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Oral Complications of Chemotherapy and Head/Neck Radiation

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

Rinsing

Flossing

Lip care

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 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:

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

Relieving mucositis pain

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:

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.

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:

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:

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:

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:

Treatment of head and neck cancers may include ways to prevent or decrease radiation damage to salivary glands:

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:

A dentist can provide the following treatments:

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:

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 enteral tubefeeding 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:

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

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:

Whether radiation therapy will affect swallowing depends on several factors.

The following factors may affect the risk of developing swallowing problems after radiation therapy:

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:

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:

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:

(See the PDQ summary Nutrition in Cancer Care for more information about managing mouth sores, dry mouth, and taste changes.)