ORIGINAL RESEARCH DENTAL MEDICINE // HEMATOLOGY

The Evaluation of Caries Severity Index

and Dental Hypoplasia in Children with
Acute Lymphoblastic Leukemia. Results
from a Romanian Medical Center
Cristina Bica¹, Valentin Ion², Krisztina Mártha¹, Daniela Esian¹, Mihaela Chinceșan³,
Monica Monea⁴
1Department of Pediatric Dentistry and Orthodontics, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
² Department of Analytical Chemistry and Drug Analysis, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
³ Department of Oncological Pediatrics, University of Medicine and Pharmacy, Tîrgu Mureş, Romania
⁴ Department of Odontology and Oral Pathology, University of Medicine and Pharmacy, Tîrgu Mureş, Romania

CORRESPONDENCE ABSTRACT
Daniela Esian Acute lymphoblastic leukemia (ALL) is a type of cancer that most frequently affects children,
Str. Gheorghe Marinescu nr. 50 and its treatment involves intensive chemotherapy, which might interfere with the normal
540139 Tîrgu Mureș, Romania development of dental tissues. The aim of our study was to measure the incidence of den-
Tel: +40 729 921 317 tal caries and enamel hypoplasia in children diagnosed with ALL treated according to the
E-mail: [email protected] Berlin-Frankfurt-Munster-95 (ALL-BFM-95) protocol during the complete remission phase. Two
groups of children between 8–12 years of age were investigated: Group 1 consisted of 36
ARTICLE HISTORY children with ALL, and Group 2 of 58 control age-matched children. The decay-missing-filling
index for the deciduous teeth (DMFT) and the presence of hypoplasia in the first permanent
Received: 2 March, 2017 molars (MH) or in both incisors and molars (MIH) were recorded. The results were statistically
Accepted: 7 March, 2017 analyzed and showed that there were no differences between the groups regarding the DMFT
values (p >0.05), but there was a statistically significant difference in the incidence of MH and
MIH between groups (p <0.05). According to our results, chemotherapy was not responsible
for the decay process, as there were no differences in DMFT indices between the groups, but
the high incidence of MH and MIH in the ALL group indicates the need of a good dental care
for these children in order to prevent future dental complications.

Keywords: chemotherapy, pediatric dentistry, acute lymphoblastic leukemia, dental hypoplasia

INTRODUCTION
Cristina Bica • Str. Gheorghe Marinescu nr. 50,
540139 Tîrgu Mureș, Romania, Tel: +40 265 215 551
Valentin Ion • Str. Gheorghe Marinescu nr. 50, 540139
Malignancies are the most important cause of mortality in children under
Tîrgu Mureș, Romania, Tel: +40 265 215 551 the age of 14, with a high incidence during early childhood. Leukemia repre-
Krisztina Mártha • Str. Gheorghe Marinescu nr. 50,
540139 Tîrgu Mureș, Romania, Tel: +40 265 215 551 sents about 30% of all cancers in children, and acute lymphoblastic leukemia
Mihaela Chinceșan • Str. Gheorghe Marinescu nr. (ALL) is the most frequent type, affecting 1:25000 children/year worldwide.
50, 540139 Tîrgu Mureș, Romania, Tel: +40 265 215
551
Monica Monea • Str. Gheorghe Marinescu nr. 50,
540139 Tîrgu Mureș, Romania, Tel: +40 265 215 551
Journal of Interdisciplinary Medicine 2017;2(S1):31-35 DOI: 10.1515/jim-2017-0006
32 Journal of Interdisciplinary Medicine 2017;2(S1):31-35

