Craniofacial growth in children treated for malignant diseases

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

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

Acquired Facial, Maxillofacial, and Oral Asymmetries—A Review Highlighting Diagnosis and Management

Facial asymmetry refers to the absence of, or the deviation from the regular mirror image of facial structures, relative to a referenced midline axis. It can be attributed to a wide spectrum of deformities, including congenital, developmental, or acquired conditions, which can originate either prenatally or postnatally. Though highly prevalent, asymmetry commonly goes undiagnosed due to its subtle or relative nature. Among the spectrum of conditions, acquired cases are triggered postnatally, in previously normal individuals, thus subjecting them to sudden, eventful psychological and psychosocial disharmony. When detected early, timely management may help intervene progressive growth of these conditions. This, therefore, emphasizes the need for a thorough diagnostic workup including medical/dental history, clinical examinations, study models, photographic and radiographic records for a case-by-case basis to prevent severe functional and aesthetic complications. Recently, advanced diagnostic procedures, such as stereophotogrammetry, 3D stereolithographic models, skeletal scintigraphy (radionucleotide scans), 3D computed tomographic scans, cone-beam computed tomography, and magnetic resonance imaging, have provided innovative diagnostic instruments for numerous craniofacial defects. This descriptive review aims at focusing on the factors leading to frequently encountered conditions of acquired facial asymmetry and highlights their clinical evaluation, conservative and surgical interventions by a multi-disciplinary team of clinicians.

Alteration of facial growth after radiotherapy: orthodontic, surgical and prosthetic rehabilitation

Most patients treated in childhood with radiotherapy for head and neck tumors develop craniofacial alterations related to impaired growth of the irradiated regions. These deformities have a significant functional and aesthetic impact, generating physiological and social troubles. The therapeutic solutions are mostly surgical and multidisciplinary. In this article, we describe the orthodontic and surgical care of a teenager treated with radiotherapy for a bilateral retinoblastoma at the age of 8 month and a half. The patient presented growth defects of the middle third of the face. These growth deficiencies are at the origin of significant aesthetic and physical disorders. Moreover, the three-dimensional skeletal abnormalities and the histological changes of these irradiated tissues make surgical management of the cases complex and specific.

Dental and craniofacial alterations in long-term survivors of childhood head and neck rhabdomyosarcoma

OBJECTIVE

Rhabdomyosarcoma (RMS) represents the most common soft tissue sarcoma that affects children. Treatment involves chemoradiotherapy. This study aimed at evaluating the long-term alterations to teeth and cranial bones in children, teenagers, and young adults after oncologic treatment.

STUDY DESIGN

We conducted a cross-sectional study of patients undergoing treatment for head and neck RMS between 1988 and 2011. We evaluated demographic, clinical, and treatment data and performed panoramic radiography, cephalometry, and photography.

RESULTS

We evaluated 27 long-term survivors, most of whom had been treated between ages 0 to 5 years (51.9%). The total radiation dose applied was 50.4 Gy, and the chemotherapy combination included vincristine, actinomycin D, and cyclophosphamide in 51.9% of the cases. We observed 603 dental alterations, among which 377 (62.7%) occurred in patients ages 0 to 5 years, and root shortening was the most frequent alteration observed (24.2%). With regard to facial bones, 74% of the patients had some level of facial asymmetry, 70.4% had reduced facial depth, 48.4% had mandibles of short size, and 77.8% had reduced facial height.

CONCLUSIONS

Children submitted to RMS treatment involving chemotherapy and radiotherapy displayed significant dental and craniofacial alterations, especially when treatment occurred between ages 0 and 5 years.

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

Background

Survivors of childhood cancer are at risk of late dental development. Cyclophosphamide is one of the most commonly used chemotherapeutic agents against cancer in children. The aim of this study was to investigate the effects of cyclophosphamide on root formation in the molars of growing mice and to assess the morphological changes in these roots using three-dimensional structural images.

