1407

Pictorial Essay

Abnormal Odontogenesis in Children Treated with

Radiation and Chemotherapy: Imaging Findings
Sue C. Kenneth P. Hopkins,2 Jesse J. Jenkins lIla

Contemporary oncothenapy has improved survival of children at diagnosis, doses and schedules of treatment, and the
with malignant diseases, but chemotherapy and radiotherapy anatomic region treated [3, 4].
also have deleterious effects. This essay illustrates the effects of
chemotherapy and radiotherapy on dentition in children and
adolescents. The illustrated abnormalities were seen on pan- Oncotherapeutic Effects
onamic nadiographs obtained before, during, and after treatment
Included are examples of hypodontia (partial anodontia), micro- Chemotherapy interferes with the cell cycle and with intra-
dontia, altered eruption patterns, and root stunting. Comparison cellular metabolism, and may thereby cause retarded dental
is made with normal dental development (Fig. 1). development, microdontia, taurodontism, and root stunting.
Alterations of ameloblastic reproduction, secretory function,
membrane permeability, and calcium exchange across the
Background cell membrane can produce irregular enamel matrix forma-
Chemotherapy-induced abnormalities in odontogenesis tion and irregularities in the surface of the enamel, mani-
include dental root stunting (with on without apical closure), fested clinically by enamel opacities. Altered odontoblastic
hypodontia (absence of one or more teeth), microdontia (iso- activity (a consequence of abnormal secretory function of
lated abnormally small teeth) (Fig. 2), and taunodontism microtubules and of complex changes in inter- and intracel-
(enlarged pulp chamber) [1-3] (Fig. 3). Radiation effects lulan relationships) can produce shortened, thinned, and
include tooth or root dwarfism, hypodontia, and altered pat- blunted roots [2, 3]. The nature and extent of dental
tenns of tooth eruption. Many children receive both types of sequelae vary with the type of drugs used, their doses, and
treatment, and distinguishing the effects of chemotherapy the frequency of treatment cycles.
from those caused by radiation is difficult [1-3]. The nature The radiosensitivity of developing teeth has been demon-
and severity of potential side effects vary with the child’s age stnated in animal models. Mature ameloblasts are perma-

Received February 1 7, 1993; accepted after revision January 26, 1994.

Supported in part by the National Cancer Institute, Cancer Center Support (CORE) grant P30CA21765 and by the American Lebanese Syrian Associated Charities.
1 Department of Radiology, University of Tennessee, Memphis, TN 38103, and the Department of Diagnostic Imaging, St. Jude Children’s Research Hospital,
332 N. Lauderdale, Memphis, TN 38105. Address correspondence to S. C. Kaste.
2Department of Surgery, Division of Dentistry, University of Tennessee, Memphis, TN 38103, and the Department of Dentistry, St. Jude Children’s Research
Hospital, Memphis, TN 38101.
3Department of Pathology and Laboratory Medicine, University of Tennessee, Memphis, TN 38103, and the Department of Pathology, St. Jude Children’s Re-
search Hospital, Memphis, TN 38101.
AJR i994;i62:i407-l4ii 0361-803X/94/1626-1407 © American Roentgen Ray Society
1408 KASTE ET AL. AJR:162, June 1994

Fig. 1 .-Normal development and eruption

patterns. Primary dentition is depicted in green
and secondary dentition In white.
A and B, Drawing (A) and corresponding
panoramic radiograph (B) show normal pri-
mary dentition at approximately 4 years (±9
months) of age. Note presence of completely
formed primary incisors, bicuspids, and first
and second molars. Formation of permanent
dentition has begun.
C and D, Drawing (C) and corresponding
panoramic radiograph (D) show normal early
mixed dentition at approximately 7 years (±9
months) of age. Exfoliation (loss) of primary
incisors, eruption of secondary Incisors and
first permanent molars, onset of root resorp-
tion of the second primary molars and bicus-
pids, and further development and maturation
of secondary dentition have occurred.
(Fig. 1 is continued on the opposite page.)

nently damaged by 1 0 Gy of radiation: 30 Gy halts tooth may be normal even when the roots are damaged. Malfonma-
development at the point of maturation at which the teeth are tion of unerupted teeth can be assessed only radiographically
irradiated. Radiation damage occurs simultaneously to the (Figs. 5-7). These teeth erupt but may be malpositioned.
bone, periodontal ligament, and pulp. Radiation effects on Knowledge of these sequelae is important for planning future
teeth (unlike chemotherapy sequelae) are limited to the imra- orthodontic intervention.
diated area (Fig. 4).

