Long-term adverse effects on dentition in children with poor-risk neuroblastoma treated with high-dose chemotherapy and autologous stem cell transplantation with or without total body irradiation

Salivary and Dental Complications in Childhood Cancer Survivors Treated With Radiation Therapy to the Head and Neck: A PENTEC Comprehensive Review

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.

Prevalence of, and risk factors for, dental sequelae in adolescents who underwent cancer therapy during childhood

INTRODUCTION

The increase in survival rates in children treated for cancer has been accompanied by a rise in sequelae in permanent teeth. The aim of the study was to correlate the type of cancer therapy administered to patients during early childhood and the dental sequelae recorded in survivors.

MATERIAL AND METHODS

Single-center retrospective cohort study carried out at the Children's University Hospital of Sant Joan de Déu in Barcelona, Spain. Hundred and nine patients who had received cancer treatment during early childhood were randomly examined and grouped according to diagnosis and cancer therapy received. The type of therapy was correlated with the number and severity of dental lesions that patients presented in adolescence.

RESULTS

Dental sequelae of some kind were present in 85.3% of patients. Microdontia was the most prevalent (52.3%). Treatment with alkylating agents had a relative risk of presenting moderate lesions of 3.36 (1.18-9.60), and one of 2.29 (1.07-4.91) of presenting severe lesions. Topoisomerase inhibitors and cytotoxic antibiotics presented relative risks of 1.6 (1.07-2.38) and 2.08 (1.02-4.26) of root alterations and agenesis, respectively.

CONCLUSIONS

Treatment with alkylating agents together with cytotoxic antibiotics and topoisomerase inhibitors was associated with a higher relative risk of microdontia, agenesis, and root shortening.

Late Complications in Long-Term Childhood Cancer Survivors: What the Oral Health Professional Needs to Know

With diagnostic and therapeutic advances, over 80% of children diagnosed with cancer become long-term survivors. As the number of childhood cancer survivors (CCS) continues to increase, dental practitioners become more likely to have CCS among their patients. CCS may develop late complications from damage caused by their cancer treatment to endocrine, cardiovascular, musculoskeletal, and other organ systems. These complications may surface decades after the completion of treatment. Adverse outcomes of childhood cancer treatment frequently involve oral and craniofacial structures including the dentition. Tooth development, salivary gland function, craniofacial growth, and temporomandibular joint function may be disturbed, increasing oral health risks in these individuals. Moreover, CCS are at risk of developing subsequent malignancies, which may manifest in or near the oral cavity. It is important that dental practitioners are aware of the childhood cancer history of their patients and have knowledge of potential late complications. Therefore, this narrative review aims to inform dental practitioners of late oral complications of cancer treatment modalities commonly used in pediatric oncology. Furthermore, selected common non-oral late sequelae of cancer therapy that could have an impact on oral health and on delivering dental care will be discussed.

Tooth Abnormalities and Their Age-Dependent Occurrence in Leukemia Survivors

The multidrug nature of anticancer treatment and different treatment protocols used in the studies are likely to be a major limitation in establishing real risk factors determining the occurrence of dental abnormalities. The authors aimed to establish a relationship between the duration and the dose of chemotherapy and the number of tooth adverse effects in the group receiving the same treatment. Of the 40 anticancer therapy recipients who attended the outpatient dental clinic, 7 leukemia survivors receiving the treatment according to the ALL IC-BFM 2002 protocol were selected. The study group consisted of four females and three males aged 92 to 207 months at the time of dental examination and 29 to 91 months at leukemia diagnosis. As a result of the clinical and radiological examination, dental abnormalities such as agenesis, tooth size reduction, root abnormalities, and taurodontia were identified, and the medical records of all survivors were reviewed in terms of drugs administered, their doses, and treatment schedules. No correlation was observed between the treatment duration of an intensive therapy, the entire therapy, and the number of tooth abnormalities. No relationship was also found between the number of dental abnormalities and the cumulative dose of vincristine, L-asparaginase, methotrexate, cyclophosphamide, cytarabine, and 6-mercaptopurine. The age at the onset of antineoplastic therapy is likely to be the strongest risk factor for toxic injury during tooth development.

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.

Presentation of a Case of Short Root Anomaly in an 11-Year-Old Child

Short root anomaly (SRA) is a developmental anomaly in which the affected teeth present morphologically normal crowns and short, round roots. The exact cause of SRA is unknown. A case of an 11-year-old female patient with SRA is described. The patient presented short, round roots of all permanent teeth but first molars. Maxillary lateral incisors presented severe root resorption and mobility. Treatment plan included preservation of the maxillary lateral incisors by splinting them to their adjacent teeth using a stainless steel coaxial wire. A custom mouthguard for dental trauma protection was also constructed using a computer-aided design - computer-aided manufacturing (CAD-CAM) system in order to fabricate 3D-printed dental casts. At 2-year follow-up, the mobility of maxillary lateral incisors decreased, and the patient's dentition remained stable. Considerations regarding differential diagnosis, orthodontic management, and treatment options after an eventual loss of teeth are thoroughly discussed.

