Cancer treatments can affect your entire body, including your teeth and gums. Side effects of treatment may include inflammation of the mucous membranes in the mouth (mucositis), infections, taste changes, dry mouth, pain, tooth decay, gum disease, and sores inside your mouth.
Therefore, good dental health practices are especially important for people living with cancer. Good communication is important, too. Make certain that you inform your dentist about your cancer treatment. You should also inform your oncologist about your dental history and any planned dental work.
As a patient living with cancer, you should:
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Schedule a dental exam and cleaning before cancer treatment begins and periodically during the course of your treatment. |
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Discuss dental procedures, such as the pulling of teeth or insertion of dental implants, with your oncologist before you start your cancer treatment. |
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Have your dentist check and adjust removable dentures, if you have them. |
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Tell your physician about any bleeding of the gums, pain, or unusual feeling in your teeth or gums, or any dental infections. |
Regular dental hygiene is not that different for people with cancer than it is for people who don't have cancer, but because cancer treatments can affect the teeth and gums, it can be even more important.
If you have cancer, your routine dental hygiene should include:
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Brushing your teeth and tongue after every meal and at bedtime, using a soft toothbrush and gentle stroke. |
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Gentle flossing once a day to remove plaque (if your gums bleed or hurt, the area that is sore should be avoided, but the other teeth still should be flossed). |
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Keeping your mouth moist by rinsing often with water (many medicines cause 'dry mouth' which can lead to decay and other dental problems). |
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Avoiding use of mouthwash that contains alcohol. |
Use a mirror to check your teeth and gums daily for any changes, such as sores or bleeding gums. If you notice a problem or a change, or experience pain in your mouth, teeth, or jaws, report it to both your dentist and oncologist immediately.
Osteonecrosis (pronounced OSS-tee-oh-ne-KRO-sis) of the jaw is an uncommon condition that may involve the loss, or breakdown, of the jaw bone. It can be a serious condition. Symptoms include, but are not limited to:
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Pain, swelling, or infection of the gums |
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Loosening of teeth |
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Poor healing of the gums |
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Numbness or the feeling of heaviness in the jaw |
If you experience any of these or other dental symptoms, tell both your oncologist and your dentist immediately and follow your oncologist's recommendations regarding continuation of your cancer treatment. Your oncologist may refer you to an oral surgeon or dental oncologist with experience in osteonecrosis.
To diagnose osteonecrosis of the jaw, doctors may use X rays or tests for infection (microbial cultures). Treatments for osteonecrosis of the jaw may include antibiotics, oral rinses, and removable mouth appliances. Minor dental work may be necessary to remove injured tissue and reduce sharp edges of the bone. Surgery is typically avoided because it may make the condition worse.
Scientists do not know exactly what causes osteonecrosis of the jaw or how often it occurs. This disease has occurred in some cancer patients receiving bisphosphonates. However, a causal relationship between bisphosphonates and osteonecrosis of the jaw has not been established. Some possible factors that may increase the risk of osteonecrosis include:
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Radiation therapy to the head or neck |
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Chemotherapy |
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Steroid therapy (for example, cortisone) |
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Underlying cancer |
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Anemia (low blood count) and other bloodrelated disorders |
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Infection |
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A history of poor dental health |
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Gum disease or dental surgery (such as pulled teeth) |
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Alcohol abuse or cigarette smoking |
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Poor nutrition |
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Poor blood circulation or clotting problems |
Once your cancer treatment has started, if you experience pain in your mouth, teeth, or jaw- or any other symptom of possible dental problems- tell both your oncologist and dentist immediately.
Dental care is an important element of your overall cancer care. Beginning as soon as possible after your cancer diagnosis, your treatment team should involve your regular dentist or a dental oncologist (a dentist who is specially trained to treat people with cancer).
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Be sure to tell your regular dentist that you are being treated for cancer. |
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Update your medical history record with your dentist to include your cancer diagnosis and treatments. |
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Provide your dentist and your oncologist with each other's name and telephone number for consultation. |
Print form to record information to give to your dentist and oncologist.
This document is for informational purposes and is not intended as a substitute for medical professional help or advice, nor is it intended as a recommendation for any particular treatment plan. A medical professional should always be consulted for any health problem or medical condition.
