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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 2  |  Page : 171-175

Oral health condition and complications in pediatric cancer patients undergoing chemotherapy – A cross-sectional study

1 Department of Pedodontics and Preventive Dentistry, MNR Dental College and Hospital, Sangareddy, Telangana, India
2 Pediatric Dentist, Nagarjun Super Speciality Dental Hospital, Hyderabad, Telangana, India
3 Pediatric Dentist, Tharun Super Speciality Dental Hospital, Hyderabad, Telangana, India
4 Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Afzalgunj, Hyderabad, Telangana, India

Date of Submission17-Sep-2021
Date of Decision27-May-2022
Date of Acceptance08-Jun-2022
Date of Web Publication22-Jun-2022

Correspondence Address:
V Pranitha
Professor and Head, Department of Pedodontics and Preventive Dentistry, MNR Dental College and Hospital, Sangareddy; B 509, Magnum Opus Apartment, Gachibowli, Hyderabad - 500 032, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_271_21

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Background: Better knowledge of the prevalence of oral complications in children with malignancy improves oral health through an interdisciplinary approach between oncologists and pediatric dentists. Aim: This study aimed to assess the prevalence of oral health status in pediatric cancer patients to palliate and relieve the discomfort. Materials and Methods: This study was conducted in a cancer hospital in Hyderabad for 10 days. 158 patients aged [1-15 yrs] diagnosed with malignancy and receiving chemotherapy were selected and evaluated with a self-validated questionnaire followed by oral examination. Results: The data collected was processed and analyzed using the SPSS22 version [Corporation (IBM), Washington, DC., USA]. Mucositis 47% was the most common complication, followed by gingivitis 23.9%, xerostomia 12%, oral pain 11.6%, herpes 3%, and candidiasis 1.8%. Conclusion: Oral care of pediatric cancer patients is of critical importance in maintaining the patient's overall well-being, which can be achieved by a systematic approach at different stages of treatment.

Keywords: Chemotherapy, malignancy, oral complication, oral mucositis

How to cite this article:
Pranitha V, Meghana C, Dwijendra K S, Ravindra S V, Mounika P B, Ramana P U. Oral health condition and complications in pediatric cancer patients undergoing chemotherapy – A cross-sectional study. J Indian Acad Oral Med Radiol 2022;34:171-5

How to cite this URL:
Pranitha V, Meghana C, Dwijendra K S, Ravindra S V, Mounika P B, Ramana P U. Oral health condition and complications in pediatric cancer patients undergoing chemotherapy – A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 7];34:171-5. Available from: http://www.jiaomr.in/text.asp?2022/34/2/171/347921

   Introduction Top

Cancer is the 9th most common cause of death among children between 5 and 14 years of age in India.[1] Leukemia is the most commonly occurring cancer in children in India, with a mean incidence of 48.5% in boys and 21.2% in girls.[2] Common oral complications include oral mucositis, salivary gland inflammation, intraoral infections, dry mouth, intraoral hemorrhage, and mucosal bleeding.[3] Dental referral in recently diagnosed children is highly recommended to ensure sufficient time for appropriate oral health before the initiation of cancer therapy.[4]

   Materials and Methods Top

Ethical approval

All procedures performed involving human participants were consistent with the institutional ethical committee [Reg.No: ECR/269/Indt/TG/2016, Dated 23/10/2019] and by the Declaration of Helsinki World Medical Association.

Study sample

158 patients aged [1-15 yrs.] diagnosed with malignancy and receiving chemotherapy were selected.

Sample size estimation

A power analysis was performed to compare the sample size with the reference article's sample size using statistical software G*Power version Z tests-proportions: The difference between two independent proportions and β/α ratio = 1 and level of significance of 5% showed the power of the present study is 84.8%.

Inclusion and exclusion criteria

Based on the willingness of the parent and child, informed consent was obtained before the examination of children who were receiving chemotherapy. Uncooperative children were excluded from the study.

