Oral Care: Before, During and After Chemotherapy and/or Head and Neck Radiation Therapy

Oral Care: Before, During and After Chemotherapy
and/or Head and Neck Radiation Therapy

Your dentist is a crucial member of your cancer team.

Treatment for head and neck cancer varies according to the type, location, and extent of the
cancer, and often includes a combination of surgery, radiation therapy, and chemotherapy.
Due to the complexity of these treatments, it is essential that a multidisciplinary approach be
used for oral management before, during, and after cancer therapy. Selected head and neck
cancer patients are at risk for oral complications that are discussed in detail on the following
page. Your dentist is a crucial member of the multidisciplinary oncology team which includes
oncologists, oncology nurses, dieticians, speech therapists, social workers, patient advocates
and related healthcare professionals. This cancer team can help patients achieve optimum,
preventive and therapeutic outcomes in patients receiving chemotherapy and/or head and
neck radiation therapy.

Minimize oral complications before starting chemotherapy and/or head and neck radiation therapy.

Proactive patients can have a significant chance to minimize oral complications before, during
and after chemotherapy and/or head and neck radiation therapy. Consult with your dentist 2-3
months prior to starting chemotherapy or radiation therapy to assess your oral status and risk
for oral complications. Ask your dentist to identify and recommend treatment for existing and
potential oral problems. This may include a comprehensive exam, dental cleaning or
periodontal scaling, replacing crowns or fillings, treating tooth and gum infections, adjusting
poor fitting dentures, and necessary teeth extractions. Fluoride treatments may be
recommended to minimize the occurrence of radiation caries (rapid form of tooth decay).
Pre-emptive care can help minimize the onset of oral complications.
As part of your cancer team, your dentist can schedule dental treatment in consideration of the
chemo-radiation therapy. Invasive procedures must be completed at least 14 days before head
and neck radiation therapy starts and 7-10 days before chemotherapy.
Consider bringing a friend or family member during the consultation with your dentist. This
may give you comfort and moral support.

Cancer patients have a high risk of oral complications.

Oral complications are common in cancer patients, especially those who have undergone
chemotherapy and/or head and neck radiation therapy. Oral complications may be acute
(short-term), chronic (long-term), or permanent. Chemotherapy or radiation therapy destroy
fast-growing cancer cells. However, other normal fast growing cells located in the lining of the
mouth, salivary glands, jaw muscles, and bone are also often affected by these treatments.
Damaged salivary glands produce less saliva. This condition is called xerostomia (dry mouth).
Patients with xerostomia have an increase in bacteria that cause cavities. Plaque and calculus
(tartar) deposits occur faster, which increases the risk for radiation caries and periodontal
Patients may also develop systemic complications such as myelosuppression (suppression of
bone marrow activity) or immunosuppression (decreased immune response). Anemia (reduced
number of blood cells) is a common complication of myelosuppressive chemotherapy.
Myelosuppression and/or immunosuppression lessens a person’s ability to heal and increases
the risk of oral infection.

Common Oral Complications:
❖ Oral mucositis (mouth ulcers)
❖ Infections (bacterial/fungal/fungal)
❖ Dysgeusia (altered sense of taste)
❖ Xerostomia (dry mouth)
❖ Soft Tissue Necrosis (tissue death)
❖ Oral Pain
❖ Radiation Caries (rapid form of tooth
❖ Periodontal Disease (gum disease)
❖ Trismus (restricted jaw opening)
❖ Tissue Fibrosis (scarring)
❖ Dysphagia (difficulty swallowing)
❖ Abnormal Dental Development in
❖ Risk of Osteonecrosis of the Jaw
(jawbone death)

Osteonecrosis of the jaw is a serious oral complication.

Osteonecrosis of the jaw (ONJ), or jawbone death, is a serious oral complication. Radiation
therapy diminishes the bone’s ability to heal. Poor healing results in a higher risk of infection
and necrosis. It is important to perform any surgery, particularly tooth extraction, in the
proposed irradiated fields prior to radiation therapy to reduce or avoid the life-long risk of
osteonecrosis of the jaw. Clinical studies have illustrated that treatments using high doses of
intravenous (IV) bisphosphonates or low doses of oral bisphosphonates combined with
corticosteroids have also been associated with osteonecrosis of the jaw.

