"management of the patient irradiated for head and neck cancer"
DESCRIPTION
"Management of the Patient Irradiated for Head and Neck Cancer" A.Effects of Radiation or Chemotherapeutic Drug B. Prevention & Management of the Effects of Radiation & Chemotherapy C.The Use of Hyperbaric Oxygen Therapy D.The Use of Lasers & Cryosurgery in Oral & Maxillofacial SurgeryTRANSCRIPT
Management of the Patient Irradiated for
CancerBy:
DMD4-AAGroup 2
A. Effects of
Radiation or Chemotherapeutic
Drug
•More than 1.5 million men and women were diagnosed with some
form of cancer in 2010, the National Cancer Institute estimates.
•The treatment options for most of
them probably included
chemotherapy, radiation therapy
and surgery.
•For patients, such side effects can
take over daily life. They can make
patients uncomfortable at
best and miserable at worst sometimes
affecting their ability to stick to their
treatments, or making treatments less
effective than they could be.
List of the most
commonly reported Side
Effects
1. Nausea and vomiting
Over half of all patients receiving chemotherapy will experience these
conditions. Doctors will usually prescribe anti-
emetics for this.
2. Alopecia (Hair loss)
Some chemotherapy medications cause hair loss while others don't. If hair does start to fall
out this will usually happen a few weeks
after treatment starts.
On some occasions the hair will just
become thinner and more brittle. Hair loss can occur in any part
of the body.
3. Fatigue
Most patients receiving
chemotherapy will experience some
degree of fatigue.
This may be a general feeling
which exists most of the day, or may only appear after certain activities.
4. Neutropenia (low white blood cells)
When receiving chemotherapy the
immune system will be weakened
because the white blood cell count will
go down.
Consequently, patients become more susceptible
to infections.
5. Thrombocytopenia
(Blood clotting problems)
Chemotherapy may lower the patient's
blood platelet count. If you are affected
you will bruise more easily, you will be
more
likely to have nosebleeds and
bleeding gums, and if you cut yourself it
may be harder to stop the bleeding.
6. Anemia
Chemotherapy will lower your red blood cell count. Tissues and organs inside
your body get their oxygen from the red
blood cells.
If your red blood cell count goes down too many parts of your body will not get
enough oxygen and you will develop
anemia.
1. Hearing impairment
2. Mucositis (inflammation of the mucous membrane)
3. Loss of appetite
4. Nails and skin problems
5. Cognitive problems6. Decreased sex drive
7. Bowel movement problems (diarrhea or
constipation) 8. Depression
Oral complications are common in
cancer patients, especially those
with head and neck cancer.
Complications are new medical problems
that occur during or after a disease, procedure, or
treatment and that make recovery
harder. The complications may be
side effects of the disease or treatment,
or they may have other causes.
Chemotherapy and radiation
therapy upset the healthy balance of
bacteria in the mouth.
It may also cause changes in the
lining of the mouth and the salivary
glands, which make saliva.
This can upset the healthy balance of
bacteria. Cancer treatment
can cause mouth and throat problems.
Complications of Chemotherapy
Inflammation and ulcers of the mucous
membranes in the stomach or intestines. Easy bleeding in the
mouth. Nerve damage.
Oral Complications
caused by Radiation
Therapy to the Head & Neck
Fibrosis (growth of fibrous tissue) in the
mucous membrane in the mouth.
Tooth decay and gum disease.
Fibrosis of muscle in the area that
receives radiation.Breakdown of bone
in the area that receives radiation.
Common Oral Complications
may be caused by either
Chemotherapy or Radiation Therapy
Inflamed mucous membranes in the mouth. Infections in the mouth or that travel through the bloodstream. These can reach and affect cells all
over the body.
Taste changes
Dry mouth
Pain
Changes in dental growth and development in children.
Malnutrition caused by being unable to eat.
Dehydration (not getting the amount of water the body
needs to be healthy) caused by being unable to drink.
Tooth decay and gum disease. Oral
complications may be caused by the treatment itself (directly) or by side effects of the treatment
(indirectly).
B. Prevention & Management of the Effects of Radiation & Chemotherapy
“Preventing and controlling oral
complications can help you continue cancer treatment and have a better
quality of life.”
Finding and treating oral
problems before cancer
treatment begins can
prevent oral complications or make them less
severe.
Problems such as cavities, broken teeth, loose crowns or fillings, and gum disease
can get worse or cause problems
during cancer treatment.
Bacteria live in the mouth and may cause
an infection when the immune system is
not working well or when white blood
cell counts are low.
If dental problems are treated before cancer treatments
begin, there may be fewer or milder oral
complications.
Prevention of Oral
Complications includes a
healthy diet, good oral care,
and dental checkups
Eat a well-balanced diet. Healthy eating can help
the body stand the stress of cancer
treatment, help keep up your energy, fight
infection, and rebuild tissue.
Keep your mouth and teeth clean. This helps
prevent cavities, mouth sores, and
infections.Have a complete oral
health exam.
“It is important that patients
who have head or neck cancer stop smoking.”
