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REVIEW ARTICLE
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 70-73

Oral and dental management of leukemic children


1 Department of Pedodontics, Rural Dental College, Loni, Maharashtra, India
2 Department of Periodontics, Rural Dental College, Loni, Maharashtra, India
3 Department of Oral Medicine and Radiology, Rural Dental College, Loni, Maharashtra, India
4 Department of Pedodontics, Government Dental College, Ahmedabad, Gujarat, India

Date of Submission31-Mar-2016
Date of Acceptance04-Aug-2016
Date of Web Publication16-Nov-2016

Correspondence Address:
Vikrant O Kasat
Department of Oral Medicine and Radiology, Rural Dental College, Loni - 413 736, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.194198

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  Abstract 

Leukemia is the most common malignancy in children which constitutes approximately 30% of all childhood cancers. Leukemia is the malignancy of white blood cells precursors in which the normal marrow elements are replaced by the poorly formed blast cells. Bone marrow transplantation along with a high dose of chemotherapy and radiotherapy is the most accepted treatment for acute leukemias. Leukemic patients suffer from acute complications in the oral cavity and long-term complications in dental and craniofacial development secondary to antineoplastic therapy. This review aims to provide an insight into clinical research evidence available for the management of leukemic patients in the dental office. For review, a search of "PubMed" and "Google Scholar" was made with the keywords "acute leukemia AND dental management," "oral health considerations AND leukemic children," "chemotherapy AND acute leukemia," "radiotherapy AND acute leukemia." It was supplemented with hand search to identify related published articles in the dental journals.

Keywords: Chemotherapy, children, dental treatment, leukemia, radiotherapy


How to cite this article:
Joshi SR, Pendyala GS, Kasat VO, Mopagar V, Chaudhari S. Oral and dental management of leukemic children. Indian J Oral Sci 2016;7:70-3

How to cite this URL:
Joshi SR, Pendyala GS, Kasat VO, Mopagar V, Chaudhari S. Oral and dental management of leukemic children. Indian J Oral Sci [serial online] 2016 [cited 2017 Apr 27];7:70-3. Available from: http://www.indjos.com/text.asp?2016/7/2/70/194198


  Introduction Top


In India, leukemia continues to be the largest contributor to cancer-related mortality in children followed by lymphoma and central nervous system tumors.[1] It constitutes approximately 30% of all childhood cancers, and acute lymphoblastic leukemia is the most common subtype.[2] Leukemia is the malignancy of white blood cells precursors with the global annual incidence of 8-10 cases per 100,000 people.[3] In India, about 2.3% of cancer patients are children suffering from leukemia with an annual incidence rate of 6000 children.[4]

In leukemia, there is an excessive proliferation and uncontrolled dissemination of blast cells in the human bone marrow which manifests clinically in varying degrees. Pathophysiologically, the normal marrow elements are replaced by the poorly formed blast cells which eventually accumulate in various other tissues of the body.

Although a definitive etiology for the disorder is unknown, several factors such as viruses, radiation exposure, immunological, and genetic configuration of the patient have been identified under its causative agents.[5] The early clinical symptoms of the disease seen in children are manifested as a consequence of underlying pathological conditions, i.e., leukemic cell infiltration, thrombocytopenia, leukopenia, and anemia.[6]

Bone marrow transplantation along with a high dose of chemotherapy and radiotherapy has been used to treat the cases of acute leukemias.[2],[5] The anticancer drugs used for the treatment are stomatotoxic and depending on the agent used, and frequency of administration affect the oral health, orofacial growth, and child's developing dentition.

The purpose of this review is to provide insight for the management of leukemic patients in the dental office. For review, a search of "PubMed" and "Google Scholar" was made with the keywords "acute leukemia AND dental management," "oral health considerations AND leukemic children," "chemotherapy AND acute leukemia," "radiotherapy AND acute leukemia." It was supplemented with hand search to identify related published articles in dental journals. For review, articles published in English language were considered.


