Children with malignancy are at the increase risk of short and long term effects of radiation and chemotherapy. Treatment for cancer is directed mainly to rapidly dividing cells but children at the age of 2-3 years old have higher metabolic activity towards all the cells. This would mean the growth of actively dividing structures like bones, teeth and soft tissue are going to be hugely impacted.
Only radiation as low as 200cGy is microscopically evident to cause cellular damage, when children are subjected to 1800 cGy we are looking at irreparable damages with greatest cranial disturbances and anomalies amounting to lack of mid facial growth, loss of anteroposterior dimension and discrepancy of transracial height and orbital dimension. Chemotherapy adversely affects the metabolic hormone production leading to osteoporosis, thinning of bones and loss of bone density as a result of which increased susceptibility to fractures are noticed.
Most of the children diagnosed with cancer are at the age of 1-6 years. Tooth development begins in the 6 weeks of intrautrine life and continues till 14-15 years. Each tooth bud undergoes quantitative and qualitative differentiation during odontogenesis and any interferences during the cycle leads to defects in shape, structure, number and tooth eruption. When chemotherapy/ radiation coincides with dental development odontoblast necrotizes and their activity decreases, secretory function is impacted, membrane permeability diminishes and mineralization of tooth is affected causing loss of teeth and hypo mineralized structures. These changes are well observed as hypoplastic enamel patch.
Alteration in cell cycle extends to root development as the cytostatic drugs prevent the formation of Herwig Epithelial Root system( precursor for roots). The root aberrations are manifested as short , fragile roots and taurodonts (large crowns at the expense of roots).Root edification of deciduous(milk) teeth is evident with intensified resorption before their physiological age resulting in premature tooth loss effecting the sequence of eruption in permanent teeth. The severity of these damages will depend on the type of medication, dosage and frequency of therapeutic cycles, the age of the child at the moment of initiation of cancer therapy, and the stage of the dental development. Among the commonly used cytostatic agent is colchicine, vinblastine, cyclophosphamide, and methotrexate.
Damages of the soft tissues following immediate radiation (4000 cGy/rads or higher ) often occurs on the salivary glands due to alteration in their vascular supply. As a result of which xerostomia (dry mouth) ensues and the pH falls from 7.0 to 5.0, which is cariogenic, the buffering capacity of saliva decreases, consequently, remineralization capacity of saliva is hampered, and the minerals of enamel and dentin therefore dissolve easily.
With radiation as low as 40 Gy persistent sore throat, hoarseness, burning sensation in the mouth and gums, problems speaking, difficulty in swallowing, trismus( hardening of jaw muscles) make it difficult to open mouth due to scaring. The harm on the chemical and microbiological barrier function is devastating. Destruction of epithelial barrier may lead to extreme painful condition like oral mucositis and ulceration reducing nutritional intake in a stressed child.
Education of parents regarding short and long term effects in the oral cavity and craniofacial complex will provide emphasis on the importance of oral care. Radiation and cytostatic drugs both attack the periodontal status aggravating bleeding due to lower platelet count and damaged neutrophil functionality. Therefore, all local factors causing infection should be eliminated before therapy. Cancer therapy targets the bone marrow, suppressing the defense mechanism and causes reduced antibody and proteins to fight infections. Any existing lesion may flare up presenting a life threatening scenario when the child immunity is already compromised.
Quality of life of leukemic child is adversely affected and requires early intervention and definitive management. To reduce the risk of oral and systemic complication comprehensive oral hygiene measure should be established that could provide dental and oral care before initiation of cancer therapy, during immunosuppression and to manage post effect of the treatment. Teeth with poor prognosis should be removed ideally 3 weeks before cancer therapy to allow adequate healing and prevent the a risk of osteoradionecrosis. Endodontic management is severely compromised due to short roots. Orthodontics is restricted to removable appliances and retainers in order to minimize the risk of root resorption and to use lighter forces as the supporting bone are not strong enough for braces. Bonding of teeth and restorative treatment becomes a necessity for hypoplastic teeth prone to radiation caries. Oral pediatric medications are high on the sugar content which makes hypoplastic teeth susceptible to dental caries. A regular follow up and fluoride application will help to maintain the oral health for already compromised teeth.
The present health network is not supportive in providing adequate dental health and effective oral care. Here it is for the the benefit of community at large that a cooperation must exists between pediatric and dental clinic for easy referral and primary care. To avoid complications and to reduce morbidity following cancer therapy the presence of pediatric dentist in the oncology team must be made mandatory. Finally, health governing body must take significant initiative to improve oral care of children with leukemia.
GAMEFACE 