Overview of complications and patient coping mechanisms
Chemotherapy and radiation therapy of the head and neck often results in oral complications. The oral cavity is highly susceptible to side effects from anticancer treatments for a variety of reasons, including:
- Radiation therapy and chemotherapy target cells that rapidly divide, whether the cells are cancerous or healthy. The cells of the mucosal lining of the mouth reproduce quickly, to heal the trauma that occurs from normal oral activity. But anticancer treatments can prevent this rapid cell division, slowing the production of new, healthy cells to populate the mucosal lining, and also slowing the healing of any wear and tear that may occur or infections that may arise.
- The mouth contains hundreds of different bacteria, some beneficial, some not. Normally these bacteria remain in balance. However, chemotherapy and radiation therapy can upset this balance, and can also affect saliva production. These factors can lead to mouth sores, infection, and tooth decay.
The number of oral cancer patients who experience oral complications from anticancer treatment varies. The following are some estimates according to therapy:
- 10% in patients receiving adjunctive chemotherapy
- 40% in patients receiving primary chemotherapy
- 80% in patients receiving hematopoietic stem cell transplantation in which myeloablative conditioning regimens are used
- 100% in patients receiving head and neck radiation therapy to fields involving the oral cavity
Oral side effects can affect the ability of some patients to receive all of their cancer treatment—and sometimes treatment must be stopped. This disruption can directly affect a patient’s chances for survival. Preventing and controlling oral complications is vital, then, to enhancing a patient's quality of life and to ensuring they get the most benefit from cancer therapy.
Assessing a patient’s oral status and stabilizing any existing oral disease before beginning cancer therapy are critical to overall patient care. Preventing and treating oral complications after cancer therapy has started include identifying and educating patients who are or may be at risk, taking preventive action before anticancer treatments are started, and treating any complications promptly.
Description and Causes
Radiation therapy and chemotherapy may cause some of the same direct oral side effects (those caused by treatment), including:
- Jaw stiffness
- Mucositis (an inflammation of the mucous membranes in the mouth)
- Salivary gland dysfunction
- Changes in the sense of taste
- Dry mouth
- Changes in dental growth and development in children
These can lead to serious indirect complications (those that arise as side effects of treatment), including:
- Tooth decay and gum disease. These can be caused by many factors of treatment and its side effects.
- Bone or tissue loss. Treated areas may scar or waste away.
- Infections in the mouth. This can be caused by the weakening of the immune system that occurs with chemotherapy and radiation therapy.
- Systemic infections. Infections in the mouth can, particularly in immune-suppressed patients, travel through the bloodstream, reaching and affecting cells all over the body.
- Slow healing. Cancer treatment can reduce the ability of the cells lining the oral cavity to reproduce as quickly as they normally would. Thus, trauma from normal wear and tear takes longer to heal.
- Dehydration. This can result from lack of ability to drink, or drink enough, to keep the body adequately hydrated.
- Malnutrition. Lack of ability to eat properly or comfortably can cause malnutrition.
Acute and chronic complications
Oral complications of anticancer treatment are either acute or chronic.
Acutecomplications occur while treatment is ongoing. Patients undergoing chemotherapy usually experience acute complications that heal after treatment ends.
Chronic complications are either acute complications that go on after treatment has ended, or complications that develop months to years after treatment ends. For example, radiation therapy can cause acute complications—but it may also cause permanent tissue damage (a chronic complication). The following chronic complications are common after radiation therapy to the head or neck has ended:
- Dry mouth
- Tooth decay
- Impaired sense of taste
- Difficulty using the mouth and jaw because of tissue and bone loss or the growth of benign tumors in the skin and muscle.
Because of these ongoing complications, invasive dental procedures can be a cause for concern. Dentists must often adapt their care of patients who have undergone radiation therapy to take this into consideration.
Managing oral complications during and after treatment
To reduce complications, it’s important to keep up with good oral hygiene during and after chemotherapy and radiation therapy. The following are guidelines for everyday oral care during treatment:
- Brush teeth and gums with a soft bristle brush twice or three times per day for two to three minutes.
- To soften the bristles of the toothbrush, take a break from brushing every 15 to 30 seconds and rinse the toothbrush in hot water
- If using a foam toothbrush, use an antibacterial rinse along with it.
- Air dry the toothbrush between brushings.
- Use a fluoride toothpaste.