Continuing to smoke tobacco may slow down recovery. It can also increase the risk that the
head or neck cancer will recur or that a second
cancer will form.
Managing Oral ComplicationsDuring and After Chemotherapy or Radiation Therapy
Regular Oral Care“Good dental hygiene
may help prevent or decrease
complications.”Everyday oral care for cancer patients includes
keeping the mouth clean and being gentle with the tissue
lining the mouth.
Oral Mucositis“Oral mucositis is an
inflammation of mucous membranes in the
mouth.”Care of mucositis during
chemotherapy and radiation therapy includes cleaning the mouth and
relieving pain.
Swishing ice chips in the mouth for 30
minutes, beginning 5 minutes before
patients receive fluorouracil, may help prevent mucositis. Patients
who receive high-dose chemotherapy and stem cell transplant may be given medicine to help
prevent mucositis or keep it from lasting as long.
PainA cancer patient's pain may
come from the following:- The cancer.
- Side effects of cancer treatments.
- Other medical conditions not related to
the cancer.
Non-drug treatments may also help, including the
following:Physical therapy.
TENS (transcutaneous electrical nerve
stimulation).Applying cold or heat.
Hypnosis.Acupuncture. (See
the PDQ summary on Acupuncture.)Distraction.Relaxation
therapy or imagery.
Cognitive behavioral therapy.
Music or drama therapy.Counseling.
InfectionInfections may be caused by bacteria, a
fungus, or a virus.Treatment of bacterial infections in patients who
have gum disease and receive high-dose
chemotherapy may
include the following:a. Using medicated and
peroxide mouth rinses.b. Brushing and flossing.
c. Wearing dentures as little as possible.
d. Patients receiving cancer treatment may
be given drugs to help prevent fungal infections from
occurring.e. Giving antiviral drugs before treatment starts
can lower the risk of viral infections.
BleedingBleeding may occur when anticancer drugs
make the blood less able to clot.
Most patients can safely brush and floss while blood
counts are low.
Treatment for bleeding during chemotherapy may
include the following:Medicines to reduce blood
flow and help clots form.Topical products that cover
and seal bleeding areas.
Topical products that cover and seal bleeding areas.
Rinsing with a mixture of saltwater and 3% hydrogen
peroxide. (The mixture should have 2 or 3 times the amount of saltwater
than hydrogen
peroxide.) To make the saltwater mixture, put
1/4 teaspoon of salt in 1 cup of water. This helps
clean wounds in the mouth. Rinse carefully so clots are not disturbed.
Dry Mouth
“Dry mouth (xerostomia) occurs when the salivary glands don't make
enough saliva.”Salivary glands usually
return to normal after chemotherapy ends.
Salivary glands may not recover completely after radiation therapy ends.
“Careful oral hygiene can help prevent mouth sores, gum disease, and tooth decay caused by dry mouth.”
Care of dry mouth may include the following:
Clean the mouth and teeth at least 4 times a day.Floss once a day.
Brush with a fluoride toothpaste.
Apply fluoride gel once a day at bedtime, after cleaning the teeth.
Rinse 4 to 6 times a day with a mixture of salt and
baking soda (mix ½ teaspoon salt and ½
teaspoon baking soda in 1 cup of warm water).
Avoid foods and liquids that have a lot of sugar in
them.Sip water often to relieve
mouth dryness.A dentist may give the
following treatments:• Rinses to replace
minerals in the teeth.Rinses to fight infection in
the mouth.Saliva substitutes or medicines that help the
salivary glands make more saliva.
Fluoride treatments to prevent tooth decay.
Taste ChangesChanges in taste
(dysguesia) are common during chemotherapy and radiation therapy.
In most patients receiving chemotherapy and in some patients receiving radiation
therapy, taste
returns to normal a few months after treatment
ends. However, for many radiation therapy patients,
the change is permanent. In others, the taste buds may
recover 6 to 8 weeks or more after radiation therapy
ends.
Zinc sulfate supplements may
help some patients recover their sense
of taste.
MalnutritionLoss of appetite can lead to malnutrition.
Nutrition support may include liquid diets and
tube feeding.
The following may help patients with cancer meet their nutrition
needs:• Serve food chopped, ground,
or blended, to shorten the amount of time it needs to stay in the mouth before
being swallowed.
• Eat between-meal snacks to add calories and nutrients• Eat foods high in calories
and protein.• Take supplements to
get vitamins, minerals, and calories.
Swallowing ProblemsPain during swallowing
and being unable to swallow (dysphagia) are
common in cancer patients before, during,
and after treatment.• Swallowing problems are
managed by a team of
experts.• Speech therapist: A speech
therapist can assess how well the patient is
swallowing and give the patient swallowing therapy and information to better understand the problem.
• Dietitian: A dietitian can help plan a safe way for
the patient to receive the nutrition needed for health
while swallowing is a problem.
• Dental specialist: Replace missing teeth and
damaged area of the
mouth with artificial devices to help swallowing.
• Psychologist: For patients who are having a hard time adjusting to being unable to
swallow and eat normally, psychological counseling may help.
