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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ�)

Introduction

This patient summary on oralcomplications of cancer and cancer therapy is adapted from the summary written for health professionals by cancer experts. This and other accurate, credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials is available from the National Cancer Institute. Oral complications are common in cancer patients, especially those with head and neck cancer. This summary describes oral complications caused by chemotherapy and radiation therapy and various methods of prevention and treatment.

This summary is about oral complications in adults and children with cancer. Section titles show when the information is about children.

Overview

Oral complications are common in patients receiving chemotherapy or undergoing radiation therapy to the head and neck.

Oralcomplications are medical problems that involve the mouth during or after a disease, procedure, or treatment. The complications may be side effects of the disease or treatment, or they may have other causes.

The oral cavity is at high risk of side effects from chemotherapy and radiation therapy for a number of reasons.

  • Chemotherapy and radiation therapy stop the growth of rapidly dividing cells, such as cancer cells. 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 tissue to 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 saliva and 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 controlling oral complications will enhance both the patient's quality of life and the effectiveness of cancer therapy.

Preventing and treating oral complications of cancer therapy involve identifying the patient at risk, starting preventive measures before cancer therapy begins, and treating complications as soon as they appear. Patients with poor mouth care before treatment begins may have more frequent and severe oral complications after treatment has started.

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 oncologist will work closely with the patient's dentist and may refer the patient to other health professionals with special training. These may include the following specialists:

  • Oncology nurse.

  • Dental specialists.

  • 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 oralcomplications caused by chemotherapy include the following:

  • Nerve damage

  • Changes in the growth and development of teeth and jaws in children.

  • Mucositis (an inflammation of the mucous membranes in the digestive tract) in the stomach or 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 fibroustissue) 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.

  • Infections in the mouth or that travel through the bloodstream, reaching and affecting cells all over the body.

  • Taste changes.

  • Dry mouth.

  • Pain.

  • Changes in dental growth and development in children.

  • Malnutrition (lack of nutrients needed 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.

Oral complications associated with chemotherapy and radiation therapy may be caused directly by the treatment or may result indirectly from side effects of the treatment. Radiation therapy may directly damage oral tissue, salivary glands, and bone. Areas treated may scar or waste away.

Slow healing and infection are indirect complications of cancer treatment. Both chemotherapy and radiation therapy can affect the ability of cells to reproduce, which slows the healing process in the mouth. Chemotherapy may reduce the number of white blood cells and weaken the immune system (the organs and cells that defend the body against infection and disease), making it easier for the patient to develop an infection.

Complications can be acute or chronic.

Acute complications are those that occur during therapy. Chemotherapy usually causes acute complications that heal after treatment ends.

Chronic complications or late effects are those that continue or develop months to years after therapy ends. Radiation can cause acute complications but may also cause permanent tissue damage that puts the patient at a lifelong risk of oral complications. The following chronic complications commonly continue or occur after radiation therapy to the head and/or neck has ended:

  • Dry mouth.

  • Tooth decay.

  • Infections.

  • Taste changes.

  • Problems using the mouth and jaw due to tissue and bone loss and/or the growth of benign tumors in the skin and muscle.

Total-body radiation can cause permanent damage to the salivary glands. This can change the way foods taste and cause dry mouth.

Invasive dental procedures can cause additional problems. The dental care of patients who have undergone radiation therapy will therefore need to be adapted to the patient's ongoing complications.

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.

Oralcomplications in patients undergoing treatment for head and neck cancer may be reduced by aggressive prevention measures taken before treatment begins. This will get the mouth and teeth in the best possible condition to withstand treatment.

Preventive measures include the following:

  • Eating a well-balanced diet. Proper nutrition can help the body tolerate the stress of cancer treatment, maintain energy, fight infection, and rebuild tissue.

  • Learning how to care for the mouth and teeth during and after anticancer therapy. Good dental hygiene helps prevent cavities, mouth sores, and infections.

  • Having a complete oral health exam by a dentist familiar with the oral side effects of 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 chemotherapy and/or radiation therapy. An evaluation of the patient's oral health at least a month before treatment begins usually provides enough time for the mouth to heal after dental work. The dentist will identify and treat teeth at risk for infection or decay, so the patient may avoid having invasive dental treatment during anticancer therapy. The dentist may also provide appropriate preventive care to lessen the severity of dry mouth, a common complication of radiation therapy to the head and neck.

