Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ�)
This patient summary on
This summary is about oral complications in adults and children with cancer. Section titles show when the information is about children.
Oral complications are common in patients receiving chemotherapy or undergoing radiation therapy to the head and neck.
Chemotherapy and radiation therapy stop the growth of rapidly dividing
cells, such as cancercells. Since normal cells in the lining of the mouth also divide rapidly, anticancer treatment can prevent cells in the mouth from reproducing, making it difficult for oral tissueto repair itself.
The mouth contains hundreds of different
bacteria, some helpful and some harmful. Chemotherapy and radiation therapy can cause changes in the lining of the mouth and production of salivaand upset the healthy balance of bacteria. These changes may lead to mouth sores, infections, and tooth decay.
Wear and tear occur from normal use of the mouth, teeth, and jaws, making healing more difficult.
Preventive measures may lessen the severity of oral complications.
Oral side effects may make it difficult for a patient to receive all of his or her cancer treatment. Sometimes treatment must be stopped.
Preventing and treating oral complications of cancer therapy involve identifying the patient at risk, starting
Patients receiving chemotherapy or undergoing radiation therapy to the head and neck should have their care planned by a team of doctors and specialists.
To manage oral complications, the
Dietitian. Speech therapist. Social worker.
Description and Causes
Chemotherapy and radiation therapy to the head and neck may each cause different oral side effects.
Some of the
Changes in the growth and development of teeth and jaws in children.
Mucositis(an inflammationof the mucous membranesin the digestive tract) in the stomachor intestines.
Easy bleeding in the mouth.
Some of the oral complications caused by radiation therapy to the head and neck include the following:
Fibrosis(growth of fibrous tissue) in the mucous membrane in the mouth.
Tooth decay and gum disease.
Breakdown of tissue in the radiated area.
Breakdown of bone in the radiated area.
Fibrosis of muscle in the radiated area.
Radiation therapy and chemotherapy may cause some of the same oral side effects, including the following:
Mucositis in the mouth.
Infectionsin the mouth or that travel through the bloodstream, reaching and affecting cellsall over the body.
Changes in dental growth and development in children.
Malnutrition(lack of nutrientsneeded by the body for health, often caused by the inability to eat). Dehydration(lack of water needed by the body for health, often caused by the inability to drink).
Tooth decay and gum disease.
Complications may be caused directly or indirectly by anticancer therapy.
Slow healing and infection are indirect complications of
Complications can be acute or chronic.
Problems using the mouth and jaw due to tissue and bone loss and/or the growth of
benign tumorsin the skin and muscle.
Prevention and Treatment of Oral Complications Before Chemotherapy and/or Radiation Therapy Begins
Finding and treating oral problems before anticancer therapy begins can prevent or lessen the severity of oral complications.
Preventive measures include the following:
Eating a well-balanced
diet. Proper nutritioncan help the body tolerate the stressof cancertreatment, maintain energy, fight infection, and rebuild tissue.
Learning how to care for the mouth and teeth during and after anticancer therapy. Good dental
hygienehelps prevent cavities, mouth sores, and infections.
Having a complete oral health exam by a
dentistfamiliar with the oral side effectsof anticancer treatments.
The cancer care team should include the patient's dentist. It is important to choose a dentist familiar with the oral side effects of
A preventive oral health exam will check for the following:
Mouth sores or infections.
Dentures that do not fit well.
Problems moving the jaw.
Problems with the
Patients undergoing high-dose chemotherapy, stem cell transplant, and/or radiation therapy need an oral care plan in place before treatment begins.
The goal of the oral care plan is to find and treat oral disease that may produce complications during treatment and to continue oral care throughout treatment and recovery. Different oral complications may occur during the different phases of
Ongoing oral care during radiation therapy will depend on the specific needs of the patient; the
It is important that patients who have head or neck cancer stop smoking.
