Cancer : Fatigue, Pain, Tissue and Bone Loss

by National Cancer Institute

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Fatigue

Cancer patients who are undergoing high-dose chemotherapy and/or radiation therapy often experience fatigue (lack of energy) that is related to either the cancer or its treatment. Some patients may have difficulty sleeping. The patient may feel too tired to perform routine oral care, which may further increase the risk for mouth ulcers, infection, and pain.

Pain

Certain anticancer drugs can cause nerve damage that may result in oral pain.

If an anticancer drug is causing the pain, stopping the drug usually stops the pain. Because there may be many causes of oral pain during cancer treatment, a careful diagnosis is important. This may include obtaining a medical history, performing physical and dental exams, and taking x-rays of the teeth.

Tooth sensitivity may occur in some patients weeks or months after chemotherapy has ended. Fluoride treatments and/or toothpaste for sensitive teeth may relieve the discomfort.

Pain in the teeth or jaw muscles may occur from tooth grinding or stress.

Pain in the teeth or jaw muscles may occur in patients who grind their teeth or clench their jaws, often because of stress or the inability to sleep. Treatment may include the following:

• Muscle relaxers.
• Drugs to treat anxiety.
• Physical therapy (moist heat, massage, and stretching).
• Mouthguards to wear while sleeping.

Jaw Stiffness

A long-term complication of radiation therapy is the growth of benign tumors in the skin and muscles. These tumors may make it difficult for the patient to move the mouth and jaw normally. Oral surgery may also affect jaw mobility. Management of jaw stiffness may include the following:

• Physical therapy.
• Oral appliances.
• Pain treatments.
• Medication.

Tissue and Bone Loss

Radiation therapy can cause tissue and bone in the treated area to waste away. When tissue death occurs, ulcers may form in the soft tissues of the mouth, grow in size, and cause pain or loss of feeling. Infection becomes a risk. As bone tissue is lost, fractures can occur. Preventive care can lessen the severity of tissue and bone loss.

Treatment of tissue and bone loss may include the following:

• Eating a well-balanced diet.
• Wearing removable dentures or appliances as little as possible.
• Not smoking.
• Not drinking alcohol.
• Using topical antibiotics.
• Using painkillers.
• Undergoing surgery to remove dead bone or to reconstruct bones of the mouth and jaw.
• Receiving hyperbaric oxygen therapy, a method of delivering oxygen under pressure to the surface of a wound to help it heal.

Management of Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant

Patients who have received transplants are at risk of graft-versus-host disease.

Graft-versus-host disease (GVHD) is a reaction of donated bone marrow or stem cells against the patient's tissue. Symptoms of oral GVHD include the following:

• Sores that appear in the mouth 2 to 3 weeks after the transplant.
• Dry mouth.
• Pain from spices, alcohol, or flavoring (such as mint in toothpaste).

Biopsies taken from the lining of the mouth and salivary glands may be needed to diagnose oral GVHD. Treatment of oral GVHD may include the following:

• Topical rinses, gels, creams, or powders.
• Antifungal drugs taken by mouth or injection.
• Psoralen (a drug used with ultraviolet light to treat skin disease).
• Drugs that promote the production of saliva.
• Fluoride treatments.
• Treatments to replace minerals lost from teeth by acids in the mouth.

Dentures, braces, and oral appliances require special care during high-dose chemotherapy and/or stem cell transplant.

The following are guidelines for the care and use of dentures, braces, and other oral appliances during high-dose chemotherapy and/or stem cell transplant:

• Remove brackets, wires, and retainers before high-dose chemotherapy begins.
• Wear dentures only when eating during the first 3 to 4 weeks after the transplant.
• Brush dentures twice a day and rinse them well.
• Soak dentures in an antibacterial solution when they are not being worn.
• Clean denture soaking cups and change denture soaking solution every day.
• Remove appliances or dentures when cleaning the mouth.
• If mouth sores are present, avoid wearing removable appliances until the mouth is healed.

Dental treatments may be resumed when the transplant patient's immune system returns to normal.

Routine dental treatments, including scaling and polishing, should be delayed until the transplant patient's immune system returns to normal. Caution is advised for at least a year after the transplant.

Relapse and Second Cancers

Cancer survivors who received chemotherapy or a transplant or who underwent radiation therapy are at risk of developing a second cancer later in life. Oral squamous cell cancer is the most common second cancer occurring in transplant patients. The lips and tongue are the sites most often affected.

Mental and Social Considerations

The social aspects of oral complications can make them the most difficult problems for cancer patients to cope with. Oral complications affect eating and speaking and may make the patient unable or unwilling to take part in mealtimes or to dine out. Patients may become frustrated, withdrawn, or depressed, and they may avoid other people. Some drugs that are used to treat depression may not be an option because they cause side effects that make oral complications worse.

Education, supportive care, and the treatment of symptoms are important for patients who have mouth problems that are related to cancer therapy. Patients will be closely monitored for pain, ability to cope, and response to treatment. Supportive care from health care providers and family can help the patient cope with cancer and its complications.

Special Considerations for Children

A change in dental growth and development is a special complication for cancer survivors who received high-dose chemotherapy and/or radiation therapy to the head and neck for childhood cancers. Changes may occur in the size and shape of the teeth; eruption of teeth may be delayed; and development of the head and face may not reach full maturity. The role and timing of orthodontic treatment for patients with altered dental growth and development is under study. Some treatments have been successful, but standard guidelines have not yet been established.

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