Damage to the lining of the mouth and a weakened immune system make it easier for infection to occur.

Oral mucositis breaks down the lining of the mouth, allowing germs and viruses to get into the bloodstream. When the immune system is weakened by chemotherapy, even good bacteria in the mouth can cause infections, as can disease-causing organisms picked up from the hospital or other sources. As the white blood cell count gets lower, infections may occur more often and become more serious. Patients who have low white blood cell counts for a long time are more at risk of developing serious infections. Dry mouth, common during radiation therapy to the head and neck, may also raise the risk of infections in the mouth. Preventive dental care during chemotherapy and radiation therapy can reduce the risk of mouth, tooth, and gum infections.

The following types of infections may occur:

Bacterial infections

Treatment of bacterial infections in patients who have gum disease and receive high-dose chemotherapy may include the following:

• Medicated and peroxide mouth rinses.
• Brushing and flossing.
• Wearing dentures as little as possible.

Bacterial infections in patients undergoing radiation therapy are usually treated with antibiotics.

Fungal infections

The mouth normally contains fungi that can exist on or in the body without causing any problems. An overgrowth of fungi, however, can be serious and requires treatment.

Antibiotics and steroid drugs are often used when a patient receiving chemotherapy has a low white blood cell count. These drugs change the balance of bacteria in the mouth, making it easier for a fungal overgrowth to occur. Fungal infections are common in patients treated with radiation therapy.

Drugs may be given to prevent fungal infections from occurring. Treatment of surface fungal infections in the mouth only may include mouthwashes and lozenges that contain antifungal drugs. These are used after removing dentures, brushing the teeth, and cleaning the mouth. An antibacterial rinse should be used on dentures and dental appliances and to rinse the mouth.

Deeper fungal infections, such as those in the esophagus or intestines, are treated with drugs taken by mouth or injection.

Viral infections

Patients receiving chemotherapy, especially those with weakened immune systems, are at risk of mild to serious viral infections. Finding and treating the infections early is important. Drugs may be used to prevent or treat viral infections.

Herpes virus infections may recur in radiation therapy patients who have these infections.

Bleeding

Bleeding may occur during chemotherapy when anticancer drugs affect the ability of blood to clot.

Areas of gum disease may bleed on their own or when irritated by eating, brushing, or flossing. Bleeding may be mild (small red spots on the lips, soft palate, or bottom of the mouth) or severe, especially at the gumline and from ulcers in the mouth. When blood counts drop below certain levels, blood may ooze from the gums.

With close monitoring, most patients can safely brush and floss throughout the entire time of decreased blood counts.

Continuing regular oral care will help prevent infections that may further complicate bleeding problems. The dentist or doctor can provide guidance on how to treat bleeding and safely keep the mouth clean when blood counts are low.

Treatment for bleeding during chemotherapy may include the following:

• Medications to reduce blood flow and help clots form.
• Topical products that cover and seal bleeding areas.
• Rinsing with a mixture of one part 3% hydrogen peroxide to 2 or 3 parts saltwater solution (1 teaspoon of salt in 4 cups of water) to help clean oral wounds. Rinsing must be done carefully so clots are not disturbed.

Relieving pain

• Try topical medications for pain. Rinse the mouth before applying the medication onto the gums or lining of the mouth. Wipe mouth and teeth gently with wet gauze dipped in saltwater to remove particles.
• Painkillers may provide relief when topical medications do not. Nonsteroidal anti-inflammatory drugs (NSAIDS, aspirin -type painkillers) should not be used by patients receiving chemotherapy because these patients have a bleeding risk.
• Capsaicin, the active ingredient in hot peppers, may be used to increase a person’s ability to tolerate pain. When capsaicin is put on inflamed tissues in the mouth, mucositis pain may decrease as the burning feeling from the capsaicin decreases. The side effects of capsaicin are not known.
• Zinc supplements taken during radiation therapy may help treat mucositis as well as dermatitis (inflammation of the skin).

