Oral Complications of Cancer Treatment: 

What the Oral Health Team Can Do 

With more than 1 million new cases of 

cancer diagnosed each year and a shift to 

outpatient management, it is likely that 

you will see some of these patients in your 

practice. 

affect the oral tissues, you need to know 

about potential oral complications. 

Moreover, preexisting or untreated oral 

disease can complicate cancer treatment. 

Your role in patient management can 

extend benefits beyond the oral cavity. 

Oral complications from radiation to the 

head and neck or chemotherapy for any 

malignancy can seriously compromise 

patients’ health and quality of life, as well 

as affect their ability to complete planned 

cancer treatment. 

be so debilitating that patients may tolerate only lower and less effective doses of 

therapy, may postpone scheduled treatments, or may have to discontinue treatment entirely. 

also lead to potentially life-threatening 

systemic infections. y 

oral care before, during, and after cancer 

treatment can prevent or reduce the 

incidence and severity of oral complications, enhancing both patient survival 

and quality of life. 

Oral Complications Related 

to Cancer Treatment 

Oral complications of cancer treatment arise in various forms and 

degrees of severity, depending on the 

individual and the cancer treatment. 

Chemotherapy often impairs the function 

of bone marrow, suppressing the formation of white blood cells, red blood cells, 

and platelets (myelosuppression). 

cancer treatments are described as 

stomatotoxic because they have toxic 

effects on the oral tissues. ollowing are 

lists of complications common to both 

chemotherapy and radiation therapy, and 

complications specific to each type of 

treatment. ou will need to consider the 

possibility of these complications each 

time you evaluate a patient with cancer. 

Oral complications common to both 

chemotherapy and radiation 

• Oral mucositis: inflammation and 

ulceration of the mucous membranes; 

can increase the risk for pain, oral and 

systemic infection, and nutritional 

compromise. 

• Infection: viral, bacterial, and fungal; 

results from myelosuppression, xerostomia, and/or damage to the mucosa from 

chemotherapy or radiotherapy. 

• Xerostomia/salivary gland dysfunction: dryness of the mouth because of 

thickened, reduced, or absent salivary 

flow; increases the risk of infection and 

compromises speaking, chewing, and 

swallowing. 

chemotherapy can also cause salivary 

gland dysfunction. ersistent dry 

mouth increases the risk for dental 

caries. 

• Functional disabilities: impaired 

ability to eat, taste, swallow, and speak 

because of mucositis, dry mouth, 

trismus, and infection. 

ORAL TH M 

Oral Health, Cancer Care, and You 

Fitting the Pieces Together 

Because cancer treatment can 

The complications can 

Oral complications can 

Medically necessar

Some 

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Medications other than 

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HEAL TEA
• Taste alterations: changes in taste 

perception of foods, ranging from 

unpleasant to tasteless. 

• Nutritional compromise: poor nutrition from eating difficulties caused by 

mucositis, dry mouth, dysphagia, and 

loss of taste. 

• 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. 

Additional complications 

of chemotherapy 

• 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. 

• Bleeding: oral bleeding from the 

decreased platelets and clotting factors 

associated with the effects of therapy 

on bone marrow. 

Additional complications 

of radiation therapy 

• 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. 

• Trismus/tissue fibrosis: loss of elasticity of masticatory muscles that restricts 

normal ability to open the mouth. 

• Osteonecrosis: blood vessel compromise and necrosis of bone exposed to 

high-dose radiation therapy; results in 

decreased ability to heal if traumatized. 

Who Has Oral Complications? 

Oral complications occur in almost all 

patients receiving radiation for head and 

neck malignancies, in up to 75 percent of 

blood and marrow transplant recipients, 

and in nearly 40 percent of patients 

receiving chemotherapy. Risk for oral 

complications can be classified as low 

or high: 

• Lower risk: Patients receiving minimally myelosuppressive or nonmyelosuppressive chemotherapy. 

• Higher risk: Patients receiving 

stomatotoxic chemotherapy resulting in 

prolonged myelosuppression, including 

patients undergoing blood and marrow 

transplantation; and patients undergoing head and neck radiation for oral, 

pharyngeal, and laryngeal cancer. 

