Metrics details. Oral complications may be observed during chemotherapy and are important side effects that may directly affect the anticancer treatment, even causing septicaemia in some cases.
Chemotherapy-induced Oral Mucositis
The study design was longitudinal, 45 patients were evaluated and monitored for 1 month after the initiation of chemotherapy. The results show an increase in the number of mucositis cases and a decrease in xerostomia cases after the initiation of treatment, and other oral lesions were also found in low numbers.
It is possible to avoid oral complications by maintaining a good oral health, and reducing infectious outbreaks. This outcome requires the presence of a dental surgeon on the multidisciplinary cancer treatment team. Cancer is a term used to describe a group of diseases that involve the uncontrolled growth of cells [ 1 ].
In recent decades, cancer has become a serious global public health problem. The World Health Organisation WHO has estimated that in the year , there will be 27 million incident cases of cancer, 17 million deaths from cancer, and 75 million people each year living with cancer. The regions most affected by these increases are developing countries [ 2 ].
Infant-juvenile cancers differ from adult cancers in many respects, such as types, sites, aetiologies, characteristics, and treatments [ 1 ]. This fact is particularly troubling when one considers that younger individuals comprise a large proportion of the Brazilian population. There has been an improvement in the survival rates of children with cancer due to dosage intensification and the combination of chemotherapy drugs, which has also led to success in the cancer treatment healing response [ 4 — 6 ].
Chemotherapy acts by destroying or inhibiting the growth of rapidly multiplying cells, without differentiating cancer cells, which proliferate rapidly, from normal cells, such as the oral mucosa [ 7 ]. The following oral manifestations related to anticancer treatment are commonly found: mucositis, xerostomia [ 10 , 11 ], infections, salivary gland dysfunction, dysgeusia, and pain [ 12 ]. The individuals were evaluated on two occasions approximately 1 month after the initiation of chemotherapy.
When individuals were admitted to HEINSG and diagnosed with a malignant neoplasm, at the first study stage, an interview and clinical examination were performed before or within 3 days of starting chemotherapy. At this stage, data regarding oral health and sociodemographic characteristics, such as gender, age, place of birth, education, maternal education, and socioeconomic status, were collected. Being a public referral hospital usually the patients treated are less favored socioeconomic status.
The Economic Classification of individuals followed the New Economic Classification Standard Criteria of Brazil, which aims to discriminate large groups of people according to their consumption capacity of accessible products and services to a significant portion of the population and classify households, assuming, as an assumption that the class is a familiar feature among others. According to this criterion individuals can be classified into five classes A, B, C, D and E, and class A is the best economic status and class E the worst economic condition [ 13 ].
For information about xerostomia, mucositis, oral candidiasis, herpes simplex and cold sore, a clinical examination was conducted after completing the interview. A preparation was made through pictures of the most common oral alterations that would be expected to be found in the study group. Through sialometry it is possible to evaluate the production of unstimulated saliva, or by chemical, mechanical or gustatory stimulation [ 14 ].
Individuals commonly produce 0. The test was performed after 1. When the sialometry test performed in patients obtained a measure less than 0.
Chemotherapy Clearance and Management of Oral Complications
Mucositis was diagnosed via clinical examination by evaluating the appearance of the oral mucosa. Mucositis was not graded according to severity but was considered absent or present according to whether a change in the mucosa was noted on any of the severity scales discoloration, erythema, pseudomembrane, or deep ulceration proposed by the WHO [ 16 ].
Complications including oral candidiasis, labial herpes simplex, and mouth ulcers were evaluated by visual clinical examination [ 17 ]. A descriptive analysis was performed on the sociodemographic characteristics and oral manifestations of the participants at the three study stages, according to their respective frequencies and percentages.
The Kappa statistic was used to measure concordance in cases in which a particular individual presented an oral manifestation at the next stage. All parents or guardians of the participants signed the consent form and previously clarified data collection. Between the months April and , a total of 66 children and adolescents were admitted to HEINSG diagnosed with cancer to make chemotherapy. In 15 of these patients it was not possible to approach Fig. The initial study population was composed of 51 individuals so. The final sample size was 45 children and adolescents at the second evaluation 1 month after the initial examination.
