Facial growth and morphology in long-term survivors after bone marrow transplantation

Characteristics of Orthodontic Treatment in Cancer Survivors: A Systematic Review

Background: Survival rates of cancer patients have increased globally and across age groups. Challenges arising from craniofacial growth-development disturbances and dental abnormalities might warrant modifications to standard orthodontic pathways of care. Objective: The aim of this study was to systematically summarize and critically assess the available literature regarding the characteristics of orthodontic treatment in cancer survivors. Materials and Methods: A systematic search was conducted in seven databases for studies on malignant tumor survivors having undergone orthodontic intervention with fixed appliances following cancer treatment up to August 2023. The outcomes of interest included quantitative data regarding various characteristics of orthodontic treatment and the post-treatment period. The risk of bias was assessed individually with the Newcastle-Ottawa scale. Results: Out of 347 records, 4 cohort studies were eventually included in the qualitative synthesis. Leukemia was the most common malignancy type, with treatment involving mainly chemotherapy and/or radiotherapy. The duration of orthodontic treatment in cancer survivors varied. Occlusal results, quality of life, and satisfaction were comparable to healthy peers. However, in some survivors' groups, treatment was shorter and the final results were compromised. Root resorption and oral mucositis were reported among the treated cancer survivors. Reduced occlusal outcome stability during the retention period was also reported. Conclusions: Overall, the duration of orthodontic treatment varied among cancer survivors. The occlusal results achieved were similar to those of their healthy peers, though potentially less stable. Patient-reported outcomes did not differ significantly between cancer survivors and healthy individuals treated orthodontically.

A Systematic Review and Meta-Analysis of the Impact of Cancer and Its Treatment Protocol on the Success of Orthodontic Treatment

BACKGROUND

There are several significant gaps in current studies of the relationship between anti-cancer medications and orthodontic care that call for more investigation. As a result, the main goals of this systematic review and meta-analysis were to summarise and assess the information that was available regarding the effect of radiotherapy and anti-cancer medications on the overall successful completion of an orthodontic treatment plan.

METHODS

A standardised data extraction form was devised in accordance with the PRISMA guidelines to conduct a systematic review and meta-analysis, with specific criteria implemented for selecting studies with low to moderate risk of bias.

RESULTS

Five studies involving different methodologies were selected at the conclusion of the search strategy. The statistical analysis revealed an estimated odds ratio (OR) of 0.31 and relative risk (RR) of 0.48, indicating a statistically significant association between the use of radiotherapy and anti-neoplastic drugs and a noticeable reduction in the successful completion of orthodontic treatment. The heterogeneity analysis showed significant heterogeneity among the studies.

CONCLUSIONS

This review emphasises that, although orthodontic therapies can still be beneficial for children receiving chemotherapy, the effectiveness of the therapy may be diminished in older populations. The findings further highlight how crucial it is to take cancer therapies into account when planning and managing orthodontic treatment in order to optimise results and reduce problems.

A Long-Term Follow-Up of Dental and Craniofacial Disturbances after Cancer Therapy in a Pediatric Rhabdomyosarcoma Patient: Case Report

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents. A boy aged seven years and five months was diagnosed with stage three group III embryonal parameningeal RMS with intracranial extension. He received chemotherapy for 23 weeks in combination with localized radiotherapy during the inductive phase of nine weeks (a total tumor dose of 5040 cGy). Three months later, he was referred to the department of pediatric dentistry for radiation-induced caries, the treatment of which was later terminated because of severe trismus and radiation-induced oropharyngeal mucositis. Three years later, the patient returned for the fitting of a prosthesis because of mastication problems. The dental treatments performed included: extraction, banding, composite resin restorations, root canal fillings, and stainless steel crown fabrication. An interim denture was fitted due to the poor retention of the fixed prosthesis. As the patient grew older, they developed facial asymmetry as a result of the prominent atrophy of their right cheek. By the age of 32, they had lost multiple teeth and exhibited severe facial deformity. Therefore, it is essential not only to involve a multidisciplinary medical team before, during, and after cancer therapy, but also to initiate long-term follow-ups given the potential effects of late sequelae after chemoradiation in multiple developmental areas.

Orthodontic Therapy for Paediatric Cancer Survivors: A Review

The paper aims at reviewing the possibilities of orthodontic therapy for paediatric cancer survivors. It is important to understand the fundamental disease, it's treatment protocols, effects on growing skeleton, dental development, oral cavity and oral mucosa, dental caries, bone, orthodontic tooth movement.

