National Cancer Institute
Last Modified: October 23, 2012
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Complications are new medical problems that occur during or after a disease, procedure, or treatment and that make recovery harder. The complications may be side effects of the disease or treatment, or they may have other causes. Oral complications affect the mouth.
Cancer patients have a high risk of oral complications for a number of reasons:
These cancer treatments slow or stop the growth of fast growing cells, such as cancer cells. Normal cells in the lining of the mouth also grow quickly, so anticancer treatment can stop them from growing, too. This slows down the ability of oral tissue to repair itself by making new cells. to repair itself by making new cells.
There are many different kinds of bacteria in the mouth. Some are helpful and some are harmful. Chemotherapy and radiation therapy may cause changes in the lining of the mouth and the salivary glands, which make saliva. This can upset the healthy balance of bacteria. These changes may lead to mouth sores, . This can upset the healthy balance of bacteria. These changes may lead to mouth sores, infections, and tooth decay., and tooth decay.
This summary is about oral complications caused by chemotherapy and radiation therapy.
Sometimes treatment doses need to be decreased or treatment stopped because of oral complications. Preventive care before cancer treatment begins and treating problems as soon as they appear may make oral complications less severe. When there are fewer complications, cancer treatment may work better and you may have a better quality of life.
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Oral complications caused by radiation therapy to the head and neck include the following:
Radiation therapy can directly damage oral tissue, salivary glands, and bone. Areas treated may scar or waste away. Total-body radiation can cause permanent damage to the salivary glands. This can change the way foods taste and cause dry mouth.
Slow healing and infection are indirect complications of cancer treatment. Both chemotherapy and radiation therapy can stop cells from dividing and slow the healing process in the mouth. Chemotherapy may decrease the number of white blood cells and weaken the immune system (the organs and cells that fight infection and disease). This makes it easier to get an infection.
Acute complications are ones that occur during treatment and then go away. Chemotherapy usually causes acute complications that heal after treatment ends.
Chronic complications are ones that continue or appear months to years after treatment ends. Radiation can cause acute complications but may also cause permanent tissue damage that puts you at a lifelong risk of oral complications. The following chronic complications may continue after radiation therapy to the head or neck has ended:
Oral surgery or other dental work can cause problems in patients who have had radiation therapy to the head or neck. Make sure that your dentist knows your health history and the cancer treatments you received.
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Problems such as cavities, broken teeth, loose crowns or fillings, and gum disease can get worse or cause problems during cancer treatment. Bacteria live in the mouth and may cause an infection when the immune system is not working well or when white blood cell counts are low. If dental problems are treated before cancer treatments begin, there may be fewer or milder oral complications.
Your dentist should be part of your cancer care team. It is important to choose a dentist who has experience treating patients with oral complications of cancer treatment. A checkup of your oral health at least a month before cancer treatment begins usually allows enough time for the mouth to heal if any dental work is needed. The dentist will treat teeth that have a risk of infection or decay. This will help avoid the need for dental treatments during cancer treatment. should be part of your cancer care team. It is important to choose a dentist who has experience treating patients with oral complications of cancer treatment. A checkup of your oral health at least a month before cancer treatment begins usually allows enough time for the mouth to heal if any dental work is needed. The dentist will treat teeth that have a risk of infection or decay. This will help avoid the need for dental treatments during cancer treatment. Preventive care may help lessen dry mouth, which is a common complication of care may help lessen dry mouth, which is a common complication of radiation therapy to the head or neck. to the head or neck.
The goal of the oral care plan is to find and treat oral disease that may cause complications during treatment and to continue oral care during treatment and recovery. Different oral complications may occur during the different phases of a transplant. Steps can be taken ahead of time to prevent or lessen how severe these side effects will be.
Continuing to smoke tobacco may slow down recovery. It can also increase the risk that the head or neck cancer will recur or that a second cancer will form. (See the PDQ® summary on Smoking in Cancer Care for more information.)
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It is important to keep a close watch on oral health during cancer treatment. This helps prevent, find, and treat complications as soon as possible. Keeping the mouth, teeth, and gums clean during and after cancer treatment may help decrease complications such as cavities, mouth sores, and infections.
