by Andrew Coughlin MD, Aru Panwar MD, & Jeffery Markt DDS

What is it?

Patients with head & neck cancer may experience problems with teeth and oral health due to many different causes. While it may seem obvious that the tumor itself may cause damage or destruction of the teeth and jaw, other causes can be implicated. Through surgery or radiation therapy, the salivary glands can be removed or damaged leading to decreased salivary flow which is instrumental to our oral health defenses. Common problems related to poor oral health include cavities, tooth loss, exposed bone, painful non-healing wounds and jaw fracture. These problems may be exacerbated by xerostomia (dry mouth) and osteoradionecrosis (ORN), both of which are covered in separate dedicated topical reviews.

How common is it among head and neck cancer patients?

Most patients with head & neck cancer will likely suffer some effects on their oral health. Some patients may have only short periods of dysfunction while others may experience more prolonged issues. The most severe issues come from those patients treated with radiation therapy.

What are the signs/symptoms?

Symptoms of oral complications or poor oral health may include dry mouth, foul smelling breath, oral pain, pain with swallowing, difficulty with chewing food, alteration of taste, bleeding, dental caries, loose teeth, exposed bone, or inability to open your mouth.

How is it diagnosed?

Dental and oral health problems are often identified through an examination by a dentist, oral surgeon or your head and neck surgeon. Additional tests may be required such as dental x-rays,  panoramic x-rays or CT scans of the jaw. Your dental care provider may recommend additional testing.

How is it treated?

Management of dental health for patients with head & neck cancer should start early in the course of cancer management. Engaging with a qualified dental provider is critical.

Prevention is the best treatment. Dental evaluation before, during and after cancer care aims to reduce the risk of developing oral complications and decrease the risk for developing these issues following radiation therapy. Topical application of fluoride gel may play a role in preventing dental cavities. It is applied with customized dental appliance, like an athletic mouth guard, and must be applied daily for 5 to 10-minutes following routine brushing and flossing at bedtime for the rest of the patient’s life.  It is recommended that you do not rinse, eat, or drink for 30 minutes following use.

Evaluation by a dental provider may benefit the planning process for the repair or replacement of teeth that might be lost or impacted by cancer or its treatment. Strategies to optimize oral health during all phases of cancer treatment may be offered. Dental providers may also complement monitoring for recurrent or new cancers, and support efforts in reducing further loss of teeth.

When should I call my doctor?

Dental health should be a priority during every phase of care for patients with head & neck cancer. You may be asked to see a dentist before starting cancer treatment. Your dental provider may discuss the impact of cancer and its treatment on your oral/ dental health.

Your dental provider may perform an examination, obtain dental x-rays (including a panoramic x-ray), and talk to you about the health of your teeth. You may be asked to think about restoration or removal of diseased teeth to reduce the risk of dental complications after treatment. Strategies for post-treatment ongoing dental care, rehabilitation and restoration may also be discussed.

Patients without a relationship with a dental provider should establish care with an experienced dentist in order to obtain periodic examination and x-rays and periodic cleanings by a general dentist, oral hygienist, or gum specialist (periodontist). Dental cleaning may sometimes be requested more frequently than usual. Dental restoration may also be needed. The restoration process may include rehabilitation of existing teeth or implantation of artificial teeth in the jaw bone. These procedures usually require involvement of a dental provider experienced in the care of patients with head & neck cancer like an oral surgeon. Patients may consider discussing the benefits of dental implantation against risk of poor wound healing, especially in those who may have received radiotherapy for their treatments.

You should call your doctor immediately for pain in your mouth, swelling, bleeding, loose teeth, open wounds, exposed bone, difficulty with speech or difficulty in the ability to chew food that lasts for more than a week or two.

Where can I learn more?

Head and Neck Radiation Treatment and Your Mouth: https://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/HeadNeckRadiation.htm

Three Good Reasons to See a Dentist Before Cancer Treatment: https://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/ThreeGoodReasonsPicto.htm