  Oral Problems due to Antineoplastic Therapy in Acute Leukemic Children Top


Leukemia is a debilitating disease suppressing children's general and dental health, rendering them immunocompromised. Children treated with chemotherapy forming a part of treatment schedule for the same, exhibit acute complications in the oral cavity and long-term complications in dental and craniofacial development. The most common side effect seen in the oral cavity secondary to treatment for leukemia is oral mucositis which is characterized by redness, soreness, and ulceration of oral mucosa. After the initiation of chemotherapy, oral mucositis appears within 4-7 days. The most commonly affected parts are soft palate, oropharynx, buccal and labial mucosa, ventral and lateral borders of the tongue and floor of the mouth. Mucositis regresses in 7-14 days after its onset.[7]

Chemoradiotherapy causes a decrease in salivary flow rate in leukemic patients which can be attributed to the fact that salivary gland hypoplasia occurs in patients receiving chemoradiation therapy. Ingestion of cytotoxic drugs for cancer decreases the salivary flow, induces vomiting, and reduces the salivary pH. Therefore, the incidence of dental caries in leukemic children draws its causation to a decrease in salivary flow rate as well as pH.[8],[9]

Chemoradiation therapy affects the odontoblasts and ameloblasts in the developmental stages of tooth formation. Patients who underwent the chemoradiation therapy have shown short, thin, and tapered roots.[2]

The overall oral health status of leukemic children is deteriorated due to increased oral mucosal and gingival inflammation. In these affected children undergoing chemotherapy, the morbidity and mortality rates due to gingival diseases may be caused mainly due to suppression of bone marrow thereby making the subject more susceptible to contracting infections.[10]


  Management of Leukemic Children in Dental Office Top


Management of leukemic child in dental office should be done through a protocol. The planning of dental treatment progresses in different steps in leukemic children. The planning should begin with proper blood investigations followed by radiographic examination. Panoramic radiographs and intraoral periapical radiographs should be considered in patients who are cooperative.[2],[11]

Patient assessment

To arrive at a correct diagnosis and subsequent treatment planning, a comprehensive, accurate, and a continuously updated medical history are key necessities. Details of chief complaint, history of presenting illness, medical condition of the patient should be obtained.[2],[11]

Medical consultation

The dentist should follow an overall comprehensive care of the patient by coordinating with the patient's physician and/or pediatrician regarding the patient's physical condition, medications, sedation, general anesthesia, and any other special preparations required to ensure the safe delivery of oral health care.[2],[11]

Informed consent

All parents should sign an informed consent before any dental procedure in the dental office.[11]

Patient and caretaker education

One of the most important ways to reduce the incidence and severity of oral sequel of the treatment protocol in leukemic children is to practice routine oral health care. Hence, regardless of the child's hematological status oral hygiene practice needs to be aggressive throughout the duration that the patient receives oncology treatment. Patient and caretaker should be educated regarding this. The patient's physician should be educated about the oral pediatric medications which may be cariogenic. These medications should be replaced with those which are noncariogenic.[11]

Preventive protocol

Oral prophylaxis, pit and fissure sealants and topical fluoride application should be done promptly irrespective of the hematologic status of the child. Soft toothbrushes and electric toothbrushes should be considered as an effective method of plaque control. Although super soft brushes cannot be considered as effective means of plaque control, they can be used in cases with severe oral mucositis.[12]

For all patients, regardless of their caries risk, twice daily toothbrushing with fluoridated toothpaste is mandatory. In addition, daily rinsing with chlorhexidine digluconate is also recommended for children with a high caries risk. Use of 0.12% chlorhexidine mouthwash twice daily has been found to effectively suppress the major pathogens present in the oral cavity.[2] Duckworth has recommended 0.2% chlorhexidine mouthrinse with warm water after toothbrushing as an effective means of chemical plaque control.[13] However, Dodd et al. suggested the discontinuation of chlorhexidine as an effective plaque control method in children with severe mucositis or those who have undergone bone marrow transplant. Their recommendation is based on the fact that chlorhexidine contained alcohol which may have negative effects such as desiccation of oral tissues and unpleasant taste.[14] 0.4% SnF2 gel is recommended along with chlorhexidine for caries prevention before and during the treatment. 0.05% NaF can be replaced for SnF2 in the remission stage of the disease.[15]

