|Year : 2016 | Volume
| Issue : 1 | Page : 96-99
Dental root agenesis following radiation and antineoplastic therapy: A Case Report
Abdul Hafiz1, Abdulla Mufeed2, Punit Bharadwaj1, Dinesh Rao3
1 Department of Paediatric Dentistry, MES Dental College, Perinthalmanna, Malappuram, Kerala, India
2 Department of Oral Medicine and Radiology, MES Dental College, Perinthalmanna, Malappuram, Kerala, India
3 Department of Pedodontics, Pacific Dental College, Udaipur, Rajasthan, India
|Date of Web Publication||2-Feb-2016|
Department of Oral Medicine and Radiology, MES Dental College, Perinthalmanna, Malappuram - 679 338, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The survival rates of patients suffering from various childhood neoplasms have improved dramatically with the advent of chemo-radiation therapy. The harmful effects of chemo-radiation therapy in the oro-facial region such as root agenesis, short roots, impaired amelogenesis, dentinogenesis, radiation caries, and other soft tissue pathologies are well recognized. In spite of these documented risks, the antineoplastic treatment modalities continue to serve the patient for overall improvement in survival and quality of life. However, a thorough understanding of the growth and development process and its relation with the complex antineoplastic treatment is very important for all clinicians. Such awareness could significantly improve the status of patients in the posttreatment period with the implementation of proper preventive and interceptive measures. This article intends to document a case of root agenesis that developed secondary to chemo-radiation therapy in a 12-year-old girl.
Keywords: Chemo-radiation therapy, root agenesis, stunted roots
|How to cite this article:|
Hafiz A, Mufeed A, Bharadwaj P, Rao D. Dental root agenesis following radiation and antineoplastic therapy: A Case Report. J Indian Soc Pedod Prev Dent 2016;34:96-9
|How to cite this URL:|
Hafiz A, Mufeed A, Bharadwaj P, Rao D. Dental root agenesis following radiation and antineoplastic therapy: A Case Report. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Oct 19];34:96-9. Available from: http://www.jisppd.com/text.asp?2016/34/1/96/175528
| Introduction|| |
Neoplasms in childhood are rare, affecting 1 in 600 children during the first 15 years of life.  The primary treatment modalities are surgery, irradiation, and chemotherapy. Standard treatment protocols and recent advances have greatly improved survival rates of cancer in childhood. Chemo-radiation therapy is an important tool in pediatric oncology and can be considered as a double-ended sword as it is known to damage the soft tissues, respiratory, cardiovascular, skeletal, and endocrine systems. It is also known to cause tooth agenesis, shortening of roots, microdontia, hypodontia, altered eruption patterns, coronal hypocalcification, and early apical closure. These complications have significant adverse effects on the patient's quality of life post-treatment. ,
Normal dental development begins in utero and completes once the roots of the third permanent molars have developed in early childhood. Chemotherapy-induced developmental anomalies of tooth occur when the patient is treated before the age of six.  The degree of damage to developing teeth and bone depends on the timing, duration, and severity of the insults.  We present the case of a girl who underwent chemo-radiation therapy for rhabdomyosarcoma (RMS) of the nose.
Rhabdomyosarcoma is a malignant tumor arising from the skeletal muscle cells and is most commonly seen in children who are between the ages of 1 and 4. It is uncommon in infants and is rarely seen in the adults. No clear etiologic factor has been identified. Three histologic variants have been described, namely embryonal, alveolar, and pleomorphic. The common sites of occurrence are head and neck region (40%), followed by genito-urinary tract (25%), extremities (20%), and para meningeal sites (15%).  The drugs employed to tackle RMS include adriamycin, dactinomycin, vincristine, actinomycin D, cyclophosphamide, ifosfamide, and VePesid. Radiation therapy along with chemotherapy inhibits the growth of rapidly dividing cancer cells.  In spite of advances in the field of surgery and chemo-radiation therapy, the recurrence of 30% RMS has been observed. The prognosis depends on several factors including initial diagnosis, histologic subtype, and stage.  With the advent of combined surgical, chemo- and radio-therapeutic management of RMS, the 5-year survival rate is approximately 85%. 