Continued smoking slows recovery and increases the risk that the head or neck cancer will
Management of Oral Complications During and After Chemotherapy and/or Radiation Therapy
Routine Oral Care
Continuing good dental
Brush teeth with a soft bristle brush 2 to 3 times a day for 2 to 3 minutes. Be sure to brush the area where the teeth meet the
gumsand rinse often.
Rinse the toothbrush in hot water every 15 to 30 seconds to soften the bristles, if needed.
Use a foam brush only if a regular bristle brush cannot be used. Brush 2 to 3 times a day and use an
antibacterialrinse. Rinse often.
Allow the toothbrush to air dry between brushings.
Choose toothpaste with care:
Use a mild-tasting toothpaste; flavoring may irritate the mouth, especially mint flavors.
If toothpaste irritates the mouth, brush with a solution of 1 teaspoon of salt added to 4 cups (1 quart) of water.
One of the following rinses made with salt and/or baking soda may be used:
1 teaspoon of salt in 4 cups of water.
1 teaspoon of baking soda in 1 cup (8
ounces) of water.
� teaspoon salt and 2 tablespoons baking soda in 4 cups of water.
An antibacterial rinse may be used 2 to 4 times a day for gum disease. Rinse for 1 to 2 minutes.
If dry mouth occurs, rinsing may not be enough to clean the teeth after a meal. Brushing and flossing may be needed.
Floss gently once a day.
Use lip care products to prevent drying and cracking.
For special oral care during
Mucositis is an inflammation of mucous membranes in the mouth.
The terms "oral
Mucositis is an
inflammationof mucous membranesin the mouth. It usually appears as red, burn-like sores or as ulcer-like sores throughout the mouth.
Stomatitis is an inflammation of
tissuesin the mouth, such as the gums, tongue, roof and floor of the mouth, and tissues inside the lips and cheeks. It includes infections of mucous membranes.
Mucositis may be caused by either radiation therapy or chemotherapy. The risk of having mucositis is increased when the cancer is treated with both chemotherapy and radiation therapy at the same time. In patients receiving chemotherapy, mucositis will heal by itself, usually in 2 to 4 weeks when there is no infection. Mucositis caused by radiation therapy usually lasts 6 to 8 weeks, depending on the duration of treatment.
The following problems may occur:
Bleeding, in patients receiving chemotherapy. Patients undergoing radiation therapy usually do not have a bleeding risk.
Inability to breathe and eat normally.
Swishing ice chips in the mouth for 30 minutes may help prevent mucositis from developing in patients who are given
Care of mucositis during chemotherapy and radiation therapy focuses on cleaning the mouth and relieving the symptoms.
Treatment of mucositis caused by either radiation therapy or chemotherapy is generally the same. After mucositis has developed, proper treatment depends on its severity and the patient's
Cleaning the mouth
Clean the teeth and mouth every 4 hours and at bedtime, more often if the mucositis becomes worse.
Use a soft bristle toothbrush.
Replace the toothbrush often.
solublelubricating jelly to moisturize the mouth.
Use bland rinses or plain
sterilewater. Frequent rinsing removes particles and bacteriafrom the mouth, prevents crusting of sores, and moistens and soothes sore gums and the lining of the mouth.
If crusting of sores occurs, the following rinse may be used:
hydrogen peroxideand water or saltwater (1 teaspoon of salt in 4 cups of water).
This should not be used for more than 2 days because it will keep mucositis from healing.
Relieving mucositis pain
topicalmedications for pain. Rinse the mouth before applying the medication onto the gums or lining of the mouth. Wipe mouth and teeth gently with wet gauze dipped in saltwater to remove particles. Topical treatments may include coating agents and lozenges.
Painkillers may provide relief when topical medications do not.
Nonsteroidal anti-inflammatory drugs(NSAIDS, aspirin-type painkillers) should not be used by patients receiving chemotherapy because these patients have a bleeding risk. Zinc supplementstaken during radiation therapy may help treat mucositis as well as dermatitis(inflammation of the skin).
iodinemouthwash that does not contain alcoholmay help delay or decrease mucositis caused by radiation therapy.