- Make sure to choose a mild toothpaste, as flavoring may irritate the mouth.
- If toothpaste irritates the mouth, brush instead with a solution of 1 teaspoon of salt added to 4 cups of water.
- Rinse the mouth three or four times while brushing the teeth.
- Avoid rinses that contain alcohol. Choose a mild rinse or try one of the following homemade rinses:
- 1 teaspoon of salt in 4 cups of water
- 1 teaspoon of baking soda in 1 cup of water
- 1⁄2 teaspoon salt and 2 tablespoons baking soda in 4 cups of water
- For gum disease, an antibacterial rinse may be used two to four times a day. Rinse for one to two minutes.
- For patients with dry mouth, rinsing may not be enough to clean the teeth after a meal. Brushing and flossing may be needed.
- Floss once daily, using a gentle touch.
- Use lip balm to prevent drying, cracking and chapping.
Descriptions and Treatments
Mucositis occurs when the mucous membranes in the mouth become inflamed. Patients usually experience red, ulcerous or burn-like sores throughout the mouth. Oral mucositis is often referred to as “stomatitis.” Stomatitis is similar to mucositis in that it involves inflammation of the mouth tissues. But with stomatitis, infection is present.
Causes of mucositis include both radiation therapy and chemotherapy. Patients receiving chemotherapy generally heal from mucositis in two to four weeks. Patients receiving radiation therapy can experience longer healing time, six to eight weeks, particularly if there is infection.
Patients with mucositis may experience the following problems:
- Bleeding (this occurs mainly in patients receiving chemotherapy)
- 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.
Treatment of mucositis depends on its severity and on how robust the patient’s immune system is. The following are guidelines for treating mucositis during anticancer treatment:
- Clean the teeth and mouth every four hours and at bedtime, and more often if the mucositis worsens.
- Use a soft bristle toothbrush
- 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.
- The following rinse may be used to neutralize acid and dissolve thick saliva: 1⁄2 teaspoon salt and 2 tablespoons baking soda in 4 cups of water.
- 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 rinse should not be used for more than two days because it will keep mucositis from healing.
- Topical medications may soothe pain. Before applying the medication, rinse the mouth and teeth gently with wet gauze dipped in saltwater to remove particles.
- If topical medications do not provide relief, painkillers might. Patients receiving chemotherapy have a bleeding risk and therefore should not use nonsteroidal anti-inflammatory drugs (NSAIDS, aspirin-type painkillers).
- Capsaicin, the active ingredient in hot peppers, is thought to increase a person's ability to tolerate pain. The side effects of capsaicin are not known.
Infection can arise from damage to the lining of the mouth. Oral mucositis damages the mouth’s lining, letting germs and viruses into the bloodstream. Immune systems weakened by anticancer treatment have a more difficult time combating these invaders. Dry mouth, a common result of radiation therapy to the head and neck, may also contribute to mouth infections. Preventive dental care during anticancer treatment can reduce the risk of oral infections.
Treatment of bacterial infections in chemotherapy patients may include:
- Medicated and peroxide mouth rinses
- Brushing and flossing
- Limiting denture wearing time
For patients receiving radiation therapy, bacterial infections are generally treated with antibiotics.
The mouth normally contains fungi that don’t cause any problems. Cancer treatment can suppress the immune system and affect the oral environment, leading to an overgrowth of fungi that can be serious and require treatment. Some patients may be given drugs to prevent fungal overgrowth from occurring. In patients who develop fungal infections, treatment includes antifungal rinses and lozenges, along with antibacterial rinses for the mouth, for dentures and for dental appliances. More advanced fungal infections are treated with oral or injected drugs.
Mild to serious viral infections are a risk for patients undergoing immune-suppressing cancer treatments. Patients who harbor herpesvirus may experience a symptom flare-ups during radiation therapy. It’s important to diagnose and treat viral infections early. Drugs may be used to prevent or treat these infections.
Some anticancer drugs affect blood’s ability to clot. Patients who receive these drugs are at risk for mild to severe bleeding, either at areas of gum disease or mouth ulcers, or where mouth tissues are irritated by eating, brushing, or flossing.
Blood may ooze from the gums when blood counts drop below certain levels, but with close monitoring, most patients with decreased blood counts can still safely brush and floss, which is crucial to good oral care during treatment to prevent infections that can lead to more bleeding.
