Oral complications in children with cancer

Chemotherapy and Radiotherapy Long-Term Adverse Effects on Oral Health of Childhood Cancer Survivors: A Systematic Review and Meta-Analysis

The survival rate for pediatric cancer has increased over the past few decades, short- and long-term complications have been detected and studied, and oral complications have emerged as an important topic of research. Here, we aimed to highlight the importance of oral manifestations that may only become apparent years or even decades after cancer treatment. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched articles using PubMed via the MEDLINE, Web of Science, and LILACS databases until October 2023. Overall, 35 observational studies were included, and the results estimated a pooled prevalence of the following dental anomalies: discoloration, 53%; crown-root malformations and agenesis, 36%; enamel hypoplasia, 32%; root development alterations, 29%; unerupted teeth, 24%; microdontia, 16%; hypodontia, 13%; and macrodontia, 7%. Most childhood cancer survivors have at least one dental sequela. Childhood cancer survivors presented a higher risk of having dental alterations than control counterparts. Additional analyses reveal possible sex-based differences that should be explored in future studies. These results collectively highlight the importance of oral healthcare and the prevention of disease in childhood cancer survivors.

Characterization of Oral Candida spp. Biofilms in Children and Adults Carriers from Eastern Europe and South America

BACKGROUND

Candida albicans and non-Candida albicans Candida species (NCACs) are known to colonize and invade various tissues, including the oral mucosa. In this work, we aimed to characterize mature biofilms of several Candida spp. clinical isolates (n = 33) obtained from the oral mucosa of children, adults, and elders of Eastern Europe and South America.

METHODS

Each strain was evaluated for its capacity to form biofilms in terms of total biomass using the crystal violet assay and for matrix components production (proteins and carbohydrates) using the BCA and phenol-sulfuric tests, respectively. The effect of different antifungals on biofilm formation was studied.

RESULTS

in the children's group, a predominance of C. krusei (81%) was observed, while, among adults, the main species was C. albicans (59%). Most strains showed a reduced response to antimicrobial drugs when in biofilm form (p < 0.01). Moreover, it was observed that strains isolated from children produced more matrix, with higher levels of protein and polysaccharides.

CONCLUSIONS

children were more likely to be infected by NCACs than adults. More importantly, these NCACs were able to form biofilms richer in matrix components. This finding is of clinical importance, particularly in pediatric care, since stronger biofilms are highly associated with antimicrobial resistance, recurrent infections, and higher therapeutic failure.

Paediatric dental outcomes among children exposed to chemotherapy in utero

AIM

Our study prospectively evaluated dental development in children exposed to chemotherapy in utero compared with unexposed controls.

DESIGN

Women who received chemotherapy while pregnant were enrolled in a research registry. After age two, each child's dentist was asked to complete a questionnaire about dental abnormalities and malformations, as well as for their unexposed siblings. Multivariate linear regression adjusting for age was used to compare the groups.

RESULTS

Dental information was received for 67 exposed children and 59 controls. The majority of mothers were treated for breast cancer (79.1%) and primarily received doxorubicin (89.6%) and cyclophosphamide (80.6%). Mean gestational age at first exposure was 20.7 (±5.7) weeks. Mean age at dental evaluation was 8.0 (±4.3) years for exposed and 10.4 (±5.1) years for controls (P < .01). Missing teeth, tooth size, shape, and color did not differ significantly between groups. There was no statistical difference in dental caries, facial abnormalities, or abnormalities of enamel or gingiva. There was no association between any chemotherapy agent or regimen and increased risk of dental abnormalities.

CONCLUSIONS

Overall, there was no difference in dental abnormalities between groups. These negative findings may be because no one received chemotherapy prior to 14 weeks when formation of primary teeth was beginning.

Orofacial Manifestations of Leukemic Children on Treatment: A Descriptive Study

Aim

To study the prevalence of orofacial manifestations in leukemic children undergoing treatment and to correlate these manifestations with various stages of chemotherapy.

Materials and methods

A prospective noninvasive study comprising 43 acute lymphocytic leukemic pediatric patients at various stages of therapy. They were examined on day of their each blood examination, and lesions were recorded on a self-designed pro forma. A total of 133 observations were recorded by a single observer. The treatment was divided into the phase of induction, consolidation, maintenance, and relapse.

