1 Volume 23 2024 e248950 Original Research Braz J Oral Sci. 2024;23:e248950http://dx.doi.org/10.20396/bjos.v23i00.8668950 1 Dentist at Dentistry and Stomatology Service, Clinical Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil. Corresponding author: Mariana Andrade Costa Clinical Hospital of Ribeirão Preto Medical School - University of São Paulo R. Tenente Catão Roxo, 3900 - Vila Monte Alegre, Ribeirão Preto - SP, Brasil, CEP: 14015-010 marianaac@hcrp.usp.br Editor: Dr. Altair A. Del Bel Cury Received: April 5, 2022 Accepted: June 29, 2024 Dental care for children in a tertiary hospital Mariana Andrade Costa1* , Karina Alessandra Michelão Grecca Pieroni1 Aim: To evaluate the profile of pediatric onco-hematological patients and the outpatient dental care provided to these individuals from January 2016 to December 2019 by the Pediatric Dentistry division of the Dentistry and Stomatology Service of a tertiary hospital. Methods: Data were collected from the medical records of 179 pediatric patients undergoing treatment for onco-hematological diseases, aged between 0 and 19 years, regarding their profile and the outpatient dental care provided by the Pediatric Dentistry Service of the Dentistry and Stomatology Service of a tertiary hospital. Data were tabulated and subjected to descriptive statistical analysis. Results: The majority of the patients were male, with a mean age of 12. Anemia and leukemia were the most prevalent diseases in this study. During the evaluation period, 1548 dental appointments were performed, 696 of which were clinical evaluations. The remaining appointments involved various dental procedures. The most common procedures included the topical application of fluoride and dental prophylaxis, followed by extractions, laser therapy, tooth decay removal, and restorations/sealants. Conclusion: Assessing patient profiles and the dental care provided are important tools for improving dental care protocols and enhancing the quality of life for pediatric onco-hematological patients. Keywords: Neoplasms. Hematology. Oral health. Pediatric dentistry. https://orcid.org/0000-0001-6689-2695 https://orcid.org/0000-0002-7314-5337 2 Costa et al. Braz J Oral Sci. 2024;23:e248950 Introduction Neoplastic pathologies in children and adolescents between 0 and 19 years old are considered rare events compared to adults, representing about 2% to 3% of all malig- nant tumors recorded in Brazil1. In malignant neoplasms, there is a disorderly growth of cells invading organs and tis- sues. However, in children, there are differences in clinical behavior, histopathological origin, and primary sites of the disease2. In children and adolescents, tumors tend to have a short latency period, being extremely aggressive and invasive, but generally, they respond better to antineoplastic treatment, thus having a better prognosis com- pared to other populations2. Authors suggest that before starting onco-hematological treatment, patients should have excellent oral health to avoid the risk of complications3,4. Carious lesions affect- ing both primary and permanent teeth, periodontal diseases where the accumula- tion of bacterial plaque increases the severity of mucosal infections, predisposing to gingival inflammation, as well as the presence of opportunistic infections caused by bacteria, fungi, and viruses, are some complications that can negatively interfere with onco-hematological treatment3-6. The profile of pediatric onco-hematological patients treated in hospitals in Brazil shows that a large part of these individuals have poor oral health, and this con- dition is often responsible for increasing hospitalization time, causing delays, and even the suspension of onco-hematological treatments, raising the risk of systemic complications6-9. Thus, the objective of this study was to retrospectively evaluate the profile of pediat- ric onco-hematological patients aged between 0 and 19 years and analyze the out- patient dental care provided to these individuals from January 2016 to December 2019 by the Pediatric Dentistry Service of the Dentistry and Stomatology