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Milgrom SA, van Luijk P, Pino R, Ronckers CM, Kremer LC, Gidley PW, Grosshans DR, Laskar S, Okcu MF, Constine LS, Paulino AC. Salivary and Dental Complications in Childhood Cancer Survivors Treated With Radiation Therapy to the Head and Neck: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:467-481. [PMID: 34074567 DOI: 10.1016/j.ijrobp.2021.04.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/14/2021] [Accepted: 04/21/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Radiation therapy (RT) to the head and neck (H&N) region is critical in the management of various pediatric malignancies; however, it may result in late toxicity. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on salivary dysfunction and dental abnormalities in survivors who received RT to the H&N region as children. MATERIALS & METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. RESULTS Of the 2,164 articles identified through a literature search, 40 were included in a qualitative synthesis and 3 were included in a quantitative synthesis. The dose-toxicity data regarding salivary function demonstrate that a mean parotid dose of 35 to 40 Gy is associated with a risk of acute and chronic grade ≥2 xerostomia of approximately 32% and 13% to 32%, respectively, in patients treated with chemo-radiation therapy. This risk increases with parotid dose; however, rates of xerostomia after lower dose exposure have not been reported. Dental developmental abnormalities are common after RT to the oral cavity. Risk factors include higher radiation dose to the developing teeth and younger age at RT. CONCLUSIONS This PENTEC task force considers adoption of salivary gland dose constraints from the adult experience to be a reasonable strategy until more data specific to children become available; thus, we recommend limiting the parotid mean dose to ≤26 Gy. The minimum toxic dose for dental developmental abnormalities is unknown, suggesting that the dose to the teeth should be kept as low as possible particularly in younger patients, with special effort to keep doses <20 Gy in patients <4 years old.
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Affiliation(s)
- Sarah A Milgrom
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ramiro Pino
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas
| | - Cecile M Ronckers
- Princess Máxima Centrum for Pediatric Oncology, Utrecht, Netherlands; Institute of Biostatistics and Registry Research, Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C Kremer
- Institute of Biostatistics and Registry Research, Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany; UMC Amsterdam, Location AMC, Department of Pediatrics, Amsterdam, Netherlands
| | - Paul W Gidley
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Siddhartha Laskar
- Department of Radiation Oncgqtology, Tata Memorial Hospital, Mumbai, India
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
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Pombo Lopes J, Rodrigues I, Machado V, Botelho J, Bandeira Lopes L. Chemotherapy and Radiotherapy Long-Term Adverse Effects on Oral Health of Childhood Cancer Survivors: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 16:110. [PMID: 38201538 PMCID: PMC10777916 DOI: 10.3390/cancers16010110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
The survival rate for pediatric cancer has increased over the past few decades, short- and long-term complications have been detected and studied, and oral complications have emerged as an important topic of research. Here, we aimed to highlight the importance of oral manifestations that may only become apparent years or even decades after cancer treatment. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched articles using PubMed via the MEDLINE, Web of Science, and LILACS databases until October 2023. Overall, 35 observational studies were included, and the results estimated a pooled prevalence of the following dental anomalies: discoloration, 53%; crown-root malformations and agenesis, 36%; enamel hypoplasia, 32%; root development alterations, 29%; unerupted teeth, 24%; microdontia, 16%; hypodontia, 13%; and macrodontia, 7%. Most childhood cancer survivors have at least one dental sequela. Childhood cancer survivors presented a higher risk of having dental alterations than control counterparts. Additional analyses reveal possible sex-based differences that should be explored in future studies. These results collectively highlight the importance of oral healthcare and the prevention of disease in childhood cancer survivors.
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Affiliation(s)
- Joana Pombo Lopes
- Clinical Research Unit, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal; (J.P.L.); (I.R.); (V.M.); (J.B.)
| | - Inês Rodrigues
- Clinical Research Unit, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal; (J.P.L.); (I.R.); (V.M.); (J.B.)
| | - Vanessa Machado
- Clinical Research Unit, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal; (J.P.L.); (I.R.); (V.M.); (J.B.)
- Evidence-Based Hub, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
| | - João Botelho
- Clinical Research Unit, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal; (J.P.L.); (I.R.); (V.M.); (J.B.)
- Evidence-Based Hub, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
| | - Luísa Bandeira Lopes
- Clinical Research Unit, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal; (J.P.L.); (I.R.); (V.M.); (J.B.)
