Questions To Ask the •

Consult the oncologist about scheduling • Avoid mouthwashes containing alcohol.

Dental Care for Oral Complications
Dental
dental treatment.
Medical Oncologist • Rinse the mouth several times a day with a
of Cancer Treatment
• Schedule oral surgery at least 7 to 10 days baking soda and salt solution, followed by a plain
• What is the patient’s complete blood count, before myelosuppressive therapy begins. water rinse. Use ¼ teaspoon each of baking Oral Mucositis: Culture lesions to identify secondary

Provider’s
including absolute neutrophil and platelet counts? soda and salt in 1 quart of warm water. Omit
• Prevent tooth demineralization and radiation caries: infection. Prescribe topical anesthetics and systemic
• If an invasive dental procedure needs to be salt during mucositis. analgesics. Consult the oncologist about prescribing
done, are there adequate clotting factors? –– Instruct the patient in home application antimicrobial agents for known infections. Have the

Oncology
• Try the following if dry mouth is a problem:
of fluoride gel (not fluoride rinses). patient avoid rough-textured foods and report oral
• Does the patient have a central venous catheter? –– Sip water frequently.
• Instruct the patient about an oral hygiene regimen. problems early.
• What is the scheduled sequence of treatments

Pocket
–– Suck ice chips or use sugar-free gum or candy. Xerostomia/salivary gland dysfunction: Advise
so that safe dental treatment can be planned?
After Transplantation the patient to soften or thin foods with liquid, chew
–– Use saliva substitute spray or gel or a
• Is radiation therapy also planned? sugarless gum, or suck ice chips or sugar-free hard
• Consult the oncologist before any dental prescribed saliva stimulant if appropriate.

Guide
procedure, including prophylaxis. candies. Suggest using commercial saliva substitutes
Questions To Ask the –– Avoid glycerin swabs. or prescribe a saliva stimulant.
Radiation Oncologist • Monitor the patient's oral health for plaque
• Exercise the jaw muscles three times a day
control, tooth demineralization, dental caries, Taste changes: Refer to a dietitian.
• What parts of the mandible/maxilla and and infection. to prevent and treat jaw stiffness from
salivary glands are in the field of radiation? radiation treatment. Etched enamel: Advise the patient to rinse the

• What is the total dose of radiation the

• Watch for infections on the tongue and oral
• Avoid candy, gum, and soda unless they
mouth with water and baking soda ­solution after Prevention and management
mucosa. Herpes simplex and Candida albicans vomiting to protect enamel.
patient will receive, and what will be the are common oral infections. are sugar-free. of oral complications
impact on these areas?
• Avoid spicy or acidic foods, toothpicks,
Complications Specific to Chemotherapy
• Has the vascularity of the mandible been
• Delay elective oral procedures for 1 year.
tobacco products, and alcohol. Neurotoxicity: Provide analgesics or systemic
Head and Neck
previously compromised by surgery? • Follow patients for long-term oral complications. pain relief. Radiation Therapy
Such problems are strong indicators of chronic
• How quickly does the patient need to graft-versus-host disease. Special Care for Children Bleeding: Advise the patient to clean teeth thoroughly
start radiation treatment? with a toothbrush softened in warm water; avoid
Chemotherapy
• Monitor transplant patients carefully for Children receiving chemotherapy and/or radiation
• Will there be induction chemotherapy therapy are at risk for the same oral complications flossing the areas that are bleeding but to keep flossing
with the radiation treatment?
second malignancies in the oral region. the other teeth. Hematopoietic Stem
as adults. Other actions to consider in managing
pediatric patients include the following: Cell Transplantation
Advice for Your Patients Complications Specific to Radiation
Hematopoietic Stem • Brush teeth, gums, and tongue gently with an • Extract loose primary teeth and teeth expected
to exfoliate during cancer treatment.
Demineralization and radiation caries:
Prescribe daily fluoride gel applications before
Cell Transplantation extra-soft toothbrush and fluoride toothpaste
after every meal and at bedtime. If brushing hurts, treatment starts. Continue for the patient’s lifetime
• Remove orthodontic bands and brackets if highly
Most stem cell transplant patients develop acute soften the bristles in warm water. stomatotoxic chemotherapy is planned or if the if changes in quality or quantity of saliva persist.
oral complications, especially patients with graft- appliances will be in the radiation field. Trismus/tissue fibrosis: Instruct the patient
• Floss teeth gently every day. If your gums bleed
versus-host disease. on stretching exercises for the jaw to prevent
and hurt, avoid the areas that are bleeding or sore • Monitor craniofacial and dental structures for
but keep flossing your other teeth. abnormal growth and development. or reduce the severity of fibrosis.
Before Transplantation U.S. Department of Health and Human Services
• Follow instructions for fluoride gel applications. Osteonecrosis: Avoid invasive procedures involving National Institutes of Health
• Conduct a pretreatment oral health irradiated bone, particularly the mandible. National Institute of Dental and Craniofacial Research
examination and prophylaxis.
 Head and Neck Radiation Therapy • Watch for mucositis and infection. • Schedule dental treatment in consultation with
the oncologist.
Oral Health, Cancer Care, and You
• Advise against wearing removable appliances
Pre-cancer Treatment Patients receiving radiation therapy to the head and neck
are at risk for developing oral complications. Because of during treatment. • Schedule oral surgery at least 7 to 10 days
This guide is part of a series on managing
and preventing oral complications of cancer
Oral Health Examination the risk of osteonecrosis in irradiated fields, oral surgery
before myelosuppressive therapy begins.
treatment developed by the National Institute of
should be performed before radiation treatment begins.
After Radiation Therapy • Consult the oncologist before conducting any oral Dental and Craniofacial Research in partnership
Objectives • Recall the patient for prophylaxis and home care procedures in patients with hematologic cancers; with the National Cancer Institute, the National
Before Head and Neck Radiation Therapy evaluation every 4 to 8 weeks or as needed for do not conduct procedures in patients who are Institute of Nursing Research, and the Centers
1. Conduct evaluation 1 month, if possible,
the first 6 months after cancer treatment. immunosuppressed or have thrombocytopenia. for Disease Control and Prevention.
before cancer treatment begins. • Conduct a pretreatment oral health examination
and prophylaxis. • Reinforce the importance of optimal oral hygiene.
2. Establish a schedule for dental treatment. During Chemotherapy To order this and other publications in the Oral
• Schedule dental treatment in consultation with the • Monitor the patient for trismus: check for pain or Health, Cancer Care, and You series, contact:
• Complete invasive procedures at least • Consult the oncologist before any dental
radiation oncologist. weakness in masticating muscles in the radiation
14 days before head/neck radiation procedure, including prophylaxis. National Institute of Dental and
field. Instruct the patient to exercise three times a
therapy starts; 7 to 10 days before • Extract teeth in the proposed radiation field that may day, opening and closing the mouth as far as possible Craniofacial Research
• Ask the oncologist to order blood work 24 hours
myelosuppressive chemotherapy. be a problem in the future. without pain; repeat 20 times. National Oral Health Information Clearinghouse
before oral surgery or other invasive procedures.
• Postpone elective oral surgical procedures • Prevent tooth demineralization and radiation caries: Postpone when 1 NOHIC Way
• Consult with the oncology team about use of
until cancer treatment is completed. Bethesda, MD 20892-3500
–– Fabricate custom gel-applicator trays for the patient. dentures and other appliances after mucositis –– the platelet count is less than 75,000/mm3 1–866–232–4528
3. Identify and treat sites of low-grade and subsides. Patients with friable tissues and or abnormal clotting factors are present
–– Prescribe a 1.1% neutral pH sodium fluoride gel xerostomia may not be able to wear them again. www.nidcr.nih.gov
acute oral infections:
or a 0.4% stannous, unflavored fluoride gel (not –– absolute neutrophil count is less than
• Caries fluoride rinses). • Watch for demineralization and caries. Lifelong, 1,000/mm3, or consider prophylactic
daily applications of fluoride gel are needed for antibiotics (www.americanheart.org).
• Periodontal disease –– Use a neutral fluoride for patients with porcelain patients with xerostomia.
• Endodontic disease crowns or resin or glass ionomer restorations. • Check for oral source of viral, bacterial, or fungal
• Advise against elective oral surgery on irradiated infection in patients with fever of unknown origin.
• Mucosal lesions –– Be sure that the trays cover all tooth structures bone because of the risk of osteonecrosis. Tooth
without irritating the gingival or mucosal tissues. extraction, if unavoidable, should be conservative, • Encourage consistent oral hygiene measures. Reprinted September 2009
4. Identify and eliminate sources of oral trauma using antibiotic coverage and possibly hyperbaric
–– Instruct the patient in home application of fluoride • Consult the oncologist about the need for
and irritation such as ill-fitting dentures, oxygen therapy.
gel. Several days before radiation therapy begins, the antibiotic prophylaxis before any dental procedures
orthodontic bands, and other appliances.
patient should start a daily 10-minute application. in patients with central venous catheters.
5. Identify and treat potential oral problems
–– Have patients brush with a fluoride gel if using Chemotherapy
within the proposed radiation field before
trays is difficult. After Chemotherapy
radiation treatment begins. The oral complications of chemotherapy depend upon
• Allow at least 14 days of healing for any oral the drugs used, the dosage, the degree of dental disease, • Place the patient on a dental recall schedule when
6. Instruct patients about oral hygiene. surgical procedures. and the use of radiation. Chemoradiation therapy chemotherapy is completed and all side effects, Centers for Disease

