Optimising oral health outcomes for cancer patients

Dr Roumiana Tzvetkova

Tue. 25 November 2025

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As dental professionals, we have all had that gut-wrenching moment when a cancer patient walks through our door mid-treatment. Their mouths are full of ulcers, their teeth are crumbling, sometimes there is exposed bone. We then think, “If only I’d seen you sooner.” Here is the hard truth: we are failing these patients—not because we lack skill or compassion, but because we are not integrated into their cancer care teams.

Through my work with the American Cancer Society, I have seen this pattern happen repeatedly. Despite clear National Cancer Institute guidelines recommending dental evaluation before cancer treatment starts, most patients never receive that referral. By the time they reach us, we are already in crisis mode. There are over two million new cancer diagnoses annually, and 30%–40% of those patients receive head or neck radiation or chemotherapy. We have both an opportunity and an obligation to do better. This is not about specialised training or expensive equipment. It is about understanding what is coming, acting early and building bridges with oncology colleagues.

Why the mouth is hit so hard

Let me explain what happens to oral tissue during cancer treatment, because understanding the pathophysiology changes how we approach prevention. Oral epithelial cells normally turn over every 14–21 days, one of the fastest renewal rates in the body. Cancer therapies do not discriminate between cancerous cells and these rapidly dividing oral cells. Chemotherapy stops cell division everywhere. Radiation to the head and neck goes further, causing permanent vascular damage, fibrosis and destruction of salivary glands.

Dr Roumiana Tzvetkova strongly advocates a proactive, preventitve approach to the dental needs of patients with cancer. (Image: Dr Roumiana Tzvetkov)

Statistics show that oral mucositis affects 30%–40% of standard chemotherapy patients, increasing to 60%–85% for stem cell transplant recipients, and hitting nearly 90% of patients receiving combined chemoradiation for head and neck cancer.¹ These are not just numbers. They are patients in excruciating pain who cannot eat, cannot swallow and sometimes cannot continue their cancer treatment.

Xerostomia might be even worse long-term. Two-thirds of head and neck radiation patients develop moderate to severe xerostomia that persists for years. Even modern intensity-modulated radiotherapy still leaves 40%–50% of patients with clinically significant xerostomia.^2, 3 Without saliva, everything falls apart: rampant caries, candidiasis, and difficulty eating and speaking.

Osteoradionecrosis (ORN) presents one of the most serious complications. A strong risk factor for the development of ORN is dentoalveolar surgery, namely, dental extractions and implantations after radiotherapy. Around 5% of ORN cases are induced by trauma from dental extractions.^4–6 For the treatment of tumours near to or involving the mandible, surgery in the area is another predisposing risk factor for ORN. This is because tissue healing after radiotherapy may be poor.⁷

Our most critical window: Pretreatment clearance

Here is where we have maximum impact: starting dental clearance before cancer treatment starts. If we miss this, we will spend the next year managing complications instead of preventing them.

When oncologists push back, which they will because they want to start treatment immediately, we need to advocate firmly for our patients. Removing all active infection from the mouth before cancer treatment starts allows adequate healing while respecting the urgency of cancer treatment. I have learned to frame it this way: we can either spend a few appointments preventing problems or spend months managing them during treatment.

“We can either spend a few appointments preventing problems or spend months managing them during treatment.”

The extraction dilemma

This is where serious choices have to be made. Which teeth do we extract, and which do we try to save? I have lost sleep over these decisions.

Let me be clear: our goal is to preserve as many healthy, functional teeth as possible. Patients value their teeth, and full-mouth extraction is not the answer. The evidence has evolved significantly. A 2024 systematic review suggests that post-radiation extraction risk might be lower than we thought, especially with hyperbaric oxygen therapy available. It has been shown in various cohort studies that tooth extraction before radiotherapy prevents ORN development.^8–11 Based on these findings, the National Comprehensive Cancer Network published guidelines in 2014 recommending that dental extractions be completed at least two weeks before the start of radiotherapy to reduce the risk of ORN development.¹²

The key is to be selective. I focus on extracting teeth that pose real risk. Specifically, I extract teeth with active infection or advanced periodontal disease, meaning pockets greater than 6 mm with bone loss, non-functional impacted teeth in the radiation area, severe caries to or beyond the pulp, non-restorable teeth and periapical pathology that we cannot treat endodontically.

For patients whose cases are borderline, which many unfortunately are, I have honest conversations. Can they maintain oral hygiene? Will they come back for follow-up? Do they have dental access after treatment? Are they motivated to save this tooth? I document these discussions thoroughly, and I encourage you to do the same.