Dental developmental complications in pediatric hematopoietic stem cell transplantation patients: A study using CMC clinical data warehouse

OBJECTIVE

This study aimed to investigate the prevalence and extent of dental developmental complications in patients who have undergone pediatric hematopoietic stem cell transplantation (SCT) and identify the risk factors.

MATERIALS AND METHODS

We retrospectively investigated the clinical data warehouse of the Catholic Medical Center information system for identifying patients who: 1) visited the Department of Pediatrics between 2009 and 2019, 2) underwent SCT under the age of 10, and 3) had panoramic radiographs. Thus 153 patients were included in this study. The prevalence and extent of tooth agenesis, microdontia, and root malformation were assessed using panoramic radiographs obtained after SCT, and the risk factors were analyzed using regression analysis.

RESULTS

All 153 patients had at least one dental anomaly. When grouped according to the age at initial chemotherapy (≤ 2.5; 2.6-5.0; 5.1-7.5; > 7.5 years), the prevalence of agenesis showed statistically significant differences among the different age groups (P < 0.001). The prevalence of agenesis was highest in the youngest age group. As the initial age at chemotherapy increased, the number of affected teeth per patient decreased for all three anomalies. The location of the affected tooth was also influenced by the age at initial chemotherapy. Regression analysis demonstrated that young age at initial chemotherapy was a risk-increasing factor for tooth agenesis and microdontia.

CONCLUSIONS

The age at initial chemotherapy may be a critical factor in determining the type, extent, and location of dental complications after SCT. These results suggest that careful dental follow-up and timely treatment are recommended for pediatric patients undergoing SCT.

Late dental effects in children submitted to chemotherapy: A case report

Chemotherapy may have many effects on teeth such a microdontia, hypoplasia and V shaped roots. The incidence and severity of dental abnormalities depend on the age at the diagnosis, the type of chemotherapeutic agent used. Therefore, it is important that general and pediatric dentists be aware of the late adverse effects of cancer therapy in children, especially in the oral cavity. This article intends to document a case illustrating different dental anomalies secondary to chemotherapy in 20 years old boy who had a history of chemotherapy in childhood.

Oligomicrodontia in a Pediatric Cancer Survivor after Chemotherapy: A Case Report

Chemotherapy used on pediatric patients especially those below 3 years of age causes disturbances in dental development. The aim of this case report was to present the late dental effects of chemotherapy in a patient treated for anaplastic ependymoma (WHO III) at an early age. Radiographic findings at the age of 9 years showed oligomicrodontia of six teeth, maxillary lateral incisors, and maxillary and mandibular first premolars. Pediatric cancer survivors after chemotherapy have an increased risk of one or more dental development disorders. To ensure proper dental care and to assess the long-term effects on oral health, tooth development, and occlusion, the involvement of a dentist is crucial. Adequate diagnosis and well-planned treatment of the dental defect can significantly improve patient oral health-related quality of life.

Long-Term Effect of Anticancer Therapy on Dentition in Childhood Cancer Survivors: An Observational, Cross-Sectional Study

OBJECTIVES

To evaluate the presence of developmental dental anomalies, like microdontia, hypodontia, abnormally shaped teeth (AST), and developmental defects of enamel (DDE) in childhood cancer survivors and compare it with the healthy controls.

METHODS

This cross-sectional analytical study was conducted in 2 groups: childhood cancer survivors (CCS) group including children (> 12 y, m/f) who had undergone anticancer therapy (ACT) before 8 y of age and healthy control group (> 12 y, m/f) without any systemic disease. Pearson chi-square test was used to analyze the difference between the CCS group and the control group for microdontia, hypodontia, AST, DDE and for intragroup analysis in CCS group. Odds ratio was also calculated.

RESULTS

A total of 120 and 121 children were included in CCS and control group, respectively. The prevalence of microdontia, hypodontia, abnormally shaped teeth, and DDE was 17.5% (21), 5% (6), 8.33% (10), and 37.5% (45), respectively in CCS group. It was 8.2% (10), 2.5% (3), 1.65% (2), and 22.3% (27), respectively in the control group. A statistically significant difference was seen in microdontia (p = 0.032), abnormally shaped teeth (p = 0.017) and DDE (p = 0.01). Higher prevalence was seen when ACT began at an early age.

CONCLUSION

An association between developmental dental anomalies and anticancer therapy (ACT) exists with significantly higher difference in microdontia, abnormally shaped teeth and DDE among survivors of childhood cancer as compared to healthy population. These known adverse effects of ACT on developing teeth should be considered during treatment planning of the children having cancers.