Results

The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 10.1. There were 24 males and 19 females in this study, aged between 3 and 13 years. The common oral lesions seen were dental caries, lymphadenopathy (86.04%), pallor (65.11%), ulcers (13.95%), mucositis (16.27%), gingival enlargement, hemorrhages (20.93%), candidiasis, herpes simplex virus (HSV) infection, xerostomia (44.18%), paresthesia, and tooth mobility. Herpes simplex virus infection was seen only during induction and consolidation phases. Ulcers were seen during all phases of therapy.

Clinical significance

Orofacial manifestations may be seen as the first sign of leukemia and a dentist may play a significant role in the diagnosis of the disease per se. This study highlights not only about commonly occurring lesions but also their variation during various phases of therapy. To the best of our knowledge, no study has such an extensive reporting of orofacial manifestations of acute lymphocytic leukemia (ALL) patients under treatment.

How to cite this article: Aggarwal A, Pai KM. Orofacial Manifestations of Leukemic Children on Treatment: A Descriptive Study. Int J Clin Pediatr Dent 2018;11(3):193-198.

The effect of zinc sulfate on prevention, incidence, and severity of mucositis in leukemia patients undergoing chemotherapy

PURPOSE

This study aimed to evaluate the effect of zinc sulfate on the incidence and severity of mucositis in leukemia patients undergoing chemotherapy.

METHODS

This was a randomized clinical trial and placebo-controlled, triple blinded study. This study was conducted on leukemia patients undergoing chemotherapy. The subjects were randomly allocated into an experimental (received 50 mg zinc sulfate capsules) and a control group (received placebo capsules). Zinc and placebo capsules were administered three times daily for 14 days from the first day of chemotherapy. Mucositis was measured by the oral mucositis index and World Health Organization mucositis scale on the 4th, 7th, and 14th days after chemotherapy. The data were analyzed using independent t-test, chi-square test, and Repeated Measures Analysis of Variance (RM-ANOVA).

RESULTS

The results showed a significant difference between the two groups in terms of the incidence of mucositis, which was 2.1 times higher in the control group in comparison to the zinc sulfate group. The results of RM-ANOVA also indicated a significant difference between the two groups regarding the mean score of objective and subjective evaluation of mucositis during the three study periods (F = 7.83, p = .007 and F = 5.79, p = .01, respectively).

CONCLUSION

The results of this study indicated that zinc sulfate reduced the incidence and severity of mucositis in leukemia patients undergoing chemotherapy. As zinc sulfate prevented and relieved mucositis in leukemia patients under chemotherapy, using zinc sulfate is recommended in clinical setting. Yet, further studies are suggested to confirm these findings.

Peroxisome proliferator activated receptor-gamma stimulation for prevention of 5-fluorouracil-induced oral mucositis in mice

BACKGROUND

Oral mucositis is a side effect of treatment regimens containing 5-fluorouracil (5-FU). The purpose of this study was to present our evaluation to see if rosiglitazone (RGZ) protected normal tissues from chemotherapy-induced oral mucositis.

METHODS

C57BL/6J mice were treated with 5-FU for 5 days, with or without RGZ. Mice were euthanized after 5, 8, 11, or 15 days, and mucosal segments were collected.

RESULTS

The RGZ did not affect the 5-FU-induced decrease in mouse body weight. The 5-FU caused loss of epithelial architecture, collagen fiber impairment, and inflammatory infiltration. The RGZ reduced leukocyte infiltration, preserved tissue structure, and dampened the 5-FU-induced expression of p53 and matrix metalloproteinase (Mmp)-2 after 5 days, and of Mmp-2 and interleukin (Il-1β after 15 days. The RGZ inhibited the 5-FU-induced increase of transforming growth factor-beta (TGF-β) and nuclear factor-kappa B (NF-κB) proteins and restored collagen protein levels.

CONCLUSION

The RGZ had a protective effect on oral mucosa damaged by chemotherapy. These data encourage the further study of RGZ for the prevention of 5-FU-induced mucositis in patients with cancer.

Dermatological Findings in Turkish Paediatric Haematology-Oncology Patients

OBJECTIVE

Diagnoses of skin, mucosae, hair and nail manifestations in malignant diseases are often challenging because of life-threatening drug reactions, opportunistic infections or skin involvement of primary processes. Description of morphology, configuration and distribution of lesions is important in order to differentiate the self-healing eruptions from serious side effects of chemotherapy. There are case reports from Turkey including dermatological manifestations of malignancies and case series in adult patients but there are no published large group studies assessing all manifestations in children. The aim of this study was to evaluate the morphological features of dermatological findings in children with haemato-oncological diseases.

MATERIALS AND METHODS

The study was performed at the Erciyes University, Faculty of Medicine Pediatric Hematology-Oncology Clinic, Turkey. Three dermatologists daily consulted all patients admitted to the clinic during a one-year period.

