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Keeping Your Mouth Healthy during Treatment

by Stephen T. Sonis, DMD, DMSC

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Oral complications are common in people being treated with chemotherapy or head and neck radiation. Complications may be caused by direct or indirect injury to the tissues of the mouth, jaws, and salivary glands. Chemotherapy may compound damage to the lining of the mouth by reducing your body’s infection-fighting cells, called neutrophils. Moreover, minor dental infections can become a bigger problem when neutrophil numbers are reduced. Fortunately, steps can be taken to reduce the likelihood of mouth problems.

Before Starting Treatment
A visit to the dentist is probably one of the last things you want to do, but seeing your dentist before you start cancer treatment can pay dividends later. Ideally, this visit should take place at least three weeks before starting treatment. The goal is to identify and eliminate potential sources of infection or irritation.

If you have a broken tooth irritating your cheek or a denture that isn’t fitting comfortably, be sure your dentist corrects it. Orthodontic braces should also be temporarily removed, as they irritate the mouth lining. Your teeth can be repositioned after you finish treatment.

You should get dental X-rays to determine if you have any asymptomatic cavities or infections. Your dentist can also recommend an aggressive oral hygiene regimen for you to follow. Evidence shows that people who maintain excellent oral hygiene before and during treatment have fewer oral complications.

Radiation and Your Mouth
The two biggest mouth problems that occur during head and neck radiation therapy are mouth sores (mucositis) and dry mouth (xerostomia). Mucositis begins between the first and second week of radiation when the lining of the mouth starts to get red. At this point, your mouth might burn a bit. By the end of the third week of radiation, actual sores may form. Communicate with your healthcare team any discomfort so medication can be prescribed.

People who maintain excellent oral hygiene before and during treatment have fewer oral complications.

Author of Article photo

Dr. Stephen Sonis

Much research is being done to develop a way to prevent mucositis; however, at the moment, warm salt water, bicarbonate solutions, or other palliative rinses are the best approach. Also try to avoid spicy or acidic foods, caffeine, and smoking.

In addition, radiation shuts down saliva production, so your mouth may start to feel dry soon after beginning radiotherapy. Exercise your salivary glands by sucking on sugar-free lemon drops. Be sure to drink plenty of water, but avoid caffeinated or sugary beverages. Mouth moisturizers (rinses, sprays, gums, and special toothpastes) may help. And medicines can be given to protect your salivary glands and stimulate salivary gland activity. Ask your doctor about these before starting treatment.

Saliva plays an important role in maintaining oral health, especially in keeping bacteria from sticking to your teeth. With dry mouth, bacteria have a tendency to build up on your teeth, placing you at risk for tooth decay and periodontal disease. You can reduce this risk with good oral hygiene. Daily use of supplemental topical fluorides (special gels and rinses) is essential. Since mouth dryness might persist, plan to see your dentist frequently so any disease can be detected and treated early.

Radiation can also cause changes to your jaws that modify their ability to heal if you have a tooth infection or need dental surgery. A condition called osteonecrosis can also be caused by radiotherapy or the use of bisphosphonates in treatment. If osteonecrosis does develop, it can be treated.

Chemotherapy and Your Mouth
Chemotherapy-related oral complications result from damage to the lining of the mouth or local infection due to chemotherapy-induced decreases in neutrophils. Almost all forms of chemotherapy can induce mucositis, although it is more common with some than with others.

Mucositis varies in severity from mild redness to large ulcers. Mucositis usually starts about four days after chemotherapy is given and lasts for slightly more than a week before healing on its own. Ice rinses before and during chemotherapy, a soft, bland diet, saline or sodium bicarbonate rinses, and good oral hygiene might help. For people receiving stem cell transplants for hematologic cancers, a growth factor called Kepivance® is available to prevent mucositis.

When chemotherapy causes a drop in neutrophils, the mouth can become a common site for infection. Fungal infections are the most common and can be easily treated. Viral infections usually produce painful blisters and sores. Let your doctor know if you have a history of cold sores, and avoid contact with people who have chicken pox, shingles, or other types of viral infections.

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Dr. Stephen Sonis is chief of the Division of Oral Medicine at the Dana-Farber Cancer Institute, senior surgeon at Brigham and Women’s Hospital, and professor of Oral Medicine at Harvard School of Dental Medicine.

This article was published in Coping® with Cancer magazine, March/April 2009.