Oral Care During Chemotherapy and/or Head and Neck Radiation Therapy

Chemotherapy and radiation therapy has many side effects such as mouth ulcers, altered taste,
and difficulty swallowing. Some patients will see the appearance of multiple brown spots, or
radiation caries, on their teeth especially along the gumline. It may be hard to open your
mouth or chew. A poor fitting dentures and ulcers can create challenges in maintaining a
healthy diet. Your gums may bleed easily. You may have pain in your mouth. Fatigue and
depression may diminish your focus on your home oral care.
Throughout your cancer treatments, you have have a huge influence over preventing oral
complications and improving your quality of life. Eat small and frequent meals to lessen pain
and mouth soreness and make it easier to eat a well balanced diet. Healthy eating can help the
body stand the stress of cancer treatment, maintain a good level of energy, fight infection, and
rebuild tissues. Good oral hygiene prevents mouth ulcers, infections, and radiation caries.
Exercise your jaw to prevent pain and stiffness. Ask your dentist about the use of Silver
Diamine Fluoride (SDF) treatment for your teeth. SDF inhibits the growth of bacteria and
promotes tooth remineralization. The use of SDF is especially beneficial to patients with
radiation caries. Schedule regular dental exams and cleanings every three months and see your
dentist immediately to manage problems as they occur.
Chemotherapy or radiation therapy can induce immunosuppression, that can affect the healing
process of dental treatment. If dental treatment is necessary during this time, ask your
oncologist to order blood work 24 hours before oral surgery or other invasive procedures. You
may need to postpone dental treatment if your platelet count is less than 75,000/mm 3 ,
abnormal clotting factors are present, or absolute neutrophil count is less than 1,000/mm 3 .
Consult your oncologist to determine if prophylactic antibiotics are necessary.

Oral Care After Chemotherapy and/or Head and Neck Radiation Therapy

By this time, you and your dentist have set a plan in place to manage your oral care. Continue
to closely monitor your oral health. For the first 6 months after chemotherapy therapy or
radiation therapy, maintain regular dental checkups and cleanings every 4-8 weeks and see
your dentist immediately for any oral problems that arise. Maintain a low sugar diet and brush
or rinse after every intake of food or beverages. Start using dentures or other dental appliances
after mucositis subsides. Continue with jaw exercises and home fluoride treatments.
It is important to remember that chemotherapy and radiation therapy may have long-term side
effects . Maintain close communications with your dentist and oncologist to support you
through these side effects long after therapy has ended.

Oral Care Recommendations:

❖ Brush your teeth, gums, and tongue gently with an extra-soft toothbrush and fluoride
toothpaste after every meal and at bedtime. Soften the bristles in warm water to make
brushing more comfortable.
❖ Floss teeth gently every day. Avoid the areas that are bleeding or sore but continue
flossing your other teeth.
❖ Use fluoride gel trays for 5 minutes twice a day, after breakfast and before bedtime.
❖ Avoid mouthwashes containing alcohol.
❖ Rinse your mouth several times a day with a baking soda and salt solution, followed by a
plain water rinse. Use 1 teaspoon each of baking soda and salt in 1 quart (4 cups) of
warm water. Omit salt during episodes of mucositis.
❖ Use a water based lip balm to prevent lips from drying and cracking.
❖ Try the following if dry mouth is a problem:
➢ Sip water frequently.
➢ Suck ice chips, sugar free gum or candy, or 100% Xylitol gum or mints.
➢ Use saliva substitute spray or gel or a prescribed saliva stimulant if needed.
➢ Avoid glycerin swabs.
❖ Exercise your jaw muscles three times a day to prevent and treat jaw stiffness from
radiation treatment. Open as wide as possible for 20 repetitions 3 times per day.
❖ Avoid wearing dentures or other dental appliance until mucositis subsides.
❖ Avoid candy, gum, and soda unless they are sugar-free.
❖ Avoid spicy or acidic foods, toothpicks, tobacco products, and alcohol.
❖ Maintain regular and ongoing dental exams and dental cleaning appointments.

The Role of Concierge Dentistry

Include your dentist as part of your multidisciplinary cancer team. Choose a dentist who has
experience with treating patients with oral complications from cancer treatment. The role of
the Concierge Dentist is to establish and maintain open communications with your medical
professionals, identify potential sources of dental infection or irritation, initiate pretreatment
interventions, and provide timely management of teeth that may cause problems as a result of
chemotherapy and/or radiation therapy. At Fabulous Smiles Dental Center, we will support you
and your family through the many issues and concerns with your oral care and cancer therapy.
Our goal is to provide you with a high level of care and as informed and comfortable as
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