Technical Information

Data collection was based on a self-validated questionnaire consisting of open and close-ended questions [Table 1] considering the opinion of one oncologist and five pediatric dentists to indicate their level of agreement with the question statements using a 5-point rating scale. Cronbach alpha reliability coefficient value is 0.82. Assessment of demographic data along with oral hygiene practices and the number of dental visits were recorded. Other aspects included were type of malignancy, chemotherapeutic drugs administered, and referral to a dental surgeon. The oral cavity of the children was examined using sterile equipment under torchlight and hard and soft tissues assessment was done without distressing children and their attendants.
Table 1: Questionnaire

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During the study, oral mucositis was clinically classified using the World Health Organization (1979) criteria.[5]

Data collection and statistical analysis

The data collected was processed and analyzed. Oral hygiene practices were assessed individually using the Chi-square test.

   Results Top

Various types of malignancies and the number of patients suffering from each type are shown in [Table 2]. Gingival hyperplasia in a patient suffering from acute myeloblastic leukemia [Figure 1]. A comparison of brushing aids, frequency of brushing, toothpaste used, and the number of dental visits has been presented [Table 3]. They were individually assessed using the Chi-square test, and P < 0.05 were considered statistically significant.
Figure 1: Gingival hyperplasia in acute myeloblastic leukemia

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Table 2: Types of malignancy

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Table 3: Comparison of brushing aids, frequency of brushing, tooth paste, and dental visits individually by using the Chi-square test

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Major chief complaints were dry mouth [48.5%] followed by difficulty in swallowing [33.3%], difficulty in speech [7.3%], and cracked lips [6.21%]. Other complaints were difficulty in opening the mouth [1.69%] and TMJ pain [2.82%] [Table 4]. Mucositis (47%) was the most common complication, followed by gingivitis [23.9%], xerostomia [12%], oral pain [11.6%], herpes [3%,] and candidiasis [1.8%.] Multiple oral complications coexisting were seen in these patients receiving chemotherapy [Table 5]. Gingivitis in a patient suffering from acute lymphoblastic Leukemia [Figure 2]. Out of 158 patients, 77 patients suffered from varying degrees of mucositis. As most children suffer from mucositis, scoring was done with 63.6% of children falling into grade-1 mucositis [Table 6].
Figure 2: Gingivitis in acute lymphoblastic leukemia

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Table 4: Chief complaints record

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Table 5: Oral complications

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Table 6: Mucositis scoring

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   Discussion Top

Antineoplastic therapy in radiotherapy and/or chemotherapy can lead to an array of oral side effects that appear more frequently in the younger population.[6] The first period of treatment [28 days] was concerned with the chemotherapeutic induction of remission.[7] Drugs used were vincristine, doxorubicin, prednisone, and L-asparaginase with 95% success rate, followed by therapy/prophylaxis phase with intrathecal injection of chemotherapeutic agent methotrexate. It is followed by a consolidation phase accomplished by administering drugs such as cyclophosphamide and cytarabine. During the maintenance phase, methotrexate and 6-mercaptopurine were used for approximately 2.5 to 3 yrs, depending on the protocol employed.[8]

Parents were more concerned about concomitant illness than their child's oral care.[9] Out of 158 patients, 110 patients brushed once a day, 46 patients brushed twice a day, and 2 didn't brush their teeth. Their parents cited the main reason was that their children were younger and unable to brush. This is in accordance with the study done by Aarushi et al.,[10] Out of 47 patients, 19 patients brushed once a day, 16 patients brushed twice a day, and 12 patients didn't brush their teeth.

In the present study, 99 out of 158 patients used fluoridated toothpaste, 57 non-fluoridated toothpaste, and 2 patients were not using toothpaste as they were very young and under their mother's assistance in cleaning the oral cavity with a finger. Wright et al.[11] stated that toothpaste with heavy flavoring agents should be avoided as they irritate the oral tissues. In the present study, the patients did not complain of irritation with toothpaste.

Children with leukemia are categorized with a high risk for dental caries.[12] Therefore prevention is essential, but regular oral care and tooth brushing are extremely difficult due to acute nausea, so referral to a pediatric dental surgeon is important. However, only 25 out of 158 patients were referred to a dental surgeon by an oncologist. 133 children were not reviewed for dental health as parents believed milk teeth were dispensable. The results are similar to those of Aarushi et al.,[10] who found that out of 47 patients, 6 received dental care from general dentists. Patients were advised chlorhexidine mouth wash and antifungal mouth gargle in the study. Approximately 80% of the children followed these instructions.

