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

Characteristics of Orthodontic Treatment in Cancer Survivors: A Systematic Review

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

Dental anomalies in children submitted to antineoplastic therapy

Cancer is the third most frequent cause of death in children in Brazil. Early diagnosis and medical advances have significantly improved treatment outcomes, which has resulted in higher survival rates and the management of late side effects has become increasingly important in caring for these patients. Dental abnormalities are commonly observed as late effects of antineoplastic therapy in the oral cavity. The incidence and severity of the dental abnormalities depend on the child's age at diagnosis and the type of chemotherapeutic agent used, as well as the irradiation dose and area. The treatment duration and aggressivity should also be considered. Disturbances in dental development are characterized by changes in shape, number and root development. Enamel anomalies, such as discoloration, opacities and hypoplasia are also observed in these patients. When severe, these abnormalities can cause functional and esthetic sequelae that have an impact on the children's and adolescents' quality of life. General dentists and pediatric dentists should understand these dental abnormalities and how to identify them aiming for early diagnosis and appropriate treatment.

[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.

Endocrine complications of high-dose therapy with stem cell transplantation

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

Root surface areas in long-term survivors of childhood cancer

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

Craniofacial morphology in obese adolescents

Overweight and obesity are growing problems in the world today. A recent survey shows that about 30% of the adolescent and adult Swedish population is overweight or obese. The etiology is a combination of many factors, the most important of which are physical inactivity and high caloric diet. Obese children have a normal to accelerated growth rate despite low growth hormone (GH) levels. The aim of our study was to investigate whether craniofacial morphology differs between obese adolescents and normal weight adolescents. Lateral cephalograms from 39 adolescents with obesity, aged 14-16 years, were analysed and compared with lateral cephalograms from an equal number of sex- and aged-matched controls. Compared to the controls, the subjects in the obesity group showed increased mandibular length, prognathic jaws and a reduced upper anterior face height. Despite low GH levels, obese children have normal levels of insulin-like growth factor (IGF-1). Since we found an advanced craniofacial growth in obese adolescents with low GH and high IGF-1 serum levels, craniofacial growth may be more dependent on free circulating LGF-1 than on the locally produced portion.

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

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

Disturbances in craniofacial morphology in children treated for solid tumors

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

Growth hormone receptor gene variant and mandibular height in the normal Japanese population

This study was aimed at quantitatively evaluating the relationship between craniofacial morphology and the Pro561Thr (P56IT) variant in the growth hormone receptor gene (GHR), which is considered to be an important factor in craniofacial and skeletal growth. The subjects were unrelated individuals in a normal Japanese population and consisted of 50 men and 50 women. With the use of genomic DNA extracted from whole blood, the GHR gene P56IT variant was detected by the polymerase chain reaction-restriction fragment length polymorphism method (with the restriction enzyme StuI). The relationships of the genotypes to body height and 5 linear measurements from lateral cephalograms were examined for evaluation of craniofacial morphology. The normal Japanese population without P56IT had a significantly greater mandibular ramus length (condylion-gonion) than did those with P56IT. This suggests that the GHR gene P56IT variant may be associated with mandibular height growth and can be a genetic marker for it. Further studies about such genetic markers may expand our understanding of the genetic control in craniofacial morphological determinants and help in the prediction of craniofacial growth.

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.