The prevalence of dental developmental anomalies among childhood cancer survivors according to types of anticancer treatment

Survival following childhood cancer has increased considerably. In an observational cross-sectional study, we assessed the prevalence of dental developmental anomalies (DDA) among childhood cancer survivors according to types of anticancer treatment. Permanent teeth were examined clinically and radiographically in 121 adolescents with a history of childhood malignancies, to identify DDA, namely hypomineralization or hypoplasia, microdontia, root changes and hypodontia. DDA were observed in 56/121 individuals (46%), in 309/3388 teeth (9%). Hypomineralization or hypoplasia of enamel appeared in 21 (17%) patients. Altered root development appeared in 26 patients and hypodontia affected 13 (10%). Dental anomalies were observed in 36 (43%) individuals who received chemotherapy and not radiation, in 20 (52%) who received radiotherapy, and in 15 (60%) of those who received head and neck radiotherapy. Among patients who received only chemotherapy, young age (6 years or younger) was associated with a higher number of malformed teeth. In conclusion, antineoplastic treatment that combines chemotherapy and radiotherapy appears to increase the risk of DDA. Radiation to the head and neck area was shown to particularly increase the risk of DDA. No specific chemotherapy agent was found to be associated more than the others with DDA.

Dental late effects of antineoplastic treatment on childhood cancer survivors: Radiographic findings

BACKGROUND

Dental anomalies are common late side effects of childhood cancer therapy and may lead to anatomical, functional, and aesthetic sequelae.

AIM

The study aimed to record dental late effects of antineoplastic treatment and associate them with disease and treatment characteristics in order to identify possible risk factors.

DESIGN

Orthopantomograms of 70 survivors aged 4-21 years, who were treated at ages 0-10 years for any type of malignancy and completed antineoplastic treatment at least one year before, were examined. Incidence of developmental disturbances was recorded. Their severity was calculated, and odds ratios for the development of severe defects were estimated.

RESULTS

Root defects presented in 62% of the participants, with impaired root growth being the most common (58%). Increased incidence was associated with combination treatment protocols, irradiation to the head and neck region, and administration of antimetabolites, steroids, and vincristine. Mean DeI value was 17.46 with risk factors for the development of severe root defects being diagnosis of acute lymphoblastic leukemia, combination treatment protocols, administration of cyclophosphamide and steroids, and hemopoietic stem cell transplantation.

CONCLUSIONS

Root defects are common among childhood cancer survivors, with their incidence and severity being affected by multiple disease and treatment characteristics.

Long-Term Effects of Childhood Cancer Treatment on Dentition and Oral Health: A Dentist Survey Study from the DCCSS LATER 2 Study

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.

Late adverse effects of childhood acute lymphoblastic leukemia treatment on developing dentition

BACKGROUND

Childhood cancer survivors show a variety of late adverse effects on dental health. The purpose of this study was to examine the prevalence and severity of dental abnormalities in permanent dentition in childhood leukemia survivors.

MATERIALS AND METHODS

Retrospective analysis of panoramic radiographs was performed for 178 childhood leukemia survivors aged below 17 years at the time of diagnosis. Sex, age at diagnosis, interval between ALL diagnosis and the follow-up radiograph, treatment protocol, and risk grouping were recorded. Abnormalities of tooth development and defect index were used to assess the frequency and severity of dental abnormalities.

RESULTS

One hundred eight (61%) patients had no dental abnormalities at follow-up examination at a median of 6.1 years after diagnosis. Microdontia was more frequent in children under 6 years of age at the time of diagnosis (5.7% vs. 0.6%, p < .001). Significant differences were noted between distinct ALL treatment protocols with more common microdontia in patients treated according to the NOPHO ALL2008 protocol. Tooth agenesis was more frequent in patients that underwent therapy according to high-risk arms compared to intermediate- or standard-risk arms (3.8% vs. 1.4%, p = .01). Patients under 6 years of age at diagnosis had a significantly higher average defect index score than older patients (7.0 vs. 2.8, p = .01).

CONCLUSIONS

Children and adolescents who received ALL treatment were at risk for dental damage. Young age and high-intensity therapy were associated with the severity of dental abnormalities.

Mandibular metastases in neuroblastoma: Outcomes and dental sequelae

BACKGROUND

Although metastatic involvement of bony sites including cranial bones is common in neuroblastoma (NB), mandibular metastases (MM) are uncommon, and specific outcomes have not been reported upon in the modern therapeutic era.

METHODS

In this retrospective study, medical records on patients with MM from NB were reviewed. Statistical analysis was performed using the Kaplan-Meier method.

RESULTS

Of 29 patients, nine (31%) had MM at diagnosis, whereas in 20 (69%) MM were first detected at NB relapse at a median time of 26 (6-89) months from diagnosis. Median maximal diameter of lesions was 3 (range 0.8-4.9) cm. MM were unilateral in 83% of patients, with ascending ramus (55%) and mandibular body (38%) being the two most common sites. All patients received systemic chemotherapy, and 26 (93%) patients received radiotherapy to MM. At a median follow-up of 37.3 (24.2-219.5) months, eight of nine patients with MM at diagnosis did not experience mandibular progressive disease. Eighteen of 20 patients with MM at relapse received therapeutic radiotherapy; objective responses were noted in 78%. Seventy-two percent (5/18) had not experienced relapse within the radiation field at a median of 12 (2-276) months postradiotherapy. Dental findings at follow-up after completion of NB therapy included hypodontia, hypocalcification of enamel, and trismus. Median 3-year overall survival in patients with relapsed MM was 51 ± 12% months from relapse.