During the oral examination of patients with ALL, pale gingiva and buccal mucosa with oral ulcerations, petechiae were detected, which was in accordance with the study conducted by Aarushi et al.,[10] mucositis, gingivitis, xerostomia, oral pain, herpes simplex virus, candida infection, and TMJ pain were some of the chemotherapy-induced complications manifested in varying forms and degree of severity. Such changes in the oral cavity can be painful and cause discomfort during eating and drinking. The most commonly seen nonhematological complication of chemotherapy is oral mucositis. 47% of the patients affected were suffering from varying degrees of oral mucositis during the induction phase and with continuous infusion of methotrexate. Jankovic et al.,[13] and Gandhi K et al.[14] have reported similar results in their studies of mucositis. This inflammatory condition persists for one week after chemotherapy. Mucositis presents clinically as mild inflammation to severe ulcerations with a risk of local opportunistic and systemic infections affecting the quality of life.[15] The primary management is palliative therapy, which includes home oral hygiene, pain control through analgesics or topical aesthetics, non-medicated oral rinses, and “foam on a stick” with chlorhexidine treatment.[16] Recently, Palifermin, a keratinocyte growth factor-1, and Interleukin-11 have been considered in patients undergoing high-dose chemotherapy; sponges and soft brushes are used in case of severe mucositis.[17]

Gingivitis [23.9%] was the next frequent oral manifestation in the study. However, Ponce-Torres et al.,[18] reported a higher incidence of 91.84%. According to Mathur et al.,[19] spontaneous gingival bleeding can occur when platelet count drops <20,000 cells per mm3. Gingival hyperplasia is the next commonly seen condition in children with AML due to the infiltration of myeloid cells. One in 10 cases in the study has shown severe gingival hyperplasia.

Xerostomia was reported by 12.2% of patients in this study, which could be linked to salivary gland dysfunction, which can be treated with meticulous oral hygiene, topical fluoride application, and pilocarpine.[19] 11.6% of patients receiving vincristine as part of their treatment reported oral pain. This contrasts with the study conducted by Gandhi et al.,[13] where they reported 43.5%. McCarthy and Skillings[20] reported similar findings in their study. They stated that oral pain in the absence of dental and periodontal infection could also be a neurotoxic side effect of vincristine.

Reactivation of latent viruses can lead to infections from the herpes simplex virus, varicella-zoster virus, and the Epstein-Barr virus. In the present study, 3% of individuals suffered from HSV during the relapse phase, which is similar to the study conducted by Figliolia et al.[21]

Oral fungal infections, particularly candidiasis, were seen in patients with prolonged neutropenic episodes. In the study, 1.8% of the patients had candidiasis [oral thrush] on the tongue's dorsal surface, which contrasts with the study conducted by Alnuaimi et al.,[22] where 14.2% was reported. The present study showed less expression of candidiasis as the patients were advised oral care during therapy.

   Limitations and Future Prospects Top

The limitation of this study was that children diagnosed were followed randomly during varying intervals for 10 days. Design can be improvized using a larger sample and at a specified recall time period after diagnosis. Future prospects can involve creating awareness of the regimen of oral care strategies to reduce the severity of pain and discomfort.

   Conclusion Top

The prevalence of oral symptoms and complications during chemotherapy emphasizes the need for continued dental vigilance during the treatment to improve the general wellness of the children. Early involvement of a pediatric dentist in the management of oral health will prove beneficial to patients.

