their long-term effects, especially in children and adolescents.

CASE DESCRIPTION

This paper discusses the long-term effects of chemotherapy and/or radiation received by the patients during their early childhood on the developing dentition. It comprises the compilation of 11 cases with alteration in the dental development screened from 138 cases of the childhood cancer patients who received the chemotherapy and/or radiation as a part of anticancer therapy.

RESULTS AND CONCLUSION

The findings revealed that the age of initiation of anticancer therapy along with the synergistic effect of chemo-irradiation, and the dose of radiation used were the principal determinants for the dental abnormalities. The root-related abnormalities were found to be varied and more common as compared to the missing teeth and defects related to the tooth crown.

Dvorak C, Den Besten P. Dental caries as a risk factor for bacterial blood stream infection (BSI) in children undergoing hematopoietic cell transplantation (HCT)

Background

Hematopoietic cell transplantation (HCT) is a potentially curative therapy for a wide range of pediatric malignant and nonmalignant diseases. However, complications, including blood stream infection (BSI) remain a major cause of morbidity and mortality. While certain bacteria that are abundant in the oral microbiome, such as S. mitis, can cause BSI, the role of the oral microbial community in the etiology of BSI is not well understood. The finding that the use of xylitol wipes, which specifically targets the cariogenic bacteria S. mutans is associated with reduced BSI in pediatric patients, lead us to investigate dental caries as a risk factor for BSI.

Methods

A total of 41 pediatric patients admitted for allogenic or autologous HCT, age 8 months to 25 years, were enrolled. Subjects with high dental caries risk were identified as those who had dental restorations completed within 2 months of admission for transplant, or who had untreated decay. Fisher's exact test was used to determine if there was a significant association between caries risk and BSI. Dental plaque and saliva were collected on a cotton swab from a subset of four high caries risk (HCR) and four low caries risk (LCR) children following pretransplant conditioning. 16SrRNA sequencing was used to compare the microbiome of HCR and LCR subjects and to identify microbes that were significantly different between the two groups.

Results

There was a statistically significant association between caries risk and BSI (p < 0.035) (Fisher's exact test). Multivariate logistic regression analysis showed children in the high dental caries risk group were 21 times more likely to have BSI, with no significant effect of age or mucositis severity. HCR subjects showed significantly reduced microbial alpha diversity as compared to LCR subjects. LEfse metagenomic analyses, showed the oral microbiome in HCR children enriched in order Lactobacillales. This order includes Streptococcus and Lactobacillus, both which contain bacteria primarily associated with dental caries.

Discussion

These findings support the possibility that the cariogenic microbiome can enhance the risk of BSI in pediatric populations. Future metagenomic analyses to measure microbial differences at, before, and after conditioning related to caries risk, may further unravel the complex relationship between the oral microbiome, and whether it affects health outcomes such as BSI.

Dental age estimation in children that have undergone antineoplastic treatment

OBJECTIVE

Even though many studies have been performed to estimate DA in general population, limited research has been performed concerning medical compromised populations such as childhood cancer survivors. The aims of this case-control study were (a) to estimate dental age in a population of children that have undergone antineoplastic treatment with three different methods and (b) to compare it with the estimates from healthy subjects (control group).

MATERIALS AND METHODS

Seventy-three oncology patients and equal number of healthy control subjects from the Pediatric dentistry Department had their dental age estimated through recent orthopantograms using Dermijian's, Willems' and London Atlas methods. All OPGs randomly assessed by two calibrated observers. Mean age difference was calculated. Intraclass Correlation Coefficient was used to assess intra-observer reliability and the Concordance Correlation Coefficient used to assess inter-observer reliability.

RESULTS

Concerning the CCS group 35 subjects (48%) were males and 38 (52%) were females, with an overall mean chronological age 10.95 years, ranging between 5.37 and 15.83 years. Intra- and inter-examiner reliability was exceptional for all methods. Mean DA differences in both groups and were not statistically sinificant regardless of the method used. The marginally lower values when males and females were investigated separately is basically due to the corresponding reduction of the sample size.

CONCLUSION

An overestimation of DA observed in both groups by all methods was not significant. All three methods produced highly accurate comparable results when it comes to estimate the actual chronological age in both groups (CCS and control subjects) regardless of gender.

