Management of Oral Complications of Cancer Chemotherapy and Radiotherapy

A comprehensive set of Q-and-A flashcards covering etiology, risk factors, clinical features, grading, prevention, and management of oral complications arising from cancer chemotherapy and head-and-neck radiotherapy.

What oral and systemic effects are most chemotherapeutic agents commonly associated with?

Alopecia, oral mucositis, bone-marrow depression (infection, bleeding, anemia), gastrointestinal changes (diarrhea, malabsorption), altered nutritional status, and possible cardiac or pulmonary dysfunctions.

Which two oral complications of chemotherapy are predictable, dose-dependent, and usually manageable?

Bone-marrow suppression and oral mucositis.

List four typical oral findings in a patient receiving myelosuppressive chemotherapy.

Erythema and ulceration of oral mucosa, secondary infections, excessive bleeding with minor trauma, xerostomia, anemia, and neurotoxicity (any four).

During head-and-neck radiotherapy, when does mucositis usually begin?

Around the second week of radiation therapy.

Name two cancer treatments that can lead to acute nausea and vomiting.

Head-and-neck radiotherapy and myelosuppressive chemotherapy.

Which oral complication of radiation presents with delayed onset and is more common in the mandible?

Osteoradionecrosis.

Define oral mucositis.

Inflammation and ulceration of the oral mucosa caused by direct cytotoxic effects of radiation or antineoplastic agents on rapidly dividing epithelial cells and by cytokine upregulation.

Approximately what percentage of chemotherapy patients develop oral mucositis?

Up to 40 %.

Which oral sites are most prone to radiation-induced mucositis?

Non-keratinized mucosa such as buccal mucosa, labial mucosa, and ventral tongue, especially adjacent to metallic restorations.

After chemotherapy, mucositis most commonly develops between which days?

Days 7 and 14.

Name three chemotherapeutic drug classes commonly linked to oral mucositis.

Alkylating agents, anthracyclines, antimetabolites (also antitumor agents, taxanes, vinca alkaloids).

Give two patient-related risk factors for oral mucositis.

Young age, female gender, Caucasian ethnicity, poor nutritional status, type of malignancy, poor pretreatment oral condition, inadequate oral care during therapy (any two).

Give two therapy-related risk factors for oral mucositis.

Multicycle chemotherapy, specific agents (cisplatin, 5-FU, methotrexate, cyclophosphamide), head-and-neck radiotherapy, conditioning for stem-cell transplant, induction therapy for leukemias (any two).

Which four phases describe the pathophysiology of oral mucositis?

Phase I – initial inflammatory/vascular; Phase II – epithelial; Phase III – ulcerative/bacteriological; Phase IV – healing.

Which pro-inflammatory cytokine is prominently released during Phase I of mucositis?

Tumor necrosis factor-α (TNF-α).

What clinical change characterizes Phase II (epithelial phase) of mucositis?

Reduced epithelial turnover leading to epithelial atrophy and erythema.

During which phase of mucositis do pseudomembranes typically form?

Phase III – ulcerative/bacteriological phase.

On average, how long does the healing phase of mucositis last?

Approximately 12–16 days, depending on several host factors.

Which grading scale is most frequently used worldwide to score oral mucositis?

The World Health Organization (WHO) Oral Toxicity Scale.

According to WHO grading, what distinguishes Grade 3 mucositis?

Presence of oral ulcers allowing only a liquid diet.

List three typical patient complaints associated with oral mucositis.

Ulceration, pain, dysphagia, loss of taste, difficulty eating, increased infection risk (any three).

At what radiation dose do salivary glands usually sustain serious functional damage?

Doses exceeding 3000 cGy.

By the end of the first week of radiotherapy, salivary flow is typically reduced by what percentage?

Approximately 50–60 %.

Why is post-radiation saliva described as thick and ropy?

Radiation damages serous acini more than mucous acini, increasing mucin content and viscosity.

Name two common opportunistic infections seen in hyposalivatory, immunosuppressed cancer patients.

Pseudomembranous candidiasis (Candida albicans) and recurrent herpes simplex virus (HSV) infections.

At what platelet count does spontaneous gingival bleeding become likely?

When platelet count drops below 50,000 cells/mm³.

Which chemotherapeutic drugs are most associated with neurotoxic, toothache-like pain?

Vincristine and vinblastine (vinca alkaloids).

What exercise can help prevent or relieve radiation-induced trismus?

Placing progressively more tongue blades between the teeth for 10-minute stretches three times daily.

Define osteoradionecrosis of the jaws.

Exposed bone that fails to heal after 6 months in an area that received high-dose radiation, due to hypocellularity, hypovascularity, and hypoxia.

Which jaw site carries the greatest risk for osteoradionecrosis?

Posterior mandible.

State two major risk factors that increase the likelihood of osteoradionecrosis.

Radiation dose > 6500 cGy, traumatic dental procedures (e.g., extractions), continued smoking, periodontal disease, dentate status (any two).