Methods

We treated 16 12-day-old ICR mice with cyclophosphamide (100 mg/kg, i.p.) and 16 control mice with saline. At 16, 20, 24, and 27 days of age, the mandibular left first molars were scanned using soft micro-computed tomography. After scanning, the structural indices were calculated using a three-dimensional image analysis system, and the images were subjected to three-dimensional reconstruction. The length and apical foramen area of all distal roots were assessed. Histological changes in the apical region were then assessed via hematoxylin and eosin staining.

Results

The mandibular molars of all experimental mice showed evidence of cytotoxic injury, which appeared in the form of anomalous root shapes. Although all roots developed further after cyclophosphamide injection, the three-dimensional structural images showed that the roots in the experimental group tended to develop more slowly and were shorter than those in the control group. At 27 days of age, the mean root length was shorter in the experimental group than in the control group. Conversely, the apical foramen of the roots in the experimental group tended to close faster than that of roots in the control group. In addition, hematoxylin and eosin staining of the distal roots in the experimental group showed increased dentin thickness in the apical region.

Conclusion

Our results suggest that cyclophosphamide can result in short root lengths and early apical foramen closure, eventually leading to V-shaped or thin roots.

[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.

Long term chemoradiotherapy-related dental and skeletal complications in a young female with nasopharyngeal carcinoma

We describe the long-term complications six years after chemoradiotherapy in a 20-year old woman with nasopharyngeal carcinoma. We wanted to know whether the radiation dose was constant throughout the oral cavity, and thus uniformly affecting the corresponding dental and skeletal structures. Clinical and radiologic findings are described six years after chemoradiotherapy based on a two-dimensional computerized treatment planning system. This revealed radiation caries limited only to posterior teeth, proximal caries in the anterior teeth, limited but continuous salivary flow, mild periodontal infection, mild xerostomia, and a regenerative capacity of bones and the developmental process. The quantitative assessment of radiation delivered to the mandible revealed a high radiation dose in the posterior area and a minimal dose in the anterior area. This explains the differences in caries manifestation between the anterior and posterior teeth. According to the present study, individualized radiation fields, using a two-dimensional treatment planning system, result in restriction of severe damage of the dental and skeletal structures, which usually follows chemoradiotherapy. Orthodontic treatment could be initiated according to individual patient needs.

The burden of cure: long-term side effects following hematopoietic stem cell transplantation (HSCT) in children

Children who survive hematopoietic stem cell transplantation (HSCT) are at risk for an inordinate number of long-term side effects. Late effects can be secondary to the underlying diagnosis for which the transplant is performed, prior treatment of the disease, the transplant preparative regimen, treatment of the complications of transplant, and immunologic interactions between the graft and the host. This article describes the risks and manifestations of the most commonly reported late effects in survivors of pediatric HSCT.

Long-term radiotherapy related complications in children with head and neck cancer: Another era for pediatric oncologic pathology

Long-term radiotherapy-related complications in children with head and neck cancer have been frequently reported, especially facial growth disorders and dental abnormalities. We report on two male children (8 and 14 years old) with head and neck cancer, who were successfully treated with chemoradiotherapy and presented with growth deficiency of middle face and mandible hypoplasia, eight years and one year later, respectively. These severe growth complications attributed to chemoradiotherapy, while the patients survived primary malignancy. Patient age at irradiation was significantly correlated with the severity of disorders. We consider late sequelae in children with head and neck cancer due to chemoradiotherapy another era for pediatric oncologic pathology for prevention, if possible, or to manage them efficiently.

Advances in hematologic stem cell transplant: an update for oral health care providers

Oral supportive care is critical in the management of patients receiving hematopoietic cell transplantation (HCT). Advances in HCT, such as the use of stem cells isolated from peripheral blood instead of bone marrow, have resulted in more rapid engraftment and thus a shorter duration of pancytopenia. Reduced-intensity conditioning regimens, associated with less toxicity, make HCT available to older patients and patients with comorbidities. These new developments have led to increased transplant rates and an altered spectrum of therapy-related complications, such as mucositis, and to shifts in the prevalence and pattern of occurrence of infections and graft-versus-host disease. The purpose of this paper is to review the main principles of HCT and to update dental providers on new technologies being applied to transplantation that may influence oral complications and oral care.