Pediatric patients receiving chemotherapy need a preventive dental approach for significantly improved treatment outcomes through good oral health maintenance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Bashar MDA, Thakur JS. Incidence and pattern of childhood cancers in india: findings from population-based cancer registries. J Med Paediatr Oncol 2017;38:240-1.  Back to cited text no. 1
Sataynarayana L, Smitha A, Preeti Labani S. Childhood cancer incidence in India: A review of population-based cancer registries. Indian J Pediatr 2014;51:218-20.  Back to cited text no. 2
Wang Y, Zeng X, Yang X, Que J, Du Q, Zhang Q, et al. Oral health, caries risk profiles, and oral microbiome of pediatric patients with leukemia submitted to chemotherapy. Biomed Res Int J 2021;34;211-4.  Back to cited text no. 3
Da Fonseca MA. Oral and dental care of local and systemic diseases. In: Nowak A, editor. Pediatric Dentistry: Infancy Through Adolescence. 6th ed. Philadelphia: Elsevier/Saunders; 2013. p. 73-8.  Back to cited text no. 4
Parulekar W, Mackenzie R, Bjarnason G, Jordan RCK. Scoring oral mucositis. Oral Oncol 1998;34:63-71.  Back to cited text no. 5
Lopez BC, Esteve CG, Perez MGS. Dental treatment considerations in the chemotherapy patient. J Clin Exp Dent 2011;3:31-42.  Back to cited text no. 6
Bagattoni S, Alessandro G, Prete A, Piana G, Pession A. Oral health and dental late adverse effects in children in remission from malignant disease: A pilot case-control study in Italian children. Eur J Paediatr Dent 2014;15:45-50.  Back to cited text no. 7
Atilla S. Oral and dental care in acute lymphoblastic 62 leukemia: Role of paediatric dentist. Int J Hem Oncol 2009;19:58-62.  Back to cited text no. 8
Wani V, Kulkarni A, Pustake B, Takate V, Wani P, Sondhi JS. Prevalence, complications and dental management of the oral cancer in the pediatric patients. J Cancer Res Ther 2018;14:1407-11.  Back to cited text no. 9
Aarushi G, Mohita M, Kalpana B, Anupam S, Ajay G. Dental awareness among parents and oral health of paediatric cancer patients receiving chemotherapy. J Clin Diagn Res 2016;10:92-5.  Back to cited text no. 10
Wright JR, McKenzie M, DeAngelis C, Foroudi F, Paul N, Rajaraman M, et al. Radiation induced mucositis: Co-ordinating a reserach agenda. Clin Oncol (R Coll Radiol) 2003;15:473-77.  Back to cited text no. 11
Hosey MT, Welbury RR. Medical disability. In: Welbury RR, Duggal M, Hosey MT, editors. Texbook of Pediatric Dentistry. 3rd ed. Newyork; Oxford University Press; 2005. p. 387-98.  Back to cited text no. 12
Jankovic L, Jelic S, Filipovic-Ljeskovic I, Ristovic Z. Salivary immunoglobulins in cancer patients with chemotherapy-related oral mucosa damage. Eur J Cancer B Oral Oncol 1995;31:160-5.  Back to cited text no. 13
Gandhi K, Datta G, Ahuja S, Saxena T, G Datta A. Prevalence of oral complications occuring in a population of pediatric cancer patients receiving chemotherapy. Int J Clin Pediatr Dent 2017;10:166-71.  Back to cited text no. 14
Bensouda S, Elgasmi FE, AI Jalil Z, Khoubilla N, Lourdane H, Hamza M, et al. Assessment of oral health-related quality of life among children with acute leukemia. Stomatological Dis Sci J 2020;4:120-4.  Back to cited text no. 15
Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, et al. Mucositis study section of the multinational association of supportive care in cancer and the international society for oral oncology. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 2007;109:820-31.  Back to cited text no. 16
Kumar S, Balan A, Sankar A, Bose T. Radiation induced oral mucositis. Indian J Palliat Care 2009;15:95-102.  Back to cited text no. 17
Ponce-Torres E, Ruiz-Rodriguez Mdel S, Alejo-Gonzalez F, Hernandez-Sierra JF, PozosGuillen Ade J. Oral manifestations in pediatric patients receiving chemotherapy for acute lymphoblastic leukemia. J Clin Pediatr Dent 2010;34:275-9.  Back to cited text no. 18
Mathur VP, Dhillon JK, Kalra G. Oral health in children with Leukemia. Indian J Palliat Care 2012;18:12-8.  Back to cited text no. 19
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Figliolia SL, Oliveria DT, Pereira MC, Lauris JR, Mauricio AR, Oliveria DT, et al. Oral mucositis in acute lymphoblastic leukemia: Analysis of 169 paediatric patients. Oral Dis 2008;14:761-6.  Back to cited text no. 21
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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