| Case Report|| |
A 12-year-old girl was referred to the Department of Pediatric Dentistry by a private dental practitioner. On extraction of an abscessed mandibular first permanent molar, he found the tooth rootless. The child had undergone chemo-radiation therapy for embryonal RMS of the nose when she was 4 years old, for which she was administered cyclophosphamide, vincristine, and actinomycin D, followed by radiation therapy over a period of 4 months. After this therapy, she has been relatively free of any symptoms.
On clinical examination, the child appeared short for her age and had a mild mid-face deficiency [Figure 1] and [Figure 2]. Intraoral examination revealed extensive caries involving all the teeth including the maxillary incisors [Figure 3]. Skeletal disturbances were ruled out from hand wrist and chest radiographs. The panoramic radiograph revealed total agenesis of the roots of all the teeth except the maxillary and mandibular incisors [Figure 4]. Endodontic treatment was performed on multiple teeth with pulpal involvement, and a mutilated maxillary premolar was extracted [Figure 5]. Since most of her teeth were short-rooted and carious, a treatment plan was formulated to conserve them with restorations and go for a prosthetic rehabilitation at a future date.
| Discussion|| |
Dental development is a long process and is subjected to many external and internal influences.  Amelogenesis and dentinogenesis are affected by radiation when it is directed at or near the mouth. Teeth located along the edge of the radiation field receive 45% of the administered dose.  Radiation directed at distant areas of the body has no significant effect on the dental development.  In a study of 68 long-term survivors of childhood cancer, Jaffe et al. found that 82% of patients receiving maxillofacial radiation exhibited dental anomalies. However, the description of such cases and their management is sparse in the literature. 
Sufficiently, high-radiation doses cause death of ameloblasts and odontoblasts regardless of their position in the cell cycle. Partially formed teeth have their remaining development halted, resulting in root agenesis. , Short-, medium-, and long-term effects of radiotherapy and antineoplastic therapy have been summarized in [Table 1] and [Table 2]. 
The effects of direct irradiation of bone, soft tissues, and blood vessels are dose related and have their most profound effects in rapidly growing patients (children younger than 6 years and those undergoing puberty). In addition, the compromised blood supply to these areas from progressive endarteritis may lead to osteoradionecrosis although this complication is rare in children.  Irradiation to the central nervous system may reduce hypothalamic-pituitary function, resulting in diminished production of growth hormone and thyroid-stimulating hormone. This may in turn adversely affect odontogenesis and craniofacial development. , Diminished root surface area due to radiation exposure is the reason for early tooth loss. 
Vincristine and vinblastine disrupt cytoplasmic microtubules of the intracellular transport system. Vinca alkaloids destroy the ruffled border and smooth-ended ameloblasts resulting in hypomature enamel defects. ,, Because of the short half-life of the chemotherapeutic agents, dental defects are localized. Repetitive high doses of some agents may result in root agenesis. 
A panoramic radiograph may be indicated as a routine part of a child's pre-oncology dental treatment care plan. Post-chemo-radiation therapy radiographs indicate the severity of dental damage and provide retrospective clues as to the stage of dental development during chemo-radiation therapy. A thorough assessment of the potential complications of each therapy, the experience of the surgeon, oncologist, radiotherapist, and the personal preferences of the patient are important factors that will influence the final outcome of the treatment.  Technical advances such as hyperfractionation, brachytherapy, intensity-modulated radiotherapy, image-guided radiotherapy, and smaller fields reduce the size of the high-dose field of irradiation and limit the exposure of adjacent vital structures. Newer developments in radiotherapy such as radiosensitizers, radioprotectors, and use of heavy particles (i.e., neutrons) promise to provide a more focused distribution of cellular damage with minimal damage to adjacent healthy tissue. 