It was not possible to follow six patients between the 1st and 2nd moments described in Fig. The prevalence of mucositis considerably increased between the first and second study stages, rising from 3. The prevalence of Xerostomia considerably decreased between the first and second stages, falling from 31 to 7. Many national and international studies in the literature show a correlation between anticancer treatments, particularly chemotherapy, and the occurrence of oral complications in infant-juvenile patients and adults [ 8 , 11 , 18 — 27 ], and the magnitude of these side effects depends on a number of factors related to the treatment, tumour, and patient [ 23 ].
A less favored socioeconomic status is usually related to a greater number of oral diseases such as caries, i. In this study, however this association was not proven statistically, probably because patients studied belonged mostly to classes B, C and D, with a greater concentration in class C, which made it difficult to compare the classes. Our results therefore showed that oral manifestations were not related to the socioeconomic status of patients.
Oral mucositis is defined as an inflammation and ulceration of the oral mucosa [ 28 — 32 ] and is one of the most common and frequent lesions in cancer patients undergoing chemotherapy. It is a major cause of pain and also represents a distressing experience for cancer patients [ 33 , 34 ]. In this study, an increase in oral mucositis cases was observed between the first and second stages.
In addition, mucositis was the most common oral manifestation found in the clinical examination conducted 1 month after the beginning of chemotherapy. Other authors [ 26 ] have observed mucositis percentages higher than those found in this study. This finding was likely due to the small sample, which included only 12 individuals. However, in general, the results reported in the literature have been higher than those found in this study, which is likely due to favourable oral health conditions before the initiation of treatment, with a low percentage of oral diseases, which reduces the risk of developing oral manifestations during treatment [ 7 ].
In this study, children and adolescents with various types of cancer were examined, which may, to some extent, be responsible for the low prevalence of mucositis, whereas in studies concentrating solely on leukaemia patients, generally speaking, a higher prevalence of oral manifestations was encountered because leukaemia is characterised by a high incidence of oral lesions during treatment [ 35 ]. Tests used in this study for measuring salivary flow were an adaptation of the standards proposed by the World Health Organization for quantification of xerostomia as a side effect of chemotherapy.
In the present study, patients evaluated were children and adolescents who showed a severe general condition, sometimes incapacitating, so we chose to perform this adaptation in sialometry test, reducing saliva collection time. In this study, the number of xerostomia cases declined between the first and second stages. Different results were found by other estudos [ 11 , 24 ] of leukaemic patients [ 27 ] in which there was an increase in the number of cases of xerostomia between stages.
A low prevalence of oral candidiasis was found in this study, which is consistent with other studies [ 24 ] and differs from the results obtained in one study [ 27 ] of leukaemia patients. The low prevalence of oral candidiasis a result of the myelosuppression caused by chemotherapy agents was likely due to the use of antifungal drugs that act topically and also systemic during the treatment [ 35 ] of most patients. These medicaments were prescribed by the hospital crew at the first signs of oral candidiasis, perhaps this influenced the low prevalence of this disease.
These antifungals are not known to cause salivary flow reduction. Patients with better oral health conditions and satisfactory oral hygiene develop fewer oral manifestations, and those conditions that do occur have a more rapid clinical course [ 35 ]. Studies have reinforced the importance of oral health for the prevention and reduction of oral complications of cancer treatment [ 10 , 31 ], so prior to chemotherapy it is important to perform a Stomatological evaluation and dental care to reduce infectious outbreaks, such as removal of carious lesions and extensive restorations, treatment of periodontal disease and even tooth extractions in cases of teeth that require prolonged treatment, as all infectious processes originated in the oral cavity present a high risk of systemic infection, which can lead to septic episodes in immunocompetent patients compromised by oncologic therapy.
The presence of a dental surgeon working directly on the medical team is essential for the prevention and treatment of oral manifestations resulting from antineoplastic treatment. This dental surgeon can assist with preventing the development of a more severe clinical course, which can even result in the suspension of antineoplastic treatment [ 24 , 35 , 36 ]. The sample size was a limitation of this study. Based on the results observed in this study, it can be concluded that oral manifestations were present, including mucositis, which increased, and xerostomia, which showed a reduction in the number of cases after the start of chemotherapy.