Continuing good dental hygiene during and after cancer treatment can reduce complications such as cavities, mouth sores, and infections. It is important to clean the mouth after eating. The following are guidelines for everyday oral care during chemotherapy and radiation therapy:

Tooth brushing

• Brush teeth and gums with a soft bristle brush 2 to 3 times a day for 2 to 3 minutes.
• Rinse the toothbrush in hot water every 15 to 30 seconds to soften the bristles, if needed.
• If it is necessary to use a foam toothbrush, use it with an antibacterial rinse, when possible.
• Allow the toothbrush to air dry between brushings.
• Choose toothpaste with care:
  • Use a mild-tasting toothpaste; flavoring may irritate the mouth.
  • If toothpaste irritates the mouth, brush with a solution of 1 teaspoon of salt added to 4 cups (1 quart) of water.
  • Use a fluoride toothpaste

Rinsing

• Rinse the mouth 3 or 4 times while brushing.
• Avoid rinses containing alcohol.
• One of the following rinses made with salt and/or baking soda may be used:
  • 1 teaspoon of salt in 4 cups of water.
  • 1 teaspoon of baking soda in 1 cup (8 ounces) of water.
  • ½ teaspoon salt and 2 tablespoons baking soda in 4 cups of water.
• An antibacterial rinse may be used 2 to 4 times a day for gum disease. Rinse for 1 to 2 minutes.
• If dry mouth occurs, rinsing may not be enough to clean the teeth after a meal. Brushing and flossing may be needed.

Flossing

• Floss gently once a day.

Lip care

• Use lip care products to prevent drying and cracking.

Oral Mucositis

Mucositis is an inflammation of mucous membranes in the mouth.

The terms “oral mucositis” and “stomatitis” are often used in place of each other, but their meanings are different.

• Mucositis is an inflammation of mucous membranes in the mouth. It usually appears as red, burn-like sores or as ulcer -like sores throughout the mouth.
• Stomatitis is an inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of the mouth, and tissues inside the lips and cheeks. It includes infections of mucous membranes.

Mucositis may be caused by either radiation therapy or chemotherapy. In patients receiving chemotherapy, mucositis will heal by itself, usually in 2 to 4 weeks when there is no infection. Mucositis caused by radiation therapy usually lasts 6 to 8 weeks, depending on the duration of treatment.

The following problems may occur:

• Pain.
• Infection.
• Bleeding, in patients receiving chemotherapy. Patients undergoing radiation therapy usually do not have a bleeding risk.
• Inability to breathe and eat normally.

Swishing ice chips in the mouth for 30 minutes may help prevent mucositis from developing in patients who are given fluorouracil. Medication may be given to help prevent mucositis or keep it from lasting as long in patients who undergo high-dose chemotherapy and bone marrow transplant.

Care of mucositis during chemotherapy and radiation therapy focuses on cleaning the mouth and relieving the symptoms.

Treatment of mucositis caused by either radiation therapy or chemotherapy is generally the same. After mucositis has developed, proper treatment depends on its severity and the patient’s white blood cell count. The following are guidelines for treating mucositis during chemotherapy, stem cell transplantation, and radiation therapy:

Cleaning the mouth

• Clean the teeth and mouth every 4 hours and at bedtime, more often if the mucositis becomes worse.
• Use a soft bristle toothbrush.
• Replace the toothbrush often.
• Use water-soluble lubricating jelly to moisturize the mouth.
• Use bland rinses or plain sterile water. Frequent rinsing removes particles and bacteria from the mouth, prevents crusting of sores, and moistens and soothes sore gums and the lining of the mouth. The following rinse may be used to neutralize acid and dissolve thick saliva:

½ teaspoon salt and 2 tablespoons baking soda in 4 cups of water.

• If crusting of sores occurs, the following rinse may be used:
  • Equal parts hydrogen peroxide and water or saltwater (1 teaspoon of salt in 4 cups of water).

This should not be used for more than 2 days because it will keep mucositis from healing.

What it is and why it occurs

Red blood cells carry oxygen throughout your body. Anemia is when you have too few red blood cells to carry the oxygen your body needs. Your heart works harder when your body does not get enough oxygen. This can make it feel like your heart is pounding or beating very fast. Anemia can also make you feel short of breath, weak, dizzy, faint, or very tired.

Some types of chemotherapy cause anemia because they make it harder for bone marrow to produce new red blood cells.

Ways to manage

• Get plenty of rest. Try to sleep at least 8 hours each night. You might also want to take 1 to 2 short naps (1 hour or less) during the day.
• Limit your activities. This means doing only the activities that are most important to you. For example, you might go to work but not clean the house. Or you might order take-out food instead of cooking dinner.
• Accept help. When your family or friends offer to help, let them. They can help care for your children, pick up groceries, run errands, drive you to doctor’s visits, or do other chores you feel too tired to do.
• Eat a well-balanced diet. Choose a diet that contains all the calories and protein your body needs. Calories will help keep your weight up, and extra protein can help repair tissues that have been harmed by cancer treatment. Talk to your doctor, nurse, or dietitian about the diet that is right for you.

