Periodontium destruction associated with oncology therapy. Five case reports

Pre-radiotherapy dental extractions in patients with head and neck cancer: a Delphi study

OBJECTIVES

To gain a consensus from consultants in restorative dentistry about the types of teeth that should be extracted from head and neck cancer patients (HNC) pre-radiotherapy.

MATERIALS

Literature- and clinician-informed questionnaires were emailed to an 'expert panel' of consultants (n = 24/28; 86%) in the United Kingdom (UK) and Ireland on three consecutive occasions (Delphi rounds). The results of Round 1 were used to revise the questionnaire that was distributed in Round 2, and this procedure was repeated for Round 3. During Rounds 2 and 3, participants were asked to indicate, on a 5-point Likert scale, their level of agreement with a series of statements on the types of teeth that should be extracted pre-radiotherapy. The target level of consensus for each statement was 70%.

RESULTS

In Round 2, there was consensus-agreement for 69 of 102 statements (i.e. ≥ 70% of participants rated 'agree' or 'strongly agree' to the relevant statement). Consensus agreement was also achieved for 20 of 28 statements in Round 3. Therefore, a total of 89 consensus statements are presented that illuminate the decision-making process for the pre-radiotherapy extraction of molar, premolar, and anterior teeth with periodontal pocketing, furcation disease, mobility, caries, tooth-wear, apical disease, or other pathology.

CONCLUSION

The statements represent the consensus professional views of participated consultants in restorative dentistry in the UK and Ireland regarding the types of teeth that should be extracted from HNC patients pre-radiotherapy. The results provide a platform for the development of future guidelines.

CLINICAL SIGNIFICANCE

Pre-radiotherapy dental assessments for head and neck cancer patients are considered mandatory. This study presents different criteria that should be considered for the treatment planning of these patients in relation to pre-radiotherapy extractions, according to the collective consensus opinion of participated consultants in restorative dentistry in the UK and Ireland.

Effect of novobiocin on the viability of human gingival fibroblasts (HGF-1)

Background

Novobiocin is a coumarin antibiotic, which affects also eukaryotic cells inhibiting activity of Heat shock protein 90 (Hsp90). The Hsp90 represents a molecular chaperone critical for stabilization and activation of many proteins, particularly oncoproteins that drive cancer progression. Currently, Hsp90 inhibitors focus a significant attention since they form a potentially new class of drugs in therapy of cancer. However, in the process of tumorigenesis a significant role is played also by the microenvironment of the tumour, and, in particular, by cancer-associated fibroblasts (CAFs). This study aimed at examination of the effect played by novobiocin on viability of human gingival fibroblasts (HGF-1).

Methods

The studies were conducted using 24 h cultures of human gingival fibroblasts – HGF-1 (CRL-2014) in Chamber Slides, in presence of 0.1, 0.5, 1.0, 2.5 or 5.0 mM novobiocin. Cell viability was evaluated using fluorescence test, ATP assay and LDH release.

Results

Viability of HGF-1 was drastically reduced after 5 hour treatment with novobiocin in concentrations of 1 mM or higher. In turn, the percentage of LDH-releasing cells after 5 h did not differ from control value although it significantly increased after 10 h incubation with 1 mM and continued to increase till the 20th hour.

Conclusions

The obtained data indicate that novobiocin may induce death of human gingival fibroblasts. Therefore, application of the Hsp90 inhibitor in neoplastic therapy seems controversial: on one hand novobiocin reduces tumour-associated CAFs but, on the other, it may induce a significant destruction of periodontium.

Periodontal Changes in Patients Undergoing Radiotherapy

BACKGROUND

The purpose of this study was to evaluate changes in the periodontium in patients who received head and neck radiation therapy.

METHODS

Periodontal clinical parameters (probing depth, clinical attachment level, gingival recession, plaque index, and bleeding on probing) were assessed on 27 patients before and 6 to 8 months following radiation therapy in the head and neck area.

RESULTS

The greatest changes occurred in clinical attachment level: overall, 70.3% of the patients showed a loss, with 92% evincing loss in the mandible. Attachment loss was directly related to the field of radiation and was greater when the jaws were actually included in the irradiated area.

CONCLUSION

Periodontal status should be evaluated prior to and following radiation therapy in the oral-maxillary-facial region to help ensure that periodontal health is maintained in oncology patients.