RESULTS

The study group comprised of 157 children (79 female/78 male) aged 1-16 years (mean 7.19±4.63). Detailed dermatological examinations were performed, including oral-genital mucosae, hair and nails. Thorough skin examination revealed that 70% of the patients exhibited at least one dermatological finding. Generalized xerosis and hyperpigmentation were the most common findings among patients undergoing chemotherapy (24.19%). Multiple nevi on at least 10 covered areas were very frequent among patients undergoing long-term chemotherapy (18.47%). Three were identified as dysplastic nevus, but malignant transformation was not observed during the one-year study period.

CONCLUSION

Regular dermatological consultation may help resolve the diagnostic and therapeutic problems in paediatric haemato-oncology clinics.

Oral manifestations resulting from chemotherapy in children with acute lymphoblastic leukemia

Introdução

A leucemia linfocítica aguda é um dos tipos de câncer mais comuns em crianças e é caracterizada pela produção excessiva e desordenada de leucócitos imaturos na medula óssea.

Objetivo

Identificar as manifestações orais mais frequentes em crianças portadoras de leucemia linfocítica aguda sob o tratamento quimioterápico.

Metodologia

A pesquisa foi realizada nas bases de dados eletrônicas PubMed/Medline, Science Direct, Scielo e Scopus. Procurou-se por artigos apresentados na íntegra, escritos em português, inglês e espanhol, publicados entre janeiro de 1992 e abril de 2013.

Resultados

Dos estudos selecionados primariamente, apenas oito atenderam aos critérios de inclusão. A população avaliada foi um grupo de crianças portadoras de leucemia linfócitica aguda. Todos os estudos realizaram exames intraorais para o diagnóstico das lesões bucais. De acordo com os resultados, as lesões mais frequentes foram mucosite, candidíase, periodontite e gengivite. A condição de saúde bucal dos portadores de leucemia linfócitica aguda variou de acordo com a higiene bucal do paciente.

Conclusão

Pacientes com LLA podem apresentar alguma lesão na cavidade oral durante ou após o início da quimioterapia. O cirurgião dentista necessita reconhecer as manifestações orais e intervir na saúde bucal do paciente com LLA, contribuindo e auxiliando no seu tratamento.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Topical morphine for oral mucositis in children: dose finding and absorption

CONTEXT

Systemic opioids for painful chemotherapy-induced oral mucositis in children often result in unsatisfactory pain relief and a high frequency of side effects. Opioids applied topically can produce analgesia by binding to opioid receptors on peripheral terminals of sensory neurons. These receptors are upregulated during inflammation, for example, in oral mucositis.

OBJECTIVES

The aims of this study were to investigate the dose-response relationship (n=7) and the potential absorption of topical morphine (n=5) across oral mucosa in children with oral mucositis.

METHODS

The dose-response study was conducted according to a sequential study design (Dixon's Up-and-Down method) for topical morphine doses of 0.025-0.400mg/kg, with the decrease in oral pain score as the primary outcome. To assess potential absorption across oral mucosa after a single dose of topical morphine of 0.050mg/kg, blood samples were drawn and the plasma concentrations of morphine and metabolites were determined by high-pressure liquid chromatography.

RESULTS

A decrease in oral pain score of ≥36% was achieved in six of seven patients in the dose-response part of the study. Plasma concentrations of morphine and metabolites were well below effective analgesic levels.

CONCLUSION

No obvious dose-response effect was found for topical morphine doses of 0.025-0.400mg/kg, and topically applied morphine was not absorbed in clinically relevant doses. However, this study was limited by the small number of patients and the allowance of a systemic opioid as rescue medication. Thus, randomized controlled studies are needed to further investigate the analgesic properties of topical morphine.

Traumeel S in preventing and treating mucositis in young patients undergoing SCT: a report of the Children's Oncology Group

Mucositis can be a serious complication of hematopoietic SCT (HSCT). A previous phase II trial in 32 children undergoing HSCT reported a beneficial effect of the homeopathic remedy Traumeel S. The Children's Oncology Group sought to replicate the results in a multi-institutional trial. The study was an international multi-center, double-blind, randomized trial comparing Traumeel with placebo in patients aged 3-25 years undergoing myeloablative HSCT. Traumeel/placebo was started on Day -1 as a five-time daily mouth rinse. Efficacy of the treatment was assessed using the modified Walsh scale for mucositis, scored daily from Day -1 to 20 days after HCST. The main outcome was the sum of Walsh scale scores (area-under-the-curve (AUC)) over this period. Other outcomes included narcotic use, days of total parenteral feeding, days of nasogastric feeding and adverse events. In 181 evaluable patients, there was no statistical difference in mucositis (AUC) in the Traumeel group (76.7) compared with placebo (67.3) (P=0.13). There was a trend towards less narcotic usage in the Traumeel patients. No statistically beneficial effect from Traumeel was demonstrated for mucositis. We could not confirm that Traumeel is an effective treatment for mucositis in children undergoing HSCT.