| Conclusion|| |
The number of children affected by cancer is gradually increasing. This paper highlights the importance of dental procedures for supportive care in such patients. The deleterious effects of chemo-radiation therapy on the dental and craniofacial structures must be understood by the multidisciplinary team. Prevention and reduction of these complications is possible and should be an integral part of treatment for head and neck carcinomas [Table 3].  Frequent dental follow-up and continued surveillance of the oral cavity are of utmost importance in the management of these conditions.
|Table 3: Guidelines for the oral management of pediatric patients receiving head and neck radiation therapy (adapted from Otmani)|
Click here to view
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Dr. Anand Tavargeri, Professor and Head, Department of Paedodontics, SDMCODS, Dharwad, for helping us in the preparation of this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Balwierz W, Moryl-Bujakowska A, Kaczmarek-Kanold M, Wachowiak J, Matysiak M, Sopylo B, et al.
The health state evaluation in persons after therapy of Hodgkin's disease in childhood: Report of the Polish Pediatric Leukemia/Lymphoma Study Group. Przegl Lek 2006;63:25-8.
Marx RE. Osteoradionecrosis: A new concept of its pathophysiology. Int J Oral Maxillofac Surg 1983;41:283-8.
Folwaczny M, Hickel R. Impaired dentofacial development after radiotherapy of a non-Hodgkin lymphoma: Report of case. ASDC J Dent Child 2000;67:428-30, 407.
Maguire A, Welbury RR. Long-term effects of antineoplastic chemotherapy and radiotherapy on dental development. Dent Update 1996;23:188-94.
Hicks J, Flaitz C. Rhabdomyosarcoma of the head and neck in children. Oral Oncol 2002;38:450-9.
Rajasekhar G, Nandagopal Vura, Sudheer, Srikanth Dhanala, Damera Srikanth. Rhabdomyosarcoma - Report of two cases and review. Indian J Clin Dent Sci 2011;2:16-20.
Pappo AS, Anderson JR, Crist WM, Wharam MD, Breitfeld PP, Hawkins D, et al.
Survival after relapse in children and adolescents with rhabdomyosarcoma: A report from the Intergroup Rhabdomyosarcoma Study Group. J Clin Oncol 1999;17:3487-93.
França CM, Caran EM, Alves MT, Barreto AD, Lopes NN. Rhabdomyosarcoma of the oral tissues - Two new cases and literature review. Med Oral Patol Oral Cir Bucal 2006;11:E136-40.
Jaffe N, Toth BB, Hoar RE, Ried HL, Sullivan MP, McNeese MD. Dental and maxillofacial abnormalities in long-term survivors of childhood cancer: Effects of treatment with chemotherapy and radiation to the head and neck. Pediatrics 1984;73:816-23.
Poyton HG. The effects of radiation on teeth. Oral Surg Oral Med Oral Pathol 1968;26:639-46.
Dury DC, Roberts MW, Miser JS, Folio J. Dental root agenesis secondary to irradiation therapy in a case of rhabdomyosarcoma of the middle ear. Oral Surg Oral Med Oral Pathol 1984;57:595-9.
Hwang SY, Yoon RK. Developmental defects linked to chemo-radiation therapy: A case report. J Clin Pediatr Dent 2011;35:309-14.
Fayle SA, Duggal MS, Williams SA. Oral problems and the dentist's role in the management of paediatric oncology patients. Dent Update 1992;19:152-6, 158-9.
Fromm M, Littman P, Raney RB, Nelson L, Handler S, Diamond G, et al.
Late effects after treatment of twenty children with soft tissue sarcomas of the head and neck. Experience at a single institution with a review of the literature. Cancer 1986;57:2070-6.
Greenberg MS, Glick M, Ship JA. Burket's Oral Medicine.11 th
ed. BC Decker Inc; 2012. p. 153-89.
Otmani N. Oral and maxillofacial side effects of radiation therapy on children. J Can Dent Assoc 2007;73:257-61.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]