Oral complications, despite their relatively low prevalence, were nonetheless present and are among the most devastating complications in both the short and long term, affecting basic human activities such as eating and communicating. Furthermore, these lesions may interfere with cancer treatment, causing more serious infections or even sepsis. The presence of an active dental surgeon on the multidisciplinary oncology team is therefore indispensable, as they can assist in the prevention, early diagnosis, and treatment of oral manifestations.
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Chemotherapy: oral side effects and dental interventions -a review of the literature
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Drugs Approved for Different Types of Cancer. Drugs Approved for Conditions Related to Cancer. Access to Experimental Drugs. Key Points Oral complications are common in cancer patients, especially those with head and neck cancer. Preventing and controlling oral complications can help you continue cancer treatment and have a better quality of life.
Patients receiving treatments that affect the head and neck should have their care planned by a team of doctors and specialists. Chemotherapy and radiation therapy slow or stop the growth of new cells. Radiation therapy may directly damage and break down oral tissue, salivary glands , and bone.
Chemotherapy and radiation therapy upset the healthy balance of bacteria in the mouth. Oncology nurse. Dental specialists. Speech therapist. Social worker. Before cancer treatment, the goal is to prepare for cancer treatment by treating existing oral problems. During cancer treatment, the goals are to prevent oral complications and manage problems that occur. After cancer treatment, the goals are to keep teeth and gums healthy and manage any long-term side effects of cancer and its treatment. Oral mucositis inflamed mucous membranes in the mouth.
Salivary gland problems. Change in taste. Key Points Cancer treatment can cause mouth and throat problems. Complications of chemotherapy Complications of radiation therapy Complications caused by either chemotherapy or radiation therapy Oral complications may be caused by the treatment itself directly or by side effects of the treatment indirectly. Complications may be acute short-term or chronic long-lasting. Inflammation and ulcers of the mucous membranes in the stomach or intestines.
Easy bleeding in the mouth. Nerve damage. Fibrosis growth of fibrous tissue in the mucous membrane in the mouth. Tooth decay and gum disease. Breakdown of tissue in the area that receives radiation. Breakdown of bone in the area that receives radiation. Fibrosis of muscle in the area that receives radiation. Inflamed mucous membranes in the mouth. Infections in the mouth or that travel through the bloodstream. These can reach and affect cells all over the body. Taste changes. Dry mouth. Changes in dental growth and development in children.
Malnutrition not getting enough of the nutrients the body needs to be healthy caused by being unable to eat. Dehydration not getting the amount of water the body needs to be healthy caused by being unable to drink. Tooth decay. Problems in the mouth and jaw caused by loss of tissue and bone. Problems in the mouth and jaw caused by the growth of benign tumors in the skin and muscle. Key Points Finding and treating oral problems before cancer treatment begins can prevent oral complications or make them less severe.
Prevention of oral complications includes a healthy diet, good oral care, and dental checkups. Patients receiving high-dose chemotherapy, stem cell transplant, or radiation therapy should have an oral care plan in place before treatment begins. It is important that patients who have head or neck cancer stop smoking. Eat a well-balanced diet. Healthy eating can help the body stand the stress of cancer treatment, help keep up your energy, fight infection, and rebuild tissue.
Keep your mouth and teeth clean. This helps prevent cavities, mouth sores, and infections. Have a complete oral health exam. A preventive oral health exam will check for the following: Mouth sores or infections. Gum disease. Dentures that do not fit well. Problems moving the jaw. Problems with the salivary glands. Specific needs of the patient. The radiation dose. The part of the body treated.
How long the radiation treatment lasts. Specific complications that occur. Everyday oral care for cancer patients includes keeping the mouth clean and being gentle with the tissue lining the mouth. Oral Mucositis Oral mucositis is an inflammation of mucous membranes in the mouth. Care of mucositis during chemotherapy and radiation therapy includes cleaning the mouth and relieving pain. Pain There can be many causes of oral pain in cancer patients.
Oral pain in cancer patients may be caused by the cancer. Oral pain may be a side effect of treatments. Certain anticancer drugs can cause oral pain. Teeth grinding may cause pain in the teeth or jaw muscles. Pain control helps improve the patient's quality of life. Infection Damage to the lining of the mouth and a weakened immune system make it easier for infection to occur.
