Oral Complications of Cancer Treatment:

What the Dental Team Can Do

With over 1.4 million new cases of 

cancer diagnosed each year and a shift to 

outpatient management, you will likely see 

some of these patients in your practice. 

Because cancer treatment can affect the 

oral tissues, you need to know about 

potential oral side effects. Preexisting or 

untreated oral disease can also 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 compromise 

patients’ health and quality of life, and 

affect their ability to complete planned 

cancer treatment. For some patients, 

the complications can be so debilitating 

that they may tolerate only lower 

doses of therapy, postpone scheduled 

treatments, or discontinue treatment 

entirely. Oral complications can also lead 

to serious systemic infections. Medically 

necessary 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). Some cancer 

treatments are described as stomatotoxic 

because they have toxic effects on the 

oral tissues. Following are lists of side 

effects common to both chemotherapy 

and radiation therapy, and complications 

specific to each type of treatment. You 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 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. 

• Functional disabilities: impaired ability 

to eat, taste, swallow, and speak because 

of mucositis, dry mouth, trismus, and 

DENTAL TEAM

infection. 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Institute of Dental and Craniofacial Research
•	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. 

Other 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. 

Other 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 highdose radiation therapy; results in 

decreased ability to heal if traumatized. 

Who Has Oral Complications?

Oral complications occur in virtually all 

patients receiving radiation for head and 

neck malignancies, in approximately 80 

percent of hematopoietic (blood-forming) 

stem cell 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 hematopoietic 

stem cell 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, patients 

with cancer do not always receive oral care 

until serious complications develop.

The Role of Pretreatment 

Oral Care

A thorough oral evaluation by a 

knowledgeable dentist 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. 

2 What the Dental Team Can Do
•	Improves the likelihood that the patient 

will successfully complete planned 

cancer treatment. 

•	Prevents, eliminates, or reduces oral pain. 

•	Minimizes oral infections that could lead 

to potentially serious 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

Ideally, a comprehensive oral evaluation 

should take place a month before cancer 

treatment starts to allow adequate time 

for recovery from any required invasive 

dental procedures. 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. 

•	Extract teeth in the radiation field that 

are nonrestorable or may pose a future 

problem to prevent later extractioninduced osteonecrosis.

•	Conduct a prosthodontic evaluation 

if indicated. If a removable prosthesis 

is worn, make sure that it is clean and 

well adapted to the tissue. Instruct the 

patient not to wear the prosthesis during 

treatment, if possible; or at the least, not 

to wear it at night. 

•	Perform oral prophylaxis if indicated.

•	Time oral surgery to allow at least 

2 weeks for healing 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.

What the Dental Team Can Do 3
Remove orthodontic bands and brackets 

if highly stomatotoxic chemotherapy is 

planned or if the appliances will be in the 

radiation field. 

•	

Consider extracting highly mobile primary 

teeth in children, 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.

•	

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

Brush teeth, gums, and tongue gently 

with an extra-soft toothbrush and fluoride 

toothpaste after every meal and before 

bed. If brushing hurts, soften the bristles 

in warm water. 

•	

Floss teeth gently every day. If gums are 

sore or bleeding, avoid those areas but 

keep flossing other teeth. 

•	

4 What the Dental Team Can Do

Supplemental Fluoride

Fluoride rinses are not adequate to prevent tooth 

demineralization. Instead, a high-potency fluoride gel, 

delivered via custom gel-applicator trays, is recommended. 

Several days before radiation therapy begins, patients should 

start a daily 10-minute application of a 1.1% neutral pH 

sodium fluoride gel or a 0.4% stannous fluoride (unflavored) 

gel. Patients with porcelain crowns or resin or glass ionomer 

restorations should use a neutral pH fluoride. Be sure that 

the trays cover all tooth structures 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. Either 1.1% neutral pH sodium or 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 

10 minutes. If gel oozes out of the tray, you are using 

too much. 

•	

After 10 minutes, remove the trays and spit out any 

excess gel. Do not rinse. 

•	

•	 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 rinse. 

•	 Do not eat or drink for 30 minutes. 
•	Follow instructions for using fluoride gel. 

•	Avoid mouthwashes containing alcohol. 

Rinse the mouth with a baking soda 

and salt solution, followed by a plain 

water rinse several times a day. (Use 

1/4 teaspoon each of baking soda and 

salt in 1 quart of warm water.) Omit salt 

during mucositis.

