LEUKAEMIA AND OTHDONTICS

 Nearly 50 % paediatric cancers = haematological

 60% of patients diagnosed with malignancy will be long-term survivors> 5yrs (Jaffe et al 84)
 Treatment is divided into 3 parts: induction, consolidation and maintenance

Treatment can involve the following in isolation or together:

1. Chemotherapy
2. Radiation
3. Surgery
4. Bone marrow transplant (also known as hematopoietic stem cell transplantation- SCT)
a. Syngeneic= From identical twin
b. Allogenic = close relative/matched donor
c. Autologous= from patient themselves
 All patients with indwelling catheters should receive subacute bacterial endocarditis
prophylaxis when undergoing dental procedures to avoid infection.

LEUKAEMIA
 ACUTE LYMPHOBLASTIC LEUKEMIA- ALL
 ACUTE MYELOID LEUKEMIA - AML
 CHRONIC MYELOID LEUKEMIA –CML

WHICH LEUKAEMIA HAS THE WORST PROGNOSIS?

Chronic myeloid leukaemia> acute myeloid> acute lymphoblastic leukaemia

LYMPHOMA
 HODGKINS DISEASE
 NON HODGKINS LYMPHOMA NHL

ROLE OF THE ORTHODONTIST (Sheller and Williams

AJODO 1996)
1. Refer patient to a physician if they present with the following signs & symptoms
 gingival oozing
 petechiae
 haematomas
 ulcerations
 gingival pain
 gingival hypertrophy
 mucosal pallor
 pharyngitis & lymphadenopathy
2. WOULD YOU CARRY ON WITH FIXED APPLIANCES?
 Debond and retain as chemotherapy causes significant oral complications. Orthodontic
appliances cause stress to the oral mucosa and ulceration may occur in reaction to the
slightest oral insult because the neutropenia resulting from chemotherapy impairs the
regenerative capability of the mucous membranes. Mucositis may progress from swelling,
soreness and whitening of the mucosa to glossitis, cheilitis, and stomatitis which can be so
painful morphine may be necessary for pain relief. Oral infection from opportunistic
infections can occur and Xerostomia is the side effect from chemotherapy or the radiation
treatment given before bone marrow transplant.
 Stress you are not giving up on the orthodontic tmt, explain that appliance removal can help
ensure the patient is comfortable during chemotherapy.
 Retainers should fit well to ensure no source of irritation, ulceration or infection.
 Once the patient is in remission tmt can restart, it has been suggested to wait 2 yrs after a
bone marrow transplant (Sheller and Williams 1996).

3. RISK OF OSTEORADIONECROSIS (ORN) FOLLOWING RADIOTHERAPY

 Increased risk of ORN in adults having extn following radiotherapy
 3M:1F risk of ORN
 Mandible>maxilla
 50% of all cases of ORN caused by dental extns
 No reports of ORN in children following dental extns – u would anticipate this as you ideally
wait 2yrs post tmt to ext teeth and start ortho

4. ORTHODONTIC MECHANICS FOLLOWING REMISSION:

 Use appliances that minimise the risk of RR
 Use weaker forces
 Use the simplest tmt plan
 Treat upper arch only
 If RR anticipated – take xray 6/12 in to tmt and if RR occurred pause tmt for 3/12- place
passive archwire (Levander and Malmgren 1994)

5. EFFECTS OF CHEMOTHERAPY AND RADIATION ON THE GROWING SKELETON

 Cranial radiation can cause growth retardation, most probably due to effect on pituitary
function, specifically growth hormone deficiency.
 Decreased final height is explained through early onset puberty and a shorter pubertal
growth spurt.
 Radiation causes hypovascularity and has a direct cytotoxic effect on the epiphyseal
chondrocytes.
 In addition tumour cells stimulate osteoclast function and bone resorption and
chemotherapeutic drugs further stimulate osteoclastic function e.g methotrexate. The
reduced bone mineral density after chemotherapeutic tmt can be permanent.
 ? use of functional appliance in the tmt of class II as radiation therapy has a growth
suppressive effect.
  Shortened cranial base
 Reduced vertical development of the alveolar process
 Facial asymmetry due to cranial irradiation of soft tissue sarcomas

6. WHAT ARE THE RADIOLOGICAL FINDINGS (DENTAL) FOR A CHILD WHO IS IRRADIATED?

LT survivors of chemotherapy have been found to have increased incidence of:

 Enamel opacities
 Reduced tooth size
 Disturbance in root development & increased risk RR

Rosenburg et al (cancer 1987) carried out a study looking at seventeen patients treated for acute lymphoblastic
leukemia by combination chemotherapy before 10 years of age for altered dental root development of their
premolar teeth. Five of the 17 patients showed subjective radiographic evidence of marked shortening of the
premolar dental roots; 13 had thinning of the roots. A quantitative analysis was developed and verified, which
disclosed a 63.33% to 84.38% reduction of premolar root length when compared with the mean of the historical
controls. With recent significant increases in long-term survival rates of children with malignancies, altered dental
development becomes an important factor to follow years after chemotherapy is discontinued. The findings of
these chemotherapy-associated dental development changes impacts on the patient's quality of life and also can
serve as a research tool to assess permanent effects of chemotherapy on normal tissue growth and
development.

7. SHOULD AN OPG BE USED TO DIAGNOSE/MONITOR RR?

There are limitations of using a dental panoramic tomograph for pre and mid tmt-orthodontic
assessment and there is a need for vigilance in the correct patient positioning during radiographic
exposure. The narrow focal trough in the anterior portion of the maxilla presents a particular problem for
many orthodontic patients with abnormally positioned or proclined incisors. The apices of the upper
incisors may not be shown and the appearance can mimic root resorption, while supernumerary and/or
unerupted teeth may not be detected. Supplementary views may therefore be necessary whenever there
is any doubt that the dental panoramic tomograph demonstrates the necessary detail in this region.
Paralleling technique periapicals are the intraoral views of choice but if unavailable an upper standard
occlusal can demonstrate the anterior maxilla but the image may be geometrically inaccurate. The true
cephalometric lateral skull can be used to assess incisor root length, but not for detailed diagnosis of
external root resorption. In order to correctly assess the degree of external root resorption care should
be taken to employ the radiographic technique(s) that ensure geometrically accurate images. In some
instances it may be necessary to take more than one radiograph.

8. WOULD THE APICES OF THE DEVELOPING TEETH CLOSE?

Looking at the literature, the root apices close but root length is reduced. Thus, loss of vitality is high