See the Pain section of this summary for more information on pain control.
A cancer patient's pain may come from more than one source.
Sources of pain in a cancer patient include:
Damage to the nervous system.
Other medical conditions not related to the cancer.
Because there can be many causes of oral pain, a careful
Oral pain in cancer patients may be caused by the cancer.
Cancer can cause pain in different ways:
The tumor presses on nearby areas as it grows, affecting
nervesand causing inflammation. Leukemiasand lymphomas, which spread through the body, may affect sensitive areas in the mouth. Multiple myelomacan affect the teeth. Brain tumorsmay cause headaches.
Cancers may spread to the head and neck from other parts of the body, causing oral pain.
With some cancers, pain may be felt in parts of the body not near the cancer. This is called referred pain. Tumors of the nose,
throat, and lungscan cause referred pain in the mouth or jaw.
Pain caused by cancer may get worse as the cancer
Oral pain may be a side effect of treatments for the cancer and its symptoms.
Oral mucositis is the most common side effect of radiation therapy and chemotherapy. Pain in the mucous membranes often continues for a while even after the mucositis is healed.
Damage to bone, nerves, and/or tissue by
surgerymay cause pain. Bisphosphonates, drugs taken to treat bone pain, sometimes cause bone to break down. This most commonly happens after a dental procedure such as having a tooth pulled. (See the Oral Complications Not Related to Chemotherapy or Radiation Therapy section of this summary for more information.)
Patients who have
transplantsmay develop graft-versus-host-disease, which can cause inflammation of the mucous membranes and jointpain. (See the Management of Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant section of this summary for more information).
Certain anticancer drugs can cause damage to the nervous system that may result in oral pain.
If an anticancer drug is causing the pain, stopping the drug usually stops the pain. Because there may be many causes of oral pain during cancer treatment, a careful diagnosis is important. This may include obtaining a medical history, performing
physicaland dental exams, and taking x-rays of the teeth.
Tooth sensitivity may occur in some patients weeks or months after chemotherapy has ended. Fluoride treatments and/or toothpaste for sensitive teeth may relieve the discomfort.
Pain in the teeth or jaw muscles may occur from tooth grinding or stress.
Pain in the teeth or jaw muscles may occur in patients who grind their teeth or clench their jaws, often because of
stressor the inability to sleep. Treatment may include muscle relaxers, drugs to treat anxiety, physical therapy (moist heat, massage, and stretching), and mouth guards to wear while sleeping.
Pain control helps improve the patient's quality of life.
Oral and facial pain can affect eating, talking, and many other activities that involve the head, neck, mouth, and throat. Most patients with
For oral mucositis pain, topical treatments will be tried first. See the Mucositis section of this summary for information on relieving oral mucositis pain.
Pain control may include pain medicines. Sometimes, more than one pain medicine is needed.
Physical therapy. TENS(transcutaneous electrical nerve stimulation).
Applying cold or heat.
Acupuncture.(See the PDQsummary on Acupuncture.) Distraction. Relaxation therapyor imagery.
Cognitive behavioral therapy.
Music or drama therapy.
Damage to the lining of the mouth and a weakened immune system make it easier for infection to occur.
Oral mucositis breaks down the lining of the mouth, allowing germs and
The following types of infections may occur:
Medicated and peroxide mouth rinses.
Brushing and flossing.
Wearing dentures as little as possible.
The mouth normally contains
Patients receiving chemotherapy, especially those with immune systems weakened by stem cell transplant, are at risk of mild to serious
Bleeding may occur during chemotherapy when anticancer drugs affect the ability of blood to clot.
Areas of gum disease may bleed on their own or when irritated by eating, brushing, or flossing. Bleeding may be mild (small red spots on the lips,
With close monitoring, most patients can safely brush and floss throughout the entire time of decreased blood counts.