As a dental oncologist, I am concerned with the effects of oral/dental disease on various cancer treatment modalities, especially bone marrow/stem cell transplant and head and neck radiation, as well as the effects of such therapies on the oral cavity. Very often mundane dental problems can adversely affect the course of cancer therapy. A dental infection can become life-threatening in a patient whose immune system is severely compromised by high-dose chemotherapy. A thorough pre-treatment dental/oral assessment can minimize such complications. Conversely, head and neck radiation therapy can promote post-treatment dental disease and can result in osteoradionecrosis (ORN) if dental surgery is required in irradiated bone. At MSKCC, pre-treatment extraction of teeth with poor prognosis, the prescription of high-potency fluoride for patient self-application, and frequent dental follow-up have resulted in one of the lowest rates of ORN in the literature. Oral cavity cancer is an important cancer globally and is one of the ten most frequent cancers worldwide. Tobacco is the primary etiological factor in its development, other factors being alcohol, genetic predisposition and a diet lacking in micronutrients. The proposal that reactive oxygen species (ROS) such as superoxide radicals (O2•), hydroxyl radicals (OH•) and hydrogen peroxide (H2O2) play a key role . Short- and Long-Term Use of Oral Bisphosphonates Linked to Jaw Necrosis.
LOS ANGELES -- January 2, 2008 -- A study published in the January 1 issue of the Journal of the American Dental Association shows that even short-term use of common oral bisphosphonates may leave the jaw vulnerable to devastating necrosis.
Parish Sedghizadeh, University of Southern California, School of Dentistry, Los Angeles, California, and colleagues sought to investigate the relationship between oral bisphosphonate use and osteonecrosis of the jaw (ONJ).
The study included 208 healthy patients from the School of Dentistry. After controlling for referral bias, 9 of the 208 patients who take or have taken alendronate sodium (Fosamax) for any length of time were diagnosed with ONJ.
The study's results are in contrast to drug makers' prior assertions that bisphosphonate-related ONJ risk is only noticeable with intravenous use of the drugs, not oral usage, said Sedghizadeh. "We've been told that the risk with oral bisphosphonates is negligible, but 4% is not negligible."
The danger is especially pronounced with procedures that directly expose the jaw bone, such as tooth extractions and other oral surgery.
Sedghizadeh hopes to have other researchers confirm his findings and thus encourage more doctors and dentists to talk with patients about the oral health risks associated with the widely used drugs.
The results confirm the suspicions of many in the oral health field, he said. "Here at the School of Dentistry we're getting 2 or 3 new patients a week that have bisphosphonate-related ONJ," he said, "and I know we're not the only ones seeing it."
The study's results are in contrast to drug makers' prior assertions that bisphosphonate-related ONJ risk is only noticeable with intravenous use of the drugs, not oral usage, said Sedghizadeh. "We've been told that the risk with oral bisphosphonates is negligible, but 4% is not negligible."
The danger is especially pronounced with procedures that directly expose the jaw bone, such as tooth extractions and other oral surgery.
Sedghizadeh hopes to have other researchers confirm his findings and thus encourage more doctors and dentists to talk with patients about the oral health risks associated with the widely used drugs.
The results confirm the suspicions of many in the oral health field, he said. "Here at the School of Dentistry we're getting 2 or 3 new patients a week that have bisphosphonate-related ONJ," he said, "and I know we're not the only ones seeing it." The study's results are in contrast to drug makers' prior assertions that bisphosphonate-related ONJ risk is only noticeable with intravenous use of the drugs, not oral usage, said Sedghizadeh. "We've been told that the risk with oral bisphosphonates is negligible, but 4% is not negligible."
The danger is especially pronounced with procedures that directly expose the jaw bone, such as tooth extractions and other oral surgery.
Sedghizadeh hopes to have other researchers confirm his findings and thus encourage more doctors and dentists to talk with patients about the oral health risks associated with the widely used drugs.
The results confirm the suspicions of many in the oral health field, he said. "Here at the School of Dentistry we're getting 2 or 3 new patients a week that have bisphosphonate-related ONJ," he said, "and I know we're not the only ones seeing it.
