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Date issued: September 2022

Review date: September 2024 

Ref: B-448/SS/head and neck/dental Cancer Patients undergoing radiotherapy v2

PDF:  Cancer Patients undergoing radiotherapy final September 2022 v2.pdf [pdf] 392KB

Introduction

As part of your preparation for your cancer treatment you have an assessment from the dental team. This leaflet explains why it is important to see a dentist before and after your treatment for head and neck cancer. It also explains what you can expect when you come to the hospital dental department before, during and after your cancer treatment.

Please take time to read this leaflet as it explains we do to help you and what you can do to help yourself.  

If you have any further questions, please speak to a dentist, doctor or nurse caring for you. There is a contact telephone number at the end of the leaflet in case you have any urgent questions.

Head and Neck Cancer treatment and your mouth

Radiotherapy may be used, in addition to surgery and chemotherapy, for treating cancers of the head and neck but it can have a number of side effects in your mouth: 

1. A sore mouth 

The mouth often becomes inflamed, ulcerated, and painful.  This is called ‘mucositis’. Swallowing can become extremely difficult and brushing your teeth may be uncomfortable, but you should continue brushing to prevent dental problems.  It is important to report changes or concerns to the team at your review appointments.

2. A dry mouth

The mouth may become dry after radiotherapy to the head and neck.  This is called ‘xerostomia’. It can make the mouth uncomfortable and eating and wearing dentures more difficult.  It also increases the chances of tooth decay and gum disease.  Xerostomia may be a permanent problem although the extent of dryness does vary.

3. Loss or change of taste

This is usually temporary but does make eating less enjoyable.

4. Tooth sensitivity and decay

The teeth and mouth can become sensitive to hot, cold, sweet and spicy things. You may have to dilute your mouth rinse at this time. Brushing your teeth may be uncomfortable but you should continue brushing to prevent dental decay forming.

5. Restricted jaw opening

Difficulties opening your mouth are common after jaw surgery and radiotherapy.  This is called ‘trismus’.  It makes brushing your teeth, eating and dental treatment more difficult. 

6. Osteoradionecrosis

This is an aggressive bone infection that may follow tooth extractions.  It is caused by changes in the bone by radiotherapy which affect healing.  Teeth may be removed before radiotherapy to prevent this occurring.

Oral hygiene

Before you start your treatment, you will be given lots of reading material and information about your diagnosis. Undoubtedly, your priority will be to get better, and perhaps brushing your teeth regularly may seem like a relatively minor concern. However, caring for your mouth can help make you more comfortable and reduce complications during your treatment period. It will also reduce the severity, complications, and lasting side effects after the treatment.

The key to healthy teeth and a healthy mouth is thorough brushing of your teeth twice a day with fluoride toothpaste and having a low sugar diet (amount and frequency of sugar). Stopping smoking will also be extremely helpful for your mouth, the cancer treatment and also for your future dental treatment.  Achieving good oral health is hard work but the team are here to help you.  Follow this guide for some basic instructions on how to brush your teeth effectively:

Dry Mouth and Increased risk of dental disease

Radiotherapy can damage the glands which produce saliva, leaving you will have less or in some cases no saliva in your mouth. This will give you the feeling of a ‘dry mouth’. Saliva moistens the mouth, protects against tooth decay, tooth sensitivity and gum problems. Therefore without or with less saliva you are at a higher risk of developing tooth decay and gum disease.

In order to prevent the decay, it is important to have fluoride available around your teeth (Fluoride is the mineral in the toothpaste that helps to prevent decay). You should continue to brush your teeth thoroughly 2x a day for 2 minutes, but with a high fluoride toothpaste (Duraphat 5000). This toothpaste is only available on prescription from your Doctor or Dentist as it contains more than 3 times the amount of fluoride of regular toothpaste.  With this brushing we also recommend to use a Fluoride mouthwash (Fluorigard). If you require this toothpaste in the long term please ask your dentist to prescribe it for you.

 Your normal quantity of saliva may not return completely and you might continue to suffer from a dry mouth.  There will be lots of information on options for management provided by the whole oncology team, probably the best advice at the moment is to take frequent sips of water. We have included a couple of samples of dry mouth products for you to try.