CONCLUSION

MM when detected at diagnosis is associated with a prognosis similar to that for other skeletal metastases of NB. Radiotherapy is effective for control of MM detected both at diagnosis and relapse. Significant dental abnormalities posttherapy warrant regular dental evaluations and appropriate intervention.

Some Cancer Chemotherapy (CH) Agents May Be Associated With Tooth Agenesis, Though CH Dose, Age of CH Exposure, and Dental Development at the Time of Treatment May Be Critical Determinants

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Adverse effects of chemotherapy on the teeth and surrounding tissues of children with cancer: A systematic review with meta-analysis. Busenhart DM, Erb J, Rigakos G, Eliades T, Papageorgiou SN. Oral Oncol 2018;83: 64-72.

SOURCE OF FUNDING

None.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Second primary molar hypomineralisation and drugs used during pregnancy and infancy. A systematic review

OBJECTIVES

Hypomineralised second primary molars (HSPM) are due to idiopathic hypomineralisation that affects from 1- to 4-s primary molars, and its aetiology remains unclear. Our objective was to systematically review studies in which the investigators had studied the association between HSPM and drug use during pregnancy and the first year of life.

MATERIALS AND METHODS

A systematic search for publications until July 2018 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. No restrictions were placed on year of publication. The PECO Question was as follows: P, children exposed to drugs during pregnancy and the first year of life; E, drugs to which mothers, during pregnancy and their offspring were exposed; C, control groups from studies with the same characteristics not exposed to drugs during pregnancy and the first year of life; and O, relationship between drug exposure during pregnancy and the first year of life and HSPM. Two reviewers extracted the data and assessed the risk of bias using the Newcastle-Ottawa Scale criteria.

RESULTS

We initially identified 986 articles, or which seven were selected for review: two case-control studies, one cross-sectional studies and four cohort studies. Four studies reported data on drug consumption during pregnancy and four investigated drug use during the first year of life and the occurrence of enamel defects in primary dentition.

CONCLUSIONS

There is no clear evidence that the use of drugs during pregnancy and during the first year of life is associated with HSPM. Further well-designed prospective studies are needed.

CLINICAL RELEVANCE

Determining the etiological factors related to the development of HSPM would help to establish preventive protocols in patients at potential risk. As HSPM is predictive of molar incisor hypomineralisation (MIH), the application of preventive protocols would avoid complications in both the primary and permanent dentition.

Long-term Dental Anomalies after Pediatric Cancer Treatment in Children

Objective:

The aim of this study is to determine the frequency of dental anomalies (DAs) (microdontia, hypodontia, hyperdontia, enamel defect, root malformation) in pediatric cancer patients at the ages <5 years and between 5 and 7 years, and understand their relationship with the received therapy.

Materials and Methods:

Pediatric patients who were diagnosed with cancer and treated before the age of 7 years were investigated in a case- control design. The study included 93 pediatric patients whose ages at diagnosis were between 9 months and 7 years and whose treatments were completed before 5-8 years. Group A consisted of patients in the age range of 9 months to 4 years and Group B consisted of patients in the age range of 5-7 years. Seventy-two siblings with compatible dental age ranges were included in the control group. For both groups, intraoral examinations were performed and panoramic radiographs were taken.

Results:

Among the 93 pediatric patients, the mean age was 9.54±1.25 (range: 8-13 years) and 48 (51.6%) patients were male. The most common diagnosis was hematologic malignancy with a rate of 65.5%. At least one DA was detected in 7 (9.7%) individuals of the control group and in 78 (83.9%) of the patient group. While the patients in the study group had all kinds of DAs, those in the control group had only enamel defects. The rates of microdontia (p=0.077) and hypodontia (p=0.058) were detected to be significantly higher in Group A than in Group B. Root malformation was more common in patients receiving chemotherapy and radiotherapy than in those receiving only chemotherapy (p=0.006).

Conclusion:

In this study it was found that the pediatric patients who received cancer treatment before the age of 7 years constituted a high-risk group for DAs. The frequencies of microdontia and hypodontia were increased even more when the patient was treated for cancer before 5 years of age.

Supernumerary Incisors in CB6F1 Mice Conditioned with Chemotherapy and Total Body Irradiation before Bone Marrow Transplantation

Multiple adult female CB6F1 mice presented with supernumerary incisors after preconditioning with chemotherapy and total body irradiation for bone marrow transplantation (BMT). Mice received nonmyeloablative total body irradiation (3 Gy) and either cyclophosphamide or bendamustine, followed by BMT and posttransplantation cyclophosphamide or bendamustine. Here we describe the clinical presentation, μCT findings, and histopathologic evaluation of the affected mice. These analyses confirmed the gross diagnosis and revealed details of the abnormal tooth morphology. We surmise that the combination of total body irradiation and chemotherapy resulted in the abnormal formation of supernumerary incisors. Supernumerary teeth should be considered as a potential confounding factor in tracking weight loss after BMT. These conditions can be managed to allow animals to reach their intended scientific endpoint.