Late effects of chemo and radiation treatment on dental structures of childhood cancer survivors. A systematic review and meta-analysis

BACKGROUND

This systematic review summarizes the prevalence of dental defects after chemo and radiation therapy and correlates the findings with specific characteristics of each treatment modality.

METHODS

Database search was performed for studies reporting dental late effects of chemo and radiation therapy. After data extraction and risk of bias assessment, prevalence of crown and root defects was assessed. Correlations between each defect and the characteristics of the antineoplastic treatment were performed.

RESULTS

Sixteen nonrandomized studies were included, yielding a total of 1300 patients with a mean age at diagnosis of 4.5 years. Results reported that root defects were more common than crown defects. The most common root defect was impaired root growth and microdontia the most common crown defect. Age, radiation dose and field were statistically associated with higher prevalence of dental defects.

CONCLUSION

Defects were associated with combination of chemotherapy and radiotherapy, as used in current therapeutic antineoplastic modalities.

Dental and craniofacial alterations in long-term survivors of childhood head and neck rhabdomyosarcoma

OBJECTIVE

Rhabdomyosarcoma (RMS) represents the most common soft tissue sarcoma that affects children. Treatment involves chemoradiotherapy. This study aimed at evaluating the long-term alterations to teeth and cranial bones in children, teenagers, and young adults after oncologic treatment.

STUDY DESIGN

We conducted a cross-sectional study of patients undergoing treatment for head and neck RMS between 1988 and 2011. We evaluated demographic, clinical, and treatment data and performed panoramic radiography, cephalometry, and photography.

RESULTS

We evaluated 27 long-term survivors, most of whom had been treated between ages 0 to 5 years (51.9%). The total radiation dose applied was 50.4 Gy, and the chemotherapy combination included vincristine, actinomycin D, and cyclophosphamide in 51.9% of the cases. We observed 603 dental alterations, among which 377 (62.7%) occurred in patients ages 0 to 5 years, and root shortening was the most frequent alteration observed (24.2%). With regard to facial bones, 74% of the patients had some level of facial asymmetry, 70.4% had reduced facial depth, 48.4% had mandibles of short size, and 77.8% had reduced facial height.

CONCLUSIONS

Children submitted to RMS treatment involving chemotherapy and radiotherapy displayed significant dental and craniofacial alterations, especially when treatment occurred between ages 0 and 5 years.

Impact of Hematopoietic Stem Cell Transplantation on Dental Development

To investigate dental development in patients treated with a hematopoietic stem cell transplantation (HSCT), 42 children and young adults who were under 12 years old at time of HSCT were examined for dental agenesis, microdontia, and root-to-crown ratio. Conditioning regimens were total body irradiation (TBI) based in 12 patients, busulfan based in 21 patients, and 9 patients had other chemotherapeutic agents. Sixteen patients were <3 years old, 9 patients were 3 to 6 years old, and 17 patients were 6 to 12 years old at HSCT. Prevalence of agenesis and microdontia of at least 1 permanent tooth were, respectively, 51.3% and 46.2% in the study population, and 76.3% had an aberrant root-to-crown ratio. All these results were highly different from the prevalence in the healthy population. Patients treated before the age of 3 years had more microdontia (76.9%) and agenesis (92.3%) compared with patients treated at an older age. In the subgroup of patients treated after 6 years, there was more microdontia when treated with busulfan (50%) compared with treatment with TBI (0%) (P = .044). Patients treated with HSCT had many disturbances in dental development. Age at HSCT and possibly also the conditioning regimen used had an effect on their type and prevalence. Dental follow-up should be incorporated in the multidisciplinary follow-up program of these patients.

Late Effects after Umbilical Cord Blood Transplantation in Very Young Children after Busulfan-Based, Myeloablative Conditioning