Head and Neck Radiation Therapy
Patients receiving radiation therapy to the head and neck are at high risk for developing oral complications. Because of the risk of osteonecrosis in irradiated fields, the only opportunity to perform oral surgery may be before radiation treatment begins. Before treatment, the dentist will consider extracting all potentially problem teeth.
Before Head and Neck Radiation Therapy
Conduct a pretreatment oral health examination and prophylaxis. Schedule dental treatment in consultation with the radiation oncologist. Extract teeth in the proposed radiation field that may be a problem in the future.
Prevent tooth demineralization and radiation caries:
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Fabricate custom gel-applicator trays for the patient. |
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Prescribe a 1.1% neutral pH sodium fluoride gel or a 0.4% stannous, unflavored fluoride gel (not fluoride rinses). |
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Use a neutral fluoride for patients with porcelain crowns or resin or glass ionomer restorations. |
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Be sure that the trays cover all tooth structures without irritating the gingival or mucosal tissues. |
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Instruct the patient in home application of fluoride gel. Several days before radiation therapy begins, the patient should start a daily 10-minute application. |
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Have patients brush with a fluoride gel if using trays is difficult. |
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Allow at least 14 days of healing for any oral surgical procedures. |
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Conduct prosthetic surgery before treatment, since elective surgical procedures are contraindicated on irradiated bone. |
During Radiation Therapy
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Monitor the patient's oral hygiene. |
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Watch for mucositis and infection. |
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Advise against wearing removable appliances during treatment. |
After Radiation Therapy
Recall the patient for prophylaxis and home care evaluation every 4 to 8 weeks or as needed for the first 6 months after cancer treatment.
Reinforce the importance of optimal oral hygiene.
Monitor the patient for trismus: check for pain or weakness in masticating muscles in the radiation field. Instruct the patient to exercise three times a day, opening and closing the mouth as far as possible without pain; repeat 20 times.
Consult with the oncology team about use of dentures and other appliances after mucositis subsides. Patients with friable tissues and xerostomia may not be able to wear them again.
Watch for demineralization and caries. Lifelong, daily applications of fluoride gel are needed for patients with xerostomia.
Advise against elective oral surgery on irradiated bone because of the risk of osteonecrosis. Tooth extraction, if unavoidable, should be conservative, using antibiotic coverage and possibly hyperbaric oxygen therapy.
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Oral mucositis: inflammation and ulceration of the mucous membranes; can increase the risk for pain, oral and systemic infection, and nutritional compromise. |
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Infection: viral, bacterial, and fungal; results from myelosuppression, xerostomia, and/or damage to the mucosa from chemotherapy or radiotherapy. |
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Xerostomia/salivary gland dysfunction: dryness of the mouth due to thickened, reduced, or absent salivary flow; increases the risk of infection and compromises speaking, chewing, and swallowing. Medications other than chemotherapy can also cause salivary gland dysfunction. Persistent dry mouth increases the risk for dental caries. |
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Functional disabilities: impaired ability to eat, taste, swallow, and speak because of mucositis, dry mouth, trismus, and infection. |
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Taste alterations: changes in taste perception of foods, ranging from unpleasant to tasteless. |
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Nutritional compromise: poor nutrition from eating difficulties caused by mucositis, dry mouth, dysphagia, and loss of taste. |
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Abnormal dental development: altered tooth development, craniofacial growth, or skeletal development in children secondary to radiotherapy and/or high doses of chemotherapy before age 9. |
Other complications of chemotherapy
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Neurotoxicity: persistent, deep aching and burning pain that mimics a toothache, but for which no dental or mucosal source can be found. This complication is a side effect of certain classes of drugs, such as the vinca alkaloids. |
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Bleeding: oral bleeding from the decreased platelets and clotting factors associated with the effects of therapy on bone marrow. |
Other complications of radiation therapy
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Radiation caries: lifelong risk of rampant dental decay that may begin within 3 months of completing radiation treatment if changes in either the quality or quantity of saliva persist. |
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Trismus/tissue fibrosis: loss of elasticity of masticatory muscles that restricts normal ability to open the mouth. |
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Osteonecrosis: blood vessel compromise and necrosis of bone exposed to high-dose radiation therapy; results in decreased ability to heal if traumatized. |
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