Infections may be caused by bacteria, a fungus, or a virus. Bleeding Bleeding may occur when anticancer drugs make the blood less able to clot. Most patients can safely brush and floss while blood counts are low. Dry Mouth Dry mouth xerostomia occurs when the salivary glands don't make enough saliva. Salivary glands usually return to normal after chemotherapy ends. Salivary glands may not recover completely after radiation therapy ends. Careful oral hygiene can help prevent mouth sores, gum disease, and tooth decay caused by dry mouth.
Tooth Decay Taste Changes Changes in taste dysguesia are common during chemotherapy and radiation therapy. Fatigue Malnutrition Loss of appetite can lead to malnutrition. Nutrition support may include liquid diets and tube feeding. Mouth and Jaw Stiffness Swallowing Problems Pain during swallowing and being unable to swallow dysphagia are common in cancer patients before, during, and after treatment.
Trouble swallowing increases the risk of other complications. Whether radiation therapy will affect swallowing depends on several factors. Swallowing problems sometimes go away after treatment Swallowing problems are managed by a team of experts. Tissue and Bone Loss. Brushing teeth Brush teeth and gums with a soft-bristle brush 2 to 3 times a day for 2 to 3 minutes.
Be sure to brush the area where the teeth meet the gums and to rinse often. Rinse the toothbrush in hot water every 15 to 30 seconds to soften the bristles, if needed. Use a foam brush only if a soft-bristle brush cannot be used. Brush 2 to 3 times a day and use an antibacterial rinse. Rinse often. Let the toothbrush air-dry between brushings. Use a fluoride toothpaste with a mild taste. Flavoring may irritate the mouth, especially mint flavoring.
Rinsing Use a rinse every 2 hours to decrease soreness in the mouth. An antibacterial rinse may be used 2 to 4 times a day for gum disease. Rinse for 1 to 2 minutes. If dry mouth occurs, rinsing may not be enough to clean the teeth after a meal. Brushing and flossing may be needed. Flossing Floss gently once a day. Lip care Use lip care products, such as cream with lanolin , to prevent drying and cracking. Denture care Brush and rinse dentures every day. Use a soft-bristle toothbrush or one made for cleaning dentures.
Clean with a denture cleaner recommended by your dentist. Keep dentures moist when not being worn. Place them in water or a denture soaking solution recommended by your dentist. Do not use hot water, which can cause the denture to lose its shape. Oral mucositis is an inflammation of mucous membranes in the mouth. It usually appears as red, burn-like sores or as ulcer -like sores in the mouth.
Stomatitis is an inflammation of mucous membranes and other tissues in the mouth. These include the gums, tongue, roof and floor of the mouth, and the inside of the lips and cheeks. Mucositis caused by chemotherapy will heal by itself, usually in 2 to 4 weeks if there is no infection. Mucositis caused by radiation therapy usually lasts 6 to 8 weeks, depending on how long the treatment was. In patients receiving high-dose chemotherapy or chemoradiation for stem cell transplant: Mucositis usually begins 7 to 10 days after treatment begins, and lasts for about 2 weeks after treatment ends.
Bleeding, in patients receiving chemotherapy. Patients receiving radiation therapy usually do not have bleeding. Trouble breathing and eating. Clean your teeth and mouth every 4 hours and at bedtime. Do this more often if the mucositis becomes worse. Use a soft-bristle toothbrush. Replace your toothbrush often.
Use lubricating jelly that is water- soluble , to help keep your mouth moist. Use mild rinses or plain water. Frequent rinsing removes pieces of food and bacteria from the mouth, prevents crusting of sores, and moistens and soothes sore gums and the lining of the mouth.
If mouth sores begin to crust over, the following rinse may be used: Three percent hydrogen peroxide mixed with an equal amount of water or saltwater. Try topical medicines for pain. Rinse your mouth before putting the medicine on the gums or lining of the mouth. Wipe mouth and teeth gently with wet gauze dipped in saltwater to remove pieces of food.