Dental Caries in Children and Adolescents During and After Antineoplastic Chemotherapy

OBJECTIVE

To assess caries incidence, intensity, and treatment in children and adolescents under/after antineoplastic treatment.

STUDY DESIGN

Patients with permanent and mixed dentition were divided into three groups of 60 patients each (5-18 years): CH - under chemotherapy; PCH - after chemotherapy; CG - generally healthy subjects. Caries incidence, intensity (DMFT/dmft, DMFS/dmfs), and mean numbers of teeth/surfaces with white spot lesions-WSL (D₁₊₂/d₁₊₂) were assessed following the ICDAS-II criteria.

STATISTICAL ANALYSIS

Mann-Whitney U test, significance at p≤0.05).

RESULTS

Caries incidence was significantly higher in PCH and CH (88.33% and 90%) than in CG (66.66%). Caries intensity was higher in both mixed and permanent dentition in patients under and after chemotherapy. The DMFS/DMFT correlation was the highest in PCH. Treatment indexes for primary and permanent teeth treatment were significantly lower in PCH and CH than CG.

CONCLUSION

Antineoplastic chemotherapy is associated with caries development and its high incidence during/after treatment. As dental hygiene was poor in patients under and after antineoplastic treatment, dental checkups need to be more frequent and thorough.

Clinical Risk Factors Influencing Dental Developmental Disturbances in Childhood Cancer Survivors

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.

Changes in the chemical composition of mineralised teeth in children after antineoplastic treatment

Introduction

Chemotherapy, neoplasms, and their complications linked to malabsorption, malnutrition, and metabolic disorders may lead to improper tooth development and frequent severe caries in patients during/after antineoplastic treatment and to a more frequent improper tooth development in patients undergoing chemotherapy during odontogenesis. However, the causes of these abnormalities remain unknown; there are no studies on the impact of antineoplastic treatment and its complications on the chemical composition of mineralised teeth.

Aim of the study

To compare the chemical composition of mineralised teeth extracted due to complicated caries in children after chemotherapy, and of teeth extracted due to orthodontic treatment in generally healthy children.

Material and methods

The treatment group included five teeth extracted due to complicated caries in children after antineoplastic treatment. The control group included five teeth extracted due to orthodontic treatment in generally healthy children. The chemical composition of enamel, dentine, cementum, interior of the canal, and enamel abnormalities in teeth extracted from patients after chemotherapy and in generally healthy patients were assessed with energy-dispersive X-ray spectroscopy. Results were analysed statistically.

Results

The magnesium (Mg) and zinc (Zn) mass contents in the enamel of patients after chemotherapy increased and so did the calcium (Ca) to phosphorus (P) ratio when compared to controls. Areas with abnormal enamel in patients after chemotherapy had lower concentrations of Ca and P, and higher concentrations of trace elements (Mg, Cl, and Na). The levels of the assessed elements in dentine, cementum, and inside the canal were similar in both groups of teeth.

Antineoplastic chemotherapy and congenital tooth abnormalities in children and adolescents

AIM OF THE STUDY

Chemotherapeutic treatment in children and adolescents carries a risk of congenital tooth disorders and dentinoma. Study objective is to assess the correlation between tooth abnormalities, early complications of multidrug chemotherapy, and chemotherapeutics used in different antineoplastic therapies in children and adolescents.

MATERIAL AND METHODS

Enamel defects (developmental defects of enamel index - DDE index) and defects in tooth number, size, and structure were assessed clinically and radiologically in 60 patients who underwent chemotherapy on average 4.9 ±3.4 years earlier (PCH), and 60 generally healthy subjects (control group - CG), aged 6-18 years. Höltta's defect index (DeI) was calculated. Medical files provided information on neoplasm type, age at treatment start and chemotherapy duration, chemotherapeutic type and dose, vomiting, and mucositis (CTCAE v4.0). Statistical significance of differences between groups was assessed with the Mann-Whitney U test and the correlation between dental defects and chemotherapy with Spearman's rank correlation coefficient (significance p ≤ 0.05).

RESULTS

Enamel defects, tooth agenesis, microdontia, root resorption, taurodontism, and dentinoma occurred statistically significantly more often in the PCH group. A correlation was established between vincristine use and dose and all types of dental defects; cyclophosphamide, doxorubicin, and isophosphamide and hypodontia; microdontia, root resorption, and enamel defects; etoposide and cisplatin and microdontia, root resorption, and enamel defects; methotrexate root resorption and enamel defects; carboplatin and dentinoma and enamel defects. Mucositis and vomiting promoted root resorption, microdontia, and enamel defects.