What is the first (Stage I) level in Kagan & Schwartz’s staging of osteoradionecrosis?

Minimal soft-tissue ulceration with limited exposed cortical bone managed conservatively.

According to NCI criteria, which grade of bone toxicity involves severe symptoms limiting self-care ADL?

Grade 3.

List two radiation effects on normal bone tissue under an external beam.

Decreased osteocyte numbers and reduced blood flow (also fewer osteoblasts).

When should questionable teeth be extracted before head-and-neck radiotherapy?

Ideally at least 3 weeks (minimum 2 weeks) before radiation begins.

Before starting chemotherapy, how long before therapy should mandibular extractions ideally be completed?

At least 7 days.

What is the minimum acceptable granulocyte count for routine outpatient dental care during chemotherapy?

2000 cells/µm³.

Name two recommended agents for the management of oral mucositis pain.

Benzydamine 0.15 % mouthwash, 2 % morphine mouthwash, 0.5 % doxepin mouthwash, palifermin, low-level laser therapy (any two).

What is the composition of the commonly prescribed "magic mouthwash"?

Diphenhydramine (Benadryl) + Maalox + viscous lidocaine 0.5 % ± nystatin ± sucralfate.

Give two strategies to manage xerostomia in irradiated patients.

Frequent water sipping, sugarless lemon drops or sorbitol gum, salivary substitutes, sialogogue drugs such as pilocarpine or cevimeline (any two).

Which fluoride regimen is advised daily to help prevent radiation caries?

Custom trays with 5–10 drops of 1–2 % acidulated fluoride gel for 5 minutes daily (or 0.5 % neutral NaF if tissue irritation occurs).

Which salivary stimulant is prescribed 5 mg three to four times daily?

Pilocarpine HCl (Salagen).

What antibiotic prophylaxis is suggested 1 hour before oral surgery to minimize osteoradionecrosis?

Penicillin VK 2 g orally.

Why should vasoconstrictors be minimized in irradiated bone?

They further reduce blood supply to hypovascular tissue, increasing risk of osteoradionecrosis.

Name two mechanical oral-hygiene aids recommended after head-and-neck radiotherapy.

Oral irrigators, chlorhexidine rinses, daily fluoride gels, Waterpik devices (any two).

Which platelet level necessitates transfusion before dental extraction?

< 50,000 cells/mm³.

What WBC or ANC values warrant delaying extractions or adding prophylactic antibiotics in chemotherapy patients?

WBC < 2000/µL or absolute neutrophil count < 1000/µL.

Give two over-the-counter products that can provide saliva substitutes.

Glandosane spray, Salivart spray, MouthKote, Optimoist, Moi-Stir (any two).

What is the recommended frequency of dental recall visits during the first year after radiotherapy?

Monthly recall to confirm patient compliance.

Name one systemic supplement that may enhance oral mucosal healing.

Systemic zinc supplements or vitamin C.

Which taste sensation change is common during head-and-neck radiotherapy, and how long does recovery usually take?

Diminished taste (dysgeusia); recovery in 3–4 months post-therapy.

Which organisms typically replace normal flora in immunosuppressed cancer patients, leading to gram-negative oral ulcerations?

Pseudomonas, Klebsiella, Proteus, Escherichia coli, or Enterobacter species.

What radiographic or clinical findings accompany chemotherapy-induced neurotoxicity tooth pain?

None; pain mimics irreversible pulpitis but lacks clinical or radiographic pathology.

Why are endodontic procedures preferred over extractions in irradiated jaws?

They minimize trauma and preserve bone blood supply, reducing osteoradionecrosis risk.

What topical agent is recommended to manage sensitivity of radiation-affected teeth?

Topical fluoride applications.

Give two contraindicated oral-hygiene devices when platelet levels are low during chemotherapy.

Toothpicks, dental floss, and water-irrigating appliances.

What daily fluoride toothpaste is recommended for caries-prone xerostomic patients?

Biotene fluoridated toothpaste or Prevident 5000 (1.1 % neutral NaF).

Which conditioning regimen increases the risk of oral mucositis in stem-cell transplant patients?

High-dose myeloablative chemotherapy or total-body irradiation used before hematopoietic stem-cell transplantation.

How should bone be managed at extraction sites before radiotherapy?

Trim sharp edges and obtain primary soft-tissue closure; avoid intra-alveolar hemostatic packing agents.

List two low-level laser therapy benefits for oral mucositis.

Reduces pain, promotes faster epithelial healing, and decreases severity of lesions.

What is the role of hyperbaric oxygen in osteoradionecrosis management?

Enhances tissue oxygenation, angiogenesis, and healing in hypoxic irradiated bone, useful before or after surgical intervention.

Which scale specifically quantifies ulcer size and erythema for oral mucositis assessment?

OMAS – Oral Mucositis Assessment Scale.

What is the earliest radiation dose threshold at which radiation caries become a concern?

Delayed effect but generally after cumulative head-and-neck doses above 3000 cGy, especially with hyposalivation.