A preventive oral health exam will check for the following:

  • Mouth sores or infections.

  • Gum disease.

  • Tooth decay.

  • Dentures that do not fit well.

  • Problems moving the jaw.

  • Problems with the salivary glands.

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 transplantation. Steps can be taken ahead of time to prevent or lessen the severity of these side effects.

Ongoing oral care during radiation therapy will depend on the specific needs of the patient; the dose, locations, and duration of the radiation treatment; and the specific complications that occur.

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 recur or that a second cancer will develop. (See the PDQ summary on Smoking Cessation and Continued Risk in Cancer Patients for more information.)

Management of Oral Complications During and After Chemotherapy and/or Radiation Therapy

Routine Oral Care

Continuing good dental hygiene during and after cancer treatment can reduce complications such as cavities, mouth sores, and infections. It is important to clean the mouth after eating. The following are guidelines for everyday oral care during chemotherapy and radiation therapy:

Tooth brushing

  • 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 gums and 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 antibacterial rinse. 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.

Rinsing

  • Use a fluoride toothpaste.

  • 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.

Flossing

  • Floss gently once a day.

Lip care

  • Use lip care products to prevent drying and cracking.

For special oral care during high-dose chemotherapy and stem cell transplant, see the Management of Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant section of this summary

Oral Mucositis

Mucositis is an inflammation of mucous membranes in the mouth.

The terms "oral mucositis" and "stomatitis" are often used in place of each other, but their meanings are different.

  • Mucositis is an inflammation of mucous membranes in the mouth. It usually appears as red, burn-like sores or as ulcer-like sores throughout the mouth.

  • Stomatitis is an inflammation of tissues in 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:

  • Pain.

  • Infection.

  • 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 fluorouracil. Medication may be given to help prevent mucositis or keep it from lasting as long in patients who undergo high-dose chemotherapy and bone marrow transplant.

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 white blood cell count. The following are guidelines for treating mucositis during chemotherapy, stem cell transplantation, and radiation therapy:

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.

  • Use water-soluble lubricating jelly to moisturize the mouth.

  • Use bland rinses or plain sterile water. Frequent rinsing removes particles and bacteria from 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:

    • Equal parts hydrogen peroxide and 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

  • Try topical medications 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.

  • Zincsupplements taken during radiation therapy may help treat mucositis as well as dermatitis (inflammation of the skin).

  • Povidone-iodine mouthwash that does not contain alcohol may help delay or decrease mucositis caused by radiation therapy.

See the Pain section of this summary for more information on pain control.

Pain

A cancer patient's pain may come from more than one source.

Sources of pain in a cancer patient include:

  • The cancer.

  • Cancer treatments.

  • Damage to the nervous system.

  • Other medical conditions not related to the cancer.

Because there can be many causes of oral pain, a careful diagnosis is important. This may include obtaining a medical history, performing physical and dental exams, and taking x-rays of the teeth. The patient may be asked to rate the level of pain at different times.

  • 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 nerves and causing inflammation.

    • Leukemias and lymphomas, which spread through the body, may affect sensitive areas in the mouth.

    • Multiple myeloma can affect the teeth.

    • Brain tumors may 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 lungs can cause referred pain in the mouth or jaw.

    Pain caused by cancer may get worse as the cancer progresses.

  • 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 surgery may 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 transplants may develop graft-versus-host-disease, which can cause inflammation of the mucous membranes and joint pain. (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 physical and 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 stress or 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 head and neck cancers have pain. The doctor may ask the patient to rate the pain using a rating system, for example on a scale from 0 to 10, with 10 being the worst. The level of pain felt may be affected by anxiety or depression, cultural factors, and whether there are problems sleeping. It's important for patients to talk with their doctors about pain. Controlling pain helps to improve the quality of life.

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. Opioids may be prescribed for use under careful supervision by the medical team. Muscle relaxers and medicines for anxiety or depression or to prevent seizures may be helpful in some cases.

Non-drug treatments may also help, including some of these:

  • Physical therapy.