carries a significant risk for mucositis. including immunosuppression, have resolved. Control and Prevention
7. Educate patients on preventing • Conduct prosthetic surgery before treatment, since
demineralization and dental caries. elective surgical procedures are contraindicated on • Confirm normal hematologic status prior
irradiated bone. Before Chemotherapy to dental treatment. U.S. Department of Health
and Human Services
• Conduct a pretreatment oral health examination • Ask if the patient has received intravenous National Institutes of Health
During Radiation Therapy and prophylaxis. bisphosphonate therapy.
• Monitor the patient’s oral hygiene.
 Head and Neck Radiation Therapy • Watch for mucositis and infection. • Schedule dental treatment in consultation with
the oncologist.
Oral Health, Cancer Care, and You
• Advise against wearing removable appliances
Pre-cancer Treatment Patients receiving radiation therapy to the head and neck
are at risk for developing oral complications. Because of during treatment. • Schedule oral surgery at least 7 to 10 days
This guide is part of a series on managing
and preventing oral complications of cancer
Oral Health Examination the risk of osteonecrosis in irradiated fields, oral surgery
before myelosuppressive therapy begins.
treatment developed by the National Institute of
should be performed before radiation treatment begins.
After Radiation Therapy • Consult the oncologist before conducting any oral Dental and Craniofacial Research in partnership
Objectives • Recall the patient for prophylaxis and home care procedures in patients with hematologic cancers; with the National Cancer Institute, the National
Before Head and Neck Radiation Therapy evaluation every 4 to 8 weeks or as needed for do not conduct procedures in patients who are Institute of Nursing Research, and the Centers
1. Conduct evaluation 1 month, if possible,
the first 6 months after cancer treatment. immunosuppressed or have thrombocytopenia. for Disease Control and Prevention.
before cancer treatment begins. • Conduct a pretreatment oral health examination
and prophylaxis. • Reinforce the importance of optimal oral hygiene.
2. Establish a schedule for dental treatment. During Chemotherapy To order this and other publications in the Oral
• Schedule dental treatment in consultation with the • Monitor the patient for trismus: check for pain or Health, Cancer Care, and You series, contact:
• Complete invasive procedures at least • Consult the oncologist before any dental
radiation oncologist. weakness in masticating muscles in the radiation
14 days before head/neck radiation procedure, including prophylaxis. National Institute of Dental and
field. Instruct the patient to exercise three times a
therapy starts; 7 to 10 days before • Extract teeth in the proposed radiation field that may day, opening and closing the mouth as far as possible Craniofacial Research
• Ask the oncologist to order blood work 24 hours
myelosuppressive chemotherapy. be a problem in the future. without pain; repeat 20 times. National Oral Health Information Clearinghouse
before oral surgery or other invasive procedures.
• Postpone elective oral surgical procedures • Prevent tooth demineralization and radiation caries: Postpone when 1 NOHIC Way
• Consult with the oncology team about use of
until cancer treatment is completed. Bethesda, MD 20892-3500
–– Fabricate custom gel-applicator trays for the patient. dentures and other appliances after mucositis –– the platelet count is less than 75,000/mm3 1–866–232–4528
3. Identify and treat sites of low-grade and subsides. Patients with friable tissues and or abnormal clotting factors are present
–– Prescribe a 1.1% neutral pH sodium fluoride gel xerostomia may not be able to wear them again. www.nidcr.nih.gov
acute oral infections:
or a 0.4% stannous, unflavored fluoride gel (not –– absolute neutrophil count is less than
• Caries fluoride rinses). • Watch for demineralization and caries. Lifelong, 1,000/mm3, or consider prophylactic
daily applications of fluoride gel are needed for antibiotics (www.americanheart.org).
• Periodontal disease –– Use a neutral fluoride for patients with porcelain patients with xerostomia.
• Endodontic disease crowns or resin or glass ionomer restorations. • Check for oral source of viral, bacterial, or fungal
• Advise against elective oral surgery on irradiated infection in patients with fever of unknown origin.
• Mucosal lesions –– Be sure that the trays cover all tooth structures bone because of the risk of osteonecrosis. Tooth
without irritating the gingival or mucosal tissues. extraction, if unavoidable, should be conservative, • Encourage consistent oral hygiene measures. Reprinted September 2009
4. Identify and eliminate sources of oral trauma using antibiotic coverage and possibly hyperbaric
and irritation such as ill-fitting dentures, –– Instruct the patient in home application of fluoride • Consult the oncologist about the need for
gel. Several days before radiation therapy begins, the oxygen therapy.
orthodontic bands, and other appliances. antibiotic prophylaxis before any dental procedures
patient should start a daily 10-minute application. in patients with central venous catheters.
5. Identify and treat potential oral problems
–– Have patients brush with a fluoride gel if using Chemotherapy
within the proposed radiation field before
trays is difficult. After Chemotherapy
radiation treatment begins. The oral complications of chemotherapy depend upon
• Allow at least 14 days of healing for any oral the drugs used, the dosage, the degree of dental disease, • Place the patient on a dental recall schedule when
6. Instruct patients about oral hygiene. surgical procedures. and the use of radiation. Chemoradiation therapy chemotherapy is completed and all side effects, Centers for Disease

