Abstract

INTRODUCTION

Acute leukemia is the most common childhood cancer representing 24% of all childhood malignancies.[1] The treatment regimen includes multi-agent chemotherapy (three phases: induction therapy, intensification therapy, maintenance therapy) and central nervous system directed radiotherapy. Immune suppression caused due to disease, and its therapy makes these children more prone to infections with severe stomatologic complications.[2]

The most common complications are mucositis, xerostomia, bleeding, dysgeusia and infections leading to pain, discomfort and interfere with the course and prognosis of the neoplasm.[3]

The study was planned to study the oral manifestations in pediatric population with acute leukemias during the induction phase only.

MATERIALS AND METHODS

This was a cross-sectional noninvasive study. Thirty three patients both sexes age range (5-15 years) in pediatric oncology unit with diagnosis of acute lymphoblastic leukemia and acute myeloblastic leukemia were the subjects for the study. They were admitted for undergoing chemotherapy induction treatment at the institute.

These patients were examined thoroughly for any signs and symptoms of oral diseases. Single clinician (dental surgeon) performed oral examination of children at the 1st week of induction and 4th week of induction of chemotherapy. Patients who have completed first induction phase or those who were on maintenance therapy were excluded from the study. The parents/responsible guardians were informed and explained about the aim and character of the study. Patients were evaluated after obtaining an informed consent.

Dental mouth mirror and diagnostic probe were used to conduct simple observational examination. Patients were evaluated for, oral hygiene by using “oral hygiene index-simplified (OHI-S)” [Table ​[Table1a,1a, ​,b],b], dental caries by using “def index” and “decayed missing filled teeth (DMFT) index,” [Table 2] and gingival findings by using “Loe and Silness index” [Table 3].[4,5] The patients were also scrutinized for any other findings or lesions in the oral cavity, i.e., lesion including site and size of the lesion, candidiasis, any other infections as herpes simplex virus, varicella zoster virus, Cytomegalovirus, acute necrotizing and ulcerative gingivitis.

Table 1a

RESULTS

A total of 23 male and 10 female patients with acute leukemia were studied prospectively. We found that the dental status namely the gingival and periodontal tissues were affected in this period due to lack of good oral hygiene and overall poor health status following chemotherapy [Table 1]. 15 out of 30 (50%) subjects showed increase in “OHI-S,” “Loe and Silness gingival index.” A significant change was observed in these indices (P = 0.002; 0.003, respectively). def/DMFT index finding showed increase of 33% [Table 4]. There were no extractions or dental filling done; the decay factor was mainly noticed in this period. Poor oral hygiene, in these patients has led to increase caries activity.

Table 4

DISCUSSION

Leukemia is a disease resulting from the malignant transformation of stem cells whose proliferation starts in the bone marrow. This type of cancer most frequently affects children.[6,7]

Oral complaints precipitated by the side-effects of the antineoplastic agents are primarily those of discomfort, sensitivity of teeth and pain, ulceration, gingival hemorrhage, dryness and impaired taste sensation.[8,9,10,11] Mucositis is most common but reversible finding of these patients. Maintenance of oral hygiene is the basic preventive aid from all kinds of oral infections. But in induction phase of leukemia treatment, the platelet and neutrophil count decreases. Patients are advised against any vigorous mechanical dental cleansing aid (tooth brush/floss/interdental cleaning aids) to avoid triggering of any bleeding episodes. An alkaline saline rinse of warm water flavored with salt and sodium bicarbonate is recommended for oral cleansing.[12]

Gingiva reacts differently to even slight amount of plaque if subject is on anti-neoplastic therapy for blood dyscrasias.

In the present study, it was observed that the OHI-S count was increased in 50% of individuals. This change in OHI-S definitely affects other oral hard and soft-tissues. Inflammation in the gingiva is most common and probably earliest presentation of changes in oral tissues due to plaque.

The increased scores of GI in 50% of individuals clearly highlight the problems associated oral hygiene maintenance in these patients. The gingival inflammation, if not treated leads to periodontal problems and may eventually lead to loss of teeth in adult patients.

DMFT/def index was found to be increased in 10 patient's, i.e., 33% of study population. Since no active dental treatment is advocated (advisable) to any patient undergoing induction therapy, the difference in DMFT was only in D, i.e., decay component of the DMFT. This suggests that 33% individuals got affected with caries during induction phase. Although the induction therapy drugs are not directly responsible for the decay process, the change in oral environment due to excess plaque accumulation and/or change in quality and quantity of saliva due to drugs might have played important role in increased in caries process.

In most of the patient's erythematous oral mucosa, burning sensation of mouth was common, since mucositis was not primary objective of this study, the findings were not noted. One subject demonstrated an aphthous ulcer on palatal mucosa but it responded well to the symptomatic therapy. In another subject, angular cheilitis was seen. The angular cheilitis is generally a clinical sign of an inflammatory response to fungal infection. There was no statistical significant difference was observed in terms of short term outcomes of leukemia therapy due to dental problem.

CONCLUSION

In this study, it was observed that the oral health status worsened following first induction chemotherapy in acute leukemic pediatric patients. There was a significant increase in level of OHI, gingival index and def/DMFT. Lesions like aphthous ulcer and angular cheilitis were noticed in two of the subjects while other subjects did not have any oral complications.

These finding suggest that there is a need to institute optimum oral health, during and in between induction phases. Poor oral health did not affect the induction outcome in this study. Further study is study with larger sample size is needed to conclude the role of oral hygiene in the induction outcome of pediatric patients receiving treatment for acute leukemia.

Footnotes