When you get up from lying down, sit for a minute before you stand. Stand up slowly. You may feel dizzy if you stand up too fast.

Your doctor or nurse will check your blood cell count throughout your chemotherapy. You may need a blood transfusion if your red blood cell count falls too low. Your doctor may also prescribe a medicine to boost (speed up) the growth of red blood cells or suggest that you take iron or other vitamins.

Call your doctor or nurse if:

• Your level of fatigue changes or you are not able to do your usual activities
• You feel dizzy or like you are going to faint
• You feel short of breath
• It feels like your heart is pounding or beating very fast

ScienceDaily (Jul. 26, 2007) — Cancer patients who receive a drug that stimulates the growth of infection-fighting white blood cells may be significantly less likely to die from a chemotherapy-related complication characterized by fever and low white blood cell levels, according to a multi-institutional study led by researchers from the University of Rochester School of Medicine and Dentistry and the Duke Comprehensive Cancer Center.

“Chemotherapy drugs target cancer cells, but they can affect healthy cells as well, including infection-fighting white blood cells,” said Nicole M. Kuderer, M.D., a hematology-oncology fellow at Duke and lead author on the publication. “When patients’ white blood cell counts drop too low, they are at risk for dangerous infections that can cause death.”

Often, chemotherapy must be delayed, reduced in strength or halted when a patient’s white blood cell count is too low, potentially leading to poorer outcomes, she added.

“Patients taking a drug known as granulocyte colony-stimulating factor early in their chemotherapy were about half as likely to develop dangerously low white blood cell counts with fever, and half as likely to die from infection,” Kuderer said. “This study represents an important part of the effort to better treat this common complication in cancer patients receiving chemotherapy.”

The researchers published their findings in the July 20, 2007 issue of the Journal of Clinical Oncology. The work was part of research being conducted by the Awareness of Neutropenia in Chemotherapy (ANC) Study Group, a multi-institution, university-based network of investigators whose work is unrestrictedly funded by Amgen, the maker of a commonly utilized white blood cell booster that goes by the names Neupogen and Neulasta. Kuderer also receives funding from the National Institutes of Health.

This study compiled the results of 17 trials involving more than 3,000 patients receiving chemotherapy of varying intensity to treat several different types of cancers. The researchers found that nearly 40 percent of the patients who did not receive the white blood cell booster early in treatment developed the fever and low white blood cell levels called febrile neutropenia, compared to only 22 percent of the patients who took the drug in conjunction with their chemotherapy, Kuderer said.

While white blood cell boosters were known to help patients receiving very intense doses of chemotherapy, this study showed that the drugs are also a benefit to cancer patients receiving more common chemotherapy doses, Kuderer said.

Recently revised American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Center Network (NCCN) guidelines for the use of drugs such as Neulasta and Neupogen align with the conclusions reached by this study.

“The new guidelines recommend using these types of drugs when at-risk patients begin chemotherapy, rather than waiting for complications to develop,” said Jeffrey Crawford, M.D., chief of the division of medical oncology at Duke and one of the study’s investigators. “The new recommendations also suggest that we need better methods to identify patients who are at higher risk of developing febrile neutropenia, and future studies will be aimed at doing just that.”

White blood cell boosters can have side effects, including bone pain, which need to be reviewed and discussed with each patient, Crawford said.

Other investigators on the study include Gary Lyman of Duke and David Dale of the University of Washington.

Duke University Medical Center (2007, July 26). White Blood Cell Booster May Help Cancer Patients Avoid Deadly Complications. ScienceDaily. Retrieved December 4, 2007, from http://www.sciencedaily.com­ /releases/2007/07/070725110020.htm

What they are and why they occur

Chemotherapy can cause damage to your nervous system. Many nervous system problems get better within a year of when you finish chemotherapy, but some may last the rest of your life. Symptoms may include:

• Tingling, burning, weakness, or numbness in your hands or feet
• Feeling colder than normal
• Pain when walking
• Weak, sore, tired, or achy muscles
• Being clumsy and losing your balance
• Trouble picking up objects or buttoning your clothes
• Shaking or trembling
• Hearing loss
• Stomach pain, such as constipation or heartburn
• Fatigue
• Confusion and memory problems
• Dizziness
• Depression

Ways to manage

• Let your doctor or nurse know right away if you notice any nervous system changes. It is important to treat these problems as soon as possible.
• Be careful when handling knives, scissors, and other sharp or dangerous objects.
• Avoid falling. Walk slowly, hold onto handrails when using the stairs, and put no-slip bath mats in your bathtub or shower. Make sure there are no area rugs or cords to trip over.
• Always wear sneakers, tennis shoes, or other footwear with rubber soles.
• Check the temperature of your bath water with a thermometer. This will keep you from getting burned by water that is too hot.
• Be extra careful to avoid burning or cutting yourself while cooking.
• Wear gloves when working in the garden, cooking, or washing dishes.
• Rest when you need to.
• Steady yourself when you walk by using a cane or other device.
• Talk to your doctor or nurse if you notice memory problems, feel confused, or are depressed.
• Ask your doctor for pain medicine if you need it.

The side effects of chemotherapy depend on the type of chemotherapy and the amount given. Anticipating and managing side effects can help to minimize them and provide the best possible experience for the person receiving chemotherapy.

Chemotherapy’s potential effects on the skin and nails:

As each person’s individual medical profile and diagnosis is different, so is his/her reaction to treatment. Side effects may be severe, mild, or absent. Be sure to discuss with your cancer care team any/all possible side effects of treatment before the treatment begins.

Chemotherapy can affect both the skin and nails. It may cause an increased sensitivity to the sun as well as redness, rashes, itching, peeling, dryness, or acne. Nails may become darkened, yellow, brittle, or cracked, and may also develop vertical lines or ridges.

Sometimes, chemotherapy causes the skin along the vein to darken, especially in people who have very dark skin. Cosmetics or makeup may be used to cover the darkened area, but this can take a lot of time if more than one vein is affected. After treatment ends, the darkened areas often fade in a few months.

Although some side effects can be self-managed, some conditions require immediate medical attention. If you are receiving intravenous (IV) drugs, be sure that you immediately report any burning or pain to your physician. Sometimes, intravenous drugs can leak out of the vein, potentially causing tissue damage. These symptoms need to be reported to your physician right away.

Other skin and nail symptoms may indicate an allergic reaction. Consult your physician or cancer care team immediately if you develop sudden or severe itching, rash or hives, wheezing, or any other labored breathing.

How can I manage skin and nail problems?

The National Cancer Institute (NCI) recommends the following strategies for reducing skin and nail problems related to chemotherapy:

Acne

• Keep your face clean and dry.
• Discuss with your physician the use of any over-the-counter medicated creams or soaps before using them.

Itching and dryness

• Apply cornstarch like you would using a dusting powder.
• Take quick showers or sponge baths, not long, hot baths. Use a moisturizing soap.
• Apply cream or lotion to your skin while it is still moist.
• Avoid perfume, cologne, or aftershave lotions that contain alcohol.

Nail problems

• Avoid nail-strengthening products as they may bother your skin and nails.
• Wear gloves when doing housework or working in the garden.
• If you note redness, pain, or changes around the cuticles, consult your physician.

Sunlight sensitivity

• Avoid direct sunlight as much as possible, and especially stay out of the sun between the peak hours of 10 a.m. and 4 p.m. when the sun’s rays are the strongest. Even if you have dark skin, protect yourself from the sun.
• Use a sunscreen lotion with a skin protection factor (SPF) of 15 or higher. Zinc oxide, sold over the counter, can block the sun’s rays completely.
• Use a lip balm with a high sun protection factor.
• Wear long-sleeve cotton shirts, pants, and hats with a wide brim (especially if you are experiencing hair loss) to prevent your skin and scalp from sunburn.

• Trouble wearing contact lenses. Some types of chemotherapy can bother your eyes and make wearing contact lenses painful. Ask your doctor or nurse if you can wear contact lenses while getting chemotherapy.
• Blurry vision. Some types of chemotherapy can clog your tear ducts, which can cause blurry vision.
• Watery eyes. Sometimes, chemotherapy can seep out in your tears, which can cause your eyes to water more than usual.

If your vision gets blurry or your eyes water more than usual, tell your doctor or nurse.