Tooth Decay• Dry mouth and changes in
the balance of bacteria in the mouth increase the risk
of tooth decay (cavities).• Careful oral hygiene and regular care by a dentist can
help prevent cavities.
Mouth and Jaw Stiffness
“Treatment for head and neck cancers may affect the ability to move the jaws, mouth, neck, and
tongue”Treatment should begin as soon as possible to keep the
condition from getting
worse or becoming permanent. Treatment may include the
following:• Medical devices for the mouth.
• Pain treatments.• Medicine to relax muscles.
• Jaw exercises.• Medicine to treat depression
Tissue and Bone Loss• Radiation therapy can destroy very small blood vessels within
the bone. This can kill bone tissue and lead to bone fractures or infection. Radiation can also kill tissue in the mouth. Ulcers
may form, grow, and cause pain, loss of feeling, or infection.
The following may help prevent and treat tissue and
bone loss:• Eat a well-balanced diet.•Wear removable dentures
or devices as little as possible.
• Don't smoke.• Don't drink alcohol.
• Use topical antibiotics.• Use painkillers as
prescribed.• Surgery to remove dead bone or to rebuild bones of
the mouth and jaw.• Hyperbaric oxygen therapy
C. The Use of
Hyperbaric Oxygen Therapy
I. DEFINITION:•Medical use of
oxygen at a level higher than atmospheric
pressure
• It involves breathing pure oxygen in a pressurized room•During treatment, patients can breathe
100% oxygen
II. HISTORY:• First proposed as a
treatment for cancer and other conditions in the
1960s
•1970's: - treating damage
of the maxilla and mandible occurring
during radiation treatments
III. PROCESSES:Monoplace
ChambersMultiplace
Chambers
Monoplace Chambers• single patient is placed
in a pressurized clear, acrylic chamber, about seven feet long, while
pure oxygen is compressed into the
chamber
• Chamber is comfortable, with an atmosphere similar
to that of an airplane• Chamber pressures
typically rise to two-and-a-half times the normal atmospheric pressure
• Session can last anywhere from thirty minutes to two hours• Cost less to operate
• Internal environment is maintained at 100%
oxygen
Monoplace Chambers
Multiplace Chambers
• large tanks able to accommodate
anywhere from two to fourteen people
•Allows patients to be directly cared for by staff within
the chamber
• Chamber is filled with compressed air, and
patients breathe 100% oxygen through a
facemask, head hood, or endotracheal tube.
Multiplace Chambers
IV. USES:This therapy can
be used on patients having/ suffering
from:• Air or gas embolism• Cyanide poisoning
• Crush injury
•Decompression sickness
•Enhancement of healing wounds
• Exceptional blood loss
• Gas gangrene• Necrotizing Soft
tissues infection
•Actinomycosis•Skin grafts or flaps•Osteomyelitis
•Radiation necrosis•Acute Thermal Burn
Injury
This therapy can also be applied as:
• Adjunctive treatment with maxillofacial
reconstructive procedures such as
dental extractions,
dental implants and jaw
reconstruction in the radiated patient.
V. ADVANTAGES:• help promote a well-
vascularized wound• enhancing healing
and the reconstructive process
• painless• increased oxygen delivery to
injured tissue• improved infection control•preservation of damaged
tissue• elimination and reduced effects of toxic substances
VI. COMPLICATIONS:• patients often feel light headedness and tiredness• Milder problems:– claustrophobia– fatigue– headache
Serious problems:– myopia (short sightedness) that can last for weeks or months– sinus damage– ruptured middle ear– lung damage
•Major complications:– Oxygen toxicity– convulsions –fluid in the lungs–respiratory failure
•Severe complications:– central nervous system (CNS) toxicity– pulmonary toxicity
D. The Use of Lasers &
Cryosurgery in Oral & Maxillofacial Surgery
119
CRYOSURGERY
120
Cryosurgery is a technique for freezing and killing abnormal cells.• is used to treat some kinds of cancer and some precancerous or
121
noncancerous conditions
•can be used both inside the body and on the skin.
122
WHAT IS CRYOSURGERY?
Cryosurgery (also called cryotherapy or cryoablation )
is the use of extreme cold produced by liquid nitrogen
(or argon gas) to destroy abnormal tissue.
123
BRIEF HISTORY
The first cryogens were liquid air and compressed carbon
dioxide snow. Liquid nitrogen became available in the
1940s and currently is the most widely used cryogen.
124
125
MECHANISM OF ACTIONLiquid nitrogen or argon
gas is circulated through a hollow
instrument. The doctor uses
ultrasound or MRI to guide the cryoprobe.
126
A ball of ice crystals forms around the probe,
freezing nearby cells.
127
ADVANTAGE OF CRYOSURGERY
1.Reduced bleeding2.Limited to the cancerous
tissue3.Reduced pain
4.low risk of infection5.Short recovery time
128
6. Cryosurgery requires little time and fits easily
into the physician's office schedule
7. Minimal wound care suture removal
129
8. no expensive supplies
9. treat AIDS-related Kaposi’s sarcoma
when the skin lesions are small and localized
130
DISADVANTAGE
1. Scarring
2. loss of sensation
3. loss of pigmentation
4. loss of hair in