Treatment for bleeding during chemotherapy may include:
Medications to reduce bleeding and aid clotting
Topical products that 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). Rinse carefully so clots are not disturbed.
Dry mouth (xerostomia) occurs when cancer treatment damages the salivary glands, leading them to produce too little saliva.
Saliva is vital for taste, swallowing, and speech. It neutralizes acid, which helps prevent infection and tooth decay, and it cleans the teeth and gums. When cancer treatment damages the salivary glands, the mouth is less able to clean itself. Acid remains in the mouth, leaching minerals from the teeth, which can cause tooth decay and gum disease. Symptoms of dry mouth include the following:
- Thick, stringy saliva
- Increased thirst
- Changes in taste, swallowing, and speech
- Soreness or a burning sensation (especially on the tongue)
- Cuts or cracks in the lips or at the corners of the mouth
- Changes in the surface of the tongue
- Difficulty wearing dentures
Dry mouth during chemotherapy is usually temporary. The salivary glands often recover two to eight weeks after treatment ends. However, salivary glands may not recover completely following radiation therapy. Salivary glands that were not irradiated may become more active to compensate for the destroyed glands.
To help prevent complications caused by dry mouth, careful oral hygiene is crucial.
Here are some ways to manage dry mouth:
- Clean the mouth and teeth at least four times a day.
- Floss once a day.
- Use a fluoride toothpaste when brushing.
- Apply fluoride gel once a day at bedtime, after cleaning the teeth.
- Rinse four to six times daily with a solution of salt and baking soda (mix 1⁄2 teaspoon salt and 1⁄2 teaspoon baking soda in 1 cup of warm water).
- Avoid sugary foods and liquids.
- Sip water to relieve mouth dryness.
A dentist can provide the treatments to fight infection, replace minerals lost from the teeth, stimulate the salivary glands and prevent tooth decay.
Dry mouth and changes in the balance of oral bacteria increase the risk of tooth decay in patients who undergo anticancer treatments. Stringent oral hygiene and regular dental care can help prevent tooth decay.
CHANGES IN THE SENSE OF TASTE
Patients undergoing chemotherapy and radiation commonly encounter changes in their sense of taste. This disorder is called dysgeusia.
Taste changes can be caused by damage to the taste buds, dry mouth, infection, or dental problems. They can also occur as a direct result of chemotherapy drugs and radiation.
In most patients receiving chemotherapy and in some patients undergoing radiation therapy, taste returns to normal a few months after treatment ends. But for many who receive radiation therapy, the change is permanent. Zinc sulfate supplements may help some patients recover a more normal sense of taste.
Changes in the sense of taste can affect some cancer patients’ appetites, affecting their quality of life and further compromising their health. To manage taste changes and meet nutritional needs, try the following:
Serve food chopped, ground, or blended to reduce the amount of time it must remain in the mouth before being swallowed.
Snack between meals to add calories and nutrients to the diet.
Choose high-calorie, high-protein foods.
Take vitamin, mineral and calorie supplements.
Don’t hesitate to seek nutritional counseling.
Fatigue is common in cancer patients who receive chemotherapy or radiation therapy. Some patients may feel too tired to perform routine oral care, which can increase their risk for oral complications.
Oral pain can occur when certain anticancer drugs cause nerve damage. It can also occur from tooth grinding or stress. But there are many causes of oral pain during cancer treatment, so careful diagnosis is important. Some patients may experience sensitive teeth long after chemotherapy has ended. Fluoride treatments and toothpaste for sensitive teeth may provide relief.
In patients whose oral pain results from stress or from clenching the jaw or grinding the teeth, treatments can include muscle relaxers, anxiety medications, physical therapy, or mouth guards to wear during sleep.
Radiation therapy can cause the growth of benign tumors in the skin and muscles, which can affect a patient’s ability to move their mouth and jaw normally. Oral surgery may also cause jaw stiffness. Management may include:
- Physical therapy
- Oral appliances
- Pain treatments
TISSUE AND BONE LOSS
Patients who undergo radiation therapy may experience a wasting of tissue and bone in the treated area. This wasting is referred to as necrosis, or tissue death. It can cause ulcers, which can grow, causing pain or loss of feeling, and a risk of infection. If bone tissue is lost, fractures can occur. Preventive care can lessen the severity of tissue and bone loss. Prevention, management, and treatment may include:
- Eating 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