Long-term Dental Anomalies after Pediatric Cancer Treatment in Children

Dental management of long-term childhood cancer survivors: a systematic review

PURPOSE

Critically review and summarise existing knowledge on prevalence of oral, dental, and craniofacial side-effects of antineoplastic treatment in childhood cancer survivors (CCS).

METHODS

A literature search was conducted for studies reporting on children aged 4-19 years treated for any type of malignancy up to the age of 15 years and for whom, at the time of the examination, more than 8 months have elapsed since the end of treatment. Data regarding dental late effects on teeth and craniofacial complex were collected and mean prevalence of each defect was reported.

RESULTS

From the 800 articles identified, 17 studies fulfilled inclusion criteria and were included. A total of 983 CCS were examined, with the total number of healthy controls being 1266 children. Haematological malignancy was the most prevalent diagnosis with the age at diagnosis ranging between 0-15 years. Multiple antineoplastic protocols were implemented with the elapsed time being 8 months up to 17 years. One-third of CCS experienced at least one late effect, with corresponding value for the control group being below 25%. Among the defects identified clinically, microdontia, hypodontia and enamel developmental defects were recorded in 1/4 of CCS. Impaired root growth and agenesis were the two defects mostly recorded radiographically. The effect on dental maturity and on salivary glands was unclear.

CONCLUSION

CCS are at risk of developing dental late effects because of their disease and its treatment and therefore, routine periodic examinations are essential to record their development and provide comprehensive oral healthcare.

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.

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.

The Impact of Benign Jawbone Tumors on the Temporomandibular Joint and Occlusion in Children: A Ten-Year Follow-Up Study

This study aimed to provide a complex analysis of the modifications in craniofacial skeleton development that may arise following the diagnosis of pediatric benign jaw tumors. A prospective study was undertaken involving 53 patients younger than 18 years of age, who presented for treatment at the Department of Maxillo-Facial Surgery, University of Medicine and Pharmacy, Cluj-Napoca, with a primary benign jaw lesion between 2012 and 2022. A total of 28 odontogenic cysts (OCs), 14 odontogenic tumors (OTs), and 11 non-OTs were identified. At follow-up, dental anomalies were identified in 26 patients, and overjet changes were found in 33 children; lateral crossbite, midline shift, and edge-to-edge bite were found in 49 cases; deep or open bite were found in 23 patients. Temporomandibular disorders (TMDs) were found in 51 children, with unilateral TMJ changes identified in 7 cases and bilateral modifications found in 44 patients. Degenerative changes in the TMJ were also diagnosed in 22 pediatric patients. Although benign lesions could be associated with dental malocclusions, a direct etiological factor could be not identified. The presence of jaw tumors or their surgical treatment could, however, be linked to a change of the occlusal relationships or the onset of a TMD.

A Rare Incidence of Nonsyndromic Mandibular Incisor Agenesis in a Three-generation Family: Case Report and Literature Review

Hypodontia is an inherited condition involving the absence of one to six teeth. The permanent dentition is the most frequently affected; however, it may also affect the primary dentition. A congenitally missing tooth (CMT) is the most common dental abnormality, with the missing mandibular second premolar, maxillary lateral incisor, maxillary second premolar, and mandibular central incisor accounting for 90% of CMT in hypodontia studies. The etiology of CMT has been attributed to environmental and genetic contributing factors, with the latter having a strong influence. It may occur in isolation or in association with syndromes. Congenitally missing mandibular incisor is more common in the Asian population and females. Depending on the number and location of missing teeth, hypodontia may be a considerable issue for the clinician since it may impact occlusal balance, mastication, speech, and esthetics and often requires a multidisciplinary approach. Missing mandibular incisors are of particular interest to orthodontists because of the possibility of mandibular retrognathism, the potential for the development of malocclusion, and difficulty in achieving a balanced occlusion. This case report describes the skeletal and dental features of a nonsyndromic familial occurrence of missing mandibular incisors in three generations. A comprehensive literature search was also performed to review the familial cases with missing mandibular incisors.

How to cite this article

Selvaraj M, Sennimalai K, Samrit VD, et al. A Rare Incidence of Nonsyndromic Mandibular Incisor Agenesis in a Three-generation Family: Case Report and Literature Review. Int J Clin Pediatr Dent 2023;16(2):388-395.

Late Dental Toxicities After Proton Chemoradiation for Rhabdomyosarcoma: A Pediatric Case Report

Purpose

Radiation therapy is an independent risk factor for adverse sequelae to the oral cavity and dentition in childhood cancer survivors. However, dental toxicities after radiation therapy often are underreported and there are minimal published data on disturbances in tooth development after proton beam therapy (PBT). We present the long-term clinical and radiographic dental findings 8 years after treatment completion for a patient treated with PBT and chemotherapy for rhabdomyosarcoma.