Continuing regular oral care will help prevent infections that may further complicate bleeding problems. The
Treatment for bleeding during chemotherapy may include the following:
Medications to reduce blood flow and help
Topical products that cover and seal bleeding areas.
Rinsing with a mixture of one part 3% hydrogen peroxide to 2 or 3 parts saltwater solution (1 teaspoon of salt in 4 cups of water) to help clean oral
wounds.Rinsing must be done carefully so clots are not disturbed.
Dry mouth (xerostomia) occurs when the salivary glands produce too little saliva.
Thick, stringy saliva.
Changes in taste, chewing, swallowing, and speech.
A sore or burning feeling (especially on the tongue).
Cuts or cracks in the lips or at the corners of the mouth.
Sensitive to spicy foods and strong flavorings.
Difficulty wearing dentures.
Treatment of head and neck cancers may include ways to prevent or decrease radiation damage to salivary glands:
Intensity-modulated radiation therapy(IMRT): The way this type of radiation therapy is given lessens the damage to healthy tissue near the tumor. This may be used in treating head and neck cancers.
Salivary gland transfer: In some patients, a salivary gland from the area to be treated may be moved by surgery to an area that will not receive radiation, in order to save it.
Amifostine: This is a drug used to protect normal tissues against the harmful effects of radiation or chemotherapy. It may help prevent salivary gland damage in patients treated with radiation therapy.
Salivary glands may not recover completely after radiation therapy ends.
Saliva production drops within 1 week after starting radiation therapy to the head and/or neck and continues to decrease as treatment continues. The severity of dry mouth depends on the
Careful oral hygiene can help prevent mouth sores, gum disease, and tooth decay caused by dry mouth.
The following are ways to manage a dry mouth:
Clean the mouth and teeth at least 4 times a day.
Sip water or spray the mouth with water frequently.
Floss once a day.
Use a fluoride toothpaste when brushing.
Apply fluoride gel once a day at bedtime, after cleaning the teeth.
Rinse 4 to 6 times a day with a solution of salt and baking soda (mix � teaspoon salt and � teaspoon baking soda in 1 cup of warm water). Avoid foods and liquids that contain a lot of sugar. Sip water to relieve mouth dryness.
Sugar-free lozenges, candy, or gum.
A dentist can provide the following treatments:
Solutions to replace minerals in the teeth.
Rinses to fight infection in the mouth.
Saliva substitutes or medications to stimulate the salivary glands.
Fluoride treatments to prevent tooth decay.
Dry mouth and changes in the balance of oral bacteria increase the risk of tooth decay. Meticulous oral hygiene (as described in Routine Oral Care) and regular care by a dentist can help prevent cavities.
Changes in taste are common during chemotherapy and radiation therapy.
Change in the sense of taste (
In most patients receiving chemotherapy and in some patients undergoing radiation therapy, taste returns to normal a few months after therapy ends. For many radiation therapy patients, however, the change is permanent. In others, the taste buds may recover 6 to 8 weeks, or later, after radiation therapy ends.
Cancer patients who are undergoing high-dose chemotherapy and/or radiation therapy often experience
Malnutrition and Nutritional Support
Loss of appetite can lead to malnutrition.
Patients undergoing treatment for head and neck cancers are at high risk for
Change the texture of food. Serving food chopped, ground, or blended can reduce the amount of time it needs to stay in the mouth before being swallowed.
Eat between-meal snacks to add
Choose foods high in calories and
supplementsthat provide vitamins, minerals, and calories.
Nutritional support may include liquid diets and enteral feedings.