[Children who received a radiotherapy treatment of the cranio-cervico-facial region: appraisal of the orthodontic treatment need]

INTRODUCTION

Currently, 1 out of 900 adults from the ages of 16 to 44 is a survivor of childhood cancer. The global rate of survival for all types of childhood cancer is close to 80% and progress in treatment and care continues to offer promising results. In the years following treatment, these children, just like other healthy children, should have access to orthodontic care in spite of their chronic health problems.

OBJECTIVES

A transverse epidemiological study was conducted at the Leon Bernard Cancer Treatment Center in Lyon in order to respond to these requests and to assist orthodontists with the therapeutic difficulties presented by these patients. Our objective was to identify the orthodontic treatment required for children 7 years old or older who received antineoplastic therapy with radiation of the cranio-cervico-facial region.

RESULTS

The results show that children who received radiation therapy in the cranio-facial region presented delayed growth, facial asymmetry in 74% of the cases, overbite and overjet increased respectively in 70% and 61% of the cases. Dental discrepancies in development were present in 83% of the patients who presented with stunted teeth, premature closing of the apices and hypoplasias. We found sialopathy such as reduced saliva flow rate. Finally, considerable treatment was necessary in 61% of the cases and moderate treatment for 17% of the cases, because of missing teeth, retained deciduous teeth or an increased overjet.

Disturbances in dental development and craniofacial growth in children treated with hematopoietic stem cell transplantation

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.

Dental abnormalities in children preparing for pediatric bone marrow transplantation

The purpose of our study was to describe the types and frequencies of altered dental development in pediatric patients preparing for bone marrow transplantation (BMT). Retrospective review of the medical records and panoramic radiographs of all patients who underwent BMT at St Jude Children's Research Hospital between 1990 and 2000 for whom pre-BMT dental examination and panoramic radiography records were available. All patients were treated on institutional protocols. We recorded patient demographics and radiographic evidence of microdontia, hypodontia, taurodontia, root stunting, caries, enamel pearls, and pulpal calcifications. The 259 patients identified (150 male and 109 female) had a median age of 12.82 years (range, 3.18-25.93 years) at the time of BMT. In total, 203 were Caucasian, 38 were African-American, and 18 were of other races. In all, 150 (57.9%) had abnormal dentition. The most common dental abnormalities were caries (n=84), pulpal calcifications (n = 34), and dental extractions (n = 33). Developmental abnormalities occurred less frequently: taurodontia (n = 8), hypodontia (n = 10), microdontia (n = 11), and root stunting (n = 11). Dental abnormalities are prevalent in children undergoing BMT. Pre-transplant oral hygiene and dental examination should be standard care in order to minimize potential sites of infection.

Dental abnormalities after pediatric bone marrow transplantation

Our purpose was to describe the types and frequencies of altered dental development in pediatric patients following bone marrow transplantation (BMT). A retrospective review of the medical records and panoramic radiographs of all patients who underwent BMT at St Jude Children's Research Hospital between 1990 and 2000, for whom pre-BMT and post-BMT dental examination and panoramic radiography records were available, is presented. All patients were treated on institutional protocols. We recorded patient demographics and radiographic evidence of microdontia, hypodontia, taurodontia, root stunting, caries, enamel pearls, dental restorations/extractions and pulpal calcification. The 99 patients identified (52 males, 47 females) had a median age of 13.5 years (range, 3.4-25.9 years) at the time of BMT. In all, 73 were Caucasian, 15 were African-American, and 11 were of other races. The frequency of radiographically evident root stunting in permanent teeth was significantly increased after BMT (P<0.001), but there was no significant change in the frequency of other dental abnormalities after BMT. Dental abnormalities are prevalent in survivors of childhood BMT, but only root stunting appeared to progress with BMT.

Endocrine complications of high-dose therapy with stem cell transplantation

Evaluations of endocrine function following hematopoietic cell transplantation demonstrate that the endocrine function abnormalities observed are related to the type of transplant preparative regimen received. Children given high dose cyclophosphamide (CY) only have normal thyroid function, normal growth and development. Children who received a busulfan (BU) plus CY preparative regimen usually have normal thyroid function, normal prepubertal growth, delayed or absent pubertal development, and blunted post-pubertal growth. Recipients of preparative regimens containing total body irradiation may be anticipated to have some thyroid dysfunction, impaired growth rates and delayed or absent pubertal development. Post-pubertal teens and young adults are likely to have gonadal function recover if they received a preparative regimen with CY only but are likely to have primary gonadal failure if they received a preparative regimen with BU or total body irradiation. Individuals whose gonadal function becomes normal have become parents of normal children. All patients who receive a marrow transplant should be followed long-term for development of endocrine function abnormalities.