Service of the Clinical Hospital of Ribeirão Preto Medical School - USP (HCFMRP/USP). Methods This was a retrospective study. Data were collected from the medical records of pediatric patients undergoing treatment for onco-hematological diseases aged between 0 and 19 years. The data were retrieved from an outpatient dental care service provided by the Pediatric Dentistry division of the Dentistry and Stomatology Service of a tertiary hospital from January 2016 to December 2019. Patients who had never been diagnosed with onco-hematological diseases, those with incomplete or missing clinical information, and individuals over 19 years of age were excluded from the study (Figure 1). 3 Costa et al. Braz J Oral Sci. 2024;23:e248950 3525 Total number of dental appointments Inclusion criteria for selection between 2016 and 2019 1651 dental appointments of pediatric onco-hematological patients Malignant Diseases 930 Dental appointments Non-malignant Diseases 721 Dental appointments Figure 1. Flowchart for the selection of dental appointments and distribution of medical diagnoses For sample characterization, demographic information such as gender and age was collected. Additionally, patients were classified according to the nature of the disease into two groups: I) patients with malignant diseases, and II) those with non-malignant diseases. Regarding dental appointments, these were classified into two types: I) clinical eval- uation, which includes medical history and extra- and intraoral clinical examination, and II) procedures, which encompass dental treatments typically performed in tertiary care settings. The collected data were tabulated and submitted to descriptive statistical analysis. Ethical aspects This study followed the ethical principles dictated by Resolution 466/2012 of the National Health Council and was approved by the Ethics Committee for Research in Human Beings at CHRPMS/USP (CAAE: 38625320.0.0000.5440). Results Between January 2016 and December 2019, 3525 dental appointments were con- ducted at the Dentistry and Stomatology Service of a tertiary hospital, 1651 of which were for pediatric onco-hematological patients. Specifically, 930 dental appoint- ments were for patients with malignant diseases, and 721 were for patients with non-malignant diseases (Figure 1). This study included 179 pediatric onco-hematological patients. Male patients com- prised 53% of the sample (n=95), with a mean age of 12.47 ± 3.73 years. 4 Costa et al. Braz J Oral Sci. 2024;23:e248950 Figure 2 illustrates the distribution of age intervals by sex of patients during their initial dental appointments. 0% 5% 10% 15% 20% 25% 0 a 4 Female Male > 1510 a 145 a 9 0% 13% 18% 16% 3% 11% 17% 22% Figure 2. Frequency distribution of age intervals and gender among pediatric onco-hematological patients Table 1 shows that the most prevalent malignant diseases were ALL (25%) and CNS neoplasms (25%), followed by sarcomas/osteosarcomas (18%), other solid tumors (15%), and AML (7%). Among non-malignant diseases, aplastic anemia (25%) and sickle cell anemia (21%) were the most frequent, followed by Fanconi anemia (14%) and other hematological problems (12%). Table 1. Prevalence of malignant and non-malignant diseases in pediatric patients Malignant Diseases n (%) Non-malignant Diseases n (%) ALL 29 (25) Aplastic Anemia 16 (25) CNS Neoplasms 29 (25) Sickle Cell Anemia 14 22) Sarcomas/Osteosarcomas 21 (18) Fanconi Anemia 9 (14) Other solid tumors 18 (16) Other hematological problems 8 (12) AML 8 (7) Hemophilia A 7 (11) Non-Hodgkin’s Lymphoma 6 (5) ITP 5 (8) Hodgkin Lymphoma 3 (3) Hemoglobinopathies 2 (3) CML 2 (2) Wiskott-Aldrich Syndrome 2 (3) ALL: Acute Lymphoblastic Leukemia, CNS: Central Nervous System, AML: Acute Myeloid Leukemia, CML: Chronic Myeloid Leukemia, ITP: Idiopathic Thrombocytopenic Purpura Figure 3 shows that in patients with malignant diseases, laser therapy (21%) and topical application of fluoride (TAF) were the most common procedures, followed 5 Costa et al. Braz J Oral Sci. 2024;23:e248950 by dental prophylaxis (17%) and extractions (15%). For the group of patients with non-malignant diseases, TAF (25%) and dental prophylaxis (22%) were the most per- formed, followed by restorations (14%), extractions (13%) and tooth decay removal (12%). The distribution of frequency of dental care, clinical evaluations and proce- dures performed in onco-hematological patients in the years between 2016 and 2019 is shown in Table 2. 