carries a significant risk for mucositis. including immunosuppression, have resolved. Control and Prevention
7. Educate patients on preventing • Conduct prosthetic surgery before treatment, since
demineralization and dental caries. elective surgical procedures are contraindicated on • Confirm normal hematologic status prior
irradiated bone. Before Chemotherapy to dental treatment. U.S. Department of Health
and Human Services
• Conduct a pretreatment oral health examination • Ask if the patient has received intravenous National Institutes of Health
During Radiation Therapy and prophylaxis. bisphosphonate therapy.
• Monitor the patient’s oral hygiene.
 Head and Neck Radiation Therapy • Watch for mucositis and infection. • Schedule dental treatment in consultation with
the oncologist.
Oral Health, Cancer Care, and You
• Advise against wearing removable appliances
Pre-cancer Treatment Patients receiving radiation therapy to the head and neck
are at risk for developing oral complications. Because of during treatment. • Schedule oral surgery at least 7 to 10 days
This guide is part of a series on managing
and preventing oral complications of cancer
Oral Health Examination the risk of osteonecrosis in irradiated fields, oral surgery
before myelosuppressive therapy begins.
treatment developed by the National Institute of
should be performed before radiation treatment begins.
After Radiation Therapy • Consult the oncologist before conducting any oral Dental and Craniofacial Research in partnership
Objectives • Recall the patient for prophylaxis and home care procedures in patients with hematologic cancers; with the National Cancer Institute, the National
Before Head and Neck Radiation Therapy evaluation every 4 to 8 weeks or as needed for do not conduct procedures in patients who are Institute of Nursing Research, and the Centers
1. Conduct evaluation 1 month, if possible,
the first 6 months after cancer treatment. immunosuppressed or have thrombocytopenia. for Disease Control and Prevention.
before cancer treatment begins. • Conduct a pretreatment oral health examination
and prophylaxis. • Reinforce the importance of optimal oral hygiene.
2. Establish a schedule for dental treatment. During Chemotherapy To order this and other publications in the Oral
• Schedule dental treatment in consultation with the • Monitor the patient for trismus: check for pain or Health, Cancer Care, and You series, contact:
• Complete invasive procedures at least • Consult the oncologist before any dental
radiation oncologist. weakness in masticating muscles in the radiation
14 days before head/neck radiation procedure, including prophylaxis. National Institute of Dental and
field. Instruct the patient to exercise three times a
therapy starts; 7 to 10 days before • Extract teeth in the proposed radiation field that may day, opening and closing the mouth as far as possible Craniofacial Research
• Ask the oncologist to order blood work 24 hours
myelosuppressive chemotherapy. be a problem in the future. without pain; repeat 20 times. National Oral Health Information Clearinghouse
before oral surgery or other invasive procedures.
• Postpone elective oral surgical procedures • Prevent tooth demineralization and radiation caries: Postpone when 1 NOHIC Way
• Consult with the oncology team about use of
until cancer treatment is completed. Bethesda, MD 20892-3500
–– Fabricate custom gel-applicator trays for the patient. dentures and other appliances after mucositis –– the platelet count is less than 75,000/mm3 1–866–232–4528
3. Identify and treat sites of low-grade and subsides. Patients with friable tissues and or abnormal clotting factors are present
–– Prescribe a 1.1% neutral pH sodium fluoride gel xerostomia may not be able to wear them again. www.nidcr.nih.gov
acute oral infections:
or a 0.4% stannous, unflavored fluoride gel (not –– absolute neutrophil count is less than
• Caries fluoride rinses). • Watch for demineralization and caries. Lifelong, 1,000/mm3, or consider prophylactic
daily applications of fluoride gel are needed for antibiotics (www.americanheart.org).
• Periodontal disease –– Use a neutral fluoride for patients with porcelain patients with xerostomia.
• Endodontic disease crowns or resin or glass ionomer restorations. • Check for oral source of viral, bacterial, or fungal
• Advise against elective oral surgery on irradiated infection in patients with fever of unknown origin.
• Mucosal lesions –– Be sure that the trays cover all tooth structures bone because of the risk of osteonecrosis. Tooth
without irritating the gingival or mucosal tissues. extraction, if unavoidable, should be conservative, • Encourage consistent oral hygiene measures. Reprinted September 2009
4. Identify and eliminate sources of oral trauma using antibiotic coverage and possibly hyperbaric
–– Instruct the patient in home application of fluoride • Consult the oncologist about the need for
and irritation such as ill-fitting dentures, oxygen therapy.
gel. Several days before radiation therapy begins, the antibiotic prophylaxis before any dental procedures
orthodontic bands, and other appliances.
patient should start a daily 10-minute application. in patients with central venous catheters.
5. Identify and treat potential oral problems
–– Have patients brush with a fluoride gel if using Chemotherapy
within the proposed radiation field before
trays is difficult. After Chemotherapy
radiation treatment begins. The oral complications of chemotherapy depend upon
• Allow at least 14 days of healing for any oral the drugs used, the dosage, the degree of dental disease, • Place the patient on a dental recall schedule when
6. Instruct patients about oral hygiene. surgical procedures. and the use of radiation. Chemoradiation therapy chemotherapy is completed and all side effects, Centers for Disease

