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Dental Health and Cancer Survivors
Ernest H. Rosenbaum, MD

Dental Care during Cancer Treatment
Ways to Help Prevent Side Effects
Sore Mouth
Peridontitis
Taste Blindness
Optimal Dental Health

Many medications and special cancer treatments affect parts of the body that are not directly associated with the specific disease. Likewise, bacteria and infections in other parts of the body can have a magnified impact at crucial times in cancer therapy when the immune system is in a weakened state. Health of the mouth, gums, and teeth are seldom the first thing that comes to mind in this regard, but some treatments like radiation therapy, have consistent impacts on dental health, and common infections of the teeth and gums can exert significant effects when the white blood cell count is low, as it may be at times during cancer therapy.

There is a well known relationship between dental disease and health.1 It is recognized in heart disease,2 where chlamydia infections are related to coronary artery disease, and newer evidence has related periodontal disease to cancer.

Periodontal disease is defined as unhealthy teeth and gums, which can become a health risk. Gingivitis, a mild inflammation of the gums, is a preventable disease process. It is usually controlled with good mouth care with regular brushing and flossing to remove food particles and plaque on the teeth, reducing the chance of tartar (plaque accumulations along the gum line), which often requires cleaning by a dentist for plaque removal.

Periodontitis can become a serious problem when the inflammatory problem is accentuated and can cause a loss of teeth and bone structure, as well as chronic gum disease. An association has been shown3 between periodontitis and heart, stroke and cancer problems due to systemic infections. Pregnant women with periodontal gum disease often have premature births. Smoking tobacco and/or marijuana can cause periodontal disease.


Dental Care during Cancer Treatment
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The many problems involved with cancer treatments, such as lack of time, lengthy transportations, and family responsibilities, can often cause dental care to be overlooked. Yet, the care of the teeth, gums, and lining of the mouth (mucosa) has great importance as a part of total body care and is vital to promoting better health.

Approximately one-third of cancer survivors experience major dental side effects during treatment. For those who have these side effects, proper mouth care plays a major role in their ability to speak clearly and to get appropriate nutrition, as mouth condition affects the ability to eat and to swallow.

Many of the side effects can be managed by the healthcare team (oncologist, nurse, and dentist). Sometimes specialists for mouth, teeth and gum requirements are needed, such as an oral surgeon (specializing in the mouth and jaw), periodontists (specializing in gum treatment), or prosthodontists (specializing in replacing teeth and gum repair). The advice and treatments of dental specialists is advised, Preventive techniques can help manage dental side effects. Information about what is necessary should be given before anti-cancer treatments begin. Additional information should be added as treatments proceed, highlighting possible side effects. Radiation to the head and neck or high-dose chemotherapy, for example, often cause major mouth and throat side effects, affecting swallowing and eating. Treatment can also cause ulcerations, pain and injury to the mouth and gums.

Other problems, such as dry mouth (xerostomia), mouth sores, mucositis, cavities and tooth decay (caries), swallowing difficulties (dysphasia), infections, inflammation, and pain of the mouth and tongue, need to be addressed as part of medical treatment. With appropriate care, symptoms can be partially or completely relieved.

Some symptoms are short-term, and others can be long-term. For example, dry mouth following radiation therapy may be a persistent problem for months, even years or permanently. There commonly can be radiation damage to the salivary glands causing a lack of saliva and, thus, a dry mouth. Discussion with your doctor and dentist about treatments, side effects, and how to resolve problems can be helpful. This is most important for those receiving head and neck radiation, high-dose chemotherapy or bone marrow transplant.

Often, following radiation, there is a progressive increase of dental caries and tooth decay requiring treatment. Loss of taste, gum sores and jaw stiffness are not uncommon. These effects can be temporary or long-lasting.

Sometimes defective or loose teeth need to be removed before treatment with head and neck radiation. This can help prevent radioosteonecrosis (jawbone damage). Sometimes special fluoride treatments can be used as a preventive, decreasing the risk of dental decay.

Chemotherapy has many side effects. About two-thirds of patients receiving high dose chemotherapy and about a third receiving standard chemotherapy have dental and mouth problems. Some of the symptoms are infections, burning tongue, and changes or loss of taste. Leukemia patients who receive high-dose induction chemotherapy or stem cell/bone marrow transplants usually have an increased risk of side effects.

