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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] - Overview

Aggressive treatment of malignant disease may produce unavoidable toxicities to normal cells. The mucosal lining of the gastrointestinal tract, including the oral mucosa, is a prime target for treatment-related toxicity by virtue of its rapid rate of cell turnover. The oral cavity is highly susceptible to direct and indirect toxic effects of cancer chemotherapy and ionizing radiation.[1] This risk results from multiple factors, including high rates of cellular turnover for the lining mucosa, a diverse and complex microflora, and trauma to oral tissues during normal oral function.[2] Although changes in soft tissue structures within the oral cavity presumably reflect the changes that occur throughout the gastrointestinal tract, this summary focuses on oral complications of antineoplastic drugs and radiation therapies.

It is essential that a multidisciplinary approach be used for oral management of the cancer patient before, during, and after cancer treatment. A multidisciplinary approach is warranted because the medical complexity of these patients affects dental treatment planning, prioritization, and timing of dental care. In addition, selected cancer patients (e.g., status posttreatment with high-dose head-and-neck radiation) are often at lifelong risk for serious complications such as osteoradionecrosis of the mandible. Thus, a multidisciplinary oncology team that includes oncologists, oncology nurses, and dental generalists and specialists as well as dental hygienists, social workers, dieticians, and related health professionals can often achieve highly effective preventive and therapeutic outcomes relative to oral complications in these patients.

While oral complications may mimic selected systemic disorders, unique oral toxicities emerge in the context of specific oral anatomic structures and their functions.

Frequencies of oral complications vary by cancer therapy; estimates are included in Table 1.

Table 1. Prevalence for Oral Complications with Cancer Therapies: Oral Care Study Group Systematic Reviews, MASCC/ISOO

ComplicationReference CitationWeighted Prevalence
CT = chemotherapy; EORTC QLQ-C30 = European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; HNC = head and neck cancer; IMRT = intensity-modulated radiation therapy; MASCC/ISOO = Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology; RT = radiation therapy; VAS = visual analog scale.
a Pain is common in patients with HNCs and is reported by approximately half of patients before cancer therapy, by 81% during therapy, by 70% at the end of therapy, and by 36% at 6 months posttreatment.
Bisphosphonate osteonecrosis[3]6.1% for all studies (mean)
Studies with documented follow-up = 13.3%
Studies with undocumented follow-up = 0.7%
Epidemiological studies = 1.2%
Dysgeusia[4]CT only = 56.3% (mean)
RT only = 66.5% (mean)
Combined CT and RT = 76% (mean)
Oral fungal infection[5]Of clinical oral fungal infection (all oral candidiasis):
Pretreatment = 7.5%
During treatment = 39.1%
Posttreatment = 32.6%
Of oral candidiasis clinical infection by cancer treatment:
During HNC RT = 37.4%
During CT = 38%
Oral viral infection[6]In patients treated with CT for hematologic malignancies:
Patients with oral ulcerations/sampling oral ulcerations = 49.8%
Patients sampling oral ulcerations = 33.8%
Patients sampling independently of the presence of oral ulcerations = 0%
In patients treated with RT:
Patients with RT only/sampling oral ulcerations = 0%
Patients with RT and adjunctive CT/sampling oral ulcerations = 43.2%
Dental disease[7]For dental caries in patients treated with cancer therapy:
All studies = 28.1%
CT only = 37.3%
Post-RT = 24%
Post-CT and -RT = 21.4%
Of severe gingivitis in patients undergoing CT = 20.3%
Of dental infection/abscess in patients undergoing CT = 5.8%
Osteoradionecrosis[8]In conventional RT = 7.4%
In IMRT = 5.2%
In RT and CT = 6.8%
In brachytherapy = 5.3%
Trismus[9]For conventional RT = 25.4%
For IMRT = 5%
For combined RT and CT = 30.7%
Oral paina[10]VAS pain level (0–100) in HNC patients:
Pretreatment = 12/100
Immediately posttreatment = 33/100
1 mo posttreatment = 20/100
EORTC QLQ-C30 pain level (0–100) in HNC patients:
Pretreatment = 27/100
3 mo posttreatment = 30/100
6 mo posttreatment = 23/100
12 mo posttreatment = 24/100
Salivary gland hypofunction and xerostomia[11]Of xerostomia in HNC patients by type of RT:
All studies
Pre-RT = 6%
During RT = 93%
1–3 mo post-RT = 74%
3–6 mo post-RT = 79%
6–12 mo post-RT = 83%
1–2 y post-RT = 78%
>2 y post-RT = 85%
Conventional RT
Pre-RT = 10%
During RT = 81%
1–3 mo post-RT = 71%
3–6 mo post-RT = 83%
6–12 mo post-RT = 72%
1–2 y post-RT = 84%
>2 y post-RT = 91%
Pre-RT = 12%
During RT = 100%
1–3 mo post-RT = 89%
3–6 mo post-RT = 73%
6–12 mo post-RT = 90%
1–2 y post-RT = 66%
>2 y post-RT = 68%
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