Root surface areas in long-term survivors of childhood cancer

Treatment regimes for childhood cancer are known to affect the root development in the long-term survivors (LTS) but the available the data is subjective in nature with very few quantitative data in the literature. This study aimed to quantify the root surface area (RSA) of mandibular teeth in LTS compared with controls and relate this to the treatment regime and also to the age at which the cancer was diagnosed. Panoramic radiographs were obtained from 69 LTS and an equal number of appropriately matched healthy controls. RSA were calculated using Computer Linked Image Analysis. RSA in the LTS were found to be significantly smaller as compared with controls. Also, RSA were the least in those LTS who had Total Body Irradiation followed by Bone Marrow Transplantation (TBI/BMT) compared with other treatment regimes, the difference being statistically significant for all teeth studied. There was no relationship between the RSA and the age at which the cancer was diagnosed. Smaller root areas have implications for the oral health of LTS, as bone loss around such teeth will compromise further their periodontal support thus jeopardising the long-term survival of the tooth.

Chronic graft-versus-host disease and late effects after hematopoietic stem cell transplantation

Late effects following HSCT are related to either the transplant process or to the transplant preparative regimen. Problems related to the transplant process include delayed recovery of the immune system and chronic GVHD. Chronic GVHD presents between 3-14 months post-HSCT in approximately 20% of matched sibling transplants and 40% of matched unrelated donor recipients. Most commonly involved sites are skin, mouth, liver, gastrointestinal tract, and eye. Patients with platelet count < 100,000/ml and receiving cortocosteroid therapy at day 80 with any clinical manifestations of chronic GVHD require prolonged immune suppressive therapy with prednisone, cyclosporine +/- other agents. Treatment should be administered until all clinical and pathological signs and symptoms of chronic GVHD have resolved which may take one to several years. Problems related to the transplant preparative regimen include those involving the endocrine system, eyes, lungs, bone, and development of secondary malignancies. Endocrine deficiencies include growth failure with growth hormone (GH) deficiency, overt hypothyroidism, primary gonadal failure, Type 1 or Type 2 diabetes, and exocrine pancreatic insufficiency. These problems develop at any time post-HSCT, but usually occur within the first few years and should be treated with appropriate hormone supplementation. Eye problems are primarily related to development of cateracts secondary to total body irradiation (TBI) or prolonged corticosteroid use. Cateracts developing after fractionated frequently do not require removal. Pulmonary problems may be due to bronchiolitis obliterans (BO) or to restrictive lung disease. BO may be associated with chronic GVHD and may respond to chronic GVHD therapy. Restrictive lung disease does not occur for many years after HSCT. There is not therapy for this problem. Development of decreased bone mineral density (BMD) is related to GH deficiency and/or corticosteroid therapy. Treatment includes withdrawal of corticosteroids, administration of GH and calcium, Vitamin D and antiresorptive agents. All malignant disease survivors are at risk for development of secondary malignancies, including survivors of HSCT. Recipients of TBI are at highest risk as are children. All pediatric and adult survivors of HSCT should be followed for their life-time for development of delayed effects of transplantation.

Orthodontic treatment in long-term survivors after pediatric bone marrow transplantation

Children treated for childhood cancers with both radiation and chemotherapy often exhibit disturbances in dental development. A retrospective analysis of treatment outcome in 10 orthodontically treated children was performed. A questionnaire was sent to each child's orthodontist, and 5 orthodontists reported that the patient's medical condition influenced their choice of treatment plan. Three orthodontists, all treating patients with severely disturbed root development, reported using lighter forces than they used with the average patient. With regard to complications related to orthodontic treatment, 1 of the 10 patients showed evidence of root resorption. In 4 of the 10 patients, the treatment result was judged to be unsatisfactory. This study showed that, although ideal treatment results were not always achieved, orthodontic treatment did not produce any harmful side effects in children who are long-term survivors of childhood cancer.

Disturbances in craniofacial morphology in children treated for solid tumors

Because of increased survival rates in childhood cancer, special interest has been focused on the side-effects of the therapy and the quality of life in long-term survivors. Our aim was to investigate craniofacial growth in children who had received different kinds of antineoplastic therapies for solid tumors. A total of 40 children treated in the Turku University Central Hospital were examined and divided into three different groups. Group 1 comprised 18 children treated for intracranial tumors with cranial irradiation (CRI) and chemotherapy (CT) including alkylating agents. Seven children out of 18 in this group received growth hormone (GH) therapy. In Group 2, 11 children with extracranial solid tumors also received multiagent CT including alkylating agents, but no CRI. Group 3 consisted of 11 children treated for Wilm's tumor with CT, which did not include alkylating agents or CRI. A total of 19 linear and four angular variables from the lateral cephalograms of the subjects were measured. Most deviations in craniofacial structures were found in children treated with combined CRI and multiagent CT. All disturbances were seen in the vertical measurements which were reduced when compared to the matched controls. It seems reasonable to assume that impaired growth following combined radio- and chemotherapy, as well as GH treatment, particularly affects cartilage-mediated growth. However, the deviations seen in the present study were fairly minor and did not usually require clinical consideration.

Dental care in acute lymphoblastic leukaemia: experiences of children and attitudes of parents

OBJECTIVES

To profile the dental experiences of a group of children diagnosed as suffering from Acute Lymphoblastic Leukaemia (ALL) and to examine: 1) how parents of children diagnosed as suffering from ALL perceive the importance of dental care; 2) parental preferences with regard to the provision of dental care for children with ALL.

SETTING

The study was conducted in one of the 22 United Kingdom Children's Cancer Study Group (UKCCSG) centres.

SAMPLE AND METHODS

Data were collected by means of a structured interview, employing an administered questionnaire.

RESULTS

The majority of children had attended a dentist both prior to, and following diagnosis, though the regularity of such attendance was variable and the receipt of dental preventive advice inconsistent. Parents appeared to place a high level of importance on their children's dental care, with more than two-thirds expressing a preference for this to be provided within the Paediatric Oncology Unit.

CONCLUSIONS

There is a need to establish means by which regular dental attendance may be encouraged and facilitated in the difficult circumstances posed following diagnosis. All healthcare professionals need to be equipped to give clear, consistent oral health advice. This, together with appropriate preventive measures, should be incorporated in oral care protocols. In accordance with the wishes of parents in this study, it is recommended that a comprehensive paediatric dental service be provided at all UKCCSG centres.

Subjective xerostomia in long-term surviving children and adolescents after pediatric bone marrow transplantation

BACKGROUND

The aim of the present investigation was to evaluate whether the subjective symptoms of dry mouth in long-term-surviving pediatric bone marrow transplant (BMT) patients are associated with low unstimulated salivary secretion rates (USSR) and with stimulated whole salivary secretion rates (SSSR).

METHODS

Fifty-three patients surviving > or =2 years after pediatric allogeneic BMT were included. USSR, SSSR, and the change in salivary secretion rates since the previous year were estimated. A questionnaire regarding subjective symptoms of xerostomia was answered.

RESULTS

The mean USSR and SSSR were 0.24+/-0.17 and 0.90 +/- 0.58 ml/min, respectively. Salivary gland dysfunction, defined as USSR < or =0.1 ml/min or SSSR < or =0.5 ml/min, was present in 35% of the patients. Seventy-nine percent of the patients expressed one or more symptom of dry mouth, and 49% gave at least two answers indicating dry mouth. The number of complaints increased with age at examination (P<0.05). Both USSR (P<0.01) and SSSR (P<0.01) were inversely correlated to the total number of complaints of xerostomia. A reduction in SSSR compared with the year before was correlated to two or more complaints of xerostomia (P<0.01). The presence of dry mouth at night or on awakening was indicative of both low USSR (P<0.01) and SSSR (P<0.001). Patients reporting dryness during the day had significantly lower SSSR (P<0.05).

CONCLUSION

The expression of subjective complaints of xerostomia among long-term surviving pediatric BMT patients is correlated to salivary gland dysfunction and age. It is very important to identify these patients with salivary gland dysfunction to relieve their symptoms and prevent secondary complications.