Other chemotherapy drugs, such as 5-flouracil, can cause mouth sores during or soon after treatment. This may require chemotherapy dose adjustments to help reduce toxic side effects. Medications are used to help control some of the side effects, but they can also cause a dry mouth. Sometimes teeth can become more yellow, but there is little current evidence that this is caused by chemotherapy. Mouth rinses with chemicals, such as chlorohexadine, can cause tooth discoloration.

New technologies are now being developed to help reduce some of the side effects, such as the drug palifermin (Kepivance®), which has been approved by the U.S. FDA to help reduce the risk of mouth sores for patients on high-dose chemotherapy. Palifermin is an intravenous drug that is often given before transplants.


Ways to Help Prevent Side Effects
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Many of the dental side effects of cancer treatment can be prevented or reduced by proper preparation. Here are a few important steps.

Always visit a dentist at least a few weeks before starting cancer treatment to correct defects. The dentist can give appropriate advice about mouth and teeth care. Dental procedures such as removal of decayed, rotten, or loose teeth should be performed before treatment.

Make sure you receive information on how to prevent dental side effects. Ask for dental preventive literature. It is important to brush your teeth gently two times a day and floss regularly.

Special instructions may be necessary for those receiving chemotherapy, especially when white counts (neutrophils) are low, as there is increased risk for both bleeding and infection.

Side Effect Management
The medical team will advise you how to reduce side effects such as bleeding, pain, mouth care, and tongue problems. Mouth rinses with salt and soda are helpful for mouth sores. For those with high blood pressure, avoid preparations containing a lot of salt. Pain control, using narcotics as necessary, for mouth sores may be needed. There are also medications that can be directly placed on mouth sores to obtain relief.

Use of antibiotics and antifungal medications for thrush or yeast infections are important treatments. Hydration is important, and using sugarless drinks can help dry mouth problems. Some use ice chips, which are placed in the mouth for sucking, and sometimes soda and fruit drinks need to be avoided.

Smoking, chewing tobacco, or drinking alcohol requires total abstinence, because it promotes dry mouth and mouth and gum damage.

Radiation therapy to the head and neck often causes dry mouth. Relief measures can be prescribed by the radiotherapist and dental specialists.


Sore Mouth
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The lining, or mucosa, of the gastrointestinal tract - which includes the inside of the mouth and throat - is one of the most sensitive areas of the body. Many chemotherapy drugs can inflame the lining, a condition called mucositis. Many drugs can also cause small ulcerations or sores to develop. Radiation delivered to the head and neck can irritate the lining and cause sores, too, and so can mouth or throat infections, especially fungus infections like monilia (thrush). All these can be very painful or at least uncomfortable and usually respond well to treatments.

Mouth care is very important to control mucositis. You will have to make sure your mouth stays clean and moist and that you eat the proper foods prescribed by your doctor or dentist and get and use medication for any infections that develop.

A good oral hygienic program includes dental cleaning and scaling, followed by daily brushing and flossing to reduce plaque.

Mouth Sores
If the soreness in your mouth becomes severe, there are quite a few anesthetic agents you can use on a short-term basis. If your symptoms persist, you should have a complete dental hygienic evaluation.

Benadryl elixir, lozenges and analgesics may help reduce mouth pain. Swishing and swallowing the anesthetic jelly viscous Xylocaine or spraying Hurricane (TM) spray can also help you eat especially if you have pain in your mouth, pharynx or esophagus. It may help to swish diluted milk of magnesia, sucralfate (Carafate®) slurry or Mylanta around your mouth. Orabase® - with or without Kenalog® - is a dental salve that covers mouth sores while they are healing. You may have to apply it several times a day.

Infections
Mouth infections can be dangerous and have to be cared for.

You should examine your mouth every day for any irritation or early fungus growth (white spots inside your mouth that don't wash off). Look under your tongue and at the sides of your mouth and report any changes to your doctor. If you do get an infection, especially viral and fungal, it should be treated promptly. See your doctor if any questions.

If you have a herpes virus - acute or recurrent - your doctor may prescribe oral acyclovir. Monilia requires antifungal agents, including mycostatin oral suspension Nizoral® tablets, Mycelex® troches or Mycostat® pastilles. You can freeze Nystatin® Liquid in medicine cups in the refrigerator and let it melt in your mouth.


Peridontitis
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Regular visits to your dentist and scheduling a visit well before the beginning of cancer therapy are important, though often neglected parts of cancer treatment. Familiarity with the causes and signs of periodontal disease can help guide you toward more effective dental health, thereby promoting better overall health.

