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Healthy living after treatment of childhood, adolescent, and young adult cancer

Dental Health after Cancer Treatment
Treatment for cancer during childhood often increases the risk for dental problems. As a childhood cancer survivor, it isimportant for you to understand the reasons why dental care is especially important for maintaining your health.
What are the risk factors for dental problems after childhood cancer treatment?
•Treatment with chemotherapy before your permanent teeth were fully formed, especially if you were younger
than 5 years old at the time of your treatment•Radiation that included the mouth and/or salivary glands•

Radioiodine therapy (I-131 thyroid ablation)•Treatment with azathioprine (sometimes given to patients receiving a hematopoietic cell transplant [HCT])•

Chronic graft-versus-host disease (cGVHD) associated with HCT

What dental problems can occur following treatment for cancer in childhood?
Chemotherapy and radiation can affect the health of the teeth. Survivors of childhood cancer may be at increased riskof developing cavities, having abnormal development of the teeth, roots of the teeth and the protective tooth enamel,
as well as small or absent teeth. It is important to share a history of childhood cancer treatment with your dental
health professional and attend regular dental cleanings every 6 months to preserve dental health.
In addition to affecting the teeth, cancer treatments can also affect your salivary glands, gums, taste buds, the jaw
bones and the joint (called the temporomandibular joint, or “TMJ”) between the upper and lower jaw.
What can be done for these problems?
Taking care of teeth and gums is always important, and it is even more important if you have had radiation orchemotherapy at a young age. If your gums are not healthy, they can shrink away from your teeth, causing infection in
the bone supporting the roots. This bone can dissolve away slowly, causing the teeth to become loose. This condition iscalled periodontitis (inflammation surrounding a tooth). Periodontitis can be prevented by proper brushing of your teeth
and gums and by flossing between your teeth at least once a day. Taking good care of your teeth and gums, combinedwith routine visits to your dentist, can prevent the development of cavities and gum disease.
If your permanent teeth do not develop normally, you may need caps or crowns to improve your smile and the functionof your teeth. Sometimes reconstructive surgery is needed to correct poor bone growth of the face or jaw. Radiation
can sometimes make it difficult to open your mouth fully (trismus), or cause some scarring and hardening of the jaw
muscles (fibrosis). Stretching exercises for the jaw may reduce fibrosis and improve your ability to open your mouth.
Your dentist will be able to instruct you or refer you to occupational therapy to learn these exercises. If you have crookedor small teeth, this may be improved by bonding (applying a thin coating of plastic material on the front surface of theteeth to cover any flaws). If braces are needed, your dentist will do a panorex x-ray of the teeth to see if the teeth, roots
and supporting bone are strong enough for braces. If you had high doses of radiation to the face or mouth and you
require dental surgery, you may be at increased risk of developing a bone-healing problem (osteoradionecrosis) after
the surgery. Your dentist should discuss this potential problem with a radiation oncologist before any dental surgery. If
you had an allogeneic bone marrow or stem cell transplant (from a donor other than yourself), it is important to let yourdentist know, so that the dentist can check for changes indicating cGVHD.

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What is xerostomia and what should I do if I have it?
Dry mouth, also called “xerostomia” can occur after radiation to the head or neck. Other problems related toxerostomia include persistent sore throat, burning sensation in the mouth and gums, problems speaking, difficulty
swallowing, hoarseness, or dry nasal passages. Dryness of the mouth is a result of decreased saliva and/or thickeningof the saliva, and can lead to the development of cavities.
Drinking liquids frequently and the use of artificial saliva can help relieve the symptoms of xerostomia. Sugar-freecandy stimulates saliva production. Proper brushing habits are very important for people with xerostomia, as is limiting
the intake of candy and other sweets. Your dentist may recommend application of a fluoride gel to your teeth at least
once a day. The fluoride acts on the enamel of your teeth to make it more resistant to decay. Ask your dentist about
whether you should use daily fluoride.
Should I take any special precautions when having dental work done?
Always let your dentist know if you have the following health conditions:•Splenectomy (surgical removal of the spleen)•High doses of radiation to the spleen (40 Gy–4000 cGy/rads or more)•

Heart valve replacement or repair with artificial or prosthetic material•

Ventricular shunt (surgical placement of a tube to drain fluid from the brain) that drains into the heart(ventriculoatrial/V-A) or venous system (ventriculovenus/V-V)•