Many patients treated for head and neck cancers who receive radiation therapy alone are able to eat soft foods. As treatment progresses, most patients will include or switch to liquid diets using high-calorie, high-protein nutritional drinks. Some patients may need
Normal eating by mouth begins again when treatment is finished and the site that received radiation is healed. The return to normal eating often needs a team approach, including a
Limited Jaw Movement
A long-term complication of radiation therapy is the growth of
Limitations in opening the jaw (a locked jaw) may lead to serious health problems:
Malnutrition and weight loss from being unable to eat normally.
Slower healing and recovery from poor nutrition.
Dental problems from being unable to clean the teeth and gums well and have dental treatments.
Weakened jaw joint and muscles from not using them.
Emotional problems from avoiding social contact with others because of the trouble speaking and eating.
The risk of developing jaw stiffness from radiation therapy increases with higher doses of radiation and with repeated radiation treatments. The stiffness usually begins near the end of radiation treatments and may get worse over time, remain the same, or get somewhat better on its own. Treatment should begin as soon as possible to keep the condition from getting worse or becoming permanent. Treatment may include the following
Medicine to relax muscles.
Medicine to treat depression.
Pain during swallowing and being unable to swallow (dysphagia) are common in cancer patients before, during, and after treatment.
Swallowing problems occur most often in patients who have head and neck cancers, but they can develop with other cancers also. Cancer treatment side effects such as oral mucositis, dry mouth, skin damage from radiation, infections, and graft-versus-host-disease may all contribute to problems with swallowing.
Trouble swallowing increases the risk of other complications.
Other complications can develop from being unable to swallow and these can further decrease the patient's quality of life:
Pneumonia and respiratory failure: Patients who have trouble swallowing may aspirate (inhale food or liquids into the lung) when trying to eat or drink. Aspiration can lead to serious conditions, including pneumonia and respiratory failure.
Poor nutrition: Being unable to swallow normally makes it hard to eat well. Malnutrition occurs when the body doesn't get all the nutrients needed for health. Wounds heal more slowly and the body is less able to fight off infections.
Use of tubefeeding: A patient who is not able to take in enough food by mouth may be fed through a tube. The healthcare team and a
registered dietitiancan explain the benefits and risks of tubefeeding for patients who have swallowing problems.
Side effects of pain medicine: Opioids for painful swallowing may cause dry mouth and
Emotional problems: Being unable to eat, drink, and speak, normally may cause depression and the desire to avoid other people.
Whether radiation therapy will affect swallowing depends on several factors.
The following factors may affect the risk of developing swallowing problems after radiation therapy:
Total dose and schedule of radiation therapy. Higher doses over a shorter time often have more side effects.
The way the radiation is given. Some types of radiation spare more healthy tissue.
Whether chemotherapy is given at the same time. The risk of side effects is increased if both are given.
Whether the patient is taking any food by mouth or only by tube-feeding.
Whether the patient smokes.
How well the patient copes with problems.
Swallowing problems sometimes go away after treatment, but they sometimes continue or appear years later.
Some side effects go away by 3 months after the end of treatment, and patients are able to swallow normally again. Head and neck cancer treatments, however, may cause permanent damage or
Wasting away of tissue in the treated areas.
Lymphedema(build up of lymph fluidin the body).
fibroustissue in head or neck areas that may lead to lockjaw. Chronicdry mouth.
Managing swallowing problems involves a team and may begin when planning cancer treatment.
Speech therapist: A speech therapist can assess how well the patient is swallowing, give the patient information to better understand the problem, and provide swallowing therapy.
Dietician: A dietician can help plan a safe way for the patient to receive the nutrition needed for health while swallowing is a problem.
Dental specialists: Replacing missing teeth and other oral structures with artificial devices may help swallowing.
Psychologist: For patients who are having a hard time adjusting to the being unable to swallow and eat normally, psychologicalcounseling may help.
Tissue and Bone Loss
Radiation therapy can destroy very small blood vessels within the bone. These blood vessels carry both nutrients and oxygen to the bone. When the blood vessels are destroyed, bone death occurs. When tissue death occurs, ulcers may form in the soft tissues of the mouth, grow in size, and cause pain or loss of feeling. Infection becomes a risk. As bone tissue is lost, fractures can occur. Preventive care can lessen the severity of tissue and bone loss.