Nystatin suspension (100,000 units/ml) 4 times a day is recommended to prevent oral candidiasis. As nystatin contains high sugar, its use should be followed with proper oral hygiene. Furthermore, chlorhexidine and nystatin should not be used simultaneously, as both the drugs inhibit other's action.[16]

International Society of Oral Oncology[17],[18] has published guidelines for the treatment of oral mucositis. The common prescription for the management of mucositis includes the good oral hygiene, analgesics, nonmedicated oral rinse (0.9% NaOH mouthrinse qid). Mucosal coating agents (Amphogel® , Kaopectate® ) and film-forming agents (Zilactin and Gelclair) also have been suggested.[18]

For short-term pain relief, topical anesthetics have been shown to be effective. Lips of the patient receiving chemotherapy are prone for dryness. The lips can be prevented from damage by the use of lanolin-based creams and ointments than petrolatum-based products.[19]

Endodontic treatment protocol

Although the conflicting results have been found regarding the endodontic treatment of primary and permanent teeth in leukemic patients, the literature suggests the pros and cons of the same. It is advised to proceed with root canal therapy at least 1-2 weeks before initiation of cancer therapy in the case of symptomatic vital and nonvital primary and permanent teeth.

Chronic infection of pulp can be a source of systemic infection during the phase of myelosuppression, so the endodontic treatment is avoided in this phase. If endodontic treatment is not possible, extraction is indicated followed by antibiotic therapy (penicillin or, for penicillin-allergic patients, clindamycin).[2],[11]

Oral surgical protocol

According to the American Academy of Pediatric Dentistry guidelines, patient undergoing the hematopoietic treatment, prophylactic antibiotics may or may not be prescribed for the leukemic patients since there are no clear guidelines for the prescription.[20] In addition, the surgical procedures should be as atraumatic as possible. Sharp bony edges should never be left behind since it may hinder the wound closure.[20]

Loose primary teeth should be allowed to exfoliate naturally. Nonrestorable teeth, root tips, teeth with periodontal pockets >6-7 mm, and teeth with acute infections, furcation involvement, significant bone loss or mobility should be extracted before the commencement of cancer therapy. All oral surgical procedures should be completed before the commencement of radiotherapy since these patients are at high risk for osteonecrosis.[20] The level of platelet, protrombin time and partial thromboplastin time should also be determined before tooth extraction.

The neutrophil count drops drastically once the induction of chemotherapy begins. The chances of spread of dental infection are rapid if the absolute neutrophil count (ANC) is <1000/mm3 . Antibiotic prophylaxis becomes mandatory if the ANC is <1000/mm3 .[21] Localized dental procedures can be considered if the platelet count ranges between 40,000 and 75000/mm3 . Pressurized packs, sutures and gelatin foam, should be kept ready by the dentist in case of profound bleeding.[21]

The dental procedures should be completely deferred if the platelet count is <40,000/mm3 . Minor surgical procedures can be considered if the platelet count is up to 50,000/mm3 . Major surgical procedures can be considered if the count is >100,000/mm3 . The platelet transfusion should be carried out 30-60 min before the surgical procedure.[21] The topical aminocaproic acid can be useful in patients with friable clots, and intravenous administration may be considered, in some cases, to improve coagulation and the formation of stable clots.[21] Topical use of tranexamic acid is also cited as an effective hemostatic in reducing the incidence of postoperative bleeding in patients taking continuous use of oral anticoagulants.

Periodontal therapy

Partially erupted molars pose a risk for pericoronitis. If the hematological condition of the patient permits, the pericoronal tissue should be excised. Periodontal treatment should be done either before the therapy or after the therapy, but not during the cancer treatment period.