Currently active cGVHD following HCT

In any of these situations, bacteria that normally enter the bloodstream during dental work may increase the risk ofserious infections. As a precaution against infection, if you have any of these conditions, antibiotics may be needed
before any dental work is done.
When dental work is planned, ask your dentist if you need to take antibiotics before the procedure.
What is the risk of developing oral cancer?
People who have had radiation to the head and neck during childhood, or who have cGVHD after bone marrow or stem
cell transplant, may be at increased risk for oral cancers. Using tobacco in any form or using alcohol in combination
with smoking greatly increases this risk. Infection with certain forms of the human papillomavirus (HPV) also increases
this risk. Your dentist should perform an oral cancer screening exam during each visit.
If you notice any of the following, notify your dentist immediately:•

A sore that does not heal or that bleeds easily•

A change in the color of your mouth tissues•

A lump, thickening or rough spot in the mouth•

Pain, tenderness or numbness anywhere in the mouth or on the lips

Most of the time, these symptoms do not indicate any problem, but a dentist can tell if they are the sign of a serious
problem.

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Healthy living after treatment of childhood, adolescent, and young adult cancer

What should I do to keep my teeth and mouth as healthy as possible?
Follow these recommendations (unless your dentist recommends otherwise):•See your dentist regularly at least every six months. Make sure that your dentist knows your health history
and the treatment you received. (Ask your oncologist for a summary of your treatment). Be sure that your visit
includes an oral cancer screening, and be sure to notify your dentist if you notice any warning signs of oralcancer.

•Have a panorex x-ray done before dental/orthodontic procedures to evaluate the root development of yourteeth and determine if any modifications need to be made to your dental treatment plan.

•Brush your teeth at least twice a day.

•–

Use a fluoride-containing toothpaste to help prevent tooth decay.

–Place your brush at a slight angle toward the gum when brushing along the gum line.

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Use a soft-bristle toothbrush, as recommended by your dentist.

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Clean all surfaces of the teeth.

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Brush your tongue to remove bacteria that can cause bad breath.

Floss your teeth at least once a day.
–Floss carefully between teeth because brushing alone does not remove plaque between teeth.

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Use a gentle touch to avoid injury to gums.

–

It is normal to have a small amount of bleeding when flossing, but if the bleeding increases or your gums are
red and puffy, this may be a sign of infection and you should notify your dentist.

•Use antibacterial, alcohol-free fluoride mouth rinses (your dentist can recommend the best ones for you).

•Drink liquids frequently and/or use artificial saliva (available at most pharmacies without a prescription).

•

Apply fluoride frequently. Your dentist may recommend a daily fluoride rinse or gel that you can use at home
after brushing, in addition to the special fluoride application you may receive at your regular dental cleanings.

•Limit sweets and carbohydrate-rich foods.

•Do not use tobacco products and use alcohol only in moderation (check with your healthcare provider tosee if you should drink alcohol at all, since alcohol may increase other problems following childhood cancertreatment).

•Notify your dentist immediately if you develop any signs of infection in your mouth or gums, such as
redness, tenderness, excessive bleeding of gums, painful teeth, and/or increased areas of sensitivity.

For more information about dental health issues following childhood cancer treatment:•American Dental Association’s dental health website at www.mouthhealthy.org

Adapted by Deborah Lafond, MS, RNCS, PNP, CPON®, Children’s National Medical Center, Washington, DC, from “Save Your Smile”
by Melissa Hudson, MD, St Jude Children’s Research Hospital, After Completion of Therapy (ACT) Clinic, used with permission.
Reviewed by Sarah Ford, MS, PA-C; Kayla L. Foster, MD, MPH; and Melissa Acquazzino, MD, MS.

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
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Healthy living after treatment of childhood, adolescent, and young adult cancer
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or young
adulthood.
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Introduction to Late Effects Guidelines and Health Links: The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers and accompanying Health
Links were developed by the Children’s Oncology Group as a collaborative effort of the Late Effects Committee and Nursing Discipline and are maintained and updated by the Children’sOncology Group’s Long-Term Follow-Up Guidelines Core Committee and its associated Task Forces.
To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified health provider with any questions you may have regarding amedical condition and do not rely on the Informational Content. The Children’s Oncology Group is a research organization and does not provide individualized medical care or treatment.
To physicians and other healthcare providers: The Informational Content is not intended to replace your independent clinical judgment, medical advice, or to exclude other legitimate
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