  • TENS (transcutaneous electrical nerve stimulation).

  • Applying cold or heat.

  • Hypnosis.

  • Acupuncture. (See the PDQ summary on Acupuncture.)

  • Distraction.

  • Relaxation therapy or imagery.

  • Cognitive behavioral therapy.

  • Music or drama therapy.

  • Counseling.

Infection

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 viruses to get into the bloodstream. When the immune system is weakened by chemotherapy, even good bacteria in the mouth can cause infections, as can disease-causing organisms picked up from the hospital or other sources. As the white blood cell count gets lower, infections may occur more often and become more serious. Patients who have low white blood cell counts for a long time are more at risk of developing serious infections. Dry mouth, common during radiation therapy to the head and neck, may also raise the risk of infections in the mouth. These oral symptoms can make toothbrushing uncomfortable and may prevent the patient from eating well. Poor nutrition can further increase the risk of infection. Preventive dental care during chemotherapy and radiation therapy can reduce the risk of mouth, tooth, and gum infections.

The following types of infections may occur:

Bacterial infections

Treatment of bacterial infections in patients who have gum disease and receive high-dose chemotherapy may include the following:

  • Medicated and peroxide mouth rinses.

  • Brushing and flossing.

  • Wearing dentures as little as possible.

Fungal infections

The mouth normally contains fungi that can exist on or in the body without causing any problems. An overgrowth of fungi, however, can be serious and requires treatment.

Antibiotics and steroid drugs are often used when a patient receiving chemotherapy has a low white blood cell count. These drugs change the balance of bacteria in the mouth, making it easier for a fungal overgrowth to occur. Fungal infections are common in patients treated with radiation therapy.

Candidiasis is a type of fungal infection that may occur in cancer patients, especially when treatment includes both chemotherapy and radiation therapy. Symptoms may include a burning pain and taste changes. Treatment of surface fungal infections in the mouth only may include mouthwashes and lozenges that contain antifungal drugs. These are used after removing dentures, brushing the teeth, and cleaning the mouth. An antibacterial rinse should be used to soak dentures and dental appliances and to rinse the mouth. When rinses and lozenges do not get rid of the fungal infection, treatment may be a drug taken by mouth or injection. Drugs may be given to prevent fungal infections from occurring.

Viral infections

Patients receiving chemotherapy, especially those with immune systems weakened by stem cell transplant, are at risk of mild to serious viral infections. Herpesvirus infections and other viruses that are latent (present in the body but not active or causing symptoms) may flare up. Finding and treating the infections early is important. Drugs may be used to prevent or treat viral infections.

Bleeding

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, soft palate, or bottom of the mouth) or severe, especially at the gumline and from ulcers in the mouth. When blood counts drop below certain levels, blood may ooze from the gums.

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 dentist or doctor can provide guidance on how to treat bleeding and safely keep the mouth clean when blood counts are low.

Treatment for bleeding during chemotherapy may include the following:

  • Medications to reduce blood flow and help clots form.

  • 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

Dry mouth (xerostomia) occurs when the salivary glands produce too little saliva.

Saliva is needed for taste, swallowing, and speech. It helps prevent infection and tooth decay by neutralizing acid and cleaning the teeth and gums. Radiation therapy can damage salivary glands, causing them to make too little saliva. When dry mouth (xerostomia) develops, the patient's quality of life suffers. The mouth is less able to clean itself. Acid in the mouth is not neutralized, and minerals are lost from the teeth. Tooth decay and gum disease are more likely to develop. In addition, there is some evidence that salivary glands may be damaged by certain types of chemotherapy drugs given alone or in combination. Symptoms of dry mouth include the following:

  • Thick, stringy saliva.

  • Increased thirst.

  • 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 dose of radiation and the number of glands irradiated. The salivary glands in the upper cheeks near the ears are more affected than other salivary glands.

Partial recovery of salivary glands may occur in the first year after radiation therapy, but recovery is usually not complete, especially if the salivary glands were directly irradiated. Salivary glands that were not irradiated may become more active to offset the loss of saliva from the destroyed glands.

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.

  • Acupuncture.

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.

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.

Taste Changes

Changes in taste are common during chemotherapy and radiation therapy.

