Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
HOME | ABOUT US | EDITORIAL BOARD | AHEAD OF PRINT | CURRENT ISSUE | ARCHIVES | INSTRUCTIONS | SUBSCRIBE | ADVERTISE | CONTACT
Indian Journal of Dental Research   Login   |  Users online: 162

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         

 


 
Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 523
Oral health status of children with acute lymphoblastic leukemia undergoing chemotherapy


Department of Pedodontics and Preventive Dentistry, Rajiv Gandhi Dental College and Hospital, Cholanagar, Hebbal, Bangalore, Karnataka, India

Click here for correspondence address and email

Date of Submission05-Mar-2012
Date of Decision27-Feb-2013
Date of Acceptance09-Apr-2013
Date of Web Publication19-Sep-2013
 

   Abstract 

Objective: The aim of this study was to evaluate the oral health status of children with acute lymphoblastic leukemia (ALL) undergoing chemotherapy.
Study Design : A total of 94 patients of both sexes in the age group of 2-14 years who were diagnosed with acute lymphoblastic leukemia were selected for the study. The oral cavity was examined for dental caries using def-t and DMF-T indices, gingival status was evaluated by using the modified gingival index, and the WHO oral toxicity scale was used to record oral mucositis.
Results: Statistical analysis was done by using Kruskal-Wallis and Mann-Whitney tests. Both DMF-T and def-t were highest in children during the maintenance phase of the chemotherapy followed by the induction therapy with radiotherapy (I 2 ) and induction therapy (I 1 ) phases.
The prevalence of gingival inflammation was highest in the maintenance phase of the chemotherapy followed by the induction therapy with radiotherapy (I 2 ) and Induction therapy (I 1 ) phases. Signs and severity of oral mucositis were highest in children undergoing induction therapy with radiotherapy (I 2 ).
Conclusion: Good oral care is essential to maintain healthy oral cavity in children with acute lymphoblastic leukemia, as improvement in oral conditions may diminish their sufferings and prevent the spread of serious infections from oral cavity.

Keywords: Acute lymphoblastic leukemia, dental caries, gingival status, oral mucositis

How to cite this article:
Azher U, Shiggaon N. Oral health status of children with acute lymphoblastic leukemia undergoing chemotherapy. Indian J Dent Res 2013;24:523

How to cite this URL:
Azher U, Shiggaon N. Oral health status of children with acute lymphoblastic leukemia undergoing chemotherapy. Indian J Dent Res [serial online] 2013 [cited 2019 May 24];24:523. Available from: http://www.ijdr.in/text.asp?2013/24/4/523/118371
Leukemia, first identified by researchers Virchow and Bennet in 1845, [1] is a malignant disease that starts in the blood-forming tissues such as the bone marrow and causes a large number of blood cells to be produced and enter the blood stream.

Acute lymphoblastic leukemia (ALL) accounts for 1/4th of all childhood cancer and 3/4th of all malignant leukemias. Peak age of its occurrence in children is between 3 and 5 years, and is slightly more frequent in boys than in girls. [2]

Although a few cases are associated with inherited genetic syndromes (i.e., Down syndrome, Fanconi anemia), the cause remains largely unknown. Some of the risk factors which are important in the pathogenesis of leukemia are ionizing radiation, chemicals (e.g., benzene, heavy metals, pesticides, petroleum distillates), drugs (chemotherapeutic drugs agents, alkylating agents, and etoposide, especially when used with radiotherapy), viral infections, and genetics. [2]

Advances in the treatment regimens, including multiagent chemotherapy and radiation therapy, have greatly increased the chances of survival. [3] The treatment modalities widely accepted for ALL are chemotherapy and a combination of chemotherapy with radiation. Radiotherapy to or near the oral cavity may cause mucositis, infection, trismus or xerostomia which further interrupts radiotherapy, inducing malnutrition or systemic infection. Combination of chemotherapy and radiotherapy may have an additive if not a synergistic effect on the afore mentioned complications. [4]

The immediate effects of the chemotherapy or irradiations on the soft tissues are well documented but less is known about the effects on the oral health and developing dental tissues. [5],[6]

Oral cavity is the part of the body where the side effects are frequently observed. Elimination of the oral symptoms of the disease and creation of a healthy oral environment not only improves the quality of life in these patients, but also has a real impact on the ultimate survival of these patients. Total relief may always not be achieved but creation of a healthy oral condition prior to chemotherapy results in minimized undesirable side effects. [7]

The aim of this study was to evaluate the oral health status of children with acute lymphoblastic leukemia undergoing chemotherapy.


   Materials and Methods Top


The present study was carried out in children of both sexes aged 2-14 years who were attending the treatment of acute lymphoblastic leukemia in the Department of Pediatric Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India, after obtaining approval from the ethical committee. Unco-operative, unconscious, severely ill patients on parenteral nutrition or children with any other systemic disease were excluded from the study.

A total of 94 children of both sexes who were newly diagnosed with acute lymphoblastic leukemia and already undergoing different phases of intensive chemotherapy were selected for the study. The oral cavity was examined by the dentist after obtaining informed consent from the parents. The dental health status was recorded with the help of a sterile mouth mirror, dental probe, and disposable sterile gloves. A torch was used as a light source. Patients were categorized mainly into three groups.