Materials and Methods

Clinical follow-up data of patients treated with PBT within the Proton Overseas Programme (POP) is stored in a National Database and curated by a dedicated outcomes unit at the Christie NHS PBT center. This case report was identified from the extraction and analysis of data for pediatric head and neck cancer patients in this database for a service evaluation project.

Results

The permanent dentition in this patient aged 3.5 years at the time of treatment was severely affected with abnormal dental development first observed 3.5 years after treatment completion. PBT delivered mean doses of 30 Gy(RBE = 1.1) to the maxilla and 25.9 Gy(RBE = 1.1) to the mandible.

Conclusion

Significant dental development abnormalities occurred in this pediatric patient, despite doses in areas being lower than the proposed thresholds in the literature. Improved descriptions of dental toxicities and routine contouring of the maxilla and mandible are needed to correlate dosimetric data. The dose to teeth should be kept as low as reasonably possible in younger patients until the dose thresholds for dental toxicities are known.

Head and neck radiotherapy-induced changes in dentomaxillofacial structures detected on panoramic radiographs: A systematic review

Purpose

This study aimed to summarize the impact of neck and head radiation treatment on maxillofacial structures detected on panoramic radiographs.

Materials and Methods

In this systematic review, the authors searched PubMed Central, Embase, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar for original research studies up to February 2020 that included the following Medical Subject Headings keywords: words related to “radiotherapy” and synonyms combined with keywords related to “panoramic radiography” and “oral diagnosis” and synonyms. Only original studies in English that investigated the maxillofacial effects of radiotherapy via panoramic radiographs were included. The quality of the selected manuscripts was evaluated by assessing the risk of bias using Cochrane's ROBINS-I tool for non-randomized studies.

Results

Thirty-three studies were eligible and included in this review. The main objectives pertained to the assessment of the effects of radiation on maxillofacial structures, including bone architecture alterations, periodontal space widening, teeth development abnormalities, osteoradionecrosis, and implant bone loss. The number of participants evaluated ranged from 8 to 176.

Conclusion

The interaction between ionizing radiation and maxillofacial structures results in hazard to the tissues involved, particularly the bone tissue, periosteum, connective tissue of the mucosa, and endothelium. Hard tissue changes due to radiation therapy can be detected on panoramic radiographs.

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.

Comparison of Oral Health Impact Profile (OHIP-14) Values in Cancer Survivor Patients Treated Orthodontically with Either Rapid or Standard Duration Protocols of Treatment-A Prospective Case-Control Study

BACKGROUND

The aim of the study was to compare the oral-health-related quality of life (OHRQoL) between cancer survivors: with rapid orthodontic treatment (TX) (up to 12 months) and standard TX (orthodontic treatment time longer than 16 months).

METHODS

There were 76 cancer survivors (48 women and 28 men) allocated into groups with rapid (36 people) or standard (40 people) duration of TX. OHRQoL was assessed on the basis of Oral Health Impact Profile (OHIP-14) values, measured before TX, 2 weeks and 3 months after the onset of TX, and after the end of TX. A repeated ANOVA test was used to check the statistical significance between the scores.

RESULTS

There were no significant differences regarding the OHIP-14 values between the examined groups at all stages of the examination. Both groups presented significant (p < 0.001) improvement of the values of OHRQoL at the end of TX comparing to the values achieved before the onset of TX.

CONCLUSIONS

Duration of orthodontic treatment by itself had no impact on oral-health-related quality of life.

Exploring the presence of dental anomalies as a consequence of treatment of malignancy: A case report

Simultaneous presentation of tuberculosis (TB) and lymphoma in a young child is indeed a very rare entity. Malignancy such as Hodgkin's disease (HD) most commonly causes suppression of the cell-mediated immunity, which makes the individual, especially children, more prone to tuberculous infection. One of the non-life threatening complications in these young cancer survivors is the associated dental anomalies. These can seriously impair the quality of life of teenagers and young adults. Higher incidence of caries, discoloration of teeth or even early loss of teeth requiring dental prosthesis, can be associated with the use of cytostatic drugs. These drugs can also disturb odontogenesis, resulting in the absence of tooth buds, microdontia, dilacerations or shortening of tooth roots. Some of the anticancer drugs, including busulfan, cyclophosphamide, doxorubicin etc. May particularly play a significant role in the development of dental anomalies. This paper is a short review and case report of an 11 year old child having oligodontia and secondary dental complications caused as a side effect of treatment of Hodgkin's lymphoma with Tuberculous Lymphadenitis.