carries a significant risk for mucositis. including immunosuppression, have resolved. Control and Prevention
7. Educate patients on preventing • Conduct prosthetic surgery before treatment, since
demineralization and dental caries. elective surgical procedures are contraindicated on • Confirm normal hematologic status prior
irradiated bone. Before Chemotherapy to dental treatment. U.S. Department of Health
and Human Services
• Conduct a pretreatment oral health examination • Ask if the patient has received intravenous National Institutes of Health
During Radiation Therapy and prophylaxis. bisphosphonate therapy.
• Monitor the patient’s oral hygiene.
 Head and Neck Radiation Therapy • Watch for mucositis and infection. • Schedule dental treatment in consultation with
the oncologist.
Oral Health, Cancer Care, and You
• Advise against wearing removable appliances
Pre-cancer Treatment Patients receiving radiation therapy to the head and neck
are at risk for developing oral complications. Because of during treatment. • Schedule oral surgery at least 7 to 10 days
This guide is part of a series on managing
and preventing oral complications of cancer
Oral Health Examination the risk of osteonecrosis in irradiated fields, oral surgery
before myelosuppressive therapy begins.
treatment developed by the National Institute of
should be performed before radiation treatment begins.
After Radiation Therapy • Consult the oncologist before conducting any oral Dental and Craniofacial Research in partnership
Objectives • Recall the patient for prophylaxis and home care procedures in patients with hematologic cancers; with the National Cancer Institute, the National
Before Head and Neck Radiation Therapy evaluation every 4 to 8 weeks or as needed for do not conduct procedures in patients who are Institute of Nursing Research, and the Centers
1. Conduct evaluation 1 month, if possible,
the first 6 months after cancer treatment. immunosuppressed or have thrombocytopenia. for Disease Control and Prevention.
before cancer treatment begins. • Conduct a pretreatment oral health examination
and prophylaxis. • Reinforce the importance of optimal oral hygiene.
2. Establish a schedule for dental treatment. During Chemotherapy To order this and other publications in the Oral
• Schedule dental treatment in consultation with the • Monitor the patient for trismus: check for pain or Health, Cancer Care, and You series, contact:
• Complete invasive procedures at least • Consult the oncologist before any dental
radiation oncologist. weakness in masticating muscles in the radiation
14 days before head/neck radiation procedure, including prophylaxis. National Institute of Dental and
field. Instruct the patient to exercise three times a
therapy starts; 7 to 10 days before • Extract teeth in the proposed radiation field that may day, opening and closing the mouth as far as possible Craniofacial Research
• Ask the oncologist to order blood work 24 hours
myelosuppressive chemotherapy. be a problem in the future. without pain; repeat 20 times. National Oral Health Information Clearinghouse
before oral surgery or other invasive procedures.
• Postpone elective oral surgical procedures • Prevent tooth demineralization and radiation caries: Postpone when 1 NOHIC Way
• Consult with the oncology team about use of
until cancer treatment is completed. Bethesda, MD 20892-3500
–– Fabricate custom gel-applicator trays for the patient. dentures and other appliances after mucositis –– the platelet count is less than 75,000/mm3 1–866–232–4528
3. Identify and treat sites of low-grade and subsides. Patients with friable tissues and or abnormal clotting factors are present
–– Prescribe a 1.1% neutral pH sodium fluoride gel xerostomia may not be able to wear them again. www.nidcr.nih.gov
acute oral infections:
or a 0.4% stannous, unflavored fluoride gel (not –– absolute neutrophil count is less than
• Caries fluoride rinses). • Watch for demineralization and caries. Lifelong, 1,000/mm3, or consider prophylactic
daily applications of fluoride gel are needed for antibiotics (www.americanheart.org).
• Periodontal disease –– Use a neutral fluoride for patients with porcelain patients with xerostomia.
• Endodontic disease crowns or resin or glass ionomer restorations. • Check for oral source of viral, bacterial, or fungal
• Advise against elective oral surgery on irradiated infection in patients with fever of unknown origin.
• Mucosal lesions –– Be sure that the trays cover all tooth structures bone because of the risk of osteonecrosis. Tooth
without irritating the gingival or mucosal tissues. extraction, if unavoidable, should be conservative, • Encourage consistent oral hygiene measures. Reprinted September 2009
4. Identify and eliminate sources of oral trauma using antibiotic coverage and possibly hyperbaric
–– Instruct the patient in home application of fluoride • Consult the oncologist about the need for
and irritation such as ill-fitting dentures, oxygen therapy.
gel. Several days before radiation therapy begins, the antibiotic prophylaxis before any dental procedures
orthodontic bands, and other appliances.
patient should start a daily 10-minute application. in patients with central venous catheters.
5. Identify and treat potential oral problems
–– Have patients brush with a fluoride gel if using Chemotherapy
within the proposed radiation field before
trays is difficult. After Chemotherapy
radiation treatment begins. The oral complications of chemotherapy depend upon
• Allow at least 14 days of healing for any oral the drugs used, the dosage, the degree of dental disease, • Place the patient on a dental recall schedule when
6. Instruct patients about oral hygiene. surgical procedures. and the use of radiation. Chemoradiation therapy chemotherapy is completed and all side effects, Centers for Disease

carries a significant risk for mucositis. including immunosuppression, have resolved. Control and Prevention
7. Educate patients on preventing • Conduct prosthetic surgery before treatment, since
demineralization and dental caries. elective surgical procedures are contraindicated on • Confirm normal hematologic status prior
irradiated bone. Before Chemotherapy to dental treatment. U.S. Department of Health
and Human Services
• Conduct a pretreatment oral health examination • Ask if the patient has received intravenous National Institutes of Health
During Radiation Therapy and prophylaxis. bisphosphonate therapy.
• Monitor the patient’s oral hygiene.
 Questions To Ask the • Consult the oncologist about scheduling • Avoid mouthwashes containing alcohol.
Dental Care for Oral Complications
Dental
dental treatment.
Medical Oncologist • Rinse the mouth several times a day with a
of Cancer Treatment
• Schedule oral surgery at least 7 to 10 days baking soda and salt solution, followed by a plain
• What is the patient’s complete blood count, before myelosuppressive therapy begins. water rinse. Use ¼ teaspoon each of baking Oral Mucositis: Culture lesions to identify secondary