Group I - 25 patients who were in the induction therapy-I 1 phase (26%).

Group II - 32 patients who were receiving induction therapy with radiation (I 2 ) (34%).

Group III - 37 patients who were in the maintenance phase (39%).

Oral cavity was examined for dental caries (def-t/DMF-T index), gingival status (modified gingival index), and oral mucositis (WHO oral toxicity scale [8] ). To avoid induced bleeding, probes were not used for gingival examination. Statistical analysis was done by Kruskal-Wallis and Mann-Whitney tests.


   Results Top


Gingival Status:

On gingival examination, it was observed that there was a statistically significant difference in the gingival index of children in different phases of treatment. The prevalence of gingival inflammation was highest in the maintenance phase (40%), followed by induction therapy with radiotherapy (I 2) (18%) and induction therapy (I 1 ) phases (12%) [Table 1] and [Table 2], [Figure 1].
Figure 1: Mean gingival index among children in different phases of chemotherapy

Click here to view
Table 1 : Gingival grading using the MGI index

Click here to view
Table 2 : Comparison of gingival index among the children in different phases of chemotherapy

Click here to view


Mucositis:

The signs and severity of oral mucositis were highest in children (25%) undergoing induction therapy with radiotherapy (I 2) followed by children in induction therapy-I 1 phase (20%) [Table 3]. Only 2% of the patients in the maintenance phase had oral mucositis. Ulcers with extensive erythema associated with difficulty in swallowing were observed in 6% of the patients in I 2 phase compared to 4% in the I 1 phase. About 9% of the patients in the I 2 phase had mucosal ulcers without difficulty in swallowing solid food. The common areas of mucositis were mainly on buccal mucosa and lips.
Table 3: Distribution of children according to oral mucositis in different phases of chemotherapy

Click here to view


Dental Caries:

On dental examination, it was observed that there was a significant difference in the dental caries index of children in different phases of treatment (P < 0.05). Higher mean DMF-T and def-t were found in children of maintenance phase followed by induction therapy with radiotherapy (I 2) and induction therapy-I 1 phases [Table 4] [Figure 2], [Figure 3] and [Figure 4].
Figure 2: Dental caries experience in group 1

Click here to view
Figure 3: Dental caries experience in group 2

Click here to view
Figure 4: Dental caries experience in group 3

Click here to view
Table 4: Comparison of DMF among the children in different phases of chemotherapy

Click here to view



   Discussion Top


A healthy oral cavity is required for mastication, to maintain nutrition and prevent any infection. Oral care is essential to minimize morbidity and improve the general condition of the patient before and during antineoplastic therapy.

Impressive advances made in the treatment of childhood cancer have now directed increasing attention to side effects of the therapy and to the quality of life of the survivor.

In ALL, the characteristic oral findings seen are gingival hyperplasia, oral mucositis, dental caries, delayed exfoliation, and delayed eruption. The long-term effects include hypodontia, microdontia, and enamel hypoplasia.

The gingival hyperplasia, which is one of the most common findings of the disease, is usually generalized and varies in severity. The gingival swelling is due to the infiltration of leukemic cells in areas of mild chronic irritation. The teeth may be almost completely hidden in severe cases. The gingiva is boggy, edematous, deep red, and may bleed easily. In the present study mild to moderate gingival inflammation was observed, which is in contrast to the results obtained by Nasim et al. where a significant deterioration of the gingival condition was observed in patients undergoing chemoradiation therapy (52%). [4] In a study conducted by Al-Mashhadane to evaluate the oral health status among children receiving chemotherapy, it was found that the chemotherapeutic agents modify the oral health and there was a significant increase in plaque and gingival indices. [9]

Direct stomatotoxity occurs due to the nonspecific effect of antineoplastic drugs on cells undergoing mitosis. Consequently, the renewal rate of the basal epithelium is reduced, and results in mucosal atrophy, mucositis, and ulceration. Oral mucosal lesions especially mucositis may occur in the pharynx, oral floor, and lingual mucosal regions. [10] Common areas of oral mucositis in the present study were buccal mucosa and lips. In a study conducted on Brazilian children with a mean age of 5 years, oral mucositis was reported in 71.4% children. [11] In a similar study conducted by Pels to assess oral mucosa in children with ALL during antineoplastic therapy, lesions of the mucositis type were observed in ALL children in the period from 48 hours to 6 months, having various intensity and with periods without pathological lesions, which was related to intensity of chemotherapy. [12] Patients with mucositis and neutropenia have a relative risk of septicemia that is four times greater than that of individuals without mucositis. [13]

In the present study it was observed that the number of decayed teeth were more when compared to the teeth that were restored. This indicates the absence of regular dental check-ups and a delay in the treatment which could be due to profound thrombocytopenia and neutropenia.

Another finding was that the number of decayed teeth in primary dentition was greater than that in permanent dentition, which could be related to inadequacy in manual dexterity in the early stages and more prolonged time the primary teeth were exposed to the insult of bacterial plaque.

In a study conducted by Pels and Mielnik-Blaszczak to evaluate the oral hygiene status in children with ALL during the anticancer treatment protocol it was found that oral hygiene was significantly better in children with ALL than that in healthy children in the control group. The result was attributed to the oral hygiene regimen that the children were following during the cancer treatment protocol. [14]

In the present study more than half of the patients examined needed oral care regimen for the maintenance of infection-free oral cavity, to minimize the negative effects of chemotherapy. Establishment of good oral hygiene in these patients becomes difficult due to their small age and debilitating nature of the disease which prevents performance of good oral hygiene.

The limitations of this study were the small study population and absence of a healthy control group which prevented drawing of a more definitive conclusion and comparison of the results with those of other studies.


   Conclusion Top


In conclusion, as majority of the hospitalized leukemic children had poor oral health, maintenance of good oral hygiene regimen accompanied with simultaneous caries treatment should be considered mandatory to prevent any dental and periodontal infections which have proven to interfere with general systemic conditions.


   Acknowledgments Top


The authors express their sincere thanks to Dr. Appaji, Professor and Head, Department of Pediatric Oncology, Kidwai Memorial Hospital, for his cooperation and support during this study.

 
   References Top

1.Genc A, Atalay T, Gedikoglu G, Zulfikar B, Kullu S. Leukemic children: Clinical and histopathological gingival lesions. J Clin Pediatr Dent 1998;22:253-6.  Back to cited text no. 1
[PUBMED]    
2.Escalon EA. Acute Lymphocytic Leukemia in childhood. Int Pediatr 1999;4:83-9.  Back to cited text no. 2
    
3.Runge ME, Edwarsds DL. Orthodontic treatment for an adolescent with a history of acute lymphoblastic leukemia. Pediatr Dent 2000;22:494-8.  Back to cited text no. 3
    
4.Nasim VS, Shetty RY, Hegde AM. Dental health status in children with acute lymphoblastic leukemia. Pediatr Dent 2007;31:210-3.  Back to cited text no. 4
    
5.Carl W, Sako K. Cancer and the oral cavity. Vol. 57. Chicago: Quintessence Publishing Co; 1986. p. 2070-6.  Back to cited text no. 5
    
6.Peterson DE, Sonis ST. Oral complications of cancer chemotherapy: Present status and future studies. Cancer Treat Rep 1982;66:1251-6.  Back to cited text no. 6
[PUBMED]    
7.Lockhart PB, Clark J. Pretherapy dental status of patients with malignant conditions of the head and neck. Oral Surg Oral Med Oral Pathol 1994;77:236-41.  Back to cited text no. 7
[PUBMED]    
8.World Health Organization. Oral toxicity scale. Geneva: World Health Organization; 2004.   Back to cited text no. 8
    
9.Al-Mashhadane FA. Oral Health Status among children receiving chemotherapy. Al-Rafidain Dent J 2007;7:96-100.  Back to cited text no. 9
    
10.Simon AR, Roberts MW. Management of oral complications associated with cancer therapy in pediatric patients. J Dent Child 1991;58:384-9.  Back to cited text no. 10
    
11.Costa EM, Fernandes MZ, Quindere LB, Souza BD, Pinto LP. Evaluation of an oral preventive protocol in children with acute lymphoblastic leukemia. Pesquisa Odontol Bras 2003;17:147-50.  Back to cited text no. 11
    
12.Pels E. Oral mucositis in children suffering from acute lymphoblastic leukemia. Contemp Oncol 2012;16:12-5.   Back to cited text no. 12
    
13.Djuric M, Hillier-Kolarov V, Belic A, Jankovic L. Mucositis prevention by improved dental care in acute leukemia patients. Support Care Cancer 2006;14:137-46.  Back to cited text no. 13
[PUBMED]    
14.Pels E, Mielnik-Blaszczak M. Oral hygiene in children suffering from acute lymphoblastic leukemia living in rural and urban regions. Ann Agric Environ Med 2012;19:529-33.  Back to cited text no. 14
    

Top
Correspondence Address:
Umme Azher
Department of Pedodontics and Preventive Dentistry, Rajiv Gandhi Dental College and Hospital, Cholanagar, Hebbal, Bangalore, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118371

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Oral complications and dental care in children with acute lymphoblastic leukaemia
Marie-Cécile Valéra,Emmanuelle Noirrit-Esclassan,Marléne Pasquet,Fréderic Vaysse
Journal of Oral Pathology & Medicine. 2014; : n/a
[Pubmed] | [DOI]
2 Oral manifestations in patients with neurofibromatosis type-1: A comprehensive literature review
Fawad Javed,Sundar Ramalingam,Hameeda Bashir Ahmed,Bhumija Gupta,Chalini Sundar,Talat Qadri,Khalid Al-Hezaimi,Georgios E. Romanos
Critical Reviews in Oncology/Hematology. 2014;
[Pubmed] | [DOI]



 

Top
 
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
    Materials and Me...
   Results
   Discussion
   Conclusion
   Acknowledgments
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed4187    
    Printed131    
    Emailed3    
    PDF Downloaded200    
    Comments [Add]    
    Cited by others 2    

Recommend this journal