For special oral care during high-dose chemotherapy and stem cell transplant, see the Managing Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant section of this summary.
Swishing ice chips in the mouth for 30 minutes, beginning 5 minutes before patients receive fluorouracil, may help prevent mucositis. Patients who receive high-dose chemotherapy and stem cell transplant may be given medicine to help prevent mucositis or keep it from lasting as long.
Treatment of mucositis caused by either radiation therapy or chemotherapy is about the same. Treatment depends on your white blood cell count and how severe the mucositis is. The following are ways to treat mucositis during chemotherapy, stem cell transplant, or radiation therapy:
See the Pain section of this summary for more information on pain control.
Because there can be many causes of oral pain, a careful diagnosis is important. This may include:
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.
Surgery may damage bone, nerves, or tissue and may cause pain. Bisphosphonates, drugs taken to treat bone pain, sometimes cause bone to break down. This is most common 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 (GVHD). This can cause inflammation of the mucous membranes and joint pain. (See the Managing Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant section of this summary for more information).
If an anticancer drug is causing 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 a medical history, physical and dental exams, and x-rays of the teeth.
Some patients may have sensitive teeth weeks or months after chemotherapy has ended. Fluoride treatments or toothpaste for sensitive teeth may relieve the discomfort.
Pain in the teeth or jaw muscles may occur in patients who grind their teeth or clench their jaws, often because of stress or not being able 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.
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. This may be on a scale from 0 to 10, with 10 being the worst. The level of pain felt is affected by many different things. It's important for patients to talk with their doctors about pain.
Pain that is not controlled can affect all areas of the patient's life. Pain may cause feelings of anxiety and depression, and may prevent the patient from working or enjoying everyday life with friends and family. Pain may also slow the recovery from cancer or lead to new physical problems. Controlling cancer pain can help the patient enjoy normal routines and a better quality of life.
For oral mucositis pain, topical treatments are usually used. See the Oral Mucositis section of this summary for information on relieving oral mucositis pain.
Other pain medicines may be also be used. Sometimes, more than one pain medicine is needed. Muscle relaxers and medicines for anxiety or depression or to prevent seizures may help some patients. For severe pain, opioids may be prescribed.
See the Physical, Integrative, Behavioral, and Psychosocial Interventions section of the PDQ® summary on Pain for more information.
Oral mucositis breaks down the lining of the mouth, which lets bacteria and viruses get into the blood. When the immune system is weakened by chemotherapy, even good bacteria in the mouth can cause infections. Germs picked up from the hospital or other places may also cause infections.
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 have a higher risk of serious infections. Dry mouth, which is common during radiation therapy to the head and neck, may also raise the risk of infections in the mouth.
Dental care given before chemotherapy and radiation therapy are started can lower the risk of infections in the mouth, teeth, or gums.
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. Also, fungal infections are common in patients treated with radiation therapy. Patients receiving cancer treatment may be given drugs to help prevent fungal infections from occurring.
Candidiasis is a type of fungal infection that is common in patients receiving both chemotherapy and radiation therapy. Symptoms may include a burning pain and taste changes. Treatment of fungal infections in the lining of the mouth only may include mouthwashes and lozenges that contain antifungal drugs. An antifungal rinse should be used to soak dentures and dental devices and to rinse the mouth. Drugs may be used to when rinses and lozenges do not get rid of the fungal infection. Drugs are sometimes used to prevent fungal infections.
Patients receiving chemotherapy, especially those with immune systems weakened by stem cell transplant, have an increased risk of 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. Giving antiviral drugs before treatment starts can lower the risk of viral infections.
High-dose chemotherapy and stem cell transplants can cause a lower-than-normal number of platelets in the blood. This can cause problems with the body's blood clotting process. Bleeding may be mild (small red spots on the lips, soft palate, or bottom of the mouth) or severe, especially at the gum line and from ulcers in the mouth. Areas of gum disease may bleed on their own or when irritated by eating, brushing, or flossing. When platelet counts are very low, blood may ooze from the gums.
Continuing regular oral care will help prevent infections that can make bleeding problems worse. Your dentist or doctor can explain how to treat bleeding and safely keep your mouth clean when platelet counts are low.