Oral health burden in children with systemic diseases

Children who have systemic diseases face a burden of disease distinctly greater than their healthy counterparts. Neglect or delay of addressing this burden can lead not only to significant morbidity for the child, but also to family dysfunction. This article addresses issues salient to the understanding of oral health burden in children and families living with systemic disease. Topics include the parent as caregiver, children who have cerebral palsy, juvenile arthritis, developmental delay, and organ diseases.

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

PURPOSE

The purpose of this study was to assess late effects of cytotoxic therapy with hematopoietic stem cell transplantation (HCT) on dental development in survivors of childhood cancer.

MATERIALS AND METHODS

Forty children who underwent allogeneic HCT for a variety of hematological malignancies were evaluated at a minimum of 2 years after transplantation. We obtained information on oral symptoms, exposed panoramic radiographs (PRG), and performed an oral examination. PRGs were scored for agenesis and root and/or crown abnormalities. The root-crown ratio was calculated, and dental age was assessed using Demirjian' s method.

MAIN RESULTS

The studied group showed a significantly higher prevalence of tooth agenesis compared to normative data for first and second premolars in both the maxilla and mandible, as well as the second molars in the mandible (all p values <0.001). Children who were <3 years old at the time of cancer treatment had significantly more missing teeth than older children, F(2,37) = 7.58, p < 0.002. Root-crown ratios were lower in the study sample than those from normative data. In addition, the mean dental age was higher (as a result of earlier apical root closure) than the mean chronological age, t(28) = 2.47, p < 0.020.

CONCLUSIONS

Nearly all children examined had dental development disturbances, including agenesis, short roots, and arrested root development. An oral/dental evaluation and preventative oral supportive care regimens should be part of programs monitoring late effects in long-term survivors of childhood cancer.

Management of patients who have undergone head and neck cancer therapy

Patients who undergo treatment for head and neck cancers often suffer from acute or late reactions to therapy. Severity of these oral complications may be based on the location and extent of tumor, as well as the type and extent of treatment. Some complications are transient, whereas others require a lifetime of management secondary to damage that results in permanent dysfunction. Patients who have a history of head and neck cancers are also at an increased risk for recurrences or second malignancies, and therefore require close follow-up. Dental professionals should provide preventive and supportive care, including education and symptom management, for patients experiencing oral complications related to cancer therapy, and should closely monitor patients' level of distress, ability to cope, and treatment response.

Radiation-induced craniofacial bone growth disturbances

Multimodality treatment, including radiotherapy, chemotherapy, and surgery, is required for the management of head and neck cancer in pediatric patients. Despite the modern advances in radiation dosing and targeting techniques, the radiation damage to the growing craniofacial skeleton in children remains a significant clinical problem. The first part of this review summarizes the clinical effects of radiotherapy on craniofacial bone growth in children. Experimental evidence on therapeutic radiation effects on bone growth in in vivo and in vitro models is reviewed. The second part of this review focuses on prevention of radiation-induced craniofacial bone growth inhibition using radioprotective agents.

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

OBJECTIVE

The aim of this study was to investigate the long-term effects of chemotherapy on oral health and dental development in childhood cancer survivors (CCS).

STUDY DESIGN

Ninety-six CCS patients with a mean age of 10.8 years and 96 healthy children of the same age and sex and social background composed the study group. The caries experience of the children was recorded according to the criteria of the World Health Organization, and plaque-gingival status was evaluated according to the Silness-Loe Index. The children were also investigated for stimulated salivary flow rate, buffer capacity, salivary mutans streptococci, and lactobacilli. Disturbances of enamel mineralization were recorded according to the index of developmental defects in dental enamel. Dental development disturbances were diagnosed on panoramic radiographs.

RESULTS

The caries experience, mutans streptococci, and lactobacilli colonization in CCS children were found significantly higher than in the healthy subjects (P < .05). White/cream colored opacities were the most frequent enamel mineralization disturbances (69.8 %). The occurrence of arrested root development with short V-shaped root malformation was significantly higher in CCS children than in the healthy subjects (P < .05). No statistically significant difference was found between group <or=5 years and >5 years.

CONCLUSION

This current investigation has shown that CCS children are at an increased risk of caries and developmental dental disturbances.

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.