Paediatric UpdateOral complications of childhood cancer and its treatment: current best practice
Introduction
As the advances in the treatment of children with cancer continue to improve overall survival, we need to focus our attention on the complications of treatment to reduce their frequency and their impact on disease remission, improve the cure rate and quality of life, and lessen the cost of care. Oral complications are recognised as a common adverse effect of childhood cancer therapy, with risks for septicaemia, nutritional compromise, significant pain and long-term morbidity 1, 2.
A review of current published research related to the oral complications of cancer and its treatment, while revealing a generous amount of research in adults, shows a paucity of controlled clinical trials in children. Research in this area has increased our understanding of the aetiology and pathophysiology of oral mucositis. Therapeutic approaches to the oral complications of cancer are, however, largely based on clinical experience, and therefore no approach has emerged as the ‘gold standard’. Further research is needed to standardise preventative oral care, and the prophylaxis and treatment of mucositis, bacterial, fungal and viral oral infections, in order to improve the quality of life for patients undergoing treatment for childhood cancer. This article will review recent research applicable to oral mucositis, oral infections, xerostomia and dental abnormalities in paediatric cancer therapy and discuss current best practice in the management of these complications.
Section snippets
Mucositis
Oral mucositis is the term used to describe the erythematous inflammatory changes that occur on buccal and labial surfaces, the ventral surface of the tongue, the floor of the mouth and the soft palate of patients receiving stomatotoxic chemotherapy and radiation. 1, 2. Patients describe the initial condition as a burning or tingling sensation making the mouth hypersensitive to foods. Eating, swallowing and talking become difficult as the mucositis progresses [3]. When nutrition is impaired as
New insights into the pathophysiology of mucositis
Sonis's biophysical model describing the pathophysiological concepts of mucositis provides a new framework for both assessment and management. In Sonis's model there are four phases of mucositis: an initial inflammatory/vascular phase, an epithelial phase, an ulcerative/bacteriological phase and a healing phase [9]. Since each phase offers the opportunity for therapeutic interventions, their assessment and potential strategies for their management will be discussed together in the ensuing
Viral infections
Herpes simplex virus (HSV) is the most common viral infection occurring in child patients being treated for oncological diseases 2, 29, 30. It occurs most often as a reactivation of the virus in a previously infected individual. HSV infection usually begins as vesicular lesions either peri- or intraorally, which will then progress to crusted lesions. Intraoral lesions may never develop this crusted appearance, but rather may remain ulcerated with a yellowish appearance [31]. In many cases, it
Dental abnormalities
Kaste and colleagues found dental abnormalities, including root stunting, microdontia, hypodontia, enlarged pulp chambers and over-retention of primary teeth, in children treated for acute lymphoblastic leukaemia [40]. The same investigators found similar abnormalities in 71% of children treated for neuroblastoma, as well as excessive caries and enamel hypoplasia [41]. In another study, 83% of children treated for acute lymphoid leukaemia were found to have dental abnormalities, including
Preventive intervention
The most effective measure in the prevention and treatment of the oral complications of cancer therapy is meticulous oral hygiene. Recent studies document the benefit of preventative mouth care in children. In a study by Bonnaure-Mallet and colleagues on children receiving cancer therapy following an oral-care programme, mouth lesions were more numerous in the group that did not tooth brush than in the group that brushed [7]. Levy-Pollack and colleagues, in their study of children with acute
Conclusion
Unfortunately, there are few new treatments for child patients experiencing oral complications of chemotherapy and radiation. Comprehensive research reviews of the options for the prevention and treatment of oral mucositis reveal that most of the newer interventions have not been widely used or studied in the paediatric population. Furthermore, limitations in study design and a lack of consistency in measurements in adult studies make comparisons of antimicrobials, coating agents and
Acknowledgments
The authors thank Mark L. Helpin DMD for his help in reviewing the manuscript.
References (45)
- et al.
Use of patient-controlled analgesia for pain control for children receiving bone marrow transplant
J. Pain Symptom Manage.
(1995) - et al.
Patient-controlled analgesia for mucositis pain in childrena three-period crossover study comparing morphine and hydromorphone
J. Pediatr.
(1996) - et al.
Oral complications during treatment of malignant diseases in childhoodeffects of tooth brushing
Eur. J. Cancer
(1998) - et al.
Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients
Eur. J. Cancer
(2001) Mucositis as a biological processa new hypothesis for the development of chemotherapy-induced stomatotoxicity
Oral Oncol.
(1998)- et al.
Decrease of duration and symptoms in chemotherapy-induced oral mucositis by topical GM-CSF
Eur. J. Cancer
(2001) - et al.
Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis
Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endo.
(2000) - et al.
Assessment and management of chemotherapy-induced mucositis in children
J. Pediatr. Oncol. Nurs.
(1997) - et al.
Oral complications associated with immunosuppression and cancer therapies
Infect. Dis. Clin. North Am.
(1999) - et al.
Viral and fungal infections of the oral cavity in immunocompetent patients
Infect. Dis. Clin. North Am.
(1999)