The addition of ketamine to a morphine nurse- or patient-controlled analgesia infusion (PCA/NCA) increases analgesic efficacy in children with mucositis pain

AIM

To assess the efficacy of adding ketamine to morphine nurse- or patient-controlled analgesia (NCA/PCA) infusions in treating mucositis pain in children.

BACKGROUND

Mucositis pain can be very difficult to control in some patients despite the use of parenteral opioids. In our institution, we have started adding low-dose ketamine to the morphine NCA/PCA in these children in an effort to improve analgesic efficacy.

METHODS/MATERIALS

The records of all children receiving a morphine/ketamine PCA or NCA for mucositis pain in our institution from 1999 to 2007 were reviewed. At the time of treatment, details of the analgesic management and consumption, pain scores and side effects were prospectively recorded and then entered on to an electronic database. Ketamine was added at a concentration of 20 or 40 microg x kg(-1) per ml with our standard morphine NCA/PCA infusions and protocols being used.

RESULTS

In 28 patients, there was no difference between average morphine consumption in the 24 h pre and post the addition of ketamine (33.1 (+/-10.7) vs 35.2 (+/-14.3) microg x kg(-1) per hour, P = 0.45) but in those with recorded pain scores (n = 16), the median percentage of pain scores > or =4 was 48% (13-100%) preketamine versus 33% (0-82%) postketamine (P = 0.01). In all patients, there was no change in the rates of nausea and vomiting and pruritus pre and post the addition of ketamine and no other significant side effects were reported. No difference was seen between those who had 20 or 40 microg x kg(-1) per ml of ketamine added.

CONCLUSION

The addition of ketamine to a morphine NCA/PCA improves analgesic efficacy in children with mucositis pain with no increase in the incidence of side effects.

Oral mucositis in morning vs. evening irradiated patients: a randomised prospective study

PURPOSE

Patients of head and neck cancer undergoing radiotherapy develop oral mucositis. The severity of mucositis may also depend on the time of administration of radiation apart from patient-related factors. The most radiosensitive phase of the cell cycle (G2-M) occurs in the late afternoon and evening in human oral mucosa; therefore, it is more vulnerable to radiation injury in the evening. The present study evaluated prospectively the severity of acute oral mucositis in head and neck carcinoma patients irradiated in the morning (08:00-11:00 h) versus late afternoon/evening (15:00-18:00 h).

METHOD

A total of 212 patients of head and neck carcinoma were randomised to morning (08:00-11:00 h) and evening (15:00-18:00 h) groups. The grades of oral mucosa ulceration were compared in the two groups.

RESULTS

The grades of mucositis were marginally higher in the evening-irradiated group than in the morning-irradiated group 38% vs. 26% (p = 0.08).

CONCLUSION

The observed incidence of grade III/IV mucositis in morning vs. evening irradiated patients may be because of the existence of circadian rhythm in the cell cycle of normal mucosa. This knowledge may provide a possibility of treating the patients with decreased toxicity to oral mucosa.

Candidiasis in pediatric patients with cancer interned in a university hospital

Fungi are common causes of infection in immunocompromised patients. Candida species are frequently involved in these cases. In order to investigate candidiasis in pediatric patients with cancer, clinical samples were collected from one hundred and twenty two patients interned in the Oswaldo Cruz University Hospital in Recife, Brazil. Yeasts were isolated from thirty-four clinical samples. The species isolated were: Candida albicans (fourteen isolates), C. parapsilosis (nine isolates), C. guilliermondii (two isolates) and C. tropicalis (two isolates). We found that candidemia was most frequent in patients with malignant hematology and that C. parapsilosis infections caused the highest mortality.

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.

Chemotherapy-induced oral complications in leukemic patients

The adverse effects of chemotherapy frequently involve the oral cavity, but the severity of oral complications caused by different chemotherapy protocols is unknown.

OBJECTIVE

To compare the frequency of oral complications in patients with acute lymphoblastic leukemia treated with the GBTLI-93 and BFM protocols.

PATIENTS AND METHODS

Twenty patients ranging in age from 2 to 13 years were submitted to visual and tactile examination of the teeth, periodontium and soft tissues on the day of admission and over the 3 weeks following the first phase of chemotherapy.

RESULTS

No significant difference in the proportion of patients with complications was observed between the two protocols over the 3 weeks. Complications were more frequent immediately after administration of the chemotherapeutic agents, with a gradual decline over the following 3 weeks.

CONCLUSIONS

Oral complications occur in patients with acute lymphoblastic leukemia irrespective of the chemotherapy protocol used for treatment, with a higher frequency being observed in the first week after the beginning of antineoplastic therapy.

Debridement could be a solution to promote healing of established oral mucositis in children

AIM

The aim of the study was to present a novel approach to promote healing of established oral mucositis and to alleviate symptom clusters in a group of children who were on induction chemotherapy.

STUDY DESIGN

A clinical prospective study.

METHODS

Children (40) diagnosed with Grade 3 or 4 oral mucositis were randomly assigned into two groups: In Group I (n=20), accumulated debris on ulcerations was removed (debridement); In Group II (n=20), subjects had no debridement. The condition of oral lesions, speech, lips, teeth, saliva, gingiva, and swallowing ability were examined 3 x week during the study. All subjects received the same oral care regimen. They were well balanced in respect of age, the type of antineoplastic treatment, and the number.

RESULTS

Debridement promoted resolution and decreased the severity of oral mucositis significantly. Thus, the subjects had less oral discomfort, pain, and nutritional difficulties.

STATISTICS

The data were entered in the SPSS 13.0 program, and the tests used were Kolmogorov-Smirnov, Shapiro-Wilk, Mann-Whitney, and Spearman's correlation coefficient with a 5% significance level.

CONCLUSION

Well-controlled, prospective clinical studies related to the management of established oral mucositis will lead to the development of potential interventions and improved patient care.

Mucosite bucal rádio e quimioinduzida

O aumento da intensidade da quimioterapia e radioterapia no tratamento do câncer tem elevado a incidência de efeitos colaterais, em especial da mucosite bucal. OBJETIVO E MÉTODO: Através de revisão bibliográfica realizou-se atualizar informações quanto à definição, características clínicas, incidência, etiologia, patofisiologia, morbidade associada, prevenção e tratamento dessa manifestação clínica. RESULTADOS: Estudos atuais definem a mucosite bucal como uma inflamação e ulceração dolorosa bastante freqüente na mucosa bucal apresentando formação de pseudomembrana. Sua incidência e severidade são influenciadas por variáveis associadas ao paciente e ao tratamento a que ele é submetido. A mucosite é conseqüência de dois mecanismos maiores: toxicidade direta da terapêutica utilizada sobre a mucosa e mielossupressão gerada pelo tratamento. Sua patofisiologia é composta por quatro fases interdependentes: fase inflamatória/vascular, fase epitelial, fase ulcerativa/bacteriológica e fase de reparação. É considerada fonte potencial de infecções com risco de morte, sendo a principal causa de interrupção de tratamentos antineoplásicos. Algumas intervenções mostraram-se potencialmente efetivas para sua prevenção e tratamento. Entretanto, faz-se necessária a realização de novos estudos clínicos mais bem conduzidos para obtenção de melhor evidência científica acerca do agente terapêutico de escolha para o controle da mucosite bucal, permitindo a realização da quimioterapia e radioterapia do câncer em parâmetros ideais.

Radiation therapy and chemotherapy-induced oral mucositis

TIncreasing the intensity of radiation therapy and chemotherapy in the management of cancer has increased the incidence of adverse effects, especially oral mucositis.

Aim and methods

a bibliographical review was conducted on the definition of oral mucositis, its clinical findings, the incidence, its etiology, the pathofisiology, associated morbidity, prevention and treatment.

Results

current studies define oral mucositis as a very frequent and painful inflammation with ulcers on the oral mucosa that are covered by a pseudo membrane. The incidence and severity of lesions are influenced by patient and treatment variables. Oral mucositis is a result of two major mechanisms: direct toxicity on the mucosa and myelosuppression due to the treatment. Its pathofisiology is composed of four interdependent phases: an initial inflammatory/vascular phase; an epithelial phase; an ulcerative/bacteriological phase; and a healing phase. It is considered a potential source of life-threatening infection and often is a dose-limiting factor in anticancer therapy. Some interventions have been shown to be potentially effective to prevent and treat oral mucositis. Further intensive research through well-structured clinical trials to obtain the best scientific evidence over the standard therapy of oral mucositis is necessary to attain ideal parameters for radiotherapy and chemotherapy.