It represents 75% of all leukemia cases, with the highest age. The study group (Group 1) consisted of 36 children in
incidence around the age of 4, with 85% of the cases be- evidence at the Pediatric Clinic of the Emergency County
ing diagnosed between 2–10 years of age. ALL is one of Hospital of Tîrgu Mureș, previously diagnosed with ALL
the first to respond to chemotherapy, therefore it can be at the age of 1–6 years and treated according to standard
cured in the majority of cases. The role of modern ther- risk chemotherapy based on the ALL-BFM-95 protocol,
apy is not only to offer a treatment with minor conse- who were in the complete remission phase. The control
quences regarding specific drug-related toxicity, but also group (Group 2) of 58 age-matched healthy children was
to ensure remission in the long run.1–3 In children with selected in a consecutive manner from patients who pre-
malignancies, chemotherapy overlaps with the physi- sented to the CIDM for control or routine dental treat-
ologic processes of development of mineralization of the ment. ALL patients who passed radiotherapy and/or bone
dental buds, and the interference of these drugs with the marrow transplantation and healthy children under expo-
metabolism and cellular cycle of dentin- and enamel- sure to fluoride-containing supplements or who had teeth
forming cells might be the cause of complications, such extracted due to other causes except caries (trauma), were
as dental hypoplasia.1–4 The nature and gravity of these excluded from the study.
adverse reactions are influenced by several parameters: The DMFT index implies a given score of 1 for each
type of medication, dose and frequency of therapeutic tooth with decay, filling or extraction due to caries (the
cycles, age at the beginning of the therapy, and the stage maximum DMFT = 20 for the deciduous dentition). For
of tooth development. The presence of dental caries in each child the DMFT index was recorded by two investiga-
the deciduous dentition and the lack of treatment could tors, by adding the number of decayed (d), missed (m) and
lead to eruptive disturbances and inadequate space for filled (f ) teeth, expressing the dental experience up to the
the permanent teeth with consequent development of day of examination.
dental-maxillary anomalies.3,5 The presence of MH and MIH was assessed according
The DMFT index was introduced in 1983 by Klein, to the following criteria: demarcated opacities with a di-
Palmer and Knutson, and is considered the most univer- ameter over 2 mm, post-eruptive breakdown as a result of
sally accepted method to determine the incidence and se- masticatory forces, atypical restorations involving the cus-
verity of dental caries, as it measures the whole life-time pal or incisal 1/3 of the crowns, extraction of young molars
caries experience of a person.6 It is recommended by the due to caries. If at least one of these aspects were observed
World Health Organization (WHO) in epidemiological on a first permanent molar or in both incisor and molar, a
studies for measuring and comparing dental health in a positive MH or MIH was recorded.
group or population. The recording of enamel hypoplasia
in early mixed dentition, affecting the permanent molars
Management protocol
and incisors, is a concept introduced in 2001 by Weerheijm
et al., who also set the diagnostic criteria.7 The approval to conduct this study was obtained from
The present study was conceived to evaluate the dental the Research Ethics Committee of our university. The
health status in a group of children treated for ALL accord- legal representatives of the children were fully informed
ing to the BMF-95 protocol, and to measure the incidence about the purpose and methodology of the investigation,
of dental caries in deciduous teeth using the DMFT index and were asked to sign a written consent regarding the
and the presence of enamel hypoplasia in early mixed den- inclusion of their children in the examination process
tition by recording the incidence of molar or molar-incisor and complete access to their medical records. Prior to
hypoplasia (MH and MIH respectively), in comparison the study, inter-examiner and within-examiner repro-
with a matched group of healthy children. ducibility were compared and were found to be high for
all measured clinical parameters. Following professional
cleaning, the teeth were dried and visually examined, re-
Material and methods
cording the individual DMFT scores and the presence
of MH and MIH. The enamel hypoplasia of permanent
Inclusion and exclusion criteria
incisors and molars was diagnosed after routine clinical
This study was performed in the Center of Integrated Den- and radiographic investigation. For each participant the
tal Medicine (CIDM) in the University of Medicine and total number of decayed, missed or filled deciduous teeth
Pharmacy of Tîrgu Mureș, Romania, based on the evalu- and the presence of hypoplasia in permanent teeth were
ation of two groups of children between 8–12 years of recorded.
 Journal of Interdisciplinary Medicine 2017;2(S1):31-35 33