- Evidence-Based Hub, Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, 2829-511 Almada, Portugal
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Long-Term Effects of Childhood Cancer Treatment on Dentition and Oral Health: A Dentist Survey Study from the DCCSS LATER 2 Study. Cancers (Basel) 2021; 13:cancers13215264. [PMID: 34771429 PMCID: PMC8582458 DOI: 10.3390/cancers13215264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 11/21/2022] Open
Abstract
Simple Summary We aimed to identify the prevalence of and independent risk factors for dental and oral problems in childhood cancer survivors (CCSs). This cross-sectional study is part of the Dutch Childhood Cancer Survivor Study (DCCSS) LATER 2. Our study included survey data on 154 CCSs, on whom information from dentists on oral health data was received (71.3%). In total, 36.3% of survivors were reported to have at least one dental developmental disorder (DDD). The most prevalent DDDs were short-root anomaly (14.6%), agenesis (14.3%), and microdontia (13.6%). Risk factors for at least one DDD were younger age at diagnosis (<3 years vs. 5+ years) and dose-dependent alkylating agent therapy. This study provides more insight into risk factors for oral health problems in Dutch CCSs. This information is essential in order to improve early detection, prevention, and dental care of oral health problems in CCSs. Abstract Objectives: The aim of this study was to identify the prevalence of and independent risk factors for long-term effects of childhood cancer treatment on the dentition and oral health in childhood cancer survivors (CCSs). Methods: This cross-sectional study is part of the Dutch Childhood Cancer Survivor Study (DCCSS) LATER 2. CCSs were diagnosed with cancer between 1963 and 2001. This study focuses on survey data of 154 CCSs on whom information about their oral health was received from their dentists (71.3%). Descriptive statistics and univariable and multivariable Poisson regression analyses were performed to determine the association between treatment characteristics and oral health data. Results: Of the study group, 36.3% had at least one DDD. The most prevalent DDDs were short-root anomaly (14.6%), agenesis (14.3%), and microdontia (13.6%). Risk factors for at least one DDD were younger age at diagnosis (<3 years) and dose-dependent alkylating agent therapy. Conclusions: This study provides more insight into risk factors for oral health problems in Dutch CCSs. This information is essential in order to improve early detection, prevention, dental care, and quality of life. Further studies are needed in order to better define dose-related radiotherapy exposure of the developing teeth in correlation with oral health problems.
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Afanasyev DE, Liubarets SF. ODONTOLOGICAL EFFECTS OF IONIZING RADIATION (review). PROBLEMY RADIAT︠S︡IĬNOÏ MEDYT︠S︡YNY TA RADIOBIOLOHIÏ 2020; 25:18-55. [PMID: 33361828 DOI: 10.33145/2304-8336-2020-25-18-55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Odontological effects of ionizing radiation (IR) as a result of radiotherapy, the consequences of accidents at nuclear power plants and industry, individual occupational exposure, etc. deserve significant attention interns of radiation medicine and radiation safety. OBJECTIVE to analyze and summarize clinical and experimental data on the odontological radiation effects. MATERIALS AND METHODS OBJECT the pathological changes in the hard tissues of teeth, pulp, periodontium, mucousmembranes of the mouth and jaws due to exposure to IR. METHOD search in the PubMed / MEDLINE, Google Scholarabstract medical and biological databases, scientific libraries of the relevant sources of scientific information. RESULTS Radiobiological effects of IR due to its direct and indirect action are manifested throughout the period ofodontogenesis and formation of the facial skeleton. Experimental and clinical data (in children and adults) indicatethe increased risk of dental caries, reduction of pain threshold and vascularization of tooth pulp along with its fibrosis and atrophy, periodontal dysfunction, which predispose to a high probability of tooth loss. Abnormalities in theactivity of osteoblasts and cementoblasts of dental periosteum and osteoblasts of alveolar process in combinationwith circulatory disorders due to endothelial cell death, hyalinization, thrombosis and vascular obliteration increasethe risk of jaw osteoradionecrosis. Children who have undergone a prenatal exposure to IR as a result of theChornobyl NPP accident have a premature change of teeth. Deterioration of periodontal tissues and early development of acute and complicated dental caries are typical for children and adults affected by the Chornobyl disaster. CONCLUSIONS Summarized data on the effects of radiation exposure under different conditions on teeth primordia(i.e. immature teeth), their formation and eruption in experimental and clinical settings, as well as on the odontological radiation effects in adults are summarized. Condition of the teeth in the Chornobyl NPP accident survivorsis described. Understanding and taking into account the radiobiological odontological effects is necessary in thelight of planning, preparing, and conducting local radiation therapy and developing the standards of radiation safety and measures to protect professionals and the public in the event of possible radiation accidents at the nuclearpower plants and industry facilities.
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Affiliation(s)
- D E Afanasyev
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Yuriia Illienka St., Kyiv, 04050, Ukraine
| | - S F Liubarets
- O. O. Bogomolets National Medical University of the Ministry of Health of Ukraine, 13 Tarasa Shevchenka Blvd., Kyiv, 01601, Ukraine
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Matsuo S, Toda-Nakamura M, Oka K, Kajiya H, Ogata K, Ishii H, Ozaki M, Ohno J. Cyclophosphamide Promotes Arrested Development of the Dental Root in Mice. J HARD TISSUE BIOL 2020. [DOI: 10.2485/jhtb.29.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Satoru Matsuo
- Section of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
- Research Center for Regenerative Medicine, Fukuoka Dental College
| | - Masako Toda-Nakamura
- Section of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
| | - Kyoko Oka
- Section of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
- Oral Medicine Research Center, Fukuoka Dental College
| | - Hiroshi Kajiya
- Research Center for Regenerative Medicine, Fukuoka Dental College
- Oral Medicine Research Center, Fukuoka Dental College
- Section of Cellular Physiology, Department of Physiological Science and Molecular Biology, Fukuoka Dental College
| | - Kayoko Ogata
- Oral Medicine Research Center, Fukuoka Dental College
- Section of Functional Structure, Department of Morphological Biology, Fukuoka Dental College
| | - Hanako Ishii
- Section of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
- Research Center for Regenerative Medicine, Fukuoka Dental College
| | - Masao Ozaki
- Section of Pediatric Dentistry, Department of Oral Growth and Development, Fukuoka Dental College
| | - Jun Ohno
- Research Center for Regenerative Medicine, Fukuoka Dental College
- Oral Medicine Research Center, Fukuoka Dental College
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Specific Aspects of Supportive Care in Pediatric Radiation Oncology. Radiat Oncol 2020. [DOI: 10.1007/978-3-319-52619-5_117-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Seremidi K, Kloukos D, Polychronopoulou A, Kattamis A, Kavvadia K. Late effects of chemo and radiation treatment on dental structures of childhood cancer survivors. A systematic review and meta-analysis. Head Neck 2019; 41:3422-3433. [PMID: 31228308 DOI: 10.1002/hed.25840] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/17/2019] [Accepted: 06/04/2019] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Kyriaki Seremidi
- Department of Paediatric Dentistry, Athens School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Kloukos
- Department of Orthodontics, 251 Greek Air Force Hospital, Athens, Greece.,Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland
| | - Argy Polychronopoulou
- Department of Preventive and Community Dentistry, Athens School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonis Kattamis
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Kavvadia
- Department of Comprehensive Dentistry, Division of Pediatric Dentistry, University of Louisville, Louisville, Kentucky
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8
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Oral and dental alterations and growth disruption following chemotherapy in long-term survivors of childhood malignancies. Support Care Cancer 2018; 27:1891-1899. [DOI: 10.1007/s00520-018-4454-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 08/30/2018] [Indexed: 11/30/2022]
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9
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Kang CM, Hahn SM, Kim HS, Lyu CJ, Lee JH, Lee J, Han JW. Clinical Risk Factors Influencing Dental Developmental Disturbances in Childhood Cancer Survivors. Cancer Res Treat 2018; 50:926-935. [PMID: 29020731 PMCID: PMC6056986 DOI: 10.4143/crt.2017.296] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/30/2017] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Although studies regarding dental developmental disturbances after childhood cancer treatment have increased, they have many limitations. Studies analyzing the significance of independent clinical risk factors with regard to the dental health status are also rare. We aimed to investigate the risk factors for dental developmental disturbances, particularly severe disturbances, in childhood cancer survivors (CCS). MATERIALS AND METHODS Oral examinations and retrospective reviews of medical and panoramic radiographs were performed for 196 CCS (mean age, 15.6 years). Cancer type, age at diagnosis, treatment modality, type and accumulated dose of administered drugs, and dose and site of radiation were recorded. Dental developmental disturbances were diagnosed using panoramic radiographs and graded for severity according to the Modified Dental Defect Index (MDDI). Descriptive statistics and multivariate analyseswere performed to determine the association between dental abnormalities and clinical factors. RESULTS In total, 109 CCS (55.6%) exhibited at least one dental anomaly, and the median value of MDDI was 2.5. Microdontia (30.6%) was the most prevalent anomaly, followed by tooth agenesis (20.4%), V-shaped roots (14.8%), and taurodontism (10.2%). Multivariate analysis revealed that a young age at diagnosis (≤ 3 years), a history of hematopoietic stem cell transplantation, the use of multiple classes of chemotherapeutic agents (≥ 4 classes), and the use of heavy metal agents were significant risk factors for severe dental disturbances. CONCLUSION CCS with any of the above risk factors for severe developmental disturbances should be comprehensively followed up to minimize adverse consequences to their dental development and preserve their future dental health.
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Affiliation(s)
- Chung-Min Kang
- Department of Pediatric Dentistry, Yonsei University College of Dentistry, Seoul, Korea
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Hahn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Hyo Sun Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Chuhl Joo Lyu
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Jae-Ho Lee
- Department of Pediatric Dentistry, Yonsei University College of Dentistry, Seoul, Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Woo Han
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
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Neill CC, Migliorati C, Trojan T, Kaste S, Karydis A, Rowland C, Parris W. Experience and expertise regarding orthodontic management of childhood and adolescent cancer survivors. Am J Orthod Dentofacial Orthop 2015; 148:765-70. [DOI: 10.1016/j.ajodo.2015.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 05/01/2015] [Accepted: 05/01/2015] [Indexed: 10/22/2022]
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Cyclophosphamide-Induced Morphological Changes in Dental Root Development of ICR Mice. PLoS One 2015; 10:e0133256. [PMID: 26186337 PMCID: PMC4506128 DOI: 10.1371/journal.pone.0133256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/25/2015] [Indexed: 12/11/2022] Open
Abstract
Background Survivors of childhood cancer are at risk of late dental development. Cyclophosphamide is one of the most commonly used chemotherapeutic agents against cancer in children. The aim of this study was to investigate the effects of cyclophosphamide on root formation in the molars of growing mice and to assess the morphological changes in these roots using three-dimensional structural images. Methods We treated 16 12-day-old ICR mice with cyclophosphamide (100 mg/kg, i.p.) and 16 control mice with saline. At 16, 20, 24, and 27 days of age, the mandibular left first molars were scanned using soft micro-computed tomography. After scanning, the structural indices were calculated using a three-dimensional image analysis system, and the images were subjected to three-dimensional reconstruction. The length and apical foramen area of all distal roots were assessed. Histological changes in the apical region were then assessed via hematoxylin and eosin staining. Results The mandibular molars of all experimental mice showed evidence of cytotoxic injury, which appeared in the form of anomalous root shapes. Although all roots developed further after cyclophosphamide injection, the three-dimensional structural images showed that the roots in the experimental group tended to develop more slowly and were shorter than those in the control group. At 27 days of age, the mean root length was shorter in the experimental group than in the control group. Conversely, the apical foramen of the roots in the experimental group tended to close faster than that of roots in the control group. In addition, hematoxylin and eosin staining of the distal roots in the experimental group showed increased dentin thickness in the apical region. Conclusion Our results suggest that cyclophosphamide can result in short root lengths and early apical foramen closure, eventually leading to V-shaped or thin roots.
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12
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Effinger KE, Migliorati CA, Hudson MM, McMullen KP, Kaste SC, Ruble K, Guilcher GMT, Shah AJ, Castellino SM. Oral and dental late effects in survivors of childhood cancer: a Children's Oncology Group report. Support Care Cancer 2014; 22:2009-19. [PMID: 24781353 PMCID: PMC4118932 DOI: 10.1007/s00520-014-2260-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 04/16/2014] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Karen E Effinger
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Stanford University, 1000 Welch Rd, Suite 300, Palo Alto, CA, 94304, USA,
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13
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Gawade PL, Hudson MM, Kaste SC, Neglia JP, Constine LS, Robison LL, Ness KK. A systematic review of dental late effects in survivors of childhood cancer. Pediatr Blood Cancer 2014; 61:407-16. [PMID: 24424790 PMCID: PMC4281834 DOI: 10.1002/pbc.24842] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 10/08/2013] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Prasad L. Gawade
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital, Memphis, TN 38105
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital, Memphis, TN 38105 ,Oncology, St. Jude Children’s Research Hospital, Memphis, TN
38105
| | - Sue C. Kaste
- Oncology, St. Jude Children’s Research Hospital, Memphis, TN
38105 ,Radiological Sciences at St. Jude Children’s Research
Hospital, Memphis, TN 38105 ,Department of Radiology, College of Medicine, University of
Tennessee Health Science Center, 910 Madison, Suite 1002, Memphis, TN 38163
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School,
Minneapolis, MN 55455
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, School of Medicine
and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 647,
Rochester, NY 14642
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital, Memphis, TN 38105
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital, Memphis, TN 38105
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Nishimura S, Inada H, Sawa Y, Ishikawa H. Risk factors to cause tooth formation anomalies in chemotherapy of paediatric cancers. Eur J Cancer Care (Engl) 2013; 22:353-60. [PMID: 23336315 PMCID: PMC3655612 DOI: 10.1111/ecc.12038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2012] [Indexed: 11/28/2022]
Abstract
This study aimed to investigate the risk factors of tooth formation anomalies in anti-cancer chemotherapies. Long-term survivors treated by conventional chemotherapy (n = 26), conventional chemotherapy with high-dose chemotherapy (HDC) (n = 14), and HDC with total body irradiation (TBI) (n = 6) were analysed for the incidence of tooth agenesis, microdonts, and short-rooted teeth. The tooth agenesis and/or microdonts were found in second premolars and second molars, but not in first molars or central incisors. The ratio of subjects with tooth agenesis and/or microdonts was 66.7% and 18.2% in subjects administered conventional chemotherapy at <4 years and ≥4 years of age, respectively, while it was 100% and 25% in subjects administered HDC at <4 years and ≥4 years of age. The incidence of tooth formation anomalies did not related with the duration of conventional chemotherapy but increased by HDC. The incidence of tooth formation anomalies did not show significantly differences between the HDC with and without TBI groups, and was higher in busulfan-administered subjects than in subjects given cyclophosphamide. It may be concluded that the high-risk group of tooth agenesis is the subjects with HDC under 4 years of age. However, protocols of conventional chemotherapy are not an important risk factor to cause the tooth formation anomalies.
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Affiliation(s)
- S Nishimura
- Department of Oral Growth & Development, Fukuoka Dental College, Sawara-ku, Fukuoka, Japan
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Vesterbacka M, Ringdén O, Remberger M, Huggare J, Dahllöf G. Disturbances in dental development and craniofacial growth in children treated with hematopoietic stem cell transplantation. Orthod Craniofac Res 2012; 15:21-9. [PMID: 22264324 DOI: 10.1111/j.1601-6343.2011.01533.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the correlation between age, degree of disturbances in dental development, and vertical growth of the face in children treated with hematopoietic stem cell transplantation (HSCT). PATIENTS 39 long-term survivors of HSCT performed in childhood and transplanted before the age of 12, at a mean age of 6.8±3.3 years. METHODS Panoramic and cephalometric radiographs were taken at a mean age of 16.2 years. For each patient two age- and sex-matched healthy controls were included. The area of three mandibular teeth was measured and a cephalometric analysis was performed. RESULTS The mean area of the mandibular central incisor, first and second molar was significantly smaller in the HSCT group, and the vertical growth of the face was significantly reduced, especially in the lower third, compared to healthy controls. A statistically significant correlation between age at HSCT, degree of disturbances in dental development, and vertical growth of the face was found. Children subjected to pre-HSCT chemotherapy protocols had significantly more growth reduction in vertical craniofacial variables compared to children without pre-HSCT chemotherapy. Conditioning regimens including busulfan or total body irradiation had similar deleterious effects on tooth area reduction and craniofacial parameters. CONCLUSIONS The younger the child is at HSCT, the greater the impairment in dental and vertical facial development. This supports the suggestion that the reduction in lower facial height found in SCT children mainly is a result of impaired dental development and that young age is a risk factor for more severe disturbances.
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Affiliation(s)
- M Vesterbacka
- Division of Orthodontics and Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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16
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Tolentino EDS, Centurion BS, Ferreira LHC, Souza APD, Damante JH, Rubira-Bullen IRF. Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients. J Appl Oral Sci 2012; 19:448-54. [PMID: 21986648 PMCID: PMC3984189 DOI: 10.1590/s1678-77572011000500003] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 10/26/2010] [Indexed: 11/22/2022] Open
Abstract
Radiotherapy, alone or associated with surgery or chemotherapy, produces a
significant increase in cure rates for many malignancies of the head and neck region.
However, high doses of radiation in large areas, including the oral mucosa, may
result in several undesired reactions that manifest during or after the completion of
therapy. The multidisciplinary management is the best alternative to minimize or even
prevent such reactions, and the dentist has a fundamental role in this context. This
paper reviews the literature related to the main oral sequelae from head and neck
radiotherapy and establishes clinical oral management protocol for these irradiated
patients.
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Affiliation(s)
- Elen de Souza Tolentino
- Department of Stomatology, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil
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Cubukcu CE, Sevinir B, Ercan I. Disturbed dental development of permanent teeth in children with solid tumors and lymphomas. Pediatr Blood Cancer 2012; 58:80-4. [PMID: 21254371 DOI: 10.1002/pbc.22902] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 10/11/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND Deficient dental root development has been reported after conventional pediatric anticancer therapy but less information is available on children with solid tumors and lymphomas. PROCEDURE We examined dental development from panoramic radiographs (PRGs) of 37 childhood cancer survivors (CCS) treated under the age of 10 years with multimodal chemotherapy (CT) and/or head and neck radiotherapy (RT). A novel defect index (DeI) was used to describe the total damage to permanent dentition. The DeI was also tested in matched controls. RESULTS All CCS had dental disturbances including abnormal root development (86.4%), microdontia (13.5%) and tooth agenesis (16.2%). Testing the controls gave the mean DeI value 1.9 ± 2.7 (range, 0-12), while the index scores in the study group varied from 0 to 49 (mean 10.8 ± 11.2) (P < 0.01). The statistical differences in the mean DeI values were insignificant between CT and CT and RT groups (P > 0.05). CONCLUSIONS Children treated for solid tumors and lymphomas are at considerable risk of some disturbances in developing dental structures. RT increased the severity of disturbances induced by CT. Studies should further elucidate dose-, age and time-related effects of anticancer treatment on dental development.
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Hodgson B, Pyszka B, Henry M, Buchmann E, Whelan H. Effect of Photobiomodulation on Vinblastine-Poisoned Murine HERS Cells. Photomed Laser Surg 2011; 29:233-7. [DOI: 10.1089/pho.2010.2794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- B.D. Hodgson
- Marquette University, Milwaukee, Wisconsin
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - B. Pyszka
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - M.M. Henry
- Medical College of Wisconsin, Milwaukee, Wisconsin
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - E. Buchmann
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - H.T. Whelan
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
- Medical College of Wisconsin, Milwaukee, Wisconsin
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Hsieh SGS, Hibbert S, Shaw P, Ahern V, Arora M. Association of cyclophosphamide use with dental developmental defects and salivary gland dysfunction in recipients of childhood antineoplastic therapy. Cancer 2010; 117:2219-27. [PMID: 21523736 DOI: 10.1002/cncr.25704] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/09/2010] [Accepted: 09/10/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to examine the effect of antineoplastic therapy on dental development and saliva function in recipients of childhood antineoplastic therapy. METHODS Patients attending the long-term follow-up clinic at Children's Hospital at Westmead, NSW, Australia, were included if they had received treatment prior to 16 years of age and were in remission for more than 5 years. A dental examination and saliva test were performed for each participant. Holtta's Defect Index (HDI) was used to assess tooth aplasia, microdontia, and root-crown ratio on an orthopantomogram (OPG). Multivariable-adjusted regression analyses were used to estimate the association of patient characteristics and treatment modalities with dental outcomes. RESULTS One hundred six participants (61% male) were recruited (response rate = 88%). The mean HDI score was 24.7 ± 17.8. A cumulative dose of cyclophosphamide >7500 mg/m(2) increased the HDI score by 13.06 (P = .01). Recipients of cyclophosphamide also had significantly increased odds of exhibiting very low saliva flow (<0.7 mL/min) (odds ratio = 12.43; 95% confidence interval, 2.08-74.35; P = .006). CONCLUSIONS Children and adolescents who received high doses of cyclophosphamide were at increased risk of dental disturbances. Cyclophosphamide recipients were also at greater risk of exhibiting very low saliva flow. This study applied the HDI to patients receiving all forms of antineoplastic treatment and highlights the dose-dependent relation between cumulative dose of cyclophosphamide and dental disturbances.