Absorbed doses in the head and oral cavity during total body irradiation

Conditioning before bone marrow transplantation (BMT) with total body irradiation (TBI) and cyclophosphamide carries the risk of severe long-term complications. The aim of the present study was to determine absorbed doses in the craniofacial area during TBI, using thermoluminescent dosimeters for both in vivo techniques and phantom measurements. The results from the phantom study showed that the mean deviation from the reference dose varied between -5.1 and +11.1%. The superficial part of left parotid gland received 11.1 +/- 1.5% more radiation compared with the reference. In patients, deviations from the reference dose varied in individual patients between -22.4 and +20.1% in various intra-oral sites. Since a small increase in dose can result in a significantly increased risk of pathology, the observed dose inhomogeneities for structures receiving tangentially directed radiation therapy, such as the parotid glands, may contribute to salivary dysfunction after TBI.

Dental caries, gingival health, and oral hygiene of long term survivors of paediatric malignant diseases

Fifty two children who had had cancer and been treated with chemotherapy, and who were long term event free, were examined for caries prevalence, gingival health, and oral hygiene and compared with a control group. A higher dental caries prevalence for the 14-17 year age group was noted. The restorative index was significantly lower in the age group 10-13. There were no significant differences in gingival index, plaque index, or toothbrushing frequency. It is concluded that these patients should be considered as at high risk for caries after cancer treatment. Professional dental follow up should be integrated in the medical follow up.

Changes in craniofacial development induced by growth hormone therapy in children treated with bone marrow transplantation

The effect of growth hormone (GH) treatment on craniofacial development was studied in nine children exhibiting low growth velocity after bone marrow transplantation (BMT). Comparisons were made with seven BMT children who had not received GH. Two groups of age- and sex-matched healthy children served as controls for the respective patient groups. After an average observation period of 3.5 years, the BMT children not treated with GH exhibited significantly reduced mandibular length and alveolar height (p < 0.01). The increase in mandibular length was only 30% of that found in healthy controls. Maxillary growth was less affected by BMT treatment. In the GH treated group, no significant differences were found in craniofacial growth increments compared with controls. Although exogenous GH therapy in this group of children did not induce a catch-up growth, it appears to have prevented further loss in growth potential.

Craniomandibular dysfunction in children treated with total-body irradiation and bone marrow transplantation

The prevalence of pain and dysfunction in the stomatognathic system was studied in a group of 19 long-term survivors after pediatric bone marrow transplantation (BMT), conditioned with total-body irradiation (TBI). Compared with the control group, the children and adolescents in the BMT group had a significantly reduced mouth opening capacity. A reduced translation movement of the condyles was diagnosed in 53% of children treated with TBI, compared with 5% in the control group. Signs of craniomandibular dysfunction were found in 84% of children in the BMT group, compared with 58% in the control group. Both irradiation and chemotherapy induce long-term alterations in connective and muscle tissues resulting in inflammation and eventually fibrosis. These changes in tissue homeostasis and concomitant growth retardation may lead to the observed malocclusion and reduced mobility of the temporomandibular joint, with subsequent muscle pain and headaches, which were found in this study.

Histologic changes in dental morphology induced by high dose chemotherapy and total body irradiation

Disturbances in dental development were studied with the use of radiography and histology in a patient with acute lymphoblastic leukemia who was treated with induction chemotherapy at 2.3 years of age and bone marrow transplantation at 4.3 years of age. The follow-up 9.5 years after bone marrow transplantation showed evidence of short tapered roots, enamel hypoplasia, microdontia, and aplasia. A histologic examination of two extracted permanent teeth showed that the crown of the maxillary lateral incisor exhibited numerous incremental lines that corresponded closely to the treatment periods with cytotoxic drugs. The maxillary second premolar exhibited regularly spaced incremental lines in the enamel and dentine. A gross hypoplasia was seen in the cervical part of the crown corresponding to the time of administration of 10 Gy total body irradiation. The results indicate that chemotherapy mainly induces qualitative disturbances in dentine and enamel, whereas total body irradiation induces both qualitative and quantitative changes.

Craniofacial growth in bone marrow transplant recipients treated with growth hormone after total body irradiation

The effect of growth hormone (GH) treatment on craniofacial development was studied in five children exhibiting growth retardation following bone marrow transplantation. Linear and angular measurements were made on lateral radiographic cephalograms taken prior to the start of GH treatment and after an average treatment time of 1.2 yr. The results showed that the mean growth increments of mandibular length in the GH treated children, exceeded the corresponding values of the control group by 150% during the period of investigation. It is suggested that this dimensional increase in the patients was due to GH stimulation on the chondral growth process in the mandibular condyles.