Treatment of tissue and bone loss may include the following:
Maintaining a well-balanced diet.
Wearing removable dentures or appliances as little as possible.
Not drinking alcohol.
Using topical antibiotics.
Undergoing surgery to remove dead bone or to reconstruct bones of the mouth and jaw.
hyperbaric oxygentherapy, a method of delivering oxygenunder pressure to the surface of a wound to help it heal.
(See the PDQ summary Nutrition in Cancer Care for more information about managing mouth sores, dry mouth, and taste changes.)
Management of Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant
Patients who have received transplants are at risk of graft-versus-host disease.
Sores that appear in the mouth 2 to 3 weeks after the
Pain from spices,
alcohol, or flavoring (such as mint in toothpaste).
A feeling of tightness in the skin or lining of the mouth.
It's important to have these symptoms treated as they can lead to weight loss or
Topical steroidrinses, gels, creams, or powders. Antifungal drugstaken by mouth or applied as a lotion to skin. Psoralen(a drug used with ultraviolet lightto treat skin disease).
Drugs that promote the production of
Treatments to replace
mineralslost from teeth by acids in the mouth.
Dentures, braces, and oral appliances require special care during high-dose chemotherapy and/or stem cell transplant.
The following are instructions for the care and use of dentures, braces, and other oral appliances during
Remove brackets, wires, and retainers before high-dose chemotherapy begins.
Wear dentures only when eating during the first 3 weeks after the transplant.
Brush dentures twice a day and rinse them well.
Soak dentures in an
antibacterialsolution when they are not being worn.
Clean denture soaking cups and change denture soaking solution every day.
Remove appliances or dentures when cleaning the mouth.
If mouth sores are present, avoid wearing removable appliances until the mouth is healed.
Care of the teeth and gums may continue under professional guidance.
Careful brushing and flossing may help prevent infection of oral tissues. The following are guidelines for general oral care during high-dose chemotherapy and stem cell transplant, but it's important that patients check with their medical professional for individual guidelines:
Brush teeth with a soft bristle brush 2 to 3 times a day. Be sure to brush the area where the teeth meet the gums.
Rinse the toothbrush in hot water every 15 to 30 seconds to make the bristles softer.
Rinse the mouth 3 or 4 times while brushing.
Avoid rinses containing alcohol.
Use a mild-tasting toothpaste.
Let the toothbrush air-dry between uses.
Flossing may be done according to the professional's directions.
Clean the mouth after meals.
Foam swabs may be used to clean the tongue and roof of the mouth.
Dental treatments may be resumed when the transplant patient's immune system returns to normal.
Routine dental treatments, including scaling and polishing, should be delayed until the transplant patient's
Relapse and Second Cancers
Oral Complications Not Related to Chemotherapy or Radiation Therapy
Bisphosphonates are drugs taken by some cancer patients to treat bone-related side effects.
Certain bisphosphonates are linked to a risk of bone loss.
It's important for the health care team to know if a patient at risk for oral complications has been treated with bisphosphonates. Certain bisphosphonates are linked to the breakdown of bone in the mouth, usually the jaw. This is called
Treatment of BON usually includes treating the infection and good dental hygiene.
Treatment of BON may include the following:
Removing the infected
tissue. Laser surgery may be used.
Smoothing sharp edges of exposed bone.
antibioticsto fight infection.
During treatment for BON, the patient should continue to brush and floss the teeth after meals to keep the mouth very clean. Avoiding
Stopping the use of the bisphosphonate is a decision to be made by the patient and doctor, based on the effect it would have on the patient's general health.
New types of bisphosphonates are being studied in
Mental and Social Considerations
The social aspects of
Special Considerations for Children
A change in dental growth and development is a special complication for
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