Some complications occur only during 

treatment; others, such as xerostomia, 

may persist for years. Unfortunately, 

many patients with cancer do not receive 

oral care until serious complications 

develop. 

The Role of Pretreatment 

Oral Care 

A thorough oral evaluation by a knowledgeable dental professional before 

cancer treatment begins is important to 

the success of the regimen. Pretreatment 

oral care achieves the following: 

• Reduces the risk and severity of oral 

complications. 

• Allows for prompt identification and 

treatment of existing infections or other 

problems. 

• Improves the likelihood that the patient 

will successfully complete planned 

cancer treatment. 

2 What the Oral Health Team Can Do 
• Prevents, eliminates, or reduces oral 

pain. 

• Minimizes oral infections that could 

lead to potentially fatal systemic 

infections. 

• Prevents or minimizes complications 

that compromise nutrition. 

• Prevents or reduces later incidence of 

bone necrosis. 

• Preserves or improves oral health. 

• Provides an opportunity for patient 

education about oral hygiene during 

cancer therapy. 

• Improves the quality of life. 

• Decreases the cost of care. 

With a pretreatment oral evaluation, the 

dental team can identify and treat problems such as infection, fractured teeth or 

restorations, or periodontal disease that 

could contribute to oral complications 

when cancer therapy begins. The evaluation also establishes baseline data for 

comparing the patient’s status in subsequent examinations. 

Before the exam, you will need to obtain 

the patient’s cancer diagnosis and treatment plan, medical history, and dental 

history. Open communication with 

the patient’s oncologist is essential to 

ensure that each provider has the 

information necessary to deliver the 

best possible care. 

Evaluation 

The pretreatment evaluation includes a 

thorough examination of hard and soft 

tissues, as well as appropriate radiographs 

to detect possible sources of infection and 

pathology. Also take the following steps 

before cancer treatment begins: 

• Identify and treat existing infections, 

carious and other compromised teeth, 

and tissue injury or trauma. 

• Stabilize or eliminate potential sites of 

infection. 

• In adults, extract teeth that may pose a 

future problem or are nonrestorable 

to prevent later extraction-induced 

osteonecrosis. 

• Conduct a prosthodontic evaluation, if 

indicated. If a removable prosthesis is 

worn, make sure that it is well adapted 

to the tissue and that the patient is able 

to wear and clean it daily. Instruct the 

patient to leave the prosthesis out of the 

mouth at night. 

• Perform oral surgery at least 2 weeks 

before radiation therapy begins. For 

patients receiving radiation treatment, 

this is the best time to consider surgical 

procedures. Oral surgery should be 

performed at least 7 to 10 days before 

the patient receives myelosuppressive 

chemotherapy. Medical consultation is 

indicated before invasive procedures. 

• Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy 

is planned or if the appliances will be in 

the radiation field. 

• In children, consider extracting highly 

mobile primary teeth and teeth that are 

expected to exfoliate during treatment. 

• Prescribe an individualized oral hygiene 

regimen to minimize oral complications. Patients undergoing head and 

neck radiation therapy should be 

instructed on the use of supplemental 

fluoride. 

What the Oral Health Team Can Do 3 
Supplemental Fluoride 

Fluoride rinses are not adequate to prevent tooth demineralization. high-potency fluoride gel, delivered via custom gel-applicator trays, is recommended. 

Several days before radiation therapy begins, patients 

should start a daily 5-minute application of a 1.1% neutral 

pH sodium fluoride gel or a 0.4% stannous fluoride (unflavored) gel. atients with porcelain crowns or resin or 

glass ionomer restorations should use a neutral pH fluoride. uctures 

without irritating the gingival or mucosal tissues. 

For patients reluctant to use a tray, a high-potency fluoride 

gel should be brushed on the teeth following daily brushing and flossing. 

0.4% stannous fluoride gel is recommended, based on the 

patient’s type of dental restorations. 

Patients with radiation-induced salivary gland dysfunction 

must continue lifelong daily fluoride applications. 

Instructions for Patients Using 

Supplemental Fluoride 

If using a tray 

✓ Place a thin ribbon of fluoride gel in each tray. 

✓ Place the trays on the teeth and leave in place for 5 

minutes. , you are using too 

much. 

✓ After 5 minutes, remove the trays and spit out any 

excess gel. 

✓ Rinse the applicator trays with water. 

✓ Do not eat or drink for 30 minutes. 

If using a brush-on method 

✓ After brushing with toothpaste, rinse as usual. 

✓ Place a thin ribbon of gel on the toothbrush. 

✓ Brush for 2 to 3 minutes. 

✓ Spit out any excess gel. 

✓ Do not eat or drink for 30 minutes. 

Instead, a 

P

Be sure that the trays cover all tooth str

Either a 1.1% neutral pH sodium or a 

If gel oozes out of the tray

Do not rinse. 

Do not rinse. 

Education 

Patient education is an integral part of 

the pretreatment evaluation and should 

include a discussion of potential oral 

complications. It is very important that 

the dental team impress on the patient that 

optimal oral hygiene during treatment, 

adequate nutrition, and avoiding tobacco 

and alcohol can prevent or minimize oral 

complications. To ensure that the patient 

fully understands what is required, provide 

detailed instructions on specific oral care 

practices, such as how and when to brush 

and floss, how to recognize signs of complications, and other instructions appropriate for the individual. Patients should 

understand that good oral care during 

cancer treatment contributes to its success. 

Advise patients to 

• Gently brush teeth, gums, and tongue 

with an extra-soft toothbrush and fluoride 

toothpaste after every meal and before 

bed. If brushing hurts, soften the bristles 

in warm water. 

• Follow instructions for using fluoride gel. 

• Floss teeth gently every day. If gums are 

sore or bleeding, avoid those areas but 

keep flossing other teeth. 

• Avoid mouthwashes containing alcohol. 

• Several times a day, rinse the mouth with 

a baking soda and salt solution, followed 

by a plain water rinse. (Use 1/4 teaspoon 

of baking soda and 1/8 teaspoon of salt in 

1 cup of warm water.) 

• Exercise the jaw muscles 3 times a day to 

prevent and treat jaw stiffness. Open and 

close the mouth as far as possible without 

causing pain; repeat 20 times. 

• Avoid candy, gum, and soda unless they 

are sugar-free. 

• Avoid spicy or acidic foods, toothpicks, 

tobacco products, and alcohol. 

• Keep the appointment schedule recommended by the dentist. 

4 What the Oral Health Team Can Do 
Oral Care During 

Cancer Treatment 

Careful monitoring of oral health is 

especially important during cancer 

therapy to prevent, detect, and treat 

complications as soon as possible. When 

treatment is necessary, consult the 

oncologist before any dental procedure, including dental prophylaxis. 

• Examine the soft tissues for inflammation or infection and evaluate for 

plaque levels and dental caries. 

• Review oral hygiene and oral care 

protocols; prescribe antimicrobial 

therapy as indicated. 

• Provide recommendations for treating 

dry mouth and other complications. 

– Sip water frequently. 

mine whether the patient’s platelet count, 

clotting factors, and absolute neutrophil 

count are sufficient to recommend oral 

treatment. 

Consider oral causes of fever. Fever of 

unknown origin may be related to an oral 

infection. Remember that oral signs of 

infection or other complications may be 

altered by immunosuppression related 

to chemotherapy. 

Consider prophylactic antibiotic treatment. If the patient has a central venous 

catheter, consult the oncologist about 

implementing the American Heart 

Association prophylactic antibiotic 

regimen before any dental treatment. 

This regimen can be viewed online at 

<http://circ.ahajournals.org/cgi/content/ 

full/96/1/358>. 

– Suck ice chips or sugar-free candy. 

– Chew sugar-free gum. 

–	 If appropriate, use a saliva substitute 

spray or gel or a prescribed saliva 

stimulant. 

– Avoid glycerin swabs. 

• Take precautions to protect against 

trauma. 

• Provide topical anesthetics or analgesics 

as appropriate for oral pain. 

Other factors to remember 

Schedule dental work carefully. If oral 

surgery is required, allow at least 7 to 10 

days of healing before the patient receives 

myelosuppressive chemotherapy. Elective 

oral surgery should not be performed for 

the duration of radiation treatment. 

Determine hematologic status. If the 

patient is receiving chemotherapy, have 

the oncology team conduct blood work 24 

hours before dental treatment to deterNormal Complete 

Blood Count 

Red blood cells 4.2–6.0 million/mm3 

Hemoglobin 12–18 g/dL 

Hematocrit 36–52% 

Platelets 150,000–450,000/mm3 

White blood cells 4,000–11,000/mm3 

Differential White Blood Cell 

(WBC) Count 

Neutrophils (granulocytes) 

“Segs” (or Polys or PMNs) 40–60% 

“Bands” 0–5% 

Eosinophils 1–3% 

Basophils 0–1% 

Lymphocytes 20–40% 

Monocytes 2–8% 

Absolute Neutrophil Count = total WBC × (% “Segs” + “Bands”) 

Source: , Gier RE. Oral 

Management of the Cancer Patient: 

Health Care Professional (5th ed.). ansas City, MO: 

University of Missouri–Kansas City School of 

Dentistry, 1996. 

Barker GJ, Barker BF

A Guide for the 

K

What the Oral Health Team Can Do 5 
Follow-up Oral Care 

Chemotherapy 

Once all complications of chemotherapy 

have resolved, patients may be able to 

resume their normal dental care schedule. However, if immune function continues to be compromised, determine the 

patient’s hematologic status before initiating any dental treatment or surgery. This 

is particularly important to remember for 

patients who have undergone blood and 

marrow transplantation. 

Radiation therapy 

Once the patient has completed head 

and neck radiation therapy and acute 

oral complications have abated, evaluate 

the patient regularly (every 4 to 8 weeks, 

for example) for the first 6 months. 

Thereafter, you can determine a schedule 

based on the patient’s needs. However, 

keep in mind that oral complications can 

continue or emerge long after radiation 

therapy has ended. 

Points to remember 

• High-dose radiation treatment carries a 

lifelong risk of osteonecrosis, xerostomia, 

and dental caries. 

• Because of the risk of osteonecrosis, 

principally in the mandible, patients 

should avoid invasive surgical procedures, including extractions that involve 

irradiated bone. If an invasive procedure is required, use of antibiotics and 

hyperbaric oxygen therapy before and 

after surgery should be considered. 

• Lifelong daily fluoride application, 

good nutrition, and conscientious oral 

hygiene are especially important for 

patients with salivary gland dysfunction. 

• Dentures may need to be reconstructed if treatment altered oral tissues. 

Some people can never wear dentures 

again because of friable tissues and 

xerostomia. 

• Dentists should closely monitor children who have received radiation to 

craniofacial and dental structures for 

abnormal growth and development. 

• Dentists should be mindful about the 

recurrence of malignancies, especially 

in patients with oral and head and 

neck cancers, and thoroughly examine 

all oral mucosal tissues at recall 

appointments. 

Special Considerations 

for Blood and Marrow 

Transplant Patients 

The intensive conditioning regimes of 

transplantation can result in pronounced 

immunosuppression, greatly increasing 

a patient’s risk of mucositis, ulceration, 

hemorrhage, infection, and xerostomia. 

The complications begin to resolve when 

hematologic status improves. Although 

the complete blood count and differential 

may be normal, immunosuppression may 

last for up to a year after the transplant, 

along with the risk of infections. Also, 

the oral cavity and salivary glands are 

commonly involved in graft-versus-host 

disease in allograft recipients. This can 

result in mucosal inflammation, ulceration, and xerostomia, so continued monitoring is necessary. Careful attention to 

oral care in the immediate and long-term 

posttransplant period is important to 

patients’ overall health. 

6 What the Oral Health Team Can Do 
Additional Readings 

Barker GJ, Barker BF, Gier RE. Oral 

Management of the Cancer Patient: A 

Guide for the Health Care Professional 

(5th ed.). Kansas City, MO: University 

of Missouri-Kansas City School of 

Dentistry, 1996. 

Fox PC. Management of dry mouth. 

Dental Clinics of North America, 

41(4):863–875, 1997. 