Orthodontic therapy

Craniofacial, skeletal and dental development is delayed in cancer survived children who were <6 years of age. Growth prediction is an important parameter during the planning of orthodontic treatment. Since the skeletal growth is delayed, it may pose problems to the cancer survivors for orthodontic treatment.[20]

Orthodontic care may start or resume after the completion of chemotherapy and after at least a 2 years disease free survival when the risk of relapse is decreased. The following strategies should be considered when providing orthodontic care: (1) Use of light forces, (2) use of appliances that minimize the risk of root resorption, (3) termination of treatment earlier than normal.[20]

Poorly fitting appliances which abrade the oral mucosa should be removed. In addition, if the oral hygiene of the patient is poor, the appliance should be discarded. Removable appliances and retainers that fit well and those which can be tolerated by the patient can be delivered. Fixed orthodontic appliance therapy should be initiated and completed before the commencement of chemoradiation. It should be initiated in those cases which can maintain proper oral hygiene.[2],[11] Patients undergoing bisphosphonate therapy presents a challenge to the pedodontist and orthodontist for orthodontic treatment since bisphosphonates hinder the tooth movement.[20]

Xerostomia

Sugar-free chewing gums, special dentifrices for oral dryness, saliva substitutes, frequent sipping of water, alcohol-free oral rinses are recommended.[20]

Dietary considerations

Human cancer is accompanied by a strong oxidative predominance in blood. In cancer, it has been reported that the ingestion of drugs could induce increased production of oxygen free radicals through a process known as auto-oxidation. Generation of oxygen free radicals by autooxidation is widely believed to be one of the main causes of oxidative stress in cancer. Recent clinical trials have found that antioxidant supplementation can significantly improve immune response. Supplementation with the antioxidant Vitamins A and C improved the immune responses in individuals suffering from cancer and which were exposed to sources of free radicals.[22]


  Conclusion Top


Proper oral care in children with leukemia is critical. An understanding of the nature of the disease and its treatment are an important part of total patient care. Pedodontist should educate and guide the patient and caregiver about the oral hygiene methods to minimize discomfort and maximize the chances for a successful outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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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. 10
    
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Xavier AM, Hegde AM. Preventive protocols and oral management in childhood leukemia - The pediatric specialist′s role. Asian Pac J Cancer Prev 2010;11:39-43.  Back to cited text no. 11
    
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Sepet E, Aytepe Z, Ozerkan AG, Yalman N, Guven Y, Anak S, et al. Acute lymphoblastic leukemia: Dental health of children in maintenance therapy. J Clin Pediatr Dent 1998;22:257-60.  Back to cited text no. 12
    
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Duckworth RM. The science behind caries prevention. Int Dent J 1993;43 6 Suppl 1:529-39.  Back to cited text no. 13
    
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Dodd MJ, Larson PJ, Dibble SL, Miaskowski C, Greenspan D, MacPhail L, et al. Randomized clinical trial of chlorhexidine versus placebo for prevention of oral mucositis in patients receiving chemotherapy. Oncol Nurs Forum 1996;23:921-7.  Back to cited text no. 14
    
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Wei SH, Yiu CK. Evaluation of the use of topical fluoride gel. Caries Res 1993;27 Suppl 1:29-34.  Back to cited text no. 15
    
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Barkvoll P, Attramadal A. Effect of nystatin and chlorhexidine digluconate on Candida albicans. Oral Surg Oral Med Oral Pathol 1989;67:279-81.  Back to cited text no. 16
    
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Peterson DE, Bensadoun RJ, Roila F; ESMO Guidelines Working Group. Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines. Ann Oncol 2011;22 Suppl 6:vi78-84.  Back to cited text no. 17
    
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Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 2007;109:820-31.  Back to cited text no. 18
    
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Semba SE, Mealey BL, Hallmon WW. Dentistry and the cancer patient: Part 2 - Oral health management of the chemotherapy patient. Compendium 1994;15:1378, 1380-7.  Back to cited text no. 19
    
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Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation therapy. Pediatric dentistry 2013;36:293-301. [Reference Manual].  Back to cited text no. 20
    
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Padmini C, Bai KY. Oral and dental considerations in pediatric leukemic patient. ISRN Hematol 2014;2014:895721.  Back to cited text no. 21
    
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