TABLE 1.  Mean age and standard deviation for the groups (t-test, and DMFT ≥5); we compared the number of patients
Welch correction) from each group with the same DMFT value and the re-
sults showed that there are no statistically significant dif-
Group Age p value
ferences (p >0.05).
ALL 10.1 ± 1.83 p = 0.12 The incidence of MH and MIH were measured, and the
Control 9.8 ± 1.64 p = 0.18 results showed that in Group 1 in 38.89% of cases the first
molars and in 47.22% of cases both incisors and molars had
signs of mineralization disturbances, compared to 10.34%
Statistical analysis
and 13.79% in the control group. These results are statisti-
The results were evaluated using the demo version of the cally significant (Table 3).
Graph Pad software. The non-parametric qualitative chi-
square test was used in order to evaluate the differences
Discussion
between the study groups and the level of statistical signifi-
cance was set to 0.05 (p <0.05). The ALL-BMF-95 protocol was designed to reduce acute
and long-term toxicity in patients with favorable prognosis
and to improve the outcome in poor-risk groups by treat-
Results
ment intensification. The original ALL-BMF protocol and
its later versions became the most widely used treatment
Clinical-pathological characteristics
for childhood ALL, with the best positive impact on heal-
A total number of 94 patients were examined, with a mean ing rates in the last decades. The patients included in our
age of 10.1 ± 1.83 years in the ALL group and 9.8 ± 1.64 study had been diagnosed with ALL between 1–6 years of
years in the control group. There were no statistically sig- age, a period of intense activity in the development and
nificant differences (p >0.05), therefore we considered mineralization of the dental tissues. Our results showed
that the groups matched (Table 1). high incidence for DMFT scores in both groups, which is
in contradiction with the results of other studies reporting
higher DMFT scores only for children with ALL or other
Comparative results
malignancies or systemic disorders.8–11 Venkatesh et al.
The recorded DMFT values were very high for both groups, found maximum values in 76% of children with ALL com-
as 50 children (23 from Group 1 and 27 from Group 2), rep- pared to 66% in healthy controls, which was considered a
resenting 53.19%, had a value of DMFT ≥5. Only 10.64% consequence of chemotherapy.8 Hedge et al. and Dens et
of the cases were noted with a DMFT = 0, which means al. emphasized high levels of caries intensity in children
that the patients had healthy deciduous teeth, free of den- with ALL, and furthermore, Azher et al. also reported high
tal caries (Table 2). scores of DMFT in children with ALL.9–11 Xerostomia is
By using the chi-square test (α = 0.05), we compared another frequent side effect of oncological therapy that
the impact of chemotherapy on the severity of dental car- might increase the severity of dental caries.12 High caries
ies between the groups, after the patients with DMFT = 0 levels have persisted in Romania over the last decades, and
were excluded. In this case, the statistical analysis showed we have not achieved the WHO target of an average score
no significant differences between DMFT scores in the lower than 3 at the age of 12 years. Recent published data
study and control group (p >0.05), meaning that chemo- reported a mean DMFT score of 4.79 ± 3.46 for children of
therapy had no increasing effect on the number of decayed 6–8 years of age and values of 4.52 ± 4.02 for the interval of
teeth. The same method was used to evaluate each seg- 11–13 years.6
ment of DMFT values (DMFT = 0, DMFT between 1–4
TABLE 3.  Frequency of enamel hypoplasia in the study and
TABLE 2.  The DMFT scores for the study and control group control group

Caries intensity % DMFT = 0 DMFT = 1–4 DMFT ≥5 Hypoplasia MH MIH DMFT ≥5

Group 1 2 children 11 children 23 children Group 1 14 children (38.89%) 17 children (47.22%) 23 children
Group 2 8 children 23 children 27 children Group 2 6 children (10.34%) 8 children (13.79%) 27 children
p value 0.36 (p >0.05) 0.50 (p >0.05) 0.15 (p >0.05) p values 0.0025 (p <0.05) 0.09 (p <0.05)
34 Journal of Interdisciplinary Medicine 2017;2(S1):31-35

A higher caries severity index was reported as a dental dex, as high DMFT values were found in both the group of
late effect of chemotherapy.13 Avsar et al. reported in their children with ALL and healthy controls. However, the high
case-control study that 96 survivors of childhood cancer incidence of MH and MIH demonstrates that this treat-
treated with chemotherapy and no radiation had lower ment protocol might interfere with the mineralization pro-
salivary flow rate and higher cariogenic bacteria such cess of dental enamel. Children with malignancies should
as Streptococcus mutans and Lactobacillus.14 The higher be under permanent monitoring in order to optimize the
DMFT values recorded in ALL children were explained oral health status, improve the quality of life and prevent
by the presence of demineralization defects that favored further dental complications. Further studies are needed in
the cariogenic activity of oral microorganisms. The DMFT order to identify associated risk factors of chemotherapy
score is considered to be a useful predictor of caries in per- with dental development processes and to develop better
manent teeth.15 The advantage of this index is that it gives preventive measures for children with malignancies.
an image of the caries experience and allows an evaluation
of the oral health status, but it gives no information regard-
Abbreviations
ing the rate of caries progression. According to our study,
chemotherapy was not responsible for the decay process, ALL acute lymphoblastic leukemia
as there was no difference between DMFT scores in the DMFT decay-missing-filled teeth
study and control group. Therefore, other factors must be MH molar hypoplasia
taken into consideration, such as ethnic characteristics, MIH molar incisor hypoplasia
socio-economic status and the quality of our national oral
health preventive program.
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