CONCLUSIONS

Dental defects are related to both the use of respective chemotherapeutics, especially vincristine, cyclophosphamide, doxorubicin, and isophosphamide, and to early complications in multidrug chemotherapy - mucositis and vomiting. Vincristine and carboplatin use may promote dentinoma.

Strategies to Overcome Late Complications from Radiotherapy for Childhood Head and Neck Cancers

Most pediatric head and neck cancers are treated with radiotherapy, but the morbidity associated with radiotherapy has become a prominent issue. This article discusses the common long-term complications associated with head and neck radiotherapy for childhood cancers. It reviews approaches to minimize toxicity and details the toxicities that head and neck radiation inflicts on relevant functional measures. In addition, it discusses the risk of radiation-induced secondary cancers in childhood cancer survivors, as well as strategies to reduce them. Thus, this article addresses approaches to minimize long-term radiation toxicities in order to improve the quality of life for childhood cancer survivors.

Molar root-incisor malformation: considerations of diverse developmental and etiologic factors

OBJECTIVE

The objective of this study was to evaluate the variation in the condition referred to as molar root-incisor malformation (MRIM) and elucidate the distribution of affected teeth. This study further aimed to identify associated environmental stressors.

STUDY DESIGN

Individuals were identified through retrospective review of dental radiographs and through referral to the investigators. Histologic evaluation included examination of mineralized and decalcified sections of affected first permanent molar teeth.

RESULTS

Thirty cases of MRIM were identified, with all having affected first permanent molars with dysplastic root formation. The primary second molars were affected in 57% of the cases, with permanent anterior teeth being involved in 40% of the cases. A variety of medical conditions were associated with MRIM, the most common being neurologic. Several affected individuals reported no significant past medical history or environmental stressors.

CONCLUSIONS

The etiology of MRIM remains unclear, and this unique developmental defect of the first permanent molar roots appears to occur in populations throughout the world. Clinicians identifying the MRIM phenotype should carefully evaluate the permanent incisors for associated developmental defects that could result in pulpal necrosis.

Cyclophosphamide-Induced Morphological Changes in Dental Root Development of ICR Mice

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.

Dental anomalies in children submitted to antineoplastic therapy

Cancer is the third most frequent cause of death in children in Brazil. Early diagnosis and medical advances have significantly improved treatment outcomes, which has resulted in higher survival rates and the management of late side effects has become increasingly important in caring for these patients. Dental abnormalities are commonly observed as late effects of antineoplastic therapy in the oral cavity. The incidence and severity of the dental abnormalities depend on the child's age at diagnosis and the type of chemotherapeutic agent used, as well as the irradiation dose and area. The treatment duration and aggressivity should also be considered. Disturbances in dental development are characterized by changes in shape, number and root development. Enamel anomalies, such as discoloration, opacities and hypoplasia are also observed in these patients. When severe, these abnormalities can cause functional and esthetic sequelae that have an impact on the children's and adolescents' quality of life. General dentists and pediatric dentists should understand these dental abnormalities and how to identify them aiming for early diagnosis and appropriate treatment.

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.

Risk factors to cause tooth formation anomalies in chemotherapy of paediatric cancers

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.

Microdontia and hypodontia of premolars and permanent molars in childhood cancer survivors after chemotherapy

BACKGROUND

Adverse long-term general and dental health effects of cancer and cancer therapy during childhood have been reported.

AIM

To examine the association between chemotherapy before the age of 8 years and (1): microdontia; (2): hypodontia of premolars and permanent molars.

MATERIAL AND METHODS

In The Danish Registry of Childhood Cancer (DBCR), we identified 203 children who met the following inclusion criteria: (1) age below 8 years at the start of treatment; (2) age between 12 to 18 years upon dental examination; (3) had received chemotherapy The exclusion criterion was radiotherapy to the head and neck. A total of 150 children fulfilled the inclusion criteria. As controls, a random sample of 193 age-matched unexposed children was included.

RESULTS

Microdontia was found in a total of 88 teeth in 29 (19.3%) of the 150 children who had been exposed to chemotherapy, while none of the controls had microdontia of premolars or permanent molars (difference: 19.3%; 95% CL: 13.5%; 26.4%). The earlier the exposure, the more frequent was microdontia. We found a total of 27 missing premolars and permanent molars in 14 (9.3%) of the exposed children and a total of 18 missing premolars and permanent molars in 8 (4.1%) of the controls (difference: 5.2%; 95% CL: -0.1%; 11.3%).

CONCLUSION

The present study confirms findings from previous studies that chemotherapy, especially in very young children, causes microdontia and hypodontia of premolars and permanent molars.

Disturbed dental development of permanent teeth in children with solid tumors and lymphomas

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.

Association of cyclophosphamide use with dental developmental defects and salivary gland dysfunction in recipients of childhood antineoplastic therapy

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.

Patterns of tooth agenesis in patients with Down syndrome in relation to hypothyroidism and congenital heart disease: an aid for treatment planning

INTRODUCTION

The purposes of this study were to investigate the patterns of tooth agenesis (oligodontia and nonoligodontia), maxillary canine impaction, and tooth transposition in subjects with Down syndrome and to determine whether congenital heart disease and hypothyroidism are parameters in tooth agenesis.