Conclusion
Imaging
The sequelae of oncothenapy may be as challenging to
Pretreatment panoramic radiographs are useful in predict- treat as the disease for which the therapy was used. These
ing the development of oncotherapy-induced dental abnor- side effects will be seen more often as survival from cata-
malities and in anticipating their connective intervention. strophic childhood diseases increases. Radiologists can help
Developmental abnormalities of tooth roots, such as fore- direct the care of long-term survivors by recognizing late side
shortening, malformation, premature closure, on absence of effects and providing guidance for dental, medical, and surgi-
roots, are readily seen on panoramic radiographs. Crowns cal restoration of altered odontogenesis in these children.
AJR:162, June 1994 EFFECTS OF ONCOTHERAPY ON CHILDREN’S TEETH 1409

Fig. 1.-(Continued)
E and F; Drawing (E) and corresponding
panoramic radiograph (F) show normal late
mixed dentition at approximately 1 0 years (±9
months) of age. Progressive exfoliation of pri-
mary dentitlon and maturation and eruption of
permanent dentition have occurred.
G and H, Drawing (G) and corresponding
panoramic radiograph (H) show normal perma-
nent dentitlon, which usually occurs at approxi-
mately 1 5 years (±6 months) of age. Secondary
third molars have not yet erupted and may not
erupt completely for several more years [4].

Fig. 2.-Effects of chemotherapy In a 10-year-old twin who had acute lymphocytic leukemia diagnosed at age 3 years.
A, Panoramic radiograph shows microdontla of fIrst bicuspids (solid arrows), root stunting of first permanent molars (open arrows), and absence of
left second bicuspid and all third molars.
B, Panoramic radiograph of the patient’s twin, who did not have leukemia, shows normal dental development for a 10-year-old.
1 4i 0 KASTE ET AL. AJR:162, June 1994

Fig. 3.-Taurodontism (widened pulp chamber) resulting from chemo-

therapy. Panoramic radiograph shows widened pulp chamber (arrows)
due to chemotherapy received at an early age.

- . - -- ..

Fig. 4.-Effects of combination chemotherapy and radiation therapy in a 14-year-old boy who had Hodgkin’s disease diagnosed at age 8 years.
A, Panoramic radiograph shows arrested development of mandibular molars and bicuspids (as indicated by marked diffuse root stunting) from
mantle Irradiation with sparing of maxillary teeth.
B, Drawing of field of mantle Irradiation delineates field boundaries (shaded area), which extend to submandibular area.

____

Fig. 5.-Effects of combination chemotherapy and radiation therapy Fig. 6.-Effects of combination chemotherapy and radiation therapy
in a 1 3-year-old who had rhabdomyosarcoma of the left orbit diagnosed in an 8-year-old child who had rhabdomyosarcoma of the left parotid
at age 3 months. Panoramic radiograph shows absence of third molar gland diagnosed at age 1 year. Panoramic radiograph shows rootless
(arrowhead), mlcrodontla of second molars and bicuspids (solid left maxillary and mandibular teeth (arrows). Note partial anodontia of
arrows), and rootless left maxillary teeth (open arrows). left second and third molars, left bicuspids, and right third molars.
AJR:162, June 1994 EFFECTS OF ONCOTHERAPY ON CHILDREN’S TEETH 1411

Fig. 7.-Effects of chemotherapy

and radiation therapy in a patIent who
had rhabdomyosarcoma diagnosed at age 7 years. Panoramic
of the nose
radiograph shows root stunting of bicuspids and second molars (solid
arrows) and microdontia of third molars (open arrows).

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