Change in the sense of taste (dysgeusia) is a common side effect of both chemotherapy and head and/or neck radiation therapy. Graft-versus-host disease may also cause changes in taste. Foods may have no taste or may not taste as they did before therapy. These taste changes are caused by damage to the taste buds, dry mouth, infection, and/or dental problems. Chemotherapy patients may experience unpleasant taste related to the spread of the drug within the mouth. Radiation may cause a change in sweet, sour, bitter, and salty tastes.

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. Zinc sulfate supplements may help with the recovery for some patients.

Fatigue

Cancer patients who are undergoing high-dose chemotherapy and/or radiation therapy often experience fatigue (lack of energy) that is related to either the cancer or its treatment. Some patients may have difficulty sleeping. The patient may feel too tired to perform routine oral care, which may further increase the risk for mouth ulcers, infection, and pain. (See the PDQ summary on Fatigue for more information.)

Malnutrition and Nutritional Support

Loss of appetite can lead to malnutrition.

Patients undergoing treatment for head and neck cancers are at high risk for malnutrition. The cancer itself, poor diet before diagnosis, and complications from surgery, radiation therapy, and chemotherapy can lead to nutritional shortfalls. Patients can lose the desire to eat due to nausea, vomiting, trouble swallowing, sores in the mouth, or dry mouth. When eating causes discomfort or pain, the patient's quality of life and nutritional well-being suffer. The following suggestions may help patients with cancer meet their nutritional needs:

  • 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 calories and nutrients.

  • Choose foods high in calories and protein.

  • Take supplements that provide vitamins, minerals, and calories.

Nutritional counseling may be helpful during and after treatment.

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 enteraltubefeeding to meet their nutritional needs. Almost all patients who receive chemotherapy and head and/or neck radiation therapy at the same time will require enteral nutritional support within 3 to 4 weeks. Studies show that patients benefit when they begin enteral feedings at the start of treatment, before weight loss occurs.

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 speech and swallowing therapist to ease the adjustment back to solid foods. Tubefeedings are decreased as a patient's intake by mouth increases, and are stopped when the patient is able to get enough nutrients by mouth. Although most patients will regain their ability to eat solid foods, many will have lasting complications such as taste changes, dry mouth, and trouble swallowing. These complications can interfere with meeting their nutritional needs and with their quality of life.

Limited Jaw Movement

A long-term complication of radiation therapy is the growth of benign tumors in the skin and muscles. These tumors may make it difficult for the patient to move the mouth and jaw normally. Oral surgery may damage nerves or muscles and also affect jaw movement. This muscle stiffness in the jaw is called trismus or lockjaw.

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

  • Oral medical devices.

  • Pain treatments.

  • Medicine to relax muscles.

  • Jaw exercises.

  • Medicine to treat depression.

Swallowing Problems

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 dietitian can 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 constipation.

  • 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.

  • The patient's genetic makeup.

  • 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 late effects, side effects that appear long after treatment has ended. Some conditions that may cause permanent swallowing problems or late effects include:

  • Damaged blood vessels.

  • Wasting away of tissue in the treated areas.

  • Lymphedema (build up of lymphfluid in the body).

  • Overgrowth of fibrous tissue in head or neck areas that may lead to lockjaw.

  • Chronic dry mouth.

  • Infections.

Managing swallowing problems involves a team and may begin when planning cancer treatment.

The oncologist works with other health care experts who specialize in head and neck cancers and the care of oral complications of cancer treatment. These specialists may include the following:

  • 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, psychological counseling 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 smoking.

  • Not drinking alcohol.

  • Using topical antibiotics.

  • Using painkillers.

  • Undergoing surgery to remove dead bone or to reconstruct bones of the mouth and jaw.

  • Receiving hyperbaric oxygen therapy, a method of delivering oxygen under 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.

Graft-versus-host disease (GVHD) is a reaction of donatedbone marrow or stem cells against the patient's tissue. Graft-versus-host disease can cause inflammation and breakdown of the mucous membranes. Symptoms of oral GVHD include the following:

  • Sores that appear in the mouth 2 to 3 weeks after the transplant.

  • Dry mouth.

