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Response to O'Sullivan
Dental and Maxillofacial Impact of Childhood Craniofacial Irradiation
Grateful response from a 50-year survivor
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Kevin C. Oeffinger Memorial Sloan-Kettering Cancer Center, Melissa M. Hudson
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oeffingk{at}mskcc.org Kevin C. Oeffinger, et al.
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We thank Dr. O'Sullivan for the insightful comments and agree that cancer treatment effects on craniofacial development and oral/dental health can be significant issues, particularly in young patients and in those with head and neck malignancies. The brevity of our discussion regarding these topics resulted from space constraints imposed by the complexity and enormity of late treatment effects reported in childhood cancer survivors. As Dr. O'Sullivan has eloquently defended, maxillofacial and dental malformation resulting from therapy for childhood cancer may cause significant morbidity to the long-term survivor and deserve consideration by clinicians providing care to this growing population. | |||
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Eleanor O'Sullivan University College Cork, Ireland
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eleanor.osullivan{at}ucc.ie Eleanor O'Sullivan
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I read with interest the recent article by Drs. Oeffinger & Hudson [1] which provided an extensive overview of the complex issues facing clinicians treating long-term survivors of childhood cancer. While the authors covered a wide range of topics in detail, the brief mention of the craniofacial impact of head and neck radiation as “less serious though significant late effects including dental abnormalities, periodontal disease and accelerated tooth decay” does not reflect the true functional and psychosocial impact of these complications.
Radiotherapy to the head and neck region plays a vital role in the treatment of certain childhood malignancies including lymphomas, brain tumors, rhabdomyosarcoma, osteosarcoma, retinoblastoma, SCC and ALL [1-5]. This therapy has a marked effect on both the hard and soft tissues resulting in late side-effects in a high percentage of cases. Significant dental and facial abnormalities have been reported in up to 85% of head and neck rhabdomyosarcoma survivors [6] and in the majority of patients treated for soft-tissue sarcoma of the head and neck [7]. The degree of severity depends on the age of the child at the time of treatment (inversely related to age), total radiation dose, and the field of irradiation. Dental abnormalities include tooth agenesis, bizarre crown and/or root morphology, microdontia, narrowing of pulp canal, and delayed eruption. Radiation induced salivary gland dysfunction may result in severe xerostomia, candidiasis, periodontitis and radiation caries [5,8]. The reduction in salivary flow along with changes in the oral flora favors the growth of cariogenic organisms. Irradiation can also directly damage the teeth which become hypersensitive making oral hygiene maintenance difficult. These factors, along with a change to a softer more cariogenic diet, combine to cause rampant dental caries in the incisal edges, molar cusps and cervical margins, areas which are normally relatively caries resistant. Left untreated, caries and decalcification may destroy the structural integrity of the teeth resulting in crown amputation (Figure 1: Radiation Caries). Indeed, a complete dentition may be destroyed within a year of irradiation resulting in pain/discomfort, poor aesthetics, speech and nutritional difficulties. The oral cavity may become a source of infection and if extractions are required the patient is at risk of osteoradionecrosis. Craniofacial radiotherapy may result in trismus, cranial and maxillofacial malformation, micrognathia and abnormal occlusal (bite) relationships. Trismus can occur 3-6 months after radiotherapy due to progressive endarteritis of the affected tissues with a reduction in the blood supply, scarring and fibrosis of the masticatory muscles. Maxillary and mandibular hypoplasia may occur following degenerative and vascular changes in the bone and as a result of damage to growth centers on the temporomandibular joints. Retarded growth of irradiated soft tissues also contributes to the overall deformity (Figure 2: Severe Bilateral Mandibular Hypoplasia Following Childhood Radiotherapy For Rhabdomyosarcoma). Uncompensated growth on the opposite side will make these deformities more noticeable as the child grows older and bone and tissue grafting may be required to restore facial contour. While modern surgical techniques such as bone grafting, free tissue transfer, distraction osseogenesis, and osseo-integrated implants have improved rehabilitation, radiation-induced fibrosis, scarring, reduced vascularity, delayed healing, increased