Provider’s
including absolute neutrophil and platelet counts? soda and salt in 1 quart of warm water. Omit
• Prevent tooth demineralization and radiation caries: infection. Prescribe topical anesthetics and systemic
• If an invasive dental procedure needs to be salt during mucositis. analgesics. Consult the oncologist about prescribing
done, are there adequate clotting factors? –– Instruct the patient in home application antimicrobial agents for known infections. Have the

Oncology
• Try the following if dry mouth is a problem:
of fluoride gel (not fluoride rinses). patient avoid rough-textured foods and report oral
• Does the patient have a central venous catheter? –– Sip water frequently.
• Instruct the patient about an oral hygiene regimen. problems early.
• What is the scheduled sequence of treatments

Pocket
–– Suck ice chips or use sugar-free gum or candy. Xerostomia/salivary gland dysfunction: Advise
so that safe dental treatment can be planned?
After Transplantation the patient to soften or thin foods with liquid, chew
–– Use saliva substitute spray or gel or a
• Is radiation therapy also planned? sugarless gum, or suck ice chips or sugar-free hard
• Consult the oncologist before any dental prescribed saliva stimulant if appropriate.

Guide
procedure, including prophylaxis. candies. Suggest using commercial saliva substitutes
Questions To Ask the –– Avoid glycerin swabs. or prescribe a saliva stimulant.
Radiation Oncologist • Monitor the patient's oral health for plaque
• Exercise the jaw muscles three times a day
control, tooth demineralization, dental caries, Taste changes: Refer to a dietitian.
• What parts of the mandible/maxilla and and infection. to prevent and treat jaw stiffness from
salivary glands are in the field of radiation? radiation treatment. Etched enamel: Advise the patient to rinse the

• What is the total dose of radiation the

• Watch for infections on the tongue and oral
• Avoid candy, gum, and soda unless they
mouth with water and baking soda ­solution after Prevention and management
mucosa. Herpes simplex and Candida albicans vomiting to protect enamel.
patient will receive, and what will be the are common oral infections. are sugar-free. of oral complications
impact on these areas?
• Avoid spicy or acidic foods, toothpicks,
Complications Specific to Chemotherapy
• Has the vascularity of the mandible been
• Delay elective oral procedures for 1 year.
tobacco products, and alcohol. Neurotoxicity: Provide analgesics or systemic
Head and Neck
previously compromised by surgery? • Follow patients for long-term oral complications. pain relief. Radiation Therapy
Such problems are strong indicators of chronic
• How quickly does the patient need to graft-versus-host disease. Special Care for Children Bleeding: Advise the patient to clean teeth thoroughly
start radiation treatment? with a toothbrush softened in warm water; avoid
Chemotherapy
• Monitor transplant patients carefully for Children receiving chemotherapy and/or radiation
• Will there be induction chemotherapy therapy are at risk for the same oral complications flossing the areas that are bleeding but to keep flossing
with the radiation treatment?
second malignancies in the oral region. the other teeth. Hematopoietic Stem
as adults. Other actions to consider in managing
pediatric patients include the following: Cell Transplantation
Advice for Your Patients Complications Specific to Radiation
Hematopoietic Stem • Brush teeth, gums, and tongue gently with an • Extract loose primary teeth and teeth expected
to exfoliate during cancer treatment.
Demineralization and radiation caries:
Prescribe daily fluoride gel applications before
Cell Transplantation extra-soft toothbrush and fluoride toothpaste
after every meal and at bedtime. If brushing hurts, treatment starts. Continue for the patient’s lifetime
• Remove orthodontic bands and brackets if highly
Most stem cell transplant patients develop acute soften the bristles in warm water. stomatotoxic chemotherapy is planned or if the if changes in quality or quantity of saliva persist.
oral complications, especially patients with graft- appliances will be in the radiation field. Trismus/tissue fibrosis: Instruct the patient
• Floss teeth gently every day. If your gums bleed
versus-host disease. on stretching exercises for the jaw to prevent
and hurt, avoid the areas that are bleeding or sore • Monitor craniofacial and dental structures for
but keep flossing your other teeth. abnormal growth and development. or reduce the severity of fibrosis.
Before Transplantation U.S. Department of Health and Human Services
• Follow instructions for fluoride gel applications. Osteonecrosis: Avoid invasive procedures involving National Institutes of Health
• Conduct a pretreatment oral health irradiated bone, particularly the mandible. National Institute of Dental and Craniofacial Research
examination and prophylaxis.
 Questions To Ask the • Consult the oncologist about scheduling • Avoid mouthwashes containing alcohol.
Dental Care for Oral Complications
Dental
dental treatment.
Medical Oncologist • Rinse the mouth several times a day with a
of Cancer Treatment
• Schedule oral surgery at least 7 to 10 days baking soda and salt solution, followed by a plain
• What is the patient’s complete blood count, before myelosuppressive therapy begins. water rinse. Use ¼ teaspoon each of baking Oral Mucositis: Culture lesions to identify secondary

Provider’s
including absolute neutrophil and platelet counts? soda and salt in 1 quart of warm water. Omit
• Prevent tooth demineralization and radiation caries: infection. Prescribe topical anesthetics and systemic
• If an invasive dental procedure needs to be salt during mucositis. analgesics. Consult the oncologist about prescribing
done, are there adequate clotting factors? –– Instruct the patient in home application antimicrobial agents for known infections. Have the

Oncology
• Try the following if dry mouth is a problem:
of fluoride gel (not fluoride rinses). patient avoid rough-textured foods and report oral
• Does the patient have a central venous catheter? –– Sip water frequently.
• Instruct the patient about an oral hygiene regimen. problems early.
• What is the scheduled sequence of treatments

Pocket
–– Suck ice chips or use sugar-free gum or candy. Xerostomia/salivary gland dysfunction: Advise
so that safe dental treatment can be planned?
After Transplantation the patient to soften or thin foods with liquid, chew
–– Use saliva substitute spray or gel or a
• Is radiation therapy also planned? sugarless gum, or suck ice chips or sugar-free hard
• Consult the oncologist before any dental prescribed saliva stimulant if appropriate.

