Unique to You

If you have been diagnosed with cancer, your oral health may not be on your priority list, but it should be. Cancer treatment weakens your body and reduces its ability to fight infection. These infections can start anywhere, including your mouth. This can undermine your oral health, your overall health, and your efforts to fight cancer.

While you are probably aware of common cancer treatment side effects such as nausea, fatigue, and hair loss, you may not realize that about 33% of people who undergo cancer treatment develop oral complications such as tooth decay, periodontal disease, mouth sores, dry mouth, and infection. That percentage increases to 40% of people who receive chemotherapy, 80% who have a stem cell transplant, and nearly 100% of people who receive radiation for head and neck cancers.¹

Consider these important points linking oral health and cancer.

• Poor oral health may increase your risk of cancer. Research has begun to connect periodontal disease with an increased risk of oral, esophageal, throat, head and neck, pancreatic, melanoma, lung, and other cancers.² While it may not have directly contributed to your cancer, it can affect your overall health and the challenges you face. Taking steps to avoid periodontal disease from the start, and getting treatment when needed, may help reduce this risk.
• Cancer treatment can have a significant impact on your teeth, gums, lips, and salivary glands. The side effects may make it difficult to eat, talk, chew or swallow. Untreated, some issues can lead to tooth and bone loss. Tooth and bone loss also make it more difficult to maintain proper nutrition, affecting your strength and resiliency to fight cancer. This is why the Leukemia and Lymphoma Society urges you to visit a dentist at least four weeks before cancer treatment begins in order to get an exam and any treatment that can help avoid some of the impacts of these side effects.¹

The severity of cancer therapy side effects differs for everyone. Different treatment methods may cause different oral complications. Before your treatment begins, it is important to understand how cancer treatment can impact your mouth, so you're prepared to address these challenges if and when they happen. If they get bad enough, oral complications can even impact how the cancer treatment is provided:

• Treatment doses may need to be altered.
• Schedules may need to be changed or delayed.
• Treatment may be stopped altogether until the oral complications are under control.

The Leukemia and Lymphoma Society states that different courses of cancer treatment may be accompanied by the following oral complications.¹

Chemotherapy and your mouth

Chemotherapy drugs are intended to slow or stop the growth of fast-growing cancer cells but can also prevent the growth of normal, healthy cells anywhere in your body, including your mouth. Oral tissue that cannot properly repair itself can result in painful mouth sores. It can also make it more difficult for sores to heal.

Chemotherapy can also cause a decrease in your white blood cell count. These are the cells that fight infection. As your white blood cell count gets lower, it can become more difficult for your body to fight off bacterial, viral, and fungal infections. This is important because both tooth decay and periodontal disease are essentially bacterial infections.

Finally, chemotherapy may disturb the healthy balance of bacteria in your mouth. Some of these bacteria are helpful, and some are harmful. The "good" bacteria keep the "bad" bacteria in balance. If that balance is disrupted, the changes may create an environment in your mouth that leads to problems such as tooth decay and periodontal disease.

Most of the oral complications caused by chemotherapy are short-term and resolve themselves after treatment is completed. The most common oral side effects include:

• Mouth sores (mucositis): Inflammation and ulceration of the mucous membranes cause pain, difficulty chewing and swallowing, and an increased risk of infection.
• Bleeding: This may result from the decreased number of platelets in the blood due to the effects of chemotherapy on bone marrow.
• Dry mouth: This can occur as a result of reduced saliva levels in your mouth. It can affect your ability to speak, chew, open your mouth, or swallow.
• Infection: Viral, bacterial, and fungal infections can become more prevalent due to low white blood cell counts. Also, infections that start in the mouth can travel through the bloodstream and affect cells in other parts of your body.
• Pain: Tooth and gum pain is associated with nearly all oral health problems.
• Difficulty swallowing (dysphagia): Dysphagia occurs when you have trouble getting food or liquid to pass down your mouth or throat. This can result in gagging, persistent coughing, or choking when you try to swallow. It may be caused by mouth sores, dry mouth, swollen tissues, or a combination of these.
• Malnutrition or dehydration: Both can develop when you have difficulty eating or drinking due to mouth sores, dry mouth, pain, changes in taste, or difficulty swallowing.
• Neurotoxicity: This is a side effect of a certain class of drugs used in chemotherapy that can cause a constant aching, burning pain similar to a toothache.
• Changes in the development of teeth and jaws in children.

Head and neck radiation and your mouth

Cancer cells are particularly sensitive to radiation and can be damaged by it. However, radiation therapy may also damage healthy oral tissue, salivary glands, and bone. Normal tissue cells will eventually repair themselves, so most of the side effects caused by radiation therapy will subside after treatment is completed.

While radiation therapy may cause short-term complications, it can also cause permanent tissue damage that puts you at risk for lifelong oral complications, including:

• Mouth sores (mucositis).
• Breakdown of tissue, bone, or muscle in the area receiving radiation.
• An increased risk of reduced circulation in the path of the radiation, which can cause specific complications and may be permanent.
• Tooth decay and periodontal disease.
• Infection: Viral, bacterial, and fungal infections can become more prevalent due to low white blood cell counts. Also, infections that start in the mouth can travel through the bloodstream and affect cells in other parts of your body.
• Tooth, gum, or jaw pain (which may include the development of TMJ disorders).
• Dry mouth
• Difficulty swallowing (dysphagia): Dysphagia occurs when you have trouble getting food or liquid to pass down your mouth or throat. This can result in gagging, persistent coughing, or choking when you try to swallow. It may be caused by mouth sores, dry mouth, swollen tissues, or a combination of these.
• Malnutrition or dehydration: Both can occur when you have difficulty eating or drinking due to mouth sores, dry mouth, pain, or changes in taste.
• Changes in the development of teeth and jaws in children.