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Affiliation(s)
- Susan Gyea-Su Hsieh
- Westmead Centre for Oral Health, Children's Hospital at Westmead, Westmead, Australia.
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20
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Vasconcelos NPS, Caran EMM, Lee ML, Lopes NNF, Weiler RME. Dental maturity assessment in children with acute lymphoblastic leukemia after cancer therapy. Forensic Sci Int 2009; 184:10-4. [PMID: 19147312 DOI: 10.1016/j.forsciint.2008.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 10/07/2008] [Accepted: 11/16/2008] [Indexed: 12/19/2022]
Abstract
UNLABELLED Dental age is largely used in both forensic studies and clinical practice. All over the world, many studies have been made to determine chronological age using dental ages of individuals, but selecting individuals with no chronic or acute sickness as the study group. Cancer is the second most frequent cause of death in children, and acute lymphoblastic leukemia (ALL) is the most common type of cancer in childhood. Most of the children who survived childhood cancer experienced disturbances in dental development due to cancer therapy or to cancer itself. The aim of this study is to assess dental development in children and teenagers who had suffered from childhood leukemia and were submitted to chemotherapy isolated or associated with radiotherapy, by comparing the dental ages with those corresponding features in a healthy control group. Dental development was analyzed using panoramic radiographs of 92 children divided in two groups: 46 children between 5 and 12 years old, treated for ALL at GRAACC-IOP, UNIFESP, and as a control group, 46 healthy children treated for dental reasons at APCD, São Paulo. The dental age of the subjects was estimated using the system of Demirjian et al. [A. Demirjian, H. Goldstein, J.M. Tanner, A new system of dental age assessment, Hum. Biol. 45(2) (1973) 211-227]. A significant difference was found between the chronological and dental age of patients submitted to antineoplasic therapy for ALL, when compared to those of the control group, but there were no significant differences between patients treated with different protocols for ALL. CONCLUSIONS although the study was within a small group of patients, we could clearly conclude that antineoplastic therapy can interfere in the dental maturity of patients treated for childhood cancer by interfering in dental formation and root development.
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van der Pas-van Voskuilen IGM, Veerkamp JSJ, Raber-Durlacher JE, Bresters D, van Wijk AJ, Barasch A, McNeal S, Gortzak RAT. Long-term adverse effects of hematopoietic stem cell transplantation on dental development in children. Support Care Cancer 2009; 17:1169-75. [PMID: 19139926 DOI: 10.1007/s00520-008-0567-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 12/12/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to assess late effects of cytotoxic therapy with hematopoietic stem cell transplantation (HCT) on dental development in survivors of childhood cancer. MATERIALS AND METHODS Forty children who underwent allogeneic HCT for a variety of hematological malignancies were evaluated at a minimum of 2 years after transplantation. We obtained information on oral symptoms, exposed panoramic radiographs (PRG), and performed an oral examination. PRGs were scored for agenesis and root and/or crown abnormalities. The root-crown ratio was calculated, and dental age was assessed using Demirjian' s method. MAIN RESULTS The studied group showed a significantly higher prevalence of tooth agenesis compared to normative data for first and second premolars in both the maxilla and mandible, as well as the second molars in the mandible (all p values <0.001). Children who were <3 years old at the time of cancer treatment had significantly more missing teeth than older children, F(2,37) = 7.58, p < 0.002. Root-crown ratios were lower in the study sample than those from normative data. In addition, the mean dental age was higher (as a result of earlier apical root closure) than the mean chronological age, t(28) = 2.47, p < 0.020. CONCLUSIONS Nearly all children examined had dental development disturbances, including agenesis, short roots, and arrested root development. An oral/dental evaluation and preventative oral supportive care regimens should be part of programs monitoring late effects in long-term survivors of childhood cancer.
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Zwetchkenbaum SR, Oh WS. Prosthodontic management of abnormal tooth development secondary to chemoradiotherapy: a clinical report. J Prosthet Dent 2007; 98:429-35. [PMID: 18061736 DOI: 10.1016/s0022-3913(07)60141-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Late effects of chemoradiotherapy for childhood cancer treatment include developmental disturbances of the maxillofacial and dentoalveolar structures. Prosthodontic rehabilitation of these patients presents a significant challenge in restoring function, esthetics, and comfort. This clinical report describes the prosthodontic management of a young patient who received chemoradiotherapy for neuroblastoma and subsequently developed tooth abnormalities. Osseointegrated implants and an implant-connecting bar along with an attachment system were used to provide retention, support, and stability of a removable mandibular overdenture opposing a conventional maxillary complete denture.