Guide
procedure, including prophylaxis. candies. Suggest using commercial saliva substitutes
Questions To Ask the –– Avoid glycerin swabs. or prescribe a saliva stimulant.
Radiation Oncologist • Monitor the patient's oral health for plaque
• Exercise the jaw muscles three times a day
control, tooth demineralization, dental caries, Taste changes: Refer to a dietitian.
• What parts of the mandible/maxilla and and infection. to prevent and treat jaw stiffness from
salivary glands are in the field of radiation? radiation treatment. Etched enamel: Advise the patient to rinse the

• What is the total dose of radiation the

• Watch for infections on the tongue and oral
• Avoid candy, gum, and soda unless they
mouth with water and baking soda ­solution after Prevention and management
mucosa. Herpes simplex and Candida albicans vomiting to protect enamel.
patient will receive, and what will be the are common oral infections. are sugar-free. of oral complications
impact on these areas?
• Avoid spicy or acidic foods, toothpicks,
Complications Specific to Chemotherapy
• Has the vascularity of the mandible been
• Delay elective oral procedures for 1 year.
tobacco products, and alcohol. Neurotoxicity: Provide analgesics or systemic
Head and Neck
previously compromised by surgery? • Follow patients for long-term oral complications. pain relief. Radiation Therapy
Such problems are strong indicators of chronic
• How quickly does the patient need to graft-versus-host disease. Special Care for Children Bleeding: Advise the patient to clean teeth thoroughly
start radiation treatment? with a toothbrush softened in warm water; avoid
Chemotherapy
• Monitor transplant patients carefully for Children receiving chemotherapy and/or radiation
• Will there be induction chemotherapy therapy are at risk for the same oral complications flossing the areas that are bleeding but to keep flossing
with the radiation treatment?
second malignancies in the oral region. the other teeth. Hematopoietic Stem
as adults. Other actions to consider in managing
pediatric patients include the following: Cell Transplantation
Advice for Your Patients Complications Specific to Radiation
Hematopoietic Stem • Brush teeth, gums, and tongue gently with an • Extract loose primary teeth and teeth expected
to exfoliate during cancer treatment.
Demineralization and radiation caries:
Prescribe daily fluoride gel applications before
Cell Transplantation extra-soft toothbrush and fluoride toothpaste
after every meal and at bedtime. If brushing hurts, treatment starts. Continue for the patient’s lifetime
• Remove orthodontic bands and brackets if highly
Most stem cell transplant patients develop acute soften the bristles in warm water. stomatotoxic chemotherapy is planned or if the if changes in quality or quantity of saliva persist.
oral complications, especially patients with graft- appliances will be in the radiation field. Trismus/tissue fibrosis: Instruct the patient
• Floss teeth gently every day. If your gums bleed
versus-host disease. on stretching exercises for the jaw to prevent
and hurt, avoid the areas that are bleeding or sore • Monitor craniofacial and dental structures for
but keep flossing your other teeth. abnormal growth and development. or reduce the severity of fibrosis.
Before Transplantation U.S. Department of Health and Human Services
• Follow instructions for fluoride gel applications. Osteonecrosis: Avoid invasive procedures involving National Institutes of Health
• Conduct a pretreatment oral health irradiated bone, particularly the mandible. National Institute of Dental and Craniofacial Research
examination and prophylaxis.
 Questions To Ask the • Consult the oncologist about scheduling • Avoid mouthwashes containing alcohol.
Dental Care for Oral Complications
Dental
dental treatment.
Medical Oncologist • Rinse the mouth several times a day with a
of Cancer Treatment
• Schedule oral surgery at least 7 to 10 days baking soda and salt solution, followed by a plain
• What is the patient’s complete blood count, before myelosuppressive therapy begins. water rinse. Use ¼ teaspoon each of baking Oral Mucositis: Culture lesions to identify secondary

Provider’s
including absolute neutrophil and platelet counts? soda and salt in 1 quart of warm water. Omit
• Prevent tooth demineralization and radiation caries: infection. Prescribe topical anesthetics and systemic
• If an invasive dental procedure needs to be salt during mucositis. analgesics. Consult the oncologist about prescribing
done, are there adequate clotting factors? –– Instruct the patient in home application antimicrobial agents for known infections. Have the

Oncology
• Try the following if dry mouth is a problem:
of fluoride gel (not fluoride rinses). patient avoid rough-textured foods and report oral
• Does the patient have a central venous catheter? –– Sip water frequently.
• Instruct the patient about an oral hygiene regimen. problems early.
• What is the scheduled sequence of treatments

Pocket
–– Suck ice chips or use sugar-free gum or candy. Xerostomia/salivary gland dysfunction: Advise
so that safe dental treatment can be planned?
After Transplantation the patient to soften or thin foods with liquid, chew
–– Use saliva substitute spray or gel or a
• Is radiation therapy also planned? sugarless gum, or suck ice chips or sugar-free hard
• Consult the oncologist before any dental prescribed saliva stimulant if appropriate.