Protection against chemotherapy induced mucositis by TGF-beta(2) in childhood cancer patients: results from a randomized cross-over study

BACKGROUND

Mucositis is one of the most frequent and severe side-effect of chemotherapy in childhood-cancer patients for which there is no prophylaxis available. The efficacy and feasibility of a TGF-beta(2)-enriched feeding for preventing oral and gastro-intestinal-mucositis in childhood-cancer patients were studied.

PROCEDURE

The study was designed as a two-period cross-over, randomized, double-blinded, placebo, controlled trial. Patients who had a high risk for developing mucositis and who would receive two comparable cycles of chemotherapy were eligible for the study. During one cycle of chemotherapy, TGF-beta(2)-enriched feeding was administered; during the other, a "placebo" (not enriched) feeding was used. WHO toxicity scales of diarrhea, oral mucositis, fever, anal lesions and nausea/vomiting were scored daily. In addition, the incidence of occurrence of blood cultures, antibiotic therapy, and interventions or diagnostics related to mucositis were measured.

RESULTS

The feasibility of the study was good: 83% of the patients completed two cycles and 86% of the study-feeding was effectively consumed. Administration of TGF-beta(2) was safe as serum TGF-beta(2) did not increase, and renal and liver function were not affected during TGF-beta(2) consumption compared to normal feeding. Differences in toxicity, scored during the whole observation period and the number of days with WHO 3/4 toxicity, were not significantly different between cycles with TGF-beta(2) enriched and normal feeding.

CONCLUSIONS

TGF-beta(2) administration via feeding is well tolerated and safe. Although this study might have had limitations to show potential benefit of TGF-beta(2), it does not provide evidence that TGF-beta(2) decreases the incidence or degree of mucositis induced by combination chemotherapy in childhood-cancer patients.

Establishing content validity of the oral assessment guide in children and young people

There is a need for accurate and consistent oral assessment to measure mucosal changes and oral complications associated with cancer therapies. Mucositis is an important and common side effect of cancer therapies that merits the identification of improved health-care interventions. Developing appropriate and reliable oral assessment instruments for use with children is relevant to the evaluation of these interventions. The purpose of this study was to determine the content validity of the oral assessment guide (OAG) in children: an instrument that was designed to objectively assess the physiological changes of the oral cavity following administration of chemotherapy and radiotherapy to adults. This process is considered to be most effective when undertaken systematically. A judgement quantification process was used with health care professionals in paediatric oncology to establish content validity of items (n=9) and instrument (n=10). A revised OAG more pertinent to children and young people was produced in the light of this process.

Children's acceptance and tolerance of chlorhexidine and benzydamine oral rinses in the treatment of chemotherapy-induced oropharyngeal mucositis

Oral care is of great importance in the prevention of chemotherapy-induced oropharyngeal mucositis. Although considerable attention has been given in improving oral care practices, patients' acceptance and tolerance of oral rinses is a continuing problem in oral care. A randomized crossover design was used to determine the relative acceptability and tolerability of chlorhexidine and benzydamine oral rinse agents in children receiving chemotherapy. At the end of the study, each subject was asked to compare these two agents in relation to stinging and taste, as well as his/her perception in reducing mucositis. Thirty-four children aged 6-17 years completed two courses of chemotherapy during which they alternately practiced oral care using chlorhexidine then benzydamine or benzydamine then chlorhexidine. All of the children tolerated the agents well and continued with rinsing throughout the study. Only a few children had to resort to diluting the agents with normal saline or water. Fifty-nine percent of children reported that the stinging associated with benzydamine was more accepted than chlorhexidine. The taste of both these agents was accepted by 50% of children. Approximately 60% of children reported that chlorhexidine was more helpful than benzydamine in reducing mucositis. About 47% and 50% of them preferred chlorhexidine and benzydamine in their subsequent chemotherapy, respectively. In conclusion, chlorhexidine and benzydamine are acceptable and well-tolerated by children over the age 6 years old.

Prevention of oral mucositis in paediatric patients treated with chemotherapy

This study compared the efficacy of two protocols for oral care using either chlorhexidine or benzydamine as oral rinses to alleviate mucositis in children undergoing chemotherapy. Eligible participants were randomised to receive either protocol for 3 weeks in a two-period crossover design. The occurrence of ulcerative lesions and severity of mucositis were measured at baseline and twice weekly, using the modified Oral Assessment Guide (OAG). Data were continuously analysed by plotting them directly on predefined sequential charts. According to this sequential analysis, the study could be terminated at the 34th within subject comparison, with a statistically significant reduction in ulcerative lesions (P<0.05) and severity of mucositis (P<0.05) in children on the chlorhexidine protocol. These findings suggest that chlorhexidine together with oral care might be helpful in alleviating mucositis when given prophylactically to children on chemotherapy, but the therapeutic benefit needs to be confirmed in a larger trial.