METHODS

The study included 114 patients with Down syndrome. The data were quantified by using standardized records, clinical examinations, panoramic radiographs, and solo roentgenograms. The subjects were differentiated into oligodontia (6 or more teeth missing) and nonoligodontia (5 or fewer teeth missing).

RESULTS

In these patients with Down syndrome, 59.6% had missing teeth. Those in the nonoligodontia group showed a tendency toward a negative correlation between congenital heart disease and agenesis (P = 0.093; odds ratio = 0.49) but a slight positive correlation between hypothyroidism and agenesis (P = 0.060; odds ratio = 3.71). In the oligodontia group, there was a quantitatively and qualitatively different pattern, indicating another phenotype. When both mandibular central incisors were missing, there was a remarkable chance for oligodontia (P = 0.001; odds ratio = 38.8). In the mandible, symmetrical agenesis of the canines and lateral incisors was more frequent in the nonoligodontia group.

CONCLUSIONS

The oligodontia (with a different phenotype) and nonoligodontia groups had different patterns of agenesis. Maxillary canine impaction was not related to absence of the lateral incisors. Absence of both mandibular central incisors was a high predictor for oligodontia. Congenital heart disease and hypothyroidism are parameters involved in tooth agenesis.

Long-term adverse effects of hematopoietic stem cell transplantation on dental development in children

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.

Late effects in survivors of tandem peripheral blood stem cell transplant for high-risk neuroblastoma

BACKGROUND

Increasing numbers of children with advanced neuroblastoma are achieving cure. We describe the clinical late effects specific to survivors of stage IV neuroblastoma all similarly treated using tandem autologous peripheral blood stem cell rescue with TBI.

METHOD

The medical records of 35 neuroblastoma patients treated at CHOP between 1997 and 2001 were examined. Eighteen of the 35 patients died of progressive disease, and 4 were lost to follow-up. Thirteen patients continue to follow-up in our Multidisciplinary Cancer Survivorship Clinic where they are evaluated and monitored by a consistent group of subspecialists that evaluate long-term sequelae. Data on treatment exposures including TBI and treatment related sequelae identified by clinician assessment and/or diagnostic testing were collected.

RESULTS

Results indicate late effects were present in all 13 subjects, 12 of whom suffered from multiple negative sequelae, including issues with growth hormone deficiency, dental problems, osteochondromas and hearing deficiencies, among others, most at higher rates than reported previously.

CONCLUSIONS

The findings in this small cohort indicate the need for future prospective studies of this intensive pediatric cancer treatment, and underscore the importance of medical intervention and long-term monitoring of these at-risk subjects to increase overall quality-of-life.

A population-based observational study of dental caries among survivors of childhood cancer

BACKGROUND

The few published studies on caries among childhood cancer survivors are small and their results are conflicting. The study aim was to examine the risk of dental caries among children who have survived cancer.

PROCEDURE

We included 299,426 7-year-old, 313,461 12-year-old, and 301,930 15-year-old children born between 1984 and 1988 in a nationwide population-based study linking records from Danish Cancer Registry with records from the national database on oral health. Children whose dental examinations had been preceded by a cancer diagnosis (288 7-year-old, 459 12-year-old, and 526 15-year-old) were compared with children without cancer according to presence of caries: caries-free children; children with any caries experience; and children with severe caries experience (i.e., caries in one or more smooth tooth surface).

RESULTS

Children diagnosed with cancer before the age of 5 years did not have increased caries prevalence in permanent teeth at ages 12; and 15. Children diagnosed with cancer between 5 and 6 years of age had an increased prevalence of severe caries at age 12 years (prevalence ratio (PR) = 1.59 (95% CI: 1.09-2.31; P = 0.02)), but this difference disappeared by age 15. For children diagnosed with cancer at 5 or 6 years of age and who received radiation therapy the PR of severe caries was 1.52 (95% CI: 0.97-2.37; P = 0.07), 2.13 (95% CI: 0.89-5.10; P = 0.09), and 0.31 (95% CI: 0.07-1.45; P = 0.13) at ages seven, 12 and 15 years respectively.

CONCLUSION

Cancer and cancer treatment during childhood are risk factors for caries.

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.

Long-term effects of chemotherapy on caries formation, dental development, and salivary factors in childhood cancer survivors

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.

Health-related quality of life in adult survivors of childhood Wilms tumor or neuroblastoma: A report from the childhood cancer survivor study

BACKGROUND

Long-term survivors of Wilms tumor and neuroblastoma may experience significant late adverse effects from their disease and its therapy. Little is known, however, about the health-related quality of life experienced by these survivors.

PROCEDURE

Health-related quality of life, measured by the 36-Item Short Form Health Survey (SF-36), was assessed from self-report in adult survivors of Wilms tumor (N = 654) and neuroblastoma (N = 432) who participated in the Childhood Cancer Survivor Study.