0% 5% 10% 15% 20% 25% 30% Fr eq ue nc y Malignant Non-malignant 21% 19% 17% 15% 9% 8% 3% 2% 1% 4% 0% 25% 22% 13% 14% 12% 2% 4% 3% 4% Lase r th erapy Others Endodontic Dress ing Sca lin g and Root P laning Peria pica l R adiography Toot D eca y R emova l Resto ratio ns/S ealin gs Extr acti ons Dental P rophyla xisTAF TAF: Topical Application of Fluoride Figure 3. Frequency distribution of dental procedures performed on patients with malignant and non- malignant diseases. The number of dental appointments for pediatric onco-hematological patients increases linearly each year. Dental procedures were the most frequently performed appointments throughout all the years evaluated. Table 2. Distribution of frequency of dental appointments, clinical evaluations and procedures performed in pediatric onco-hematological patients n (%) 2016 2017 2018 2019 Total Number of Dental Appointments 360 353 434 504 1651 Clinical Assessment 154 (21) 164 (22) 174 (23) 250 (34) 742 Procedures 206 (23) 189 (20) 260 (29) 254 (28) 909 Topical Application of Fluoride 45 (23) 48 (24) 49 (25) 57 (29) 199 Dental Prophylaxis 43 (25) 37 (21) 47 (27) 48 (27) 175 Extractions 30 (24) 26 (21) 33 (26) 37 (29) 126 Laser therapy 1 (1) 16 (15) 58 (55) 31 (29) 106 Restorations / Sealings 40 (38) 18 (17) 23 (22) 25 (24) 106 Tooth decay removal 36 (39) 16 (17) 17 (18) 23 (25) 92 Continue 6 Costa et al. Braz J Oral Sci. 2024;23:e248950 Continuation Scaling and root planning 3 (12) 7 (28) 5 (20) 10 (40) 25 Periapical Radiography 0 (0) 8 (36) 10 (45) 4 (18) 22 Endodontic dressing 1 (7) 6 (40) 8 (53) 0 (0) 15 Suture Removal 2 (15) 3 (23) 4 (31) 4 (31) 13 Exfoliative Cytology 0 (0) 2 (25) 2 (25) 4 (5) 8 Ulectomy 0 (0) 0 (0) 1 (100) 0 (0) 1 Intralesional Corticosteroid Application 0 (0) 0 (0) 0 (0) 4 (100) 4 Biopsy 2 (33) 0 (0) 1 (17) 3 (50) 6 Frenectomy 0 (0) 1 (50) 0 (0) 1 (50) 2 Molding 1 (100) 0 (0) 0 (0) 0 (0) 1 Prosthesis Installation 1 (100) 0 (0) 0 (0) 0 (0) 1 Prosthesis Adjustment 1 (100) 0 (0) 0 (0) 0 (0) 1 Bleeding Surgical Approach 0 (0) 1 (100) 0 (0) 0 (0) 1 Cutting Dental Edge Regularization 0 (0) 0 (0) 1 (100) 0 (0) 1 Occlusal Adjustment 0 (0) 0 (0) 1 (25) 3 (75) 4 Gingivectomy 0 (0) 0 (0) 0 (0) 1 (100) 1 Discussion This study aimed to assess the profile of pediatric onco-hematological patients. It was found that the sample characterization data corroborated with the literature, suggesting that the incidence of malignant neoplasms is 2.7 times higher in the age group between 15 and 30 years than in children under 15 years old1,10. Regarding the data on dental procedures performed between 2016 and 2019, this population’s increased dental demand was observed, demonstrating how Dentistry can contribute to a multidisciplinary team11-13. Clinical evaluations accounted for an important part of the total dental appointments performed in the studied time interval. According to the literature, periodic follow-ups of these patients are fundamental for guiding caregivers about possible oral changes resulting from underlying diseases and/or systemic treatments, as well as for pre- venting dental diseases and early intervention for problems in the oral cavity6,14,15. This contributes to the quality of life of the patient and reduces the risk of interruption or suspension of onco-hematological treatment to restore oral health16-18. Procedures accounted for the majority of dental appointments carried out in this period. Among these procedures, the topical application of fluoride and dental pro- phylaxis were the most commonly performed in patients with non-malignant dis- eases. These procedures also ranked second and third among the most performed procedures in patients with malignant diseases. This may be due to the significant increase in the