Saliva is made by salivary glands. Saliva is needed for taste, swallowing, and speech. It helps prevent infection and tooth decay by cleaning off the teeth and gums and preventing too much acid in the mouth.
Radiation therapy can damage salivary glands and cause them to make too little saliva. Some types of chemotherapy used for stem cell transplant may also damage salivary glands.
When there is not enough saliva, the mouth gets dry and uncomfortable. This condition is called dry mouth (xerostomia). The risk of tooth decay, gum disease, and infection increases, and your quality of life suffers.
Dry mouth caused by chemotherapy for stem cell transplant is usually temporary. The salivary glands often recover 2 to 3 months after chemotherapy ends.
The amount of saliva made by the salivary glands usually starts to decrease within 1 week after starting radiation therapy to the head or neck. It continues to decrease as treatment goes on. How severe the dryness is depends on the dose of radiation and the number of salivary glands that receive radiation.
Salivary glands may partly recover during the first year after radiation therapy. However, recovery is usually not complete, especially if the salivary glands received direct radiation. Salivary glands that did not receive radiation may start making more saliva to make up for the loss of saliva from the damaged glands.
Acupuncture may also help relieve dry mouth.
Dry mouth and changes in the balance of bacteria in the mouth increase the risk of tooth decay (cavities). Careful oral hygiene and regular care by a dentist can help prevent cavities. See the Regular Oral Care section of this summary for more information.
Changes in the sense of taste is a common side effect of both chemotherapy and head or neck radiation therapy. Taste changes can be caused by damage to the taste buds, dry mouth, infection, or dental problems. Foods may seem to have no taste or may not taste the way they did before cancer treatment. Radiation may cause a change in sweet, sour, bitter, and salty tastes. Chemotherapy drugs may cause an unpleasant taste.
In most patients receiving chemotherapy and in some patients receiving radiation therapy, taste returns to normal a few months after treatment ends. However, for many radiation therapy patients, the change is permanent. In others, the taste buds may recover 6 to 8 weeks or more after radiation therapy ends. Zinc sulfate supplements may help some patients recover their sense of taste.
Cancer patients who are receiving high-dose chemotherapy or radiation therapy often feel fatigue (a lack of energy). This can be caused by either the cancer or its treatment. Some patients may have problems sleeping. Patients may feel too tired for regular oral care, which may further increase the risk for mouth ulcers, infection, and pain. (See the PDQ® summary on Fatigue for more information.)
Patients treated for head and neck cancers have a high risk of malnutrition. The cancer itself, poor diet before diagnosis, and complications from surgery, radiation therapy, and chemotherapy can lead to nutrition problems. Patients may lose the desire to eat because of 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 may help patients with cancer meet their nutrition needs:
Meeting with a nutrition counselor may help during and after treatment.
Many patients treated for head and neck cancers who receive radiation therapy only are able to eat soft foods. As treatment continues, most patients will add or switch to high-calorie, high-protein liquids to meet their nutrition needs. Some patients may need to receive the liquids through a tube that is inserted into the stomach or small intestine. Almost all patients who receive chemotherapy and head or neck radiation therapy at the same time will need tube feedings within 3 to 4 weeks. Studies show that patients do better if they begin these feedings at the start of treatment, before weight loss occurs.
Normal eating by mouth can begin again when treatment is finished and the area that received radiation is healed. A team that includes a speech and swallowing therapist can help the patients with the return to normal eating. Tube feedings are decreased as eating by mouth increases, and are stopped when you are able to get enough nutrients by mouth. Although most patients will once again be able to eat solid foods, many will have lasting complications such as taste changes, dry mouth, and trouble swallowing.
The risk of having jaw stiffness from radiation therapy increases with higher doses of radiation and with repeated radiation treatments. The stiffness usually begins around the time the radiation treatments end. It may get worse over time, stay 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 are common in patients who have head and neck cancers. Cancer treatment side effects such as oral mucositis, dry mouth, skin damage from radiation, infections, and graft-versus-host-disease (GVHD) may all cause problems with swallowing.
Some side effects go away within 3 months after the end of treatment, and patients are able to swallow normally again. However, some treatments can cause permanent damage or late effects. Late effects are health problems that occur long after treatment has ended. Conditions that may cause permanent swallowing problems or late effects include: