Oral Complications of Cancer Treatment:

What the Oncology Team Can Do

ONCOLOGY TEAM

Radiation to the head and neck and 

chemotherapy for any malignancy can cause 

a range of oral side effects. For some 

patients, these complications may become 

dose-limiting and slow – or even halt – 

cancer treatment. Preventing and managing 

oral complications help support optimal 

cancer therapy, enhancing both patient 

survival and quality of life.

Who Has Oral Complications?

Oral side effects occur in virtually all 

patients receiving radiation for head and 

neck malignancies, in approximately 80 

percent of transplant recipients, and in about 

40 percent of patients receiving primary 

chemotherapy. Risk for oral complications 

varies with the treatment regimen. Patients 

administered minimally myelosuppressive or 

nonmyelosuppressive therapy are at low risk. 

As chemotherapy becomes more aggressive, 

the likelihood of oral complications increases. 

Also at high risk are patients undergoing 

head and neck radiation for oral and 

pharyngeal cancer. 

Most oral complications resolve when 

cancer treatment ends and the patient’s 

overall condition improves. Others, such 

as xerostomia, may persist for years. 

Unfortunately, patients do not always receive 

medically necessary dental care that could 

help avert or minimize oral complications. 

Ensuring that your patients receive timely 

oral care helps them maintain the prescribed 

cancer regimen and complete treatment. 

Oral Complications 

of Cancer Treatment

General 

•	Oral mucositis/stomatitis 

•	Xerostomia/salivary 

gland dysfunction 

•	Pain

•	Infection 

•	Xerostomia-associated cavities 

•	Taste alterations 

•	Nutritional compromise 

•	Functional disabilities 

•	Abnormal dental development 

in children 

Treatment-specific 

Chemotherapy 

•	Neurotoxicity 

•	Bleeding 

Radiation therapy 

•	Radiation caries 

•	Trismus/tissue fibrosis 

•	Osteonecrosis 

U.S. Department of Health and Human Services

National Institutes of Health

National Institute of Dental and Craniofacial Research
2 What the Oncology Team Can Do

By adding oral care to the pretreatment 

regimen, you can

•	Prevent, eliminate or control oral pain.

•	Prevent oral infections that could lead 

to serious systemic infections.

•	Optimize nutritional support.

•	Preserve or improve oral health.

•	 Prevent or reduce the incidence of bone 

necrosis in patients receiving radiation 

therapy to the head and neck.

•	Improve the quality of life.

•	Decrease the cost of care.

•	Improve the likelihood that the patient 

will successfully complete planned 

cancer treatment.

Minimizing Oral Complications 

of Cancer Therapy 

•	 Consider use of palifermin for patients 

with hematologic malignancies receiving 

chemotherapy/radiation and autologous 

stem cell transplantation.

•	 Utilize salivary gland-sparing radiation techniques.

•	 Administer a radioprotectant, such as 

amifostine, to reduce risk of xerostomia 

in head and neck cancer patients.

•	 Encourage patients to maintain the oral hygiene 

regimen recommended by the dentist.

•	 Work with the dentist to prevent and control 

infections with appropriate treatment before, 

during, and after cancer therapy. 

•	 Emphasize the importance of maintaining 

good nutrition. 

Oral Evaluation Before 

Cancer Treatment Makes 

a Difference

A pretreatment oral evaluation can identify 

potential problems and help educate the 

patient about the importance of good oral 

care. This evaluation can be conducted by 

a knowledgeable dentist in the community 

or by a hospital-based dental team. Ideally, 

the evaluation should be performed at least 

1 month before cancer treatment starts to 

permit adequate healing from any required 

invasive procedures. The evaluation includes 

a thorough examination of hard and soft 

tissues, as well as radiographs to detect 

trauma and possible sources of infection. 

Before cancer treatment begins, the dentist 

will take the following steps:

•	Identify and treat existing infections, 

problem teeth, and tissue injury or trauma.

•	 Stabilize or eliminate potential sites 

of infection. 

•	Remove orthodontic bands if highly 

stomatotoxic chemotherapy is planned or 

if the bands will be in the radiation field. 

•	Perform oral prophylaxis if indicated.

•	Evaluate dentures and appliances for 

comfort and fit. 

•	Perform oral surgery at least 2 weeks prior 

to the initiation of radiation therapy to 

allow healing, and at least 7–10 days before 

myelosuppressive chemotherapy begins. 

•	 Extract teeth that may pose a future problem 

to prevent extraction-induced osteonecrosis 

in adults receiving head and neck radiation.

•	Consider extracting highly mobile primary 

teeth in children, and teeth that are 

expected to exfoliate during treatment. 
What the Oncology Team Can Do 3 

•	Instruct patients on oral hygiene, use of 

fluoride gel, nutrition, and the need to 

avoid tobacco and alcohol. 

During the examination, the patient will also 

learn a home care regimen to protect mouth 

tissues and minimize oral complications. 

The dentist or dental hygienist will instruct 

the patient on special brushing and flossing 

techniques, mouth rinses, and other 

approaches to keep the mouth as moist 

and clean as possible to reduce the risk of 

infection and pain.

Oral Care During Treatment

Regular oral assessment and care are 

necessary during cancer therapy. Planning 

and communication between the oncology 

and dental teams can minimize the risk of 

oral complications and maximize the efficacy 

of dental and supportive care. Specific oral 

health considerations to remember when 

treating patients with chemotherapy or 

radiation include the following:

Radiation Therapy

Treat infections and ulcerations. 

Ulcerations and dry, friable tissues are prone 

to trauma and infection. Culture suspected 

infections and work with the dentist to 

manage the condition.

Provide dietary counseling. Instruct the 

patient on the importance of healthy eating 

to maintain nutritional status, emphasizing 

the need to avoid foods that irritate sore 

tissues or cause dental decay.

Teach exercises to reduce trismus. 

Fibrosis may develop if the chewing muscles 

are in the direct field of radiation. Work 

with the dentist to teach patients how to 

exercise and stretch these muscles properly.

Chemotherapy

Consider oral causes of fever. Fever 

of unknown origin may be related to an 

oral infection; dental consultation may 

be appropriate.

Schedule dental appointments carefully. 

Have the patient schedule appointments 

for times when blood counts will be at safe 

levels. If oral surgery is required, it should be 

performed at least 7–10 days before the patient 

receives myelosuppressive chemotherapy.

Determine hematologic status. 

Conduct blood work 24 hours before 

dental treatment to determine whether the 

patient’s platelet count, clotting factors, and 

absolute neutrophil count are sufficient to 

prevent hemorrhage and infection.

Evaluate need for prophylactic 

antibiotic treatment. If the patient has 

a central venous catheter, determine if 

antibiotic prophylaxis (www.americanheart.

org) is needed before dental treatment. 

Follow-up Oral Care

Once all complications of chemotherapy 

have resolved and blood counts have 

recovered, most patients may resume 

their normal dental care schedule. It is 

essential that the dentist know the patient’s 

hematologic status before initiating any 

dental treatment or surgery. Advise the 

dentist if a patient has received intravenous 

bisphosphonate therapy due to its 

association with osteonecrosis of the jaw.

Once radiation therapy has been completed 

and acute oral complications have abated, 

the patient should be evaluated by a dentist 

every 4 to 8 weeks for the first 6 months.

Thereafter, the dentist can determine 

a schedule based on the needs of the 

individual patient.
What the Oncology Team Can Do 4

Long-term Problems 

Following Head and Neck 

Radiation Therapy

Radiation therapy to the head and neck 

can cause oral complications that continue 

or emerge long after treatment has 

ended. Although patients may no longer 

be under an oncologist’s care at that time, 

what they learn about oral health during 

their treatment will affect how they deal 

with subsequent complications. Patients 

receiving radiation therapy need to know 

about its risks:

•	Radiation treatment carries a lifelong 

risk of osteonecrosis, xerostomia, and 

dental cavities. 

•	Because of the risk of osteonecrosis, 

people who have received radiation 

should avoid invasive surgical procedures 

(including extractions) that involve 

irradiated bone. 

•	Radiation to the head and neck may 

permanently reduce the quantity and quality 

of normal saliva, so ongoing oral care is 

crucial to optimize oral health. Daily fluoride 

tray application, good nutrition, and oral 

hygiene are especially important. 

•	Radiation may alter oral tissues, so 

dentures may need to be reconstructed 

after treatment is completed and the 

tissues have stabilized. Some people may 

not be able to wear dentures again. 

•	Craniofacial and dental structures may 

develop abnormally in younger children 

who receive high-dose radiation to 

those areas. 

Hematopoietic Stem 

 Cell Transplantation

Because of the pronounced 

immunosuppression that accompanies 

Helping Patients with 

Xerostomia 

•	Encourage patients to sip water often. 

•	 Suggest using liquids to soften or thin foods. 

•	Recommend using sugarless gum or sugar-free 

hard candies to help stimulate saliva flow. 

•	 Suggest using a commercial 

saliva substitute. 

•	Consider prescribing a saliva stimulant. 

Helping Patients with 

Mouth Pain

•	Prescribe topical anesthetics and 

systemic analgesics.

•	Detect and treat oral infections early. 

•	Encourage patients to avoid eating irritating 

or rough-textured foods. 

hematopoietic stem cell transplant 

procedures, patients have a high risk 

of developing acute oral complications, 

particularly mucositis, ulcerations, 

hemorrhage, infection, and xerostomia. 

Although these problems begin to resolve 

when hematologic status improves, 

immunosuppression may last for up to a 

year after the transplant, so the risk of 

complications continues. The oral cavity and 

salivary glands are also commonly involved 

in graft-versus-host disease in allograft 

recipients. Careful attention to oral care in 

the post-transplant period is important to the 

overall health of these patients.
What the Oncology Team Can Do 5

Oral Complications: 

Glossary of Terms

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.

Functional disabilities: Impaired ability 

to eat, taste, swallow, or speak because of 

mucositis, xerostomia, trismus, or infection.

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.