Palliation of Oral Mucositis Symptoms in Pediatric Patients Treated With Cancer Chemotherapy

This prospective randomized 2-period crossover study aimed at comparing the efficacy of 2 oral care protocols differing in the type of mouthwashes: chlorhexidine versus benzydamine in alleviating oral mucositis symptoms for children undergoing chemotherapy. Forty subjects were randomly allocated to receive either chlorhexidine first then benzydamine protocols or benzydamine first then chlorhexidine protocols. Each protocol was started on the first day of chemotherapy and continued for 21 days. Subjects were evaluated in intervals of 3 to 4 days using the World Health Organization (WHO) grading for mucositis and 10-cm visual analogue scale for oral symptoms evaluations. Among 34 evaluable subjects, 26% and 48% of them using chlorhexidine and benzydamine had WHO grade II mucositis, respectively (P < .05). The results revealed a significant difference in mean area under the curve (AUC) of mouth pain (1.35 +/- 2.26 versus 3.09 +/- 3.21) (P = .05), and a trend of a lessening of mean AUC of difficulty in eating/chewing (2.49 +/- 3.74 versus 2.71 +/- 4.1) (P = .82) and swallowing (1.34 +/- 3.31 versus 1.91 +/- 4.03) (P = .53) for subjects receiving chlorhexidine compared to those receiving benzydamine. In conclusion, chlorhexidine may be helpful in palliating mucositis symptoms for children in chemotherapy. The beneficial effect, however, is small and needs to be confirmed in a larger trial.

An oral care protocol intervention to prevent chemotherapy-induced oral mucositis in paediatric cancer patients: a pilot study

The likelihood of paediatric cancer patients experiencing oral mucositis has increased significantly as high-dose and multiple chemotherapy agents are used in the treatment of childhood cancer in recent years. The resulting oral ulcerative lesions can cause significant pain, dysphagia, alteration in nutritional status and increased risk for localized infections that could disseminate systemically. The purpose of this pilot study was to determine the clinical benefits of an oral care protocol intervention on the prevention and reduction of the severity of oral mucositis in paediatric patients receiving chemotherapy. Fourteen children were enrolled in the study; there were seven children in the control and seven in the experimental group. In the experimental group, children received a preventive oral care protocol consisting of tooth brushing, normal saline rinse and 0.2% chlorhexidine mouth rinse. Children in the control group received usual care according to the study's clinical setting. Data were collected at baseline, then twice a week for 3 weeks. The incidence of ulcerative lesions, severity of oral mucositis and the related pain intensity were used as the main outcome variables. The experimental group exhibited fewer and less painful oral mucositis lesions. The results of this study support the preventive use of oral care protocols in paediatric patients undergoing chemotherapy for cancer treatment.

Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients

Oral mucositis is the most frequent and severe complication of chemotherapy in children with cancer that can aggravate the child's clinical condition and increase the risk of infection. This prospective comparative study was designed to determine the effectiveness of a preventive oral care protocol in reducing chemotherapy-induced oral mucositis in children with cancer. During an 8-month period, 42 children aged 6 to 17 years with haematological malignancies or solid tumours were evaluated. The 21 children who were included in the first 4-month period of the study constituted the control group. Another 21 children were enrolled in the subsequent 4 months and were assigned to the experimental group, in which they were given an oral care protocol intervention. The oral care protocol consisted of tooth brushing, 0.2% chlorhexidine mouth rinse and 0.9% saline rinse. Children in both groups were evaluated twice a week for 3 weeks. The incidence of ulcerative lesions, severity of oral mucositis and the related pain intensity were used as the main outcome variables. A 38% reduction in the incidence of ulcerative mucositis was found in children using the oral care protocol compared with children in the control group. The severity of oral mucositis (P=0.000002) and the related pain (P=0.0001) were significantly reduced with the intervention. These results support the preventive use of the oral care protocol in paediatric cancer patients who undergo chemotherapy for cancer treatment.

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.