Restricted mouth opening

Radiation also has the potential to damage the chewing muscles in and around your jaw joint. This can result in something called trismus. Trismus is when you can’t open your mouth as wide as usual. It is a progressive condition, so it can get worse over time and therefore it is important to try and prevent/lessen the affects early on in treatments. The best way to do this is by doing daily simple stretching exercises of your jaw muscles. You should start jaw exercising as soon as your specialist decides it is safe to do so (i.e. not immediately after your operation). Your speech and language therapist will also go through the exercises with you and may give you a tailored exercise programme.

Here are some examples of active range of motion and stretching exercises:

Do these exercises ideally 3 times every day or as often as you can. You can do them while sitting or standing. These movements should give you a good stretch, but they shouldn’t cause pain. If an exercise is causing pain or discomfort, try doing the stretch more lightly.

Open your mouth as wide as you can, until you feel a good stretch but no pain. Hold this stretch for 10 seconds. Repeat these steps 5 times.

Move your lower jaw to the left. Hold this stretch for 3 seconds. Repeat these steps 5 times.

Move your lower jaw to the right. Hold this stretch for 3 seconds. Repeat these steps 5 times.

Osteoradionecrosis

Radiotherapy also affects your jawbone; in particular, it reduces the bone’s ability to heal itself. This means that you might be at a higher risk of developing an infection of the bone, leading to bone death after you had a tooth removed.  This is called Osteoradionecrosis and is a serious complication if you require tooth extraction after radiation therapy. The risk of osteoradionecrosis does not diminish, with time it can increase.

All teeth with a poor prognosis would have been removed by our Maxillofacial Team before you start the treatment; however, it is important to remember the better you look after your teeth the less problems will occur in the future. When you tell your dentist about your radiotherapy they will be aware that tooth extractions in the field of radiation should be avoided if at all possible.

Diet and oral health

Nutrition plays an important role during and after your treatment as it is important to maintain your weight.  Your nutritional requirements will be increased and this can mean eating high energy snacks between your meals. Eating sugary or acidic foods may cause decay and erosion to your teeth so it is very important that you follow the advice of the dietitian, hygienist and dentist.

Following radiotherapy, you may experience swallowing difficulties and changes in taste. It is very important that you continue to eat and drink when possible during this time and take any nutritional supplements advised. When you are getting better and your weight stabilises, start trying to avoid sweet and sugary drinks and food, fruit juices and fizzy-drinks, choose sugar-free sweets and keep up very good tooth brushing to reduce the risk of tooth decay.

Minimising the side effects of radiotherapy 

A sore mouth 

The anaesthetic mouthwash Difflam should be used when the mouth is very sore.  If it causes stinging, then it can be diluted as needed. Use frequent salt mouthwashes or swabs soaked in Corsodyl / Chlorhexidine to clean the insides of your mouth (cheeks and lips) and the Corsodyl / Chlorhexidine mouthwash or spray to help healing.  Avoid alcohol and smoking as these can make the mucositis worse and delay healing.   Only use a soft toothbrush if your mouth is too sore to brush with your normal toothbrush.  Return to a medium stiffness toothbrush as soon as possible as this will clean your teeth and gums better. 

Dry mouth

Take regular sips of water and use the gels and mouthwashes which have been developed specifically for mouth dryness as a result of radiotherapy.  Try chewing sugar-free chewing gum and saliva stimulating tablets to help stimulate saliva flow.  Your hygienist or specialist nurse will advise you how to use these. You can also experience taste changes, sticky saliva and swallowing difficulties which are not usually caused by a dry mouth but can be made worse by a dry mouth. Please as for The Dry Mouth leaflet at your review for further information.

Sensitivity and tooth decay

Use the Duraphat fluoride toothpaste and Fluoriguard mouthwash to protect the teeth from decay.  You may be given fluoride trays to wear at night to help further.  These are similar to sports gum shields that you fill with fluoride and fit over the teeth.

Dentures / obturators

Leave them out at night to improve the health of the teeth and gums or if they are causing ulcers or discomfort.  Clean them carefully over a basin of water after meals with a toothbrush and/or soap and water and use a denture soak. 