•	

Exercise the jaw muscles three times a 

day to prevent and treat jaw stiffness from 

radiation. 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.

•	

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. 

– Suck ice chips or sugar-free candy. 

– Chew sugar-free gum. 

– Use a saliva substitute spray or gel 

or a prescribed saliva stimulant 

if appropriate.

– Avoid glycerin swabs.

Take precautions to protect 

against trauma. 

•	

Provide topical anesthetics or 

analgesics 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 

determine whether the patient’s platelet 

count, clotting factors, and absolute 

neutrophil count are sufficient to 

recommend oral treatment. Postpone oral 

surgery or other oral invasive procedures if: 

platelet count is less than 75,000/mm3 or 

abnormal clotting factors are present. 

•	

absolute neutrophil count is less 

than 1,000/mm3

 (or consider 

prophylactic antibiotics).

•	

What the Dental Team Can Do 5
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.

Evaluate need for antibiotic prophylaxis.

If the patient has a central venous catheter, 

consult the oncologist to determine 

if antibiotics are needed before any 

dental treatment to prevent endocarditis 

(www.americanheart.org). 

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 stem cell transplantation. Ask 

if the patient has received intravenous 

bisphosphonate therapy.

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 xerostomia, dental caries, 

and osteonecrosis.

•	

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. 

•	

6 What the Dental Team Can Do

Normal Complete 

Blood Count

Red blood cells Male: 4.7 – 6.1 million 

cells/mcL 

Female: 4.2 – 5.4 million 

cells/mcL

Hemoglobin Male: 13.8 – 17.2 gm/dL 

Female: 12.1 – 15.1 gm/dL 

Hematocrit Males: 40.7 – 50.3% 

Female: 36.1 – 44.3%

Platelets 150,000-400,000/mm3

White blood cells 4,500-10,000 cells/mcL

Differential White Blood Cell 

(WBC) Count

Neutrophils 

(PMNs)

40 - 60% (3000-6000/mm3)

Neutrophils 

(Bands)

0 - 3% (0-300/mm3

)

Eosinophils 1 - 4% (50-400/mm3

)

Basophils 0.5 - 1% (15-50/mm3

)

Lymphocytes 20 - 40% (1200-3000/mm3

)

Monocytes 2 - 8% (100-600/mm3

)

Absolute Neutrophil Count = WBC x (% PMNs + %Bands)

Source: A.D.A.M. Medical Encyclopedia [Internet]. 

Atlanta (GA): A.D.A.M., Inc.; ©2005. CBC; [updated 

2006 Sept 11; cited 2008 Sept 10]; WBC; [updated 

2007 Mar 7; cited 2008 Sept 10]; [about 4 p.]. 

Available from: http://www.nlm.nih.gov/medlineplus 

/ency/article/003642.htm; http://www.nlm.nih.gov 

/medlineplus/ency/article/003643.htm.
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 in patients 

with oral and head and neck cancers, 

and thoroughly examine all oral mucosal 

tissues at recall appointments. 

•	

Special Considerations for 

Hematopoietic Stem Cell 

Transplant Patients

The intensive conditioning regimens 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.

Additional Readings

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; 109(5):820-31. Online at 

http://www.mascc.org/content/125.html 

(Accessed September 2008)

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 September 2008) 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 therapyinduced mucosal injury: pathogenesis, 

measurement, epidemiology, and 

consequences for patients. Cancer

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

What the Dental Team Can Do 7
Revised September 2008 Publication No. 08–4372

Oral Health, Cancer Care, and You

This fact sheet is part of a series on managing and preventing oral complications of cancer treatment sponsored 

by the National Institute of Dental and Craniofacial Research. The series was developed in partnership with 

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

and Prevention. Other publications in this series include:

For Health Professionals

Dental Provider's Oncology Pocket Guide 

Oral Complications of Cancer Treatment: 

What the Oncology Team Can Do 

Oncology Pocket Guide to Oral Health 

For Patients

Chemotherapy and Your Mouth

Quimioterapia y la Boca 

Head and Neck Radiation Treatment 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 contact:

National Institute of Dental and Craniofacial Research 

National Oral Health Information Clearinghouse 

1 NOHIC Way 

Bethesda, MD 20892–3500 

301-402–7364 

www.nidcr.nih.gov