Strive-The Student View
August, 2009 edition  

The Effects of Radiation Therapy for Cancer Treatment on Oral Health

By Jada Adams, Cayla Blanchard, Kayla Dudek and Brandi Keller

As we prepared this paper, we became suspicious that oral health is often overlooked during cancer treatment. Most people know of the side effects of radiation therapy; however, many do not know that radiation therapy can cause serious complications in the oral cavity. The American Dental Association (ADA) reports that of the 1.2 million people receiving treatment for cancer, about 400,000 will experience oral complications.[1] These patients are at an increased risk for developing oral problems such as ulcers, xerostomia, caries, osteonecrosis of the jaw and tightening of jaw muscles.[2,3] Some side effects are present only during treatment and will subside when treatment is stopped; however, other side effects remain long afterward.[2] Due to these oral complications, patients receiving radiation treatment should be monitored by an oral health care provider before, during and after radiation. Proper monitoring of patients can greatly aid in preventing and/or helping control oral complications. Monitoring patients during treatment may also identify the need for a lower dose of radiation and may indicate the need to stop treatment until oral health is reestablished.[2]

Dealing with cancer can be a severely emotional experience for patients; therefore, it is important to continuously support the patient throughout treatment. Patient oral health education during radiation therapy may be humbling for the patient, but it can also help to keep patients optimistic by reassuring them that their oral health care providers are concerned about their overall well-being. While continuing to remain positive, there are several ways that dental hygienists can help a cancer patient. Teaching patients how to deal with the oral side effects that may occur during treatment is a crucial aspect of their recovery. It is essential to remind the patient how important it is to comply with routine oral home care procedures, despite the fact that radiation therapy can be severely painful and tiring.

About two weeks before beginning radiation therapy, it is critical that a patient see an oral health care provider for a complete prophylaxis and examination.[4] Side effects of radiation are often more severe if the patient does not have a healthy oral cavity. For example, if a person has an existing periodontal condition, bacteria can travel from the oral cavity to other areas of the body. Also, an infection may persist due to the weakening of the immune system from radiation therapy.[3] At the initial appointment, the staff and dentist will check for caries, take X-rays, perform a complete prophylaxis and teach the patient about proper home care.[4] If problems are present, they can be addressed early so that radiation therapy does not have to be interrupted. After beginning therapy, it is crucial that the patient understand the need to adhere to a strict hygiene recall. Failure to comply could have a dire effect on the treatment process.[5] Since good oral hygiene helps to prevent caries, mouth sores and infection, it is extremely important that the patient keep up with scheduled oral hygiene appointments before, during and after treatment.

During radiation therapy, many complications may arise. Oral mucositis is a common side effect of radiation therapy. Ulcers may result in severe pain for the patient, causing poor nutritional intake and poor oral home care.[6,7] Ulcers in the mouth can serve as a source of infection which can increase a patient’s risk of contracting systemic infections, compromise radiation dosage and possibly result in death.[7] There is no effective treatment for those suffering from radiation-induced oral mucositis;[8] however, the associated pain can be managed by using a saline mouth rinse, ice chips, a topical mouth rinse containing an anesthetic or pain medications.[6] Eating soft foods can also help ease the discomfort. Patients should stay away from foods that could potentially increase the chance of inducing mouth sores. These include, but are not limited to, chips and spicy and acidic foods.[3]

Xerostomia is another side effect of radiation therapy that can persist for years following treatment.[2] To help treat xerostomia, patients should use a saliva substitute, sip water often and chew sugarless gum to help stimulate saliva flow.[2] Patients should not use a mouthwash that contains alcohol, because alcohol will increase the dryness of the oral cavity. Patients who suffer from xerostomia are at higher risk for caries and also suffer from decreased taste sensation.