Oral mucositis/stomatitis: Inflammation 

and ulceration of the mucous membranes; can 

increase the risk for pain, oral and systemic 

infection, and nutritional compromise.

Oral prophylaxis: Thorough dental cleaning.

Osteonecrosis: Blood vessel compromise 

and necrosis of bone exposed to high-dose 

radiation therapy, resulting in decreased 

ability to heal if traumatized and extreme 

susceptibility to infection.

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.

Xerostomia/salivary gland dysfunction: 

Dryness of the mouth because of thickened, 

reduced, or absent salivary flow; increases the 

risk for infection and compromises speaking, 

chewing, and swallowing. Medications other 

than chemotherapy agents, such as psychotropic 

and some antihypertensive drugs, can also cause 

salivary gland dysfunction. Persistent dry 

mouth increases the risk of dental cavities.

Additional Readings

Elting LS, Cooksley C, Chambers MS, Garden AS. 

Risk, outcomes, and costs of radiation-induced 

oral mucositis among patients with head-and-neck 

malignancies. Int J Radiat Oncol Biol Phys 2007; 

68:1110-1120.

Elting L, Cooksley C, Chambers M, Cantor S, 

Manzullo E, Rubenstein E. The burdens of cancer 

therapy: clinical and economic outcomes of 

chemotherapy-induced mucositis. Cancer. 2003; 

98:1531-1539.

Jellema AP, Slotman BJ, Doornaert P, et al.: Impact 

of radiation-induced xerostomia on quality of life 

after primary radiotherapy among patients with head 

and neck cancer. Int J Radiat Oncol Biol Phys 2007; 

69(3):751-60. 

Keefe DM, Schubert MM, Elting LS, et al. Updated 

clinical practice guidelines for the prevention 

and treatment of mucositis. Cancer. 2007 Mar 1; 

109(5):820-31. Online at http://www.mascc.org/mc/

page.do?sitePageId=87007.(Accessed July 2009)

National Cancer Institute. Mucosal Injury in Cancer 

Patients: New Strategies for Research and Treatment. 

JNCI Monographs, No. 29, 2001.

National Cancer Institute. PDQ® Cancer 

Information Summaries. Oral Complications of 

Chemotherapy and Head/Neck Radiation. Online 

at http://www.cancer.gov/cancertopics/pdq/

supportivecare/oralcomplications/healthprofessional 

(accessed July 2009) or from the Cancer Information 

Service at 1–800–4–CANCER.

Schubert MM, Appelbaum FR, Peterson DE, Lloid 

ME: Oral complications. In: Blume KG, Forman SJ, 

eds.: Thomas’ Hematopoietic Cell Transplantation. 

3rd ed. Malden, Mass: Blackwell Science Inc., 2004, 

pp 911-28. 

Shiboski CH, Hodgson TA, Ship JA, Schiødt M. 

Management of salivary hypofunction during and after 

radiotherapy. Oral Surg Oral Med Oral Pathol Oral 

Radiol Endod 2007; 103(suppl 1):S66.e1-S66.e19.

Sonis ST, Elting LS, Keefe D, et al. Perspectives on 

cancer therapy-induced mucosal injury: pathogenesis, 

measurement, epidemiology, and consequences for 

patients. Cancer. 2004; 100(9 Suppl):1995-2025.

Spielberger R, Stiff P, Bensinger W, et al. Palifermin for 

oral mucositis after intensive therapy for hematologic 

cancers. N Engl J Med 2004; 351:2590-2598.
Reprinted September 2009 Publication No. 09–4360

Oral Health, Cancer Care, and You

This fact sheet is part of the series, Oral Health, Cancer Care, and You: Fitting the Pieces Together,

focused on managing and preventing oral complications of cancer treatment. The series was 

developed by the National Institute of Dental and Craniofacial Research in partnership with the 

National Cancer Institute, the National Institute of Nursing Research, and the Centers for Disease 

Control and Prevention. Publications in this series include:

For Health Professionals:

Dental Provider’s Oncology Pocket Guide

Oral Complications of Cancer Treatment: 

What the Dental Team Can Do 

Oncology Pocket Guide to Oral Health 

Oral Complications of Cancer Treatment: 

What the Oncology Team Can Do 

For Patients:

Chemotherapy and Your Mouth

Quimioterapia y la boca 

Head and Neck Radiation and Your Mouth

Su boca y el tratamiento de radiación en 

la cabeza y el cuello

Three Good Reasons to See a Dentist 

BEFORE Cancer Treatment

Tres buenas razones para ver a un dentista 

ANTES de comenzar el tratamiento contra el cáncer 

Three Good Reasons to See a Dentist 

BEFORE Cancer Treatment (illustrated booklet 

for adults with limited reading skills) 

For free copies of these publications:

Order online at www.nidcr.nih.gov and click on 

“Oral Health” or contact:

National Institute of Dental and Craniofacial Research

National Oral Health Information Clearinghouse

1 NOHIC Way

Bethesda, MD 20892–3500

1–866–232–4528

This publication is not copyrighted.

Make as many copies as you need.

Centers for Disease 

Control and Prevention