Before any dental work is to be performed, your blood counts should be checked to be sure that they are adequate to take care of any possibility of infection or bleeding (low white cell counts can lead to infections and a low platelet count may lead to bleeding). So any periodontal or dental work has to be coordinated with your oncologist. If you have any mouth injury because of a dental procedure, antibiotics are certainly recommended.

Causes of periodontal disease
Periodontal disease can cause loss of teeth. It may be prevented with good dental care.
- Smoking causes a decrease in oxygen to the gums, which enhances bacterial growth, invasion, inflammation, and infection.
- Poor dental hygiene (not brushing and flossing at least twice a day) allows plaque and tartar to build up, causing unhealthy gums.
- Certain medications can cause gingival gum overgrowth (hyperplasia) and/or receding gums.
- Vitamin and mineral deficiency and poor nutrition promote periodontal disease. Follow healthy eating habits as best as you can to help promote healing.
- Chronic illnesses (comorbidities), such as diabetes, are associated with an increased rate of infections, poor healing, and periodontal disease.

Signs and symptoms of periodontal disease:
- Receding, swollen, puffy and painful gums.
- Bleeding after brushing teeth.
- Loose teeth or tooth loss.
- Gum infections, often with pus.
- Bad breath that is chronic and does not go away.

Preventive gum care:
- Brush teeth at least twice a day.
- Floss daily.
- Visit dentist.
- Do not smoke cigarettes, chew tobacco or use marijuana or narcotics.
- Treat comorbidities, especially diabetes. Normal blood sugar levels reduce the risk of infection.
- Eat a healthy diet, especially with fruits and vegetables, for vitamins and minerals. Nutritional supplements are not a replacement for a healthy diet.

With advanced periodontitis, surgery, occasionally even bone grafts, and antibiotics are necessary.

Taste Blindness
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Many chemotherapy drugs can change your sense of taste and smell. What these changes are depends on the individual, but they are most common with foods that are either very sweet or very bitter. Oddly enough, sweet foods might taste sour and sour foods could taste sweet. Chewed meat may have a bitter taste because of the release of proteins in your mouth. Sometimes there is a continuous metallic taste in your mouth after chemotherapy, which naturally enough can affect what you eat and how you eat.

Help for Taste Blindness:
Taste changes may not last long, but while you are experiencing them, you can do several things to lessen their effect.
- Brush your teeth several times a day and use mouth rinses such as diluted bicarbonate of soda.
- If foods and beverages taste bitter, add sweet fruits, honey or NutraSweet.
- If meat tastes bitter, substitute bland chicken or fish, eggs and mild cheeses or tofu. All of these might taste better if you use them in casseroles or stews.
- It will also help if you marinate meats, chicken or fish in pineapple juice, wine, Italian dressing, lemon juice, soy sauce or sweet-and-sour sauces.
- Add whatever flavorings you enjoy, but avoid spicy, highly seasoned foods.
- You might find that starchy foods such as bread, potatoes and rice have a more acceptable taste if you eat them without butter or margarine.

Optimal Dental Health
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It is important to maintain strong, healthy bones (a healthy jaw) to support healthy teeth.

Drugs that can be helpful include:
1,000 IU vitamin D. Fortified milk has vitamin D. Yogurt and other dairy products are good sources of vitamin D. 15 minutes of sunshine on skin without sun block daily helps provide additional vitamin D. Vitamin D supplements can help as the majority of the US population is Vitamin D deficient. 1,000-1,500 mg of calcium daily (see Osteoporosis And Cancer Survivorship). Review vitamin D and calcium needs with your doctor or nutritionist.

Osteoporosis (weakened bones) can also play a role and can cause tooth problems. There are many bisphosphonates medications to reduce bone thinning and actually promote bone strengthening as a preventive for osteoporosis and osteopenia. Bisphosphonates come in both oral and intravenous form, such as Fosamax®, Alendronate®, Zometa®, and Boniva.®

Conclusion
Preparation for cancer treatment should include a thorough dental checkup and a follow-up for any indicated repairs. Monitoring dental health during cancer treatment is an important part of maintaining long-term health. Some dental conditions may actually be side effects of cancer treatments or related medications. Following a few preventive guidelines and adding some simple remedies to the daily routine can help avoid many common dental discomforts, and often circumvent an unexpectedly dangerous health hazard.

References
1
American Dental Association (www.ada.org)
2
American Heart Association (www.heart.org)
3
Periodontal Disease JAMA Vol. 299 No. 5, February 6, 2008


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First appeared September 9, 2009; updated August 7, 2011