Infants and young children who undergo allogeneic cord blood transplantation (CBT) are at increased risk for late effects because of exposure of developing organs to chemotherapy and radiation therapy typically used in transplant conditioning regimens. Busulfan (Bu)-based myeloablative regimens were developed to eliminate radiation exposure in these young children with the hope that late effects would be minimized. We now describe the late effects in 102 consecutive patients surviving a minimum of 5 years (median follow-up, 12.9 years) post-CBT. Patients were conditioned with high-dose chemotherapy using Bu-containing regimens. No patient received total body irradiation. The median age at transplant was 1 year (range, .1 to 2). Diagnoses included inherited metabolic diseases (59.8%), leukemia (17.6%), congenital immune deficiency (20.2%), bone marrow failure/myelodysplastic syndrome (3.9%), and hemoglobinopathy (2%). Among patients surviving 5 years, the overall survival rate at 10 years post-CBT was 93% (95% CI, 84.9 to 96.8). Virtually all patients (98%) experienced at least 1 significant late effect. Most (83.3%) experienced 2 or more late effects, and more than half of the patients (64.7%) experienced 3 or more late effects. The most commonly observed late effects included dental problems (92.2%), short stature (55.9%), cognitive deficits (53.6%), pulmonary dysfunction (18.6%), and abnormal pubertal development (27.9%). This is the first report of late effects of Bu-based conditioning in a cohort of very young patients at the time of transplant. These results will inform clinical care guidelines for long-term follow-up and add to the growing information regarding outcomes of hematopoietic stem cell transplantation.

Dental pulp therapy for primary teeth in children undergoing cancer therapy

BACKGROUND

Childhood cancer treatment negatively affects the immune system, increasing the risk for bacteremia and septicemia. As the oral cavity is a major entry portal for pathogens into the bloodstream dental care in such children tends to be radical, favouring tooth extraction over less drastic treatments such as pulpotomy, the amputation of infected dental pulp. The present study aimed to compare pulpotomy treatment success rate in children with cancer receiving immunosuppressive therapy with that of healthy children, and investigate if unsuccessful pulpotomy treatment in oncologic patients may lead to systemic complications.

PROCEDURE

Twenty-six medical records of children from a paediatric oncology referral centre who had dental pulpotomy treatment (in 41 teeth) while receiving active cancer care during the years 2006-2012 were compared with records of 41 randomly selected healthy children who had undergone pulpotomy treatment (41 teeth) in the same institute during these years. Clinical and radiographic data were collected during treatments and at the end of the follow-up period (six months post dental treatment).

RESULTS

No statisticaly significant difference was found between pulpotomy success rate amongst the two groups. Treatments success rates in the study and control groups were 82.9% (± 5.9) and 90.2% (± 4.7), respectively. No patient in the study group suffered from sepsis from a dental origin during follow-up period.

CONCLUSIONS

Pulpotomy in paediatric cancer patients did not increase the risk for bacteremia or systemic complications from oral origin. We therefore recommend the re-evaluation of the current protocol for treating paediatric oncology patients.

Oral and dental late effects in survivors of childhood cancer: a Children's Oncology Group report

PURPOSE

Multi-modality therapy has resulted in improved survival for childhood malignancies. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers provide practitioners with exposure- and risk-based recommendations for the surveillance and management of asymptomatic survivors who are at least 2 years from completion of therapy. This review outlines the pathophysiology and risks for oral and dental late effects in pediatric cancer survivors and the rationale for oral and dental screening recommended by the Children's Oncology Group.

METHODS

An English literature search for oral and dental complications of childhood cancer treatment was undertaken via MEDLINE and encompassed January 1975 to January 2013. Proposed guideline content based on the literature review was approved by a multi-disciplinary panel of survivorship experts and scored according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus" system.

RESULTS

The Children's Oncology Group oral-dental panel selected 85 relevant citations. Childhood cancer therapy may impact tooth development, salivary function, craniofacial development, and temporomandibular joint function placing some childhood cancer survivors at an increased risk for poor oral and dental health. Additionally, head and neck radiation and hematopoietic stem cell transplantation increase the risk of subsequent malignant neoplasms in the oral cavity. Survivors require routine dental care to evaluate for potential side effects and initiate early treatment.

CONCLUSIONS

Certain childhood cancer survivors are at an increased risk for poor oral and dental health. Early identification of oral and dental morbidity and early interventions can optimize health and quality of life.

A systematic review of dental late effects in survivors of childhood cancer

Survivors of childhood cancer are at risk for dental late effects. This systematic review summarizes associations between treatment exposures and dental late effects among survivors of childhood cancer. We included investigations with at least 20 study participants conducted for 2 or more years after completion of childhood, adolescent, or young adult cancer therapy. This review suggests both independent and additive effects of radiotherapy and chemotherapy on dental complications, and identifies vulnerable groups with specific host and treatment characteristics. This summary provides information that will assist clinicians to prevent, detect, and facilitate early intervention for dental late effects.