Since patients suffering from xerostomia are at an increased risk of developing caries, they should be given a fluoride supplement to help prevent and reverse the progression of caries. The fluoride supplement should be administered at a high potency such as 1.1% neutral pH fluoride gel or 0.4% stannous fluoride gel.[9] If changes in either the quality or quantity of saliva persist, the patient is at risk for radiation caries. Patients should understand that the risk of radiation caries begins three months before the end of therapy and does not go away when therapy is complete; therefore, it is crucial for the patient to have optimum home care, continue fluoride use and maintain regular dental visits.[2]

Patients receiving radiation treatment directed toward the oral cavity are at an increased risk of developing jaw-related complications. High doses of radiation directed towards the jaw increase the risk of osteonecrosis of the jaw.[10] Osteonecrosis is the destruction of bone due to a lack of sufficient blood flow. Osteonecrosis can be very painful.[2] It can be managed by using antiseptic mouth rinses, antibiotics and oral pain medications. Destruction of the jaw may reverse with time once radiation is completed.[10] Patients receiving radiation therapy directed towards the jaw muscles are at an increased risk of those muscles tightening. To help prevent and treat the tightening of jaw muscles, patients should be instructed to perform jaw exercises to help stretch the muscles properly.[2]

After radiation is complete, regular visits to the dental office are still indicated. Around six to eight weeks after therapy, a complete prophylaxis should be scheduled.[4] Dental appointments after completing radiation therapy are extremely important to ensure that infections do not develop. Since the immune system is suppressed, it is critical for the patient to understand the need to keep a clean and healthy mouth.[3] Any type of infection could be serious for a patient recovering from radiation therapy. Preventing and treating oral side effects of radiation therapy involve starting prevention measures before cancer therapy begins, treating complications as soon as they appear, and continuing care after radiation therapy ends. Proper prevention and management of oral complications resulting from radiation therapy help to support optimal cancer treatment, enhancing both patient survival and quality of life.[2]

References

1. American Dental Association. Cancer treatment and oral health. Chicago: ADA; c1995-2009. Available at http://www.ada.org/public/topics/cancer_treatment.asp. Accessed Aug. 28, 2008.
2. Colgate-Palmolive Company. Oral complications of cancer treatment. Colgate; c.2002,2003. Available at http://www.colgate.com/app/Colgate/US/OC/Information/OralHealthBasics/MedCondOralHealth/CancerOralHealth/OralComplicationsofCancerTreatment.cvsp. Accessed Feb.26, 2009.
3. Family Gentle Dental Care. Radiation and chemotherapy treatment and your mouth. c1998-2008. Available at http://www.dentalcare.com/radiation_&_your _mouth.htm. Accessed Feb. 25, 2009.
4. National Institute of Dental and Craniofacial Research. Head and neck radiation treatment and your mouth. NIH; updated Feb 10, 2009. Available at http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/HeadNeckRadiation.htm. Accessed Feb. 25, 2009.
5. Delta Dental of Massachusetts. Head and neck radiation treatment and your mouth. Delta Dental; c2007. Available at http://www.deltamass.com/oralhealth/articles/Radiation.html. Accessed Feb 25. 2009.
6. Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin North Am 2008; 52(1): 61–viii. Available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18154865. Accessed Feb. 26, 2009.
7. Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral mucositis for patients with cancer receiving treatment. Aust Dent J 2008; 53: 363-5. Available at: http://0-www3.interscience.wiley.com.innopac.lsuhsc.edu/cgi-bin/fulltext/121540207/PDFSTART?CRETRY=1&SRETRY=0. Accessed Feb. 26, 2009.
8. Hamilton S, Yoo J, Hammond A, et al. Microvascular changes in radiation-induced oral mucositis. J Otolaryngol Head Neck Surg 2008; 37(5):730-7. Available at http://0-www.bcdecker.com.innopac.lsuhsc.edu/pubMedLinkOut.aspx?pub=JOTOO&vol =37&iss=5&page=730. Accessed Feb. 26, 2009.
9. National Institute of Dental and Craniofacial Research. Oral complications of cancer treatment: what the dental team can do. NIH; updated 2009. Available at http://www.nidcr. nih.gov /OralHealth/Topics/CancerTreatment/OralComplicationsCancerOral.htm. Accessed Feb. 26, 2009.
10. Silverman S. Osteonecrosis of the jaw. American College of Rheumatology Patient Education Task Force; c2008. Available at http://www.rheumatology.org/public/fact sheets/diseases_and_conditions/onj.asp. Accessed Feb. 26, 2009.

Jada Adams, Cayla Blanchard, Kayla Dudek and Brandi Keller are first-year dental hygiene students at Louisiana State University School of Dentistry.

The faculty mentor for this edition of Strive is Tricia S. Barker, RDH, MEd.