Meurman JH, Pyrhonen S, Teerenhovi L, 

Lindqvist C. Oral sources of septicemia 

in patients with malignancies. Oral 

Oncology, 33(6):389–397, 1997. 

Morgan ER, Haugen M. Late effects of 

cancer therapy. Cancer Treatment 

Research, 92:343–375, 1997. 

National Cancer Institute. CancerNet 

PDQ Cancer Information Summaries. 

Oral Complications of Chemotherapy 

and Head/Neck Radiation. Available 

at <http://www.cancer.gov/cancer_ 

information/doc_pdq.aspx?version= 

1&summaryid=208_10577> (accessed 

May 20, 2002) or call the Cancer 

Information Service at 1–800–4–CANCER. 

National Cancer Institute. Mucosal Injury 

in Cancer Patients: New Strategies for 

Research and Treatment. JNCI 

Monographs, No. 29, 2001. 

National Institutes of Health. Consensus 

Development Conference on Oral 

Complications of Cancer Therapies: 

Diagnosis, Prevention, and Treatment. 

National Cancer Institute Monographs, 

No. 9, 1990. 

Peterson DE, Schubert MM. Oral toxicity. 

In Perry MC (ed.), The Chemotherapy 

Source Book (3rd ed.). Philadelphia: 

Lippincott, Williams and Wilkins, 2001. 

pp. 404–424. 

Schubert MM, Epstein JB, Peterson DE. 

Oral complications of cancer therapy. 

In Yagelia JA, Neidle EA, Dowd FJ (eds.), 

Pharmacology and Therapeutics in 

Dentistry. St. Louis: Mosby-Year Book 

Inc., 1998. pp. 644–655. 

Scully C, Epstein J. Oral health care 

for the cancer patient. Oral Oncology, 

European Journal of Cancer, 32B(5): 

281–292, 1996. 

Silverman S, Jr. Oral Cancer (4th ed.). 

Hamilton, Ontario, Canada: BC Decker, 

1997. 

Sonis ST, Oster G, Fuchs H, et al. Oral 

mucositis and the clinical and economic 

outcomes of hematopoietic stem-cell 

transplantation. Journal of Clinical 

Oncology, 19(8):2201–2205, 2001. 

Woo SB, Lee SJ, Schubert MM. Graft 

versus host disease. Critical Reviews in Oral 

Biology and Medicine, 8(2):201–216, 1997. 

What the Oral Health Team Can Do 7 
Oral Health, Cancer Care, and You

Fitting the Pieces Together

C

U.S. Department of Health 

and Human Services

National Institutes of Health

Revised June 2002 Publication No. 02–4372

Publications

This brochure is part of Oral Health, Cancer Care, and You: ogether, an awareness

campaign sponsored by the National Institute of Dental and Craniofacial Research (NIDCR) through its

National Oral Health Information Clearinghouse (NOHIC). 

campaign and can be ordered from NOHIC.

For patients:

_____ Chemotherapy and Your Mouth

_____ Quimioterapia y la Boca

(Chemotherapy and Your Mouth)

_____ Head and Neck Radiation Treatment and Your Mouth

_____ Su Boca y el Tratamiento de Radiación en la Cabeza y

el Cuello

(Head and Neck Radiation Treatment and Your Mouth)

_____ Three Good Reasons To See a Dentist (tip sheet)

_____ Tres Buenas Razones Para Ver a un Dentista (tip sheet)

(Three Good Reasons To See a Dentist) 

_____ Three Good Reasons To See a Dentist (illustrated

booklet, appropriate for adults with reading skills

at the 2nd grade level or below)

_____ Who’s on My Cancer Care Team? (wallet card)

For professionals:

_____ Oral Complications of

Cancer Treatment:

What the Oral Health

Team Can Do

_____ Oral Complications of

Cancer Treatment:

What the Oncology

Team Can Do

_____ Oral Care Provider’s

Reference Guide for

Oncology Patients 

_____ Oncology Reference

Guide to Oral Health 

Contact NOHIC at

ATTN: 

1 NOHIC Way, Bethesda, MD 

Phone: oll-free); ax: 

E-mail: .nih.gov; .nohic.nidcr.nih.gov

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Address _____________________________________________________________________________________

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Fitting the Pieces T

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