Periodontal disease and periodontal management in patients with cancer

Periodontal infection may exacerbate during cancer therapy and may result in oral pain and infection, and systemic infection, which may cause morbidity and can lead to mortality in neutropenic cancer patients. Periodontal disease in head and neck cancer patients treated with radiation therapy may lead to acute and chronic complications. The literature was reviewed by a search of Medline of the National Library of Medicine. The search was conducted to identify publications assessing periodontal disease in cancer patients. In addition, a review of papers referenced in the retrieved papers was conducted to identify additional publications for review. Periodontal disease should be assessed and managed prior to medical treatment of cancer for those with oropharyngeal cancer, and for patients in whom neutropenia may develop during treatment. Pretreatment assessment and management, and maintenance of oral hygiene have been shown to be effective in preventing oral and systemic complications during treatment. A complete oral and periodontal examination is appropriate for all patients planned to receive head and neck radiation therapy and those to be treated with medical protocols that are anticipated to result in neutropenia. Oral and periodontal care must continue following cancer therapy, and requires that the health care provider have an understanding of the malignant disease, oral manifestations of the disease, medical management of the disease, and of the oral complications that may develop.

Periodontal attachment loss in patients after head and neck radiation therapy

OBJECTIVE

The purpose of this study was to determine the potential impact of head and neck radiation therapy on the progression of periodontal attachment loss.

STUDY DESIGN

Ten patients who received unilateral radiation fields that included the dentition were assessed before radiation treatment and after irradiation at a mean age of 6.01 years. Complete oral, dental, and periodontal examinations were completed by one examiner. The results were assessed through use of paired t tests.

RESULTS

More teeth were extracted because of periodontal disease in the field of radiation after irradiation. Remaining teeth in the radiated volume showed an increase in probing depth of 0.82 mm in comparison with 0.40 mm for teeth in the nonradiated region (P = .05). Recession on the facial aspects was 1.88 mm for teeth in the radiated volume and 1.16 mm for teeth in the nonradiated region (P = .001), and recession on the lingual aspects was 2.10 for teeth in the radiated volume and 0.91 for teeth in the nonradiated region (P = .05). Mean total attachment loss was 2.81 mm for teeth in the radiated sites; this compared with 1.43 mm for teeth in the nonradiated sites (P = .003). Increased mobility of teeth in the high-dose fields was seen (P = .02).

CONCLUSIONS

This study showed that tooth loss and greater periodontal attachment loss occur in teeth that are included within high-dose radiated sites of patients treated with irradiation therapy for cancer. These findings should be considered in preradiation treatment planning.

Surgical periodontal treatment in the radiotherapy-treated head and neck cancer patient

A series of clinical cases is presented in which surgical periodontal therapy was conducted within the high-dose volume of prior radiation therapy. Close oral supervision is required in patients following head and neck radiation therapy. Non-surgical periodontal management is crucial in the care of these patients following radiation therapy. Careful selection of patients for possible surgical therapy and care in performing the procedure may allow successful periodontal management, as is demonstrated in the cases reviewed.

New views on periodontal microbiota in special patient categories

The microorganisms in periodontitis of special patient categories have been only partially elucidated. The periodontitis microbiota of HIV-infected individuals, cancer patients on myelosuppressive therapy, and persons with other medical disorders includes common suspected periodontal pathogens as well as enteric rods, pseudomonads, staphylococci and yeasts. Failing implants also may be associated with classical periodontal pathogens as well as primarily nonoral potential pathogens. Refractory periodontitis in systemically healthy adults can show a great variety of oral and nonoral organisms. The frequent occurrence of unusual periodontal organisms in special patient categories may be due to a weakened host response and/or usage of various chemotherapeutic regimens. The unusual organisms may contribute to progressive periodontitis and in leukemia patients may even give rise to life-threatening systemic manifestations. The primary therapeutic goal in special periodontitis patients is control of pathogens and amid the wide range of pathogenic microfloras, an effective treatment strategy should include a comprehensive microbiological analysis, especially if systemic antimicrobial therapy is contemplated.

Rapidly progressive acute periodontal infection in a patient with acute leukemia

The clinical course of an adult patient with acute lymphocytic leukemia and localized, rapidly progressive periodontal disease in a setting of marrow regeneration is described. Initial presentation of this condition was consistent with herpes simplex virus infection involving the gingiva; however, more extensive evaluation including radiographs, cultures and biopsy revealed necrotic tissue, nonspecific bacterial growth and acute gingival inflammation, with no evidence of viral infection. While most acute oral infections in chemotherapy patients occur during the development of marrow aplasia, this lesion initially developed late during the marrow recovery phase. The characteristics of this lesion are compared with those occurring in noncancer patients with rapidly progressive periodontitis and who have genetically governed neutrophil and/or lymphocyte defects.