risk of infection and osteoradionecrosis add to the complexity of the reconstructive process. The maxillofacial and dental malformations highlighted above may have a significant deleterious impact on quality of life. Studies have shown that facial deformities have a significant negative effect on perceptions of social functionality and employability leaving patients at an increased risk of social and psychological stress, isolation, and rejection [9,10]. Furthermore, craniofacial deformity and loss of a normal functional, aesthetic dentition may serve as a daily reminder of their cancer experience, undermining self esteem and feelings of social acceptability. As survival rates for these patients increase, so will the number of young people presenting with complex therapeutic sequelae requiring life-long multidisciplinary care to maximize their overall outcome. REFERENCES: 1. Oeffinger KC, Hudson MM. Long-term complications following childhood and adolescence cancer: Foundations for providing risk-based health care for survivors. CA Cancer J Clin 2004;54:208-236. 2. Makdissi J, Sleeman D. Dental and maxillofacial abnormalities following treatment of malignant tumours in children. Ir Med J 2004; 97:86-88. 3. Womer RB, Pressey JG. Rhabdomyosarcoma and soft tissue sarcoma in childhood. Curr Opin Oncol 2000;12:337-344. 4. Tabone MD, Terrier P, Pacquement H, et al. Outcome of radiation-related osteosarcoma after treatment of childhood and adolescent cancer: a study of 23 cases. J Clin Oncol 1999;17:2789-2795. 5. Maguire A, Welbury RR. Long-term effects of antineoplastic chemotherapy and radiotherapy on dental development. Dent Update 1996;23:188-194. 6. Paulino AC, Simon JH, Zhen W, et al. Long-term effects in children treated with radiotherapy for head and neck rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2000;48:1489-1495. 7. Raney RB, Asmar L, Vassilopoulou-Sellin R, et al. Late complications of therapy in 213 children with localized, nonorbital soft-tissue sarcoma of the head and neck: A descriptive report from the Intergroup Rhabdomyosarcoma Studies (IRS)-II and - III. IRS Group of the Children's Cancer Group and the Pediatric Oncology Group. Med Pediatr Oncol 1999;33:362-371. 8. Vissink A, Jansma J, Spijkervet FK, et al. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med 2003;14:199-212. 9. Rankin M, Borah GL. Perceived functional impact of abnormal facial appearance. Plast Reconstr Surg 2003;111:2140-2146. 10. Pruzinsky T. Social and psychological effects of major craniofacial deformity. Cleft Palate Craniofac J 1992;29:578-84. |
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Karen M. McIver, Wilms' tumor, 1954, age 17 months; Breast cancer, 2004.
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karen{at}wilmstumor.us Karen M. McIver
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Response to Oeffinger article: Thank you, Drs. Oeffinger and Hudson, for this much-needed article. As a 50-year survivor of Wilms’ tumor – treated with surgery and the old deep-therapy cobalt radiation – and a member of the ACOR Long-Term Survivors (LTS) online discussion list, I have eagerly watched for this type of information to reach the general medical population. The late effects of cancer treatments are real and varied. Those of us who have experienced them for the last few decades know the frustration and loneliness of knowing that something very strange and real is happening to our bodies, yet not being able to identify it or find someone who can. We owe much to the pioneering doctors who are embracing the study of late effects and working to educate their peers. LTS often refer to radiation or chemo therapies as “the gifts that keep on giving”. To call someone who has had cancer and received treatment “cured” is a misnomer. Anyone who has had cancer is changed forever. The horror of the diagnosis for patient or family, the changed body image of surgeries, and the grueling and often humiliating ordeal of extended treatments leave a deep mark on everyone involved. When these things happen to a child or developing teenager, they markedly affect that patient as he or she matures, or lie in wait to present sinister repercussions later in life. Children struggle academically or socially; adolescents just want to be “like everyone else”; young adults have trouble finding a mate who is willing to accept “damaged goods”; the hunger to have children often goes unsatisfied; dreams of career or pleasure activities fade in the face of increased pain, doctor visits and financial strains; those who must leave the work force due to late effects are denied disability benefits by uninformed bureaucrats; and the prospect of an early death either remains or rears its head years later. I urge medical personnel everywhere to read and heed the growing body of literature which is presenting the needs of long-term cancer survivors. We will be truly grateful. |
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