RESULTS

More than 90% of the study population was 18-34 years old at interview, and 58% were females. There was no significant difference on any SF-36 subscale or summary scale between the two diagnostic groups. On average, survivors reported no decrement on the Physical Component Summary scale of the SF-36 when compared to population norms. However, both groups scored significantly below the population mean score (50) on the Mental Component Summary Scale of the SF-36 (Wilms tumor mean = 41.66, standard error = 2.19, P < 0.0001; neuroblastoma mean = 42.41, standard error = 2.23, P < 0.0001) reflecting decreased emotional health. Independent risk factors for lower scores on this scale included female gender, Native American race, unemployment, and household income below $20,000.

CONCLUSIONS

Adult survivors of childhood Wilms tumor and neuroblastoma do not differ from population norms on most health-related quality of life (HRQL) measures. These data, however, indicate that the emotional well being of adult survivors may be compromised. Health care providers should be aware of the risk of adverse outcomes in emotional health even many years after treatment and cure.

Biological structure and health implications from tooth size at Mission San Luis de Apalachee

This study analyzes dental metric variation to examine the biological structure of the native population at Mission San Luis de Apalachee, a late 17th century mission located in the Apalachee Province of Spanish colonial Florida. Three topics are addressed: (1) comparison of tooth sizes among adult and subadults, (2) analysis of the bio-spatial structure of skeletons within the church area, and (3) comparison of phenotypic profiles of individuals interred within coffins in the ritual nucleus of the church: the altar region. Analyses indicate that subadults had smaller average tooth sizes than adults for the posterior dentition that was particularly evident in mandibular nonpolar molars and premolars. This disparity, also documented in two other mission populations, likely represents ontogenetic stress and resulting increased mortality among those most at risk for early death. Analysis of the spatial structure of graves failed to document biological structuring by side of the aisle or by burial row, although some gross differences were evident when front, middle, and rear church burials were compared. Individuals buried in coffins within the same row were phenotypically similar to one another. However, inter-row comparisons indicated lack of phenotypic similarity among all coffin interments. These analyses suggest maintenance of kin-structured burial for elites alone within the San Luis community.

Microdontia after chemotherapy in a child treated for neuroblastoma

OBJECTIVE

Chemotherapy used on paediatric oncology patients often causes disturbances in dental development. Aim of this case report is to present the late effects of chemotherapy on dental development in a patient treated for neuroblastoma at early age.

DESIGN

Case report.

RESULTS

This paper presents a female patient treated at early age with surgery and chemotherapy for a neuroblastoma (stage IVS) in the right thorax and massive liver metastases. The examination of the patient at age 11.7 years showed microdontia of six teeth. In three of them size and form of the crown were affected, while in the other three the size was reduced but the form was not affected.

CONCLUSIONS

Chemotherapy on children treated for neuroblastoma can adversely influence tooth development. This has to be taken into consideration by the dentist when monitoring the development of the dentition and occlusion.

MDM2 inhibition sensitizes neuroblastoma to chemotherapy-induced apoptotic cell death

Novel therapeutic approaches are urgently needed for high-stage neuroblastoma, a major therapeutic challenge in pediatric oncology. The majority of neuroblastoma tumors are p53 wild type with intact downstream p53 signaling pathways. We hypothesize that stabilization of p53 would sensitize this aggressive tumor to genotoxic chemotherapy via inhibition of MDM2, the primary negative upstream regulator of p53. We used pharmacologic inhibition of the MDM2-p53 interaction with the small-molecule inhibitor Nutlin and studied the subsequent response to chemotherapy in neuroblastoma cell lines. We did 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and terminal deoxynucleotidyl transferase assays to measure proliferation and apoptosis in several cell lines (IMR32, MYCN3, and JF) treated with combinations of cisplatin, etoposide, and Nutlin. We found consistent and robust decreases in proliferation and increases in apoptosis with the addition of Nutlin 3a to etoposide or cisplatin in all cell lines tested and no response to the inactive Nutlin 3b enantiomer. We also show a rapid and robust accumulation of p53 protein by Western blot in these cells within 1 to 2 hours of treatment. We conclude that MDM2 inhibition dramatically enhances the activity of genotoxic drugs in neuroblastoma and should be considered as an adjuvant to chemotherapy for this aggressive pediatric cancer and for possibly other p53 wild-type solid tumors.

The Effect of Radiation Therapy on Normal Tissue Function

As more patients are treated for their primary malignancy with cure or increased disease-free intervals, injury to normal tissues will become more detectable and an important endpoint for study. Future protocols will probably be modified based on toxicity endpoints. In Hodgkin's disease, current protocols use response-based treatment strategies to limit therapy. The objective is to provide the same level of tumor control and follow normal tissue endpoints for outcome analysis. DVH analysis has improved the ability to analyze endpoint data for normal tissues. These image-guided platforms will provide the infrastructure needed to continue efforts in improving the delivery of radiation therapy.