Pediatric oral pathology. Soft tissue and periodontal conditions

Pediatric patients can present with various intraoral lesions that require accurate diagnosis, treatment or reassurance, and possible referral for a dental evaluation. Periodic review of oral soft-tissue pathology can help the medical team to easily recognize common and rare abnormalities affecting children. Recent years have brought new insights into the causes and treatment of periodontal diseases of children, making prevention or treatment of many formerly untreatable conditions possible. Early detection of these oral conditions may be life saving.

The mouth and palliative care

Oral complications are common among patients with advanced cancer, though relatively little research has been undertaken in this field. This review article discusses the common problem of xerostomia among the terminally ill, together with an overview of oral candidosis, oral viral infections, chemotherapy- and radiotherapy-associated mucositis, and alterations in taste sensation among those with advanced cancer. Suggested management regimes, based on the limited clinical trial data available, are provided where appropriate.

Craniofacial growth in children treated for malignant diseases

With the improving cure rate in childhood malignancies, increasing interest has been focused on the long-term survivors of childhood cancer and the quality of their life. The severity of long-term disturbances in dental and craniofacial development is dependent on the age of the child at diagnosis, if chemotherapy is combined with radiation or not. With regard to craniofacial development combination chemotherapy has no effects compared with healthy controls, whereas children treated cranial irradiation before 5 years of age exhibit a reduced growth of the mandible. Conditioning before bone marrow transplantation with total body irradiation results in a significantly reduced growth of the craniofacial skeleton. The mandible was four times more radiosensitive compared with the maxilla. With attention to the dental and craniofacial development, occlusion and craniomandibular function, children in risk groups should be followed, and given prophylactic treatment and intervention at appropriate times to reduce the consequences of the disease itself and the therapy given.

Oral complications during treatment of malignant diseases in childhood: effects of tooth brushing

During anticancer treatment, oral lesions considerably aggravate the child's clinical condition and increase the risk of infection. This prospective study evaluated the incidence, nature and chronology of oral complications arising during the first 6 weeks of chemotherapy. 131 children were included in this study, and their oral and dental health evaluated on enrolment. Each child was observed once a week, for 6 weeks. Fifty-two per cent (68/131) of the children presented with at least one oral lesion. Two oral healthcare regimens (with or without tooth brushing) were evaluated. Tooth brushing significantly reduced the number of children affected. Standardised multicentre studies should permit the definition of oral care regimens which would eliminate pain and reduce the risk of infection in children hospitalised for cancer.

Growth patterns of Candida albicans in relation to radicular dentin

Candida albicans is the most common fungal pathogen isolated from the oral cavity. The role of this organism as an endodontic pathogen is poorly understood.

OBJECTIVES

The aim of this study was to observe the interaction of C. albicans with root canal walls and the growth patterns of this microorganism in relation to radicular dentin.

STUDY DESIGN

Fifteen root sections were infected with C. albicans grown in calf serum and incubated for various periods. The sections were fixed in glutaraldehyde, split into two halves, and evaluated by scanning electron microscopy.

RESULTS

Blastospores and hyphal structures were observed on the root canal walls of all specimens. Filamentous hyphal form was dominant in 5-day specimens. Most of the hyphae and blastospores showed penetration into dentinal tubules. The body of germinating mother cells and hyphae demonstrated collapsed cell walls as a result of vacuole formation.

CONCLUSIONS

With this invasive affinity to dentinal structures, C. albicans may be considered a dentinophilic microorganism.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

Chemotherapy-associated oral mucosal lesions in patients with leukaemia or lymphoma

In order to determine the incidence rate of oral lesions associated with chemotherapy, as well as well as its association with clinical and laboratory parameters and potential risk factors, 50 in-patients with non-Hodgkin's lymphoma or leukaemia under chemotherapy were followed from January 1993 to May 1994. Basal and weekly oral examinations were performed. Clinical and laboratory data were registered. Wilcoxon's rank sum test, chi square test, univariate and multivariate logistic regression analyses were used, 36 individuals with leukaemia and 14 with non-Hodgkin's lymphoma were followed for 158 weeks; mean age was 33 years (range 15-85). Oral lesion incidence rate was 45/100 patients-week. Exfoliative cheilitis and infections (herpes and candidosis) were the most common oral complications, followed by haemorrhagic lesions and mucositis. Haemorrhagic lesions correlated with thrombocytopenia (RR = 30.5). Etoposide administration (RR = 8.6), alkylating agents (RR = 15.6), a prior course of chemotherapy (RR = 23.2) and neutropenia (RR = 4.16) were predictors of mucositis. Oral lesions were a common complication in this study, and a possible association of mucositis with several factors is suggested.

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.