How Does Cancer Therapy Affect Your Oral Health?
By Lauren Levi, DMD
Recently developing a mouth sores, she found herself feeling listless and impotent. When I greeted my patient that morning, she complained of severe mouth sores and difficulty eating. Diagnosed with metastatic breast cancer two years ago, she had two previous surgeries and a history of chemotherapy but she had never before experienced dental complaints throughout her treatment. Alarmed and frustration by this recent side effect, she expressed concern that she might lose weight given her difficulty eating. Upon physical examination, I noticed generalized mouth sores with an overlying fungal infection. I explained to her that the mouth sores, also known as mucositis, are a common side effect of chemotherapy. Although still in pain, she expressed relief upon reaching a diagnosis for her condition. I reassured her that the mouth sores are transient and prescribed her an anti-fungal medication as well as a mouth rinse for her sores. She returned two weeks later from my office no longer complaining of an itching or burning sensation in her mouth.
Indubitably, cancer therapy, including chemotherapy, may result in several side effects including those affecting the oral cavity. Nonetheless, it is important to note that the side effects typically resolve when patients end their treatment. Chemotherapy interferes with the metabolism and reproduction of tumor cells. In the process of altering the metabolism and reproduction of these cells, chemotherapy also affects other rapidly dividing cells in the body including the cells responsible for defending the body. In other words, chemotherapy affects the immune system. Typically, the side effects of chemotherapy discussed below are seen when the blood cell counts (including the white blood cells and platelets) drop.
Oral mucositis
Oral mucositis or more colloquially known as mouth sores is a condition characterized by sloughing of the oral mucosa and the presence of red and white intraoral ulcers. It affects approximately 40% of patients undergoing chemotherapy. Traditionally, oral mucositis erupts two weeks after receiving high dose chemotherapy. Mucositis is most commonly seen on the movable tissues of the mouth. In other words, oral mucositis frequently has a predilection for the cheeks, tongue, floor of the mouth, and the soft palate. Often it resolves when the blood counts recover.
How to treat/manage it
Prophylactic measures such as practicing good oral hygiene and avoiding spicy, hot, and acidic foods may help prevent the degree of mucositis experienced. Nonetheless, it is difficult to predict whether or not someone will experience oral mucositis as even those with impeccable oral hygiene may develop oral mucositis. It is important to note, however, that practicing good oral hygiene and visiting a dentist prior to undergoing high dose chemotherapy has been associated with decreasing the duration of mucositis. There are several treatments that may help to alleviate the pain associated with mucositis including bland rinses, mucosal coating agents, and magic mouthwash. It is also recommended that patients who wear dentures abstain from wearing their dentures until after the mucositis has resolved.
Oral infections
Patients undergoing chemotherapy who are not on prophylactic medications may develop bacterial, fungal, and viral infections. The bacterial infections experienced may erupt secondary to mucositis. The viral infections that may occur are often herpetic in nature such as cold sores (herpes simplex virus) and shingles (varicella zoster virus) and usually resolve as the white blood cell count increases.
How to treat/manage it
These infections can all be controlled with appropriate medications. Patients with fungal infections who wear dentures should also treat their dentures with an anti-fungal medication.
Neuropathy
Surprisingly, certain chemotherapies (vinca alkaloids) may result in neuropathies and mimic a toothache in teeth with no evidence of dental caries (cavities) or infection. These chemotherapeutic agents are also associated with peripheral neuropathy (tingling and loss of sensation of the fingers and toes) which manifests differently in the jaw resulting in the sensation of a toothache.
How to treat/manage it
Visiting the dentist for a thorough evaluation is essential to adequately diagnose the etiology of the toothache. Patients should provide a detailed history of their cancer treatment. The phantom toothache usually resolves within a week of completing the associated therapy.
Xerostomia/Hyposalivation
Xerostomia is the medical term for the sensation of dry mouth. Hyposalivation signifies a reduction in salivary flow and is an objective, measurable entity. Saliva acts as a natural buffer in the mouth, bathing and lubricating the teeth and oral tissues. Thus, reduced salivary flow leaves patients prone to an increased risk for dental decay. In addition to reduced flow, the saliva produced is ropey, thick and predominantly mucus. Xerostomia is associated with taste alterations, difficulty swallowing and difficulty speaking.
How to treat/manage it
Chemotherapy-associated dry mouth usually subsides when the therapy ends. Even so, because dry mouth is associated with an increased risk for dental decay, it is important to visit the dentist regularly and maintain good oral hygiene to help prevent cavities. Drinking water frequently, sleeping with a humidifier and rubbing olive oil on the oral tissues may help to alleviate the symptom of dry mouth. There are several other over the counter salivary substitutes.
About Lauren Levi, D.M.D.
As a general dentist with advanced training in dental oncology, Dr. Lauren Levi delivers comprehensive oral care to cancer patients in a warm, supportive, and gentle environment in New York, New York. After receiving her D.M.D. at the University of Florida College of Dentistry, Dr. Levi completed a general practice residency at New York Presbyterian-Weill Cornell Medical Center. During her residency, Dr. Levi rotated through Memorial Sloan Kettering Cancer Center, where she discovered her passion for dental oncology. She then pursued a fellowship in dental oncology at Memorial Sloan Kettering Cancer Center. This training equipped her with extensive experience performing dental treatment on patients who are receiving chemotherapy, radiation therapy, and stem cell transplants and those who may face individual dental needs because of these treatment programs.
For more information on dental oncology, visit http://www.laurenlevidmd.com.
Further Reading
Little, James W. Dental Management of the Medically Compromised Patient. St. Louis: Mosby, 2002. Print.
Oral Complications of Cancer Treatment: What the Dental Team Can Do. NIH, n.d. Web. 4 Dec. 2014.
“Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®.” National Cancer Institute. N.p., n.d. Web. 19 Nov. 2014.
Neville, Brad W. Oral and Maxillofacial Pathology. St. Louis, MO: Saunders/Elsevier, 2009. Print.