  • Pain from spices, alcohol, or flavoring (such as mint in toothpaste).

  • Swallowing problems.

  • A feeling of tightness in the skin or lining of the mouth.

  • Taste changes.

It's important to have these symptoms treated as they can lead to weight loss or malnutrition.

Biopsies taken from the lining of the mouth and salivary glands may be needed to diagnose oral GVHD. Treatment of oral GVHD may include the following:

  • Topicalsteroid rinses, gels, creams, or powders.

  • Antifungaldrugs taken by mouth or applied as a lotion to skin.

  • Psoralen (a drug used with ultraviolet light to treat skin disease).

  • Drugs that promote the production of saliva.

  • Fluoride treatments.

  • Treatments to replace minerals lost 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 high-dose chemotherapy and/or stem cell transplant:

  • 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 antibacterial solution 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 immune system returns to normal. The immune system can take 6 to 12 months to recover after high-dose chemotherapy and stem cell transplant. During this time, the risk of oral complications remains high. If dental treatments are needed, antibiotics and supportive care are given. Care must be taken to prevent accidentally breathing fluids into the lungs during dental treatments.

Relapse and Second Cancers

Cancer survivors who received chemotherapy or a transplant or who underwent radiation therapy are at risk of developing a second cancer later in life. Second cancers are more common in patients treated for leukemias and lymphomas. Multiple myeloma patients who received stem-cell transplant using their own stem cells sometimes develop an oral plasmacytoma. Oralsquamous cell cancer is the most common second cancer occurring in transplant patients. The lips and tongue are the sites most often affected.

Oral Complications Not Related to Chemotherapy or Radiation Therapy

Bisphosphonates are drugs taken by some cancer patients to treat bone-related side effects.

Bisphosphonates are drugs given to some patients whose cancer has spread to the bones. They are used to reduce pain and decrease the risk of broken bones. (See the PDQ summary on Pain for more information.) Bisphosphonates are also used to treat hypercalcemia (too much calcium in the blood). Some cancer cells secrete substances that cause calcium to be absorbed into the bloodstream from bones. (See the PDQ summary on Hypercalcemia for more information.)

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 bisphosphonate-associated osteonecrosis (BON). It occurs more often in patients taking intravenous bisphosphonates, but it sometimes develops in patients taking them by mouth. Symptoms include pain and inflamedlesions in the mouth, where areas of damaged bone may be seen. There are many patients who take bisphosphonates, but the number who develop BON is small. The risk of BON in patients with bone tumors may be decreased if dental problems are found and treated before beginning bisphosphonate therapy.

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.

  • Taking antibiotics to fight infection.

  • Using medicated mouth rinses.

During treatment for BON, the patient should continue to brush and floss the teeth after meals to keep the mouth very clean. Avoiding tobacco use while BON is healing may be advised.

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 clinical trials. The use of hyperbaric oxygentherapy (HBO) combined with stopping the use of bisphosphonates is under study for the treatment of BON. It is not known if tobacco use increases the risk of developing BON.

Mental and Social Considerations

The social aspects of oralcomplications can make them the most difficult problems for cancer patients to cope with. Oral complications affect eating and speaking and may make the patient unable or unwilling to take part in mealtimes or to dine out. Patients may become frustrated, withdrawn, or depressed, and they may avoid other people. Some drugs that are used to treat depression may not be an option because they cause side effects that make oral complications worse. (See the PDQ summaries on Depression and Adjustment to Cancer: Anxiety and Distress for more information.)

Education, supportive care, and the treatment of symptoms are important for patients who have mouth problems that are related to cancer therapy. Patients will be closely monitored for pain, ability to cope, and response to treatment. Supportive care from health care providers and family can help the patient cope with cancer and its complications.

Special Considerations for Children

A change in dental growth and development is a special complication for cancer survivors who received high-dose chemotherapy and/or radiation therapy to the head and neck for childhood cancers. Changes may occur in the size and shape of the teeth; eruption of teeth may be delayed; and development of the head and face may not reach full maturity. The role and timing of orthodontic treatment for patients with altered dental growth and development is under study. Some treatments have been successful, but standard guidelines have not yet been established.

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Changes to This Summary (09/16/2011)

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PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

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