Guide
procedure, including prophylaxis. candies. Suggest using commercial saliva substitutes
Questions To Ask the –– Avoid glycerin swabs. or prescribe a saliva stimulant.
Radiation Oncologist • Monitor the patient's oral health for plaque
• Exercise the jaw muscles three times a day
control, tooth demineralization, dental caries, Taste changes: Refer to a dietitian.
• What parts of the mandible/maxilla and and infection. to prevent and treat jaw stiffness from
salivary glands are in the field of radiation? radiation treatment. Etched enamel: Advise the patient to rinse the

• What is the total dose of radiation the

• Watch for infections on the tongue and oral
• Avoid candy, gum, and soda unless they
mouth with water and baking soda ­solution after Prevention and management
mucosa. Herpes simplex and Candida albicans vomiting to protect enamel.
patient will receive, and what will be the are common oral infections. are sugar-free. of oral complications
impact on these areas?
• Avoid spicy or acidic foods, toothpicks,
Complications Specific to Chemotherapy
• Has the vascularity of the mandible been
• Delay elective oral procedures for 1 year.
tobacco products, and alcohol. Neurotoxicity: Provide analgesics or systemic
Head and Neck
previously compromised by surgery? • Follow patients for long-term oral complications. pain relief. Radiation Therapy
Such problems are strong indicators of chronic
• How quickly does the patient need to graft-versus-host disease. Special Care for Children Bleeding: Advise the patient to clean teeth thoroughly
start radiation treatment? with a toothbrush softened in warm water; avoid
Chemotherapy
• Monitor transplant patients carefully for Children receiving chemotherapy and/or radiation
• Will there be induction chemotherapy therapy are at risk for the same oral complications flossing the areas that are bleeding but to keep flossing
with the radiation treatment?
second malignancies in the oral region. the other teeth. Hematopoietic Stem
as adults. Other actions to consider in managing
pediatric patients include the following: Cell Transplantation
Advice for Your Patients Complications Specific to Radiation
Hematopoietic Stem • Brush teeth, gums, and tongue gently with an • Extract loose primary teeth and teeth expected
to exfoliate during cancer treatment.
Demineralization and radiation caries:
Prescribe daily fluoride gel applications before
Cell Transplantation extra-soft toothbrush and fluoride toothpaste
after every meal and at bedtime. If brushing hurts, treatment starts. Continue for the patient’s lifetime
• Remove orthodontic bands and brackets if highly
Most stem cell transplant patients develop acute soften the bristles in warm water. stomatotoxic chemotherapy is planned or if the if changes in quality or quantity of saliva persist.
oral complications, especially patients with graft- appliances will be in the radiation field. Trismus/tissue fibrosis: Instruct the patient
• Floss teeth gently every day. If your gums bleed
versus-host disease. on stretching exercises for the jaw to prevent
and hurt, avoid the areas that are bleeding or sore • Monitor craniofacial and dental structures for
but keep flossing your other teeth. abnormal growth and development. or reduce the severity of fibrosis.
Before Transplantation U.S. Department of Health and Human Services
• Follow instructions for fluoride gel applications. Osteonecrosis: Avoid invasive procedures involving National Institutes of Health
• Conduct a pretreatment oral health irradiated bone, particularly the mandible. National Institute of Dental and Craniofacial Research
examination and prophylaxis.
 Questions To Ask the • Consult the oncologist about scheduling • Avoid mouthwashes containing alcohol.
Dental Care for Oral Complications
Dental
dental treatment.
Medical Oncologist • Rinse the mouth several times a day with a
of Cancer Treatment
• Schedule oral surgery at least 7 to 10 days baking soda and salt solution, followed by a plain
• What is the patient’s complete blood count, before myelosuppressive therapy begins. water rinse. Use ¼ teaspoon each of baking Oral Mucositis: Culture lesions to identify secondary

Provider’s
including absolute neutrophil and platelet counts? soda and salt in 1 quart of warm water. Omit
• Prevent tooth demineralization and radiation caries: infection. Prescribe topical anesthetics and systemic
• If an invasive dental procedure needs to be salt during mucositis. analgesics. Consult the oncologist about prescribing
done, are there adequate clotting factors? –– Instruct the patient in home application antimicrobial agents for known infections. Have the

Oncology
• Try the following if dry mouth is a problem:
of fluoride gel (not fluoride rinses). patient avoid rough-textured foods and report oral
• Does the patient have a central venous catheter? –– Sip water frequently.
• Instruct the patient about an oral hygiene regimen. problems early.
• What is the scheduled sequence of treatments

Pocket
–– Suck ice chips or use sugar-free gum or candy. Xerostomia/salivary gland dysfunction: Advise
so that safe dental treatment can be planned?
After Transplantation the patient to soften or thin foods with liquid, chew
–– Use saliva substitute spray or gel or a
• Is radiation therapy also planned? sugarless gum, or suck ice chips or sugar-free hard
• Consult the oncologist before any dental prescribed saliva stimulant if appropriate.

Guide
procedure, including prophylaxis. candies. Suggest using commercial saliva substitutes
Questions To Ask the –– Avoid glycerin swabs. or prescribe a saliva stimulant.
Radiation Oncologist • Monitor the patient's oral health for plaque
• Exercise the jaw muscles three times a day
control, tooth demineralization, dental caries, Taste changes: Refer to a dietitian.
• What parts of the mandible/maxilla and and infection. to prevent and treat jaw stiffness from
salivary glands are in the field of radiation? radiation treatment. Etched enamel: Advise the patient to rinse the