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Affiliation(s)
- Samuel R Zwetchkenbaum
- Department of Oral and Maxillofacial Surgery/Hospital Dentistry, University of Michigan School of Dentistry, Ann Arbor, MI 48109-0018, USA.
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Avşar A, Elli M, Darka O, Pinarli G. Long-term effects of chemotherapy on caries formation, dental development, and salivary factors in childhood cancer survivors. ACTA ACUST UNITED AC 2007; 104:781-9. [PMID: 17618135 DOI: 10.1016/j.tripleo.2007.02.029] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 12/07/2006] [Accepted: 02/22/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the long-term effects of chemotherapy on oral health and dental development in childhood cancer survivors (CCS). STUDY DESIGN Ninety-six CCS patients with a mean age of 10.8 years and 96 healthy children of the same age and sex and social background composed the study group. The caries experience of the children was recorded according to the criteria of the World Health Organization, and plaque-gingival status was evaluated according to the Silness-Loe Index. The children were also investigated for stimulated salivary flow rate, buffer capacity, salivary mutans streptococci, and lactobacilli. Disturbances of enamel mineralization were recorded according to the index of developmental defects in dental enamel. Dental development disturbances were diagnosed on panoramic radiographs. RESULTS The caries experience, mutans streptococci, and lactobacilli colonization in CCS children were found significantly higher than in the healthy subjects (P < .05). White/cream colored opacities were the most frequent enamel mineralization disturbances (69.8 %). The occurrence of arrested root development with short V-shaped root malformation was significantly higher in CCS children than in the healthy subjects (P < .05). No statistically significant difference was found between group <or=5 years and >5 years. CONCLUSION This current investigation has shown that CCS children are at an increased risk of caries and developmental dental disturbances.
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Affiliation(s)
- Aysun Avşar
- Department of Pediatric Dentistry, Faculty of Dentistry, University of Ondokuz Mayis, Samsun, Turkey.
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Abstract
With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.
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Affiliation(s)
- Robert E Goldsby
- Division of Pediatric Hematology/Oncology, University of California, San Francisco, USA.
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26
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Hölttä P, Hovi L, Saarinen-Pihkala UM, Peltola J, Alaluusua S. Disturbed root development of permanent teeth after pediatric stem cell transplantation. Dental root development after SCT. Cancer 2005; 103:1484-93. [PMID: 15739206 DOI: 10.1002/cncr.20967] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Deficient dental root development has been reported after conventional pediatric anticancer therapy, but less information is available on stem cell transplantation (SCT) recipients. METHODS Root-crown (R/C) ratios of fully developed permanent teeth were assessed from panoramic radiographs of 52 SCT recipients, who were treated when they were age < 10 years. Using standard deviation scores (SDSs), the authors compared the R/C ratios to the corresponding tooth and gender-specific values in a healthy population. The percentage of affected R/C ratios per individual was examined in a subgroup of 39 (SG39) patients with advanced tooth development. The effects of total body irradiation (TBI) and SCT age on the R/C ratios were studied in TBI and high-dose chemotherapy (HDC = non-TBI) groups and in 3 age groups (< or = 3.0 years, 3.1-5.0 years, > or = 5.1 years). RESULTS Per individual, 77% of the fully developed permanent teeth were affected in SG39. At the tooth level, in 77% of the 945 teeth studied (52 patients), the R/C ratios were outside +/-2 SDSs. More teeth were affected in the TBI (85%) than in the non-TBI (55%) group (P < 0.001). The teeth of the patients who were ages 3.1-5.0 years old at SCT presented with the most severe aberrations of the R/C ratio (mean SDS = -4.4) whereas the teeth of the youngest (age < or = 3.0 years) and the oldest (age > or = 5.1 years) patients were equally affected (mean SDSs = -3.1 and -3.0, respectively). CONCLUSIONS Disturbances of dental root growth always followed pediatric SCT. HDC alone intensely harmed root growth but TBI further increased the adverse effects that were most extensive in the patients 3.1-5.0 years at SCT. These sequelae should be taken into account during the lifelong dental follow-up to minimize the clinical consequences of dental injuries.
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Affiliation(s)
- Päivi Hölttä
- Department of Pedodontics and Orthodontics, Institute of Dentistry, University of Helsinki, Helsinki, Finland.
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