Stem cell transplants and your mouth

As described above, the high doses of chemotherapy typically delivered before a stem cell transplant may cause dental and oral side effects. If you receive an allogeneic stem cell transplant, you are also at risk for graft-versus-host disease (GVHD). GVHD occurs when transplanted donor cells attack your body. Symptoms of oral GVHD may be acute or long-lasting and include:

• Mouth sores (mucositis)
• Dry mouth due to a decrease in saliva flow.
• Pain from spices, alcohol, or other flavorings.
• Problems swallowing
• Change in taste
• Tightness in your skin or the lining of your mouth.
• Restricted opening of the mouth.

Bone modifying drugs and your mouth

Bisphosphonates are a class of drugs prescribed to people with certain metastatic cancer treatments, including myeloma or other cancers that have spread to your bones. Bisphosphonates can lead to weakened, dissolved, or broken bones.²

You should see your dentist before starting treatment with this class of drugs and address any dental problems, especially invasive procedures, before your cancer treatment begins. Make sure to tell your dentist or hygienist about any medications you take or upcoming treatments you expect when you discuss your health history and current health status. Also, be sure you coordinate with your dentist and oncologist throughout your cancer treatment, particularly if you experience any pain or discomfort in your jaw. This can indicate a severe side effect of bisphosphonate treatment called "osteonecrosis of the jaw" (ONJ). ONJ typically affects individuals who have cancer that has spread to their bones and are being treated with intravenous (IV) forms of these drugs. It can lead to increasing pain, loss of bone function, and progressive jaw bone destruction.³

Oral hygiene

• Follow all the recommendations from your dentist and doctor.
• Once your treatment starts, it's important to look in your mouth every day for sores or other changes you may notice.
• Make sure you are brushing at least twice a day with a soft-bristled brush and fluoride toothpaste. If brushing hurts, try softening the bristles in warm water. If you have symptoms of dry mouth, specially labeled toothpaste or gel are available to help reduce these symptoms. If your gums bleed, don't stop brushing your teeth. Bleeding gums may be a sign of inflammation or plaque build-up below your gum line, which requires more attention, not less.
• Flossing at least once a day helps remove plaque from between teeth where brushes do not reach. Tell your dentist about areas that bleed. They may want to evaluate those areas to help you maintain good oral health.

• Don't use mouthwashes containing alcohol.
• Rinse your mouth several times a day with 1/4 teaspoon of salt or one teaspoon of baking soda in eight ounces of warm water. Then, rinse your mouth with plain water.

• Dentures that don't fit well can cause problems. Be sure to talk to your dentist if you are experiencing any discomfort.
• Try to avoid:
  • Sharp, crunchy foods, like chips, that could scrape or cut your mouth.
  • Foods that are hot, spicy, or high in acid, which can irritate your mouth.
  • Sugary foods, like candy or soda, that can lead to tooth decay.
  • Using toothpicks, because they can cut your mouth.
  • All tobacco products.
  • Alcoholic drinks

Visiting the dentist

If possible, you should visit your dentist at least one month before starting cancer treatment and address as many problems as possible to reduce the risk of complications. Your dentist can help prioritize your treatment needs and work with you to establish a monitoring strategy. This may require you to visit your dentist more frequently during and following cancer treatment. Your dentist can also provide you with different at-home oral hygiene strategies, including medications, to help lessen the impact of possible side effects. It's always helpful to come prepared with questions to ask.

Questions to ask your dentist

• What dental treatments are necessary before cancer treatment begins, and what treatments can be done while I'm undergoing treatment? Generally, your dentist and oncologist will want to communicate with each other to ensure you are receiving the best care possible.
• What are the potential complications caused by cancer treatments, and how can we avoid or reduce them?
• If I am undergoing bleomycin chemotherapy and need sedation for a dental procedure, is nitrous oxide a sensible option since it exposes me to a high level of oxygen?
• Are there any medications I can use to minimize mouth sores and tenderness during cancer care?
• How often should I see you during my treatment?
• What can I do to maintain my oral health during my treatment?
• How do I maintain healthy nutrition during my treatment?
• How can I help prevent oral infections during treatment?
• Should I be using a prescription fluoride supplement to avoid cavities while being treated for cancer? Radiation and chemotherapy can reduce saliva flow and create mouth sores that make proper dental hygiene more difficult.
• I have had radiation therapy in the past. Does this affect my upcoming treatment? It is important for your dentist to know the radiation dose, time of treatment, and the body area where the radiation was directed. They may need to communicate with your oncologist for this information.

• Children: Certain types of cancer treatment can cause additional side effects in children. Problems with their teeth are the most common. Permanent teeth may be slow to erupt and may look different from normal teeth. Loosened or missing teeth are also possible.If possible, take your child to the dentist at least one month before starting cancer treatment. The dentist will check your child's mouth carefully and perform any necessary treatment to reduce potential complications. The dentist will also check for any growth problems in your child's jaws. Be sure to explore all you can do to help your child with their oral care.
• Nitrous oxide sedation: If you are undergoing bleomycin chemotherapy, nitrous oxide may not be recommended as a sedation option. Nitrous oxide exposes you to high oxygen concentrations, which may increase your risk of developing respiratory toxicity and failure.