Painkillers may help when topical medicines do not. Nonsteroidal anti-inflammatory drugs NSAIDS, aspirin -type painkillers should not be used by patients receiving chemotherapy because they increase the risk of bleeding. Zinc supplements taken during radiation therapy may help treat pain caused by mucositis as well as dermatitis inflammation of the skin. Povidone- iodine mouthwash that does not contain alcohol may help delay or decrease mucositis caused by radiation therapy.
The cancer. Side effects of cancer treatments. Other medical conditions not related to the cancer. A medical history. Physical and dental exams. X-rays of the teeth. The tumor presses on nearby areas as it grows and affects nerves and causes inflammation. Leukemias and lymphomas , which spread through the body and may affect sensitive areas in the mouth. Multiple myeloma can affect the teeth. Brain tumors may cause headaches. Cancer may spread to the head and neck from other parts of the body and cause oral pain. With some cancers, pain may be felt in parts of the body not near the cancer.
This is called referred pain. Tumors of the nose, throat , and lungs can cause referred pain in the mouth or jaw. Physical therapy. TENS transcutaneous electrical nerve stimulation. Applying cold or heat. See the PDQ summary on Acupuncture. Relaxation therapy or imagery. Cognitive behavioral therapy. Music or drama therapy. Using medicated and peroxide mouth rinses. Brushing and flossing. Wearing dentures as little as possible. Medicines to reduce blood flow and help clots form. Topical products that cover and seal bleeding areas.
The mixture should have 2 or 3 times the amount of saltwater than hydrogen peroxide. This helps clean wounds in the mouth. Rinse carefully so clots are not disturbed. Thick, stringy saliva. Increased thirst. Changes in taste, swallowing, or speech. A sore or burning feeling especially on the tongue.
Cuts or cracks in the lips or at the corners of the mouth. Changes in the surface of the tongue. Problems wearing dentures. Clean the mouth and teeth at least 4 times a day. Floss once a day. Brush with a fluoride toothpaste. Apply fluoride gel once a day at bedtime, after cleaning the teeth.
Avoid foods and liquids that have a lot of sugar in them. Sip water often to relieve mouth dryness. Rinses to replace minerals in the teeth. Rinses to fight infection in the mouth. Saliva substitutes or medicines that help the salivary glands make more saliva. Fluoride treatments to prevent tooth decay. Serve food chopped, ground, or blended, to shorten the amount of time it needs to stay in the mouth before being swallowed. Eat between-meal snacks to add calories and nutrients.
Eat foods high in calories and protein. Take supplements to get vitamins , minerals, and calories. Oral surgery. Late effects of radiation therapy. An overgrowth of fibrous tissue fibrosis in the skin, mucous membranes, muscle, and joints of the jaw may occur after radiation therapy has ended. Stress caused by the cancer and its treatment. Malnutrition and weight loss from being unable to eat normally. Slower healing and recovery from poor nutrition. Dental problems from being unable to clean the teeth and gums well and have dental treatments.
Weakened jaw muscles from not using them. Emotional problems from avoiding social contact with others because of trouble speaking and eating. Medical devices for the mouth. Pain treatments. Medicine to relax muscles.
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Jaw exercises. Medicine to treat depression. Pneumonia and other respiratory problems: Patients who have trouble swallowing may aspirate inhale food or liquids into the lung when trying to eat or drink. Aspiration can lead to serious conditions, including pneumonia and respiratory failure.
Poor nutrition: Being unable to swallow normally makes it hard to eat well. Malnutrition occurs when the body doesn't get all the nutrients needed for health. Wounds heal slowly and the body is less able to fight off infections. Need for tube feeding: A patient who is not able to take in enough food by mouth may be fed through a tube. The healthcare team and a registered dietitian can explain the benefits and risks of tube feeding for patients who have swallowing problems.
Side effects of pain medicine: Opioids used to treat painful swallowing may cause dry mouth and constipation. Emotional problems: Being unable to eat, drink, and speak normally may cause depression and the desire to avoid other people. Total dose and schedule of radiation therapy. Higher doses over a shorter time often have more side effects. The way the radiation is given. Some types of radiation cause less damage to healthy tissue. Whether chemotherapy is given at the same time.
The risk of side effects is increased if both are given. The patient's genetic makeup. Whether the patient is taking any food by mouth or only by tube feeding. Whether the patient smokes. How well the patient copes with problems. Damaged blood vessels. Wasting away of tissue in the treated areas. Lymphedema buildup of lymph in the body. Overgrowth of fibrous tissue in head or neck areas, which may lead to jaw stiffness. Chronic dry mouth. Speech therapist : A speech therapist can assess how well the patient is swallowing and give the patient swallowing therapy and information to better understand the problem.
Dietitian : A dietitian can help plan a safe way for the patient to receive the nutrition needed for health while swallowing is a problem. Dental specialist: Replace missing teeth and damaged area of the mouth with artificial devices to help swallowing. Psychologist : For patients who are having a hard time adjusting to being unable to swallow and eat normally, psychological counseling may help.
Wear removable dentures or devices as little as possible. Don't smoke. Don't drink alcohol. Use topical antibiotics. Use painkillers as prescribed. Surgery to remove dead bone or to rebuild bones of the mouth and jaw. Hyperbaric oxygen therapy a method that uses oxygen under pressure to help wounds heal.
Key Points Patients who receive transplants have an increased risk of graft-versus-host disease. Care of the teeth and gums is important during chemotherapy or stem cell transplant. Medicines and ice may be used to prevent and treat mucositis from stem cell transplant. Dental treatments may be put off until the patient's immune system returns to normal.
Sores that are red and have ulcers , which appear in the mouth 2 to 3 weeks after the transplant. Pain from spices, alcohol , or flavoring such as mint in toothpaste. Swallowing problems. A feeling of tightness in the skin or in the lining of the mouth. Topical rinses, gels, creams, or powders. Antifungal drugs taken by mouth or injection. Drugs that help the salivary glands make more saliva. Fluoride treatments.
Treatments to replace minerals lost from teeth by acids in the mouth. Have brackets, wires, and retainers removed before high-dose chemotherapy begins. Wear dentures only when eating during the first 3 to 4 weeks after the transplant. Brush dentures twice a day and rinsing them well. Soak dentures in an antibacterial solution when they are not being worn. Clean denture soaking cups and changing denture soaking solution every day. Remove dentures or other oral devices when cleaning your mouth. Continue your regular oral care 3 or 4 times a day with dentures or other devices out of the mouth.
If you have mouth sores, avoid using removable oral devices until the sores have healed. Brush teeth with a soft-bristle brush 2 to 3 times a day. Be sure to brush the area where the teeth meet the gums. Rinse the toothbrush in hot water every 15 to 30 seconds to keep the bristles soft. Rinse your mouth 3 or 4 times while brushing. Avoid rinses that have alcohol in them. Use a mild-tasting toothpaste. Let the toothbrush air-dry between uses.
Floss according to your medical doctor's or dentist's directions. Clean the mouth after meals. Use foam swabs to clean the tongue and roof of the mouth. Avoid the following: Foods that are spicy or acidic. Hot foods and drinks. Key Points Certain drugs used to treat cancer and other bone problems are linked to bone loss in the mouth. Treatment of ONJ usually includes treating the infection and good dental hygiene.
Bisphosphonates : Drugs given to some patients whose cancer has spread to the bones. They are used to decrease pain and the risk of broken bones.
Bisphosphonates are also used to treat hypercalcemia too much calcium in the blood. Bisphosphonates commonly used include zoledronic acid , pamidronate , and alendronate. Denosumab : A drug used to prevent or treat certain bone problems. Denosumab is a type of monoclonal antibody. Angiogenesis inhibitors : Drugs or substances that keep new blood vessels from forming. In cancer treatment, angiogenesis inhibitors may prevent the growth of new blood vessels that tumors need to grow. Some of the angiogenesis inhibitors that may cause ONJ are bevacizumab , sunitinib , and sorafenib.
Having teeth removed.
Dental Health Problems Related to Chemotherapy
Wearing dentures that do not fit well. Having multiple myeloma. Removing the infected tissue, which may include bone. Laser surgery may be used. Smoothing sharp edges of exposed bone. Using antibiotics to fight infection. Using medicated mouth rinses. Using pain medicine. Editorial changes were made to this summary.