• What is the total dose of radiation the

• Watch for infections on the tongue and oral
• Avoid candy, gum, and soda unless they
mouth with water and baking soda ­solution after Prevention and management
mucosa. Herpes simplex and Candida albicans vomiting to protect enamel.
patient will receive, and what will be the are common oral infections. are sugar-free. of oral complications
impact on these areas?
• Avoid spicy or acidic foods, toothpicks,
Complications Specific to Chemotherapy
• Has the vascularity of the mandible been
• Delay elective oral procedures for 1 year.
tobacco products, and alcohol. Neurotoxicity: Provide analgesics or systemic
Head and Neck
previously compromised by surgery? • Follow patients for long-term oral complications. pain relief. Radiation Therapy
Such problems are strong indicators of chronic
• How quickly does the patient need to graft-versus-host disease. Special Care for Children Bleeding: Advise the patient to clean teeth thoroughly
start radiation treatment? with a toothbrush softened in warm water; avoid
Chemotherapy
• Monitor transplant patients carefully for Children receiving chemotherapy and/or radiation
• Will there be induction chemotherapy therapy are at risk for the same oral complications flossing the areas that are bleeding but to keep flossing
with the radiation treatment?
second malignancies in the oral region. the other teeth. Hematopoietic Stem
as adults. Other actions to consider in managing
pediatric patients include the following: Cell Transplantation
Advice for Your Patients Complications Specific to Radiation
Hematopoietic Stem • Brush teeth, gums, and tongue gently with an • Extract loose primary teeth and teeth expected
to exfoliate during cancer treatment.
Demineralization and radiation caries:
Prescribe daily fluoride gel applications before
Cell Transplantation extra-soft toothbrush and fluoride toothpaste
after every meal and at bedtime. If brushing hurts, treatment starts. Continue for the patient’s lifetime
• Remove orthodontic bands and brackets if highly
Most stem cell transplant patients develop acute soften the bristles in warm water. stomatotoxic chemotherapy is planned or if the if changes in quality or quantity of saliva persist.
oral complications, especially patients with graft- appliances will be in the radiation field. Trismus/tissue fibrosis: Instruct the patient
• Floss teeth gently every day. If your gums bleed
versus-host disease. on stretching exercises for the jaw to prevent
and hurt, avoid the areas that are bleeding or sore • Monitor craniofacial and dental structures for
but keep flossing your other teeth. abnormal growth and development. or reduce the severity of fibrosis.
Before Transplantation U.S. Department of Health and Human Services
• Follow instructions for fluoride gel applications. Osteonecrosis: Avoid invasive procedures involving National Institutes of Health
• Conduct a pretreatment oral health irradiated bone, particularly the mandible. National Institute of Dental and Craniofacial Research
examination and prophylaxis.
 Head and Neck Radiation Therapy • Watch for mucositis and infection. • Schedule dental treatment in consultation with
the oncologist.
Oral Health, Cancer Care, and You
• Advise against wearing removable appliances
Pre-cancer Treatment Patients receiving radiation therapy to the head and neck
are at risk for developing oral complications. Because of during treatment. • Schedule oral surgery at least 7 to 10 days
This guide is part of a series on managing
and preventing oral complications of cancer
Oral Health Examination the risk of osteonecrosis in irradiated fields, oral surgery
before myelosuppressive therapy begins.
treatment developed by the National Institute of
should be performed before radiation treatment begins.
After Radiation Therapy • Consult the oncologist before conducting any oral Dental and Craniofacial Research in partnership
Objectives • Recall the patient for prophylaxis and home care procedures in patients with hematologic cancers; with the National Cancer Institute, the National
Before Head and Neck Radiation Therapy evaluation every 4 to 8 weeks or as needed for do not conduct procedures in patients who are Institute of Nursing Research, and the Centers
1. Conduct evaluation 1 month, if possible,
the first 6 months after cancer treatment. immunosuppressed or have thrombocytopenia. for Disease Control and Prevention.
before cancer treatment begins. • Conduct a pretreatment oral health examination
and prophylaxis. • Reinforce the importance of optimal oral hygiene.
2. Establish a schedule for dental treatment. During Chemotherapy To order this and other publications in the Oral
• Schedule dental treatment in consultation with the • Monitor the patient for trismus: check for pain or Health, Cancer Care, and You series, contact:
• Complete invasive procedures at least • Consult the oncologist before any dental
radiation oncologist. weakness in masticating muscles in the radiation
14 days before head/neck radiation procedure, including prophylaxis. National Institute of Dental and
field. Instruct the patient to exercise three times a
therapy starts; 7 to 10 days before • Extract teeth in the proposed radiation field that may day, opening and closing the mouth as far as possible Craniofacial Research
• Ask the oncologist to order blood work 24 hours
myelosuppressive chemotherapy. be a problem in the future. without pain; repeat 20 times. National Oral Health Information Clearinghouse
before oral surgery or other invasive procedures.
• Postpone elective oral surgical procedures • Prevent tooth demineralization and radiation caries: Postpone when 1 NOHIC Way
• Consult with the oncology team about use of
until cancer treatment is completed. Bethesda, MD 20892-3500
–– Fabricate custom gel-applicator trays for the patient. dentures and other appliances after mucositis –– the platelet count is less than 75,000/mm3 1–866–232–4528
3. Identify and treat sites of low-grade and subsides. Patients with friable tissues and or abnormal clotting factors are present
–– Prescribe a 1.1% neutral pH sodium fluoride gel xerostomia may not be able to wear them again. www.nidcr.nih.gov
acute oral infections:
or a 0.4% stannous, unflavored fluoride gel (not –– absolute neutrophil count is less than
• Caries fluoride rinses). • Watch for demineralization and caries. Lifelong, 1,000/mm3, or consider prophylactic
daily applications of fluoride gel are needed for antibiotics (www.americanheart.org).
• Periodontal disease –– Use a neutral fluoride for patients with porcelain patients with xerostomia.
• Endodontic disease crowns or resin or glass ionomer restorations. • Check for oral source of viral, bacterial, or fungal
• Advise against elective oral surgery on irradiated infection in patients with fever of unknown origin.
• Mucosal lesions –– Be sure that the trays cover all tooth structures bone because of the risk of osteonecrosis. Tooth
without irritating the gingival or mucosal tissues. extraction, if unavoidable, should be conservative, • Encourage consistent oral hygiene measures. Reprinted September 2009
4. Identify and eliminate sources of oral trauma using antibiotic coverage and possibly hyperbaric
–– Instruct the patient in home application of fluoride • Consult the oncologist about the need for
and irritation such as ill-fitting dentures, oxygen therapy.
gel. Several days before radiation therapy begins, the antibiotic prophylaxis before any dental procedures
orthodontic bands, and other appliances.
patient should start a daily 10-minute application. in patients with central venous catheters.
5. Identify and treat potential oral problems
–– Have patients brush with a fluoride gel if using Chemotherapy
within the proposed radiation field before
trays is difficult. After Chemotherapy
radiation treatment begins. The oral complications of chemotherapy depend upon
• Allow at least 14 days of healing for any oral the drugs used, the dosage, the degree of dental disease, • Place the patient on a dental recall schedule when
6. Instruct patients about oral hygiene. surgical procedures. and the use of radiation. Chemoradiation therapy chemotherapy is completed and all side effects, Centers for Disease

carries a significant risk for mucositis. including immunosuppression, have resolved. Control and Prevention
7. Educate patients on preventing • Conduct prosthetic surgery before treatment, since
demineralization and dental caries. elective surgical procedures are contraindicated on • Confirm normal hematologic status prior
irradiated bone. Before Chemotherapy to dental treatment. U.S. Department of Health
and Human Services
• Conduct a pretreatment oral health examination • Ask if the patient has received intravenous National Institutes of Health
During Radiation Therapy and prophylaxis. bisphosphonate therapy.
• Monitor the patient’s oral hygiene.