number of preventive procedures, or it may be associated with the 7 Costa et al. Braz J Oral Sci. 2024;23:e248950 gradual increase in restorative procedures that increasingly require preventive dental measures, serving as a preventive plan to avoid oral complications. Thus, it is possible to reduce the chance of compromised onco-hematological treatment for those with unfavorable oral health3,6,12,19. Tooth extraction was also a procedure frequently performed in the service. It was the third most performed among non-malignant diseases and ranked fourth among patients with malignant diseases. The unfavorable oral health condition of the participants may have contributed to the early condemnation of decidu- ous and permanent teeth without them being able to undergo dental treatment for dental recovery14,15,19. Analyzing other reference centers in dental care for pediatric onco-hematological patients, it was also found that tooth extractions, along with restorative and preventive procedures for caries, were the most frequently performed procedures. This indicates a greater concentration of these dental procedures in tertiary care centers15,19. Another gradual increase was observed in the number of laser therapy sessions. It is known that low-power laser has numerous purposes, including preventing and treat- ing oral mucositis. This condition arises due to antineoplastic treatments and during the Bone Marrow Transplant (BMT) conditioning phase. Thus, it is an almost exclusive procedure for patients with malignant diseases and is used sporadically for patients with non-malignant diseases undergoing BMT5,6. This study showed a linear growth of dental appointments for pediatric onco-hematological patients in our service. This result can be attributed to the 2017 implementation of the Residency Program in Cancer Care in the Dentistry area, which increased the number of dentists working in the care of children and adolescents. Addi- tionally, the opening of a dental office for the exclusive care of children and adolescents in the pediatric hospital in 2019 also facilitated access to dental services for children. It is worth noting that the individuals’ oral hygiene was not evaluated in this study, so the increase in preventive dental procedures cannot be attributed to their oral hygiene condition. Therefore, it is suggested that the oral health condition of pediatric onco-hematological patients be included as a variable in future studies to evaluate how the increase in preventive dental procedures may have contributed to the oral health of these individuals. In conclusion, it was possible to observe a linear growth in dental appointments for pediatric onco-hematological patients between 2016 and 2019, with preventive pro- cedures being the most performed. Male pediatric onco-hematological patients with malignant diseases were the most prevalent in the study. Data availability Datasets related to this article will be available to the corresponding author upon request. Conflicts of interests The investigators have no conflicts of interest to declare. They agree with the study and have no financial interests to report. 8 Costa et al. Braz J Oral Sci. 2024;23:e248950 Funding This research will not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution Mariana Andrade Costa: conception, data collection, writing the draft and the final version of the manuscript. Karina Alessandra Michelão Grecca Pieroni: review of the draft and review of final version of the manuscript. The authors actively participated in two distinct criteria related to authorship. References 1. Brazilian Ministry of Health. National Cancer Institute. [Estimative 2016: Incidence, mortality and hospital morbidity due to cancer in children, adolescents and young adults in Brazil]. Rio de Janeiro: INCA; 2016 [cited 2021 Mar 17]. Available from: https://www.inca.gov.br/publicacoes/livros/ incidencia-mortalidade-e-morbidade-hospitalar-por-cancer-em-criancas-adolescentes. Portuguese. 2. Brazilian Ministry of Health. National Cancer Institute. 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