Continue to brush your teeth and gums to remove the plaque and deposits that can build up especially when your mouth is sore and dry and you are having a soft diet.

Restricted jaw opening (trismus)

Trismus is a difficulty or restriction of mouth opening which can follow radiotherapy and jaw surgery.  It can cause problems with speech, eating, brushing teeth, wearing dentures and obturators, dental treatments and cosmetic appearance while talking.  Trismus can also increase your stress when you are already undergoing other treatment.   

Please ensure the consultants/dentist/nurse specialist is aware if you experience any difficulty in opening your mouth. Trismus can be helped by jaw exercisers (devices) and by practising the jaw opening exercises.

Some of the unwanted effects of cancer treatment such as the soreness, dry mouth and loss of taste can gradually improve in the weeks and months after treatment is completed. Unfortunately, some patients will have a permanently dry mouth, missing teeth and restrictions of jaw movement.

Restorative dentistry and oral rehabilitation

Before radiotherapy you will have a dental examination to assess and plan your dental needs: If your teeth and gums are not healthy you can have problems with pain and infection during or after your cancer treatment. In some cases these problems can be severe. A specialist dentist will discuss the current health of your teeth and gums with you. Any teeth which are likely to cause you pain or infection in future may be recommended for extraction. It is not always easy to decide which teeth should be extracted. Often more than one dentist will be involved in making the decision and many factors are considered. These include the location of your cancer and what type of treatment is planned. If your teeth are decayed, filled, have gum problems, have had issues in the past or are loose, this will affect the decision. Unfortunately, there are times when even healthy teeth (particularly back teeth) may be recommended for extraction. This is because the side effects of radiotherapy may complicate your future oral care. The dentist will always discuss with you why extraction is recommended.

Dental care

1. Any extractions will usually be arranged with the Maxillofacial Surgery Department before radiotherapy.  

2. If required you will be referred to our dental hygienist for oral hygiene instruction and advice on reducing the risk of problems with your teeth, gums, and mouth.

3. Temporary fillings if required will be carried out as soon as possible. However permanent fillings should be carried out in primary care with your own dentist.  If you do not have your own dentist, you will need to register with a dentist for this treatment to be done after your radiotherapy review (see below). You should still see your dentist for regular check-ups and emergencies such as broken fillings.  This will ensure you maintain your registration at the dental practice and that they are aware of your cancer treatment.

4. We will organise a review for you after you have finished the radiotherapy treatment.

5. Patients requiring complex rehabilitation will be planned after their post radiotherapy review.

Teeth extracted in preparation for cancer treatment cannot routinely be replaced by the hospital after treatment is completed. Replacement teeth are considered if there is exceptional need and the treatment constitutes complex rehabilitation requiring specialist level care. 

After cancer treatment, patients will be discharged from the hospital back to the care of their own dentist. It is essential that you are registered with a dentist. If you are not currently registered with a dental practice we urge you to register as soon as possible. We have attached a list of useful contacts to help you find a dentist.

If you have any questions or any urgent queries, please contact your dedicated nurse specialist on 01752 430 279 and she will discuss with a member of the dental team.

How to access NHS dental care

How to access NHS dental care

NHS Dentist		Peninsula Dental School Dental Education Facility
To find your local NHS dentist call the numbers below or email:   devondentalhelpline@nhs.net         0845 002 0034 or 01392 822348		Wide range of free NHS dental treatment for adults and children offered by fully supervised dental students.   Damerel Close, Devonport, Plymouth PL1 4JZ Research Way, Derriford, Plymouth PL6 8BT   0345 155 8109
Dental Access Centre (DAC), Nuffield Clinic		Out of Hours (OOH) Emergency Care
Emergency treatment for people in pain.   Dental Access Centre 1a Baring Street Lipson Plymouth PL4 8NF     0845 155 8070		For urgent care and help out of hours and during the weekend.   Available Monday to Thursday 7.30pm – 8.45am Weekends: Friday 6pm to Monday 8.45am   Devon Doctors   01392 823682

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A number of dental practices also offer private dental care and accept new patients, just give the practice of your choice a ring and enquire with them directly.