Dr Roumiana Tzvetkova collaborates extensively with the American Cancer Society to educate dental professionals on managing oral complications in cancer patients. (Image: Dr Roumiana Tzvetkova)

Beyond extractions: Setting them up for success

After addressing hopeless teeth, I focus on aggressive prevention. Periodontal therapy is enhanced. Beyond standard scaling and root planing, I consider laser therapy and local antibiotics placed in the pockets. The goal is to reduce maximum bacterial load before the immune system is compromised. Laser irradiation has numerous favourable characteristics, such as ablation, haemostasis, photo-biomodulation, and microbial inhibition and destruction, all of which induce various beneficial therapeutic effects and biological responses. The use of lasers is considered effective and suitable for treating a variety of inflammatory and infectious oral conditions.¹³

I evaluate existing dentures carefully. Ill-fitting prostheses become torture devices during mucositis. Better to reline or remake them now than have patients suffer for months. I spend time educating patients because they need to understand what is coming and why these preventive steps matter. All root canal treatments are done prior to any cancer treatment, because I want to reduce the risk of exacerbation.

Managing mucositis and xerostomia

Mucositis and xerostomia are anticipated. The National Cancer Institute recommends that fluoride gel products, consisting of 1.1% sodium fluoride or 0.4% stannous fluoride, be used once daily for 2–3 minutes.¹⁴Mouthwashes such as 0.9% saline, a sodium bicarbonate solution or a mixture of the two can be used every 2–4 hours to alleviate mouth discomfort.¹⁴ Patients should be educated to avoid commercial mouthwashes that contain alcohol, which may further irritate and dry the oral mucosa. In recent years, calcium phosphate-based remineralisation products have shown promising results for the non-invasive management of early carious lesions.^15–17 It has been demonstrated that the application of products containing casein phosphopeptide-amorphous calcium phosphate could lead to a suppression of demineralisation and enhancement of remineralisation, or most likely, a combination of both could occur.¹⁵ I personally use a topical cream with bioavailable calcium and phosphate. It is effective for treating lesions and demineralisation, which is common in patients undergoing chemotherapy and radiation.

Building bridges with oncology

Here is what I have learned: the barriers to optimal care are not primarily clinical. They are systemic. Many oncologists do not fully appreciate oral complications. Many patients do not realise that dental clearance matters. Furthermore, many dentists frankly do not feel confident managing medically complex patients.

We need to change this, and it starts with outreach. I reached out to every oncology practice in my area and introduced myself as a resource. I provided template letters that they could give to patients explaining why dental clearance matters. I blocked specific time slots for urgent cancer patient evaluations. These relationships matter. When oncologists know they can call me directly, when they trust that I will see their patients quickly, when I communicate clearly about treatment plans, everything improves.

I also educated my staff. Everyone needs to understand the urgency when a cancer patient calls. No seeing the patient in three weeks; these patients need priority.

Immediate steps for dentists

Let me provide some specific, actionable steps:

Reach out to local oncology practices by email or phone. Introduce yourself as a dental resource for their cancer patients. Offer to give an informal session to help them learn about oral complications.
Create template letters that oncologists can give to patients. Make it easy for them to refer. Include your direct contact information.
Block time slots for urgent cancer evaluations. Make it a policy.
Review clinical fluoride protocols. Does the clinic have custom tray fabrication set up? Is the clinic prescribing high-concentration fluoride for cancer patients?
Stock the products that help: high-concentration fluoride, remineralising pastes, saliva substitutes. Know what is available so that the best recommendations can be made.
Document cancer patient encounters thoroughly. These patients are medically complex. Document pretreatment discussions, extraction rationale and coordination with oncology.
Join or create a local multidisciplinary cancer care network. These exist in many communities and provide invaluable cross-specialty education.

The bottom line

I will be direct: we can do better for cancer patients. The interventions I have described are not exotic or beyond our scope. They do not require specialised training or expensive equipment. What they require is awareness, proactive protocols and the willingness to pick up the phone.

“Everyone needs to understand the urgency when a cancer patient calls.”

Through my work with the American Cancer Society and in daily practice at Aspen Dental, I have seen what is possible when dentistry is properly integrated into cancer care. Patients still develop complications because we cannot prevent everything, but the severity and impact are dramatically reduced.

At Aspen Dental, our mission has always been the breaking down of barriers to care. For cancer patients, those barriers include knowledge gaps, time pressures, access challenges and fragmented care delivery. Our nationwide network of over 1,100 locations helps address access issues, but infrastructure alone is not enough. We need engagement from the entire dental community.

The evidence is clear. The protocols are straightforward. The need is urgent. What we do with this knowledge is up to us.

Every cancer patient who walks through your door mid-treatment, already suffering, represents a missed opportunity. Every patient we see pretreatment and prepare appropriately represents a small victory: less pain, better nutrition, uninterrupted cancer treatment, preserved quality of life.

Our patients deserve this level of care, and our profession is capable of delivering it. The time to act is now.

Editorial note:

A full list of references for the article can be found here.