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Your Mouth During Oral Cancer Treatment

Each year, many people are treated for oral cancer. Chemotherapy treatments for cancer and radiation treatment for head and neck cancer often cause oral complications. About half of chemotherapy patients experience oral complications, particularly those being treated for leukemia and those who receive bone marrow transplants.

These oral cancer complications significantly decrease quality of life and can lead to serious systemic problems, complications, septicemia, eating difficulty, nutritional deficiencies, and dehydration. The following are descriptions of oral problems that can occur with cancer treatment:

Infections of the oral cavity can be caused by the usual organisms found in the mouth or by opportunistic organisms not usually found in the mouth. These infections can lead to serious systemic infections. The risk is higher for individuals who have reduced numbers of circulating white blood cells (leukopenia).

Candidiasis is the overgrowth of candida albicans, a fungal organism that normally is found in the mouth.

Musositis is painful and causes problems with eating and speaking. Soft tissues are red, ulcerated, and inflamed. The oral cavity is susceptible to mucositis because of its high cell turnover.

Hemorrhage or bleeding of the oral cavity can occur when clotting factors are affected and during bone marrow suppression.

Xerostomia or dry mouth is associated with decreased, sticky, or thickened saliva. Dry soft tissues are more susceptible to pain, infection, and irritation. Dry mouth is associated with a high number of dental caries.

Altered taste or loss of taste is common and is related to the reduced saliva volume, as well as its altered consistency.

Developmental abnormalities such as altered craniofacial growth and dental/tooth deformities occur with cancer treatment during developmental periods.

Trismus, fibrosis, and scarring of the chewing muscles and temporomandibular joint (TMJ, the joint that moves the lower jaw) that were in the radiation field may make opening the mouth difficult and limited.

Osteoradionecrosis (soft tissue and bone necrosis) can be spontaneous or secondary to trauma, extractions, or dental prostheses. The radiated tissues have reduced blood vessels, decreased cells, and decreased oxygen that predisposes the tissues for years after the radiation therapy to this compromised state that makes oral surgical procedures risky. Therefore, prior to and post oral surgery, patients who have had head and neck radiation may require hyperbaric oxygen treatments and antibiotic therapy to prevent osteoradionecrosis.

Radiation dental caries is a term used for rapid tooth demineralization and severe cavities that occur with head and neck radiation, particularly when the parotid, submandibular, submental, or submaxillary salivary glands are in the radiation field.

Pain accompanies oral infection, mucositis, xerostomia, trismus, dental caries, osteoradionecrosis, candidiasis and dental caries.

To reduce risk for oral cancer complications, a dentist should perform a pretreatment oral examination, as well as necessary dental treatment before initiating chemotherapy or head and neck radiation. It is important that the dentist consult with the physician or oncologist before dental treatment because people who are about to undergo treatments for cancer may be immunosuppressed or thrombocytopenic (blood clotting disorder).

The goals of the dental examination and dental treatment are to eliminate existing or potential oral infection and potential for trauma. Infection, potential infection, and trauma can be associated with soft tissue lesions, decayed or broken teeth, dental implants with poor prognosis, periodontal disease, and poorly fitting full or partial dentures. The oral examination consists of hard and soft tissue examinations, periodontal assessment, and necessary radiographs. Since long-term effects of head and neck cancer radiation treatments will be harmful to the bone in the radiated area (field), patients who undergo head and neck radiation treatment should have teeth and implants with potential for future problems considered for extraction before the cancer treatment begins.

The patient's ability and interest in maintaining oral health, as well as the ability to comply with an oral cancer prevention routine, should be factors that are considered as the dentist develops and discusses dental treatment recommendations with the patient.

By Denise J. Fedele, DMD, MS

The Effects Of Aging And Tooth Loss On The Mouth

Tooth loss is not part of the normal aging process. In fact, tooth loss is declining among older adults. Aging is not a general of cause oral diseases, according to dentists and other dentistry professionals, yet oral diseases such as tooth loss are more prevalent with age due to changes in the oral soft tissues, a depression of the immune system, an increase in the number of systemic diseases, a decreased ability to perform adequate oral hygiene and self dental care secondary to stroke, arthritis, Parkinson's disease, dementia, or Alzheimer's disease, and dry mouth due to greater use of prescription and over-the-counter medications.

With age, teeth become less white and more brittle; however, oral hygiene habits and use of tobacco, coffee, and tea also will affect tooth color. Teeth also can darken or yellow due to the thickening of the underlying tooth structure (dentin). Brittle teeth tend to be susceptible to cracks, fractures, and shearing. Over the years, the enamel layer (outer tooth layer) is subjected to wear due to chewing, grinding, and ingestion of acidic foods. In severe cases, the enamel is completely worn away and the underlying dentin is worn down as well. Inside the tooth (pulp), the number of blood vessels and cells decrease and fibroses increase with age; thus, capacity to respond to trauma may also decrease.

The fiber content and number of blood vessels of the periodontal (gum) tissues decrease with age. However, periodontal disease represents a pathologic or disease change and is not due to just age. The loss of bone and gum attachment (receded gums) associated with periodontal disease is collective and therefore greater in older adults. An outcome of periodontal disease is exposed root surfaces. Exposure of the root in older people probably gave rise to the term "long in tooth". Oral hygiene practices and certain medications affect the health of gum tissue. Receded gums and exposed root surfaces put older adults at high risk for dental decay (caries) on the relatively soft root surfaces. Dental caries on root surfaces is a disease that is common among older adults. Dry mouth and a diet high in sugars and fermentable carbohydrates greatly increase the risk for root caries. Dental caries are a major cause of tooth loss in older adults.

Studies show some reduced chewing effectiveness, decreased tongue strength, and increased swallowing time with age; however, the studies do not indicate that there is any real change in the ability to swallow with age.

The number of cells that produce saliva decrease with age. However, healthy, unmedicated older adults do not have reduced saliva flow. This is because the salivary glands have a high reserve capacity. Usually when a decrease in saliva flow is noted, it is associated with medication use, illness, medical conditions, or their treatment.

The number of taste buds do not appear to change with older age; thus, the ability to taste does not change significantly with age. However, smell decreases with age. Since the ability to taste is closely related to smell, taste perception may be altered in older adults.

Soft tissues of the mouth become thinner and lose elasticity with age and promote tooth loss. Soft tissue lesions are more common in older adults. Chronic inflammation such as candidiasis (fungus growth) and denture irritation also occurs more often. Wound healing is decreased due to reduced vascularity (blood flow to the area) and immune response with age.

Oral and oropharyngeal cancer is the most serious disease associated with age. Oral and oropharyngeal cancer lesions usually are not painful. Oral and pharyngeal cancer may appear as a red or white patch, a sore or ulceration, or a lump or bump that does not heal within two weeks. Swollen lymph nodes of the neck, difficulty swallowing and speaking, and voice changes also may be signs and symptoms of oral and oropharyngeal cancer. The risk for oral and oral pharyngeal cancer increases with age, use of all forms of tobacco, frequent alcohol use, and exposure to sunlight (for lip cancer). See a dentist if any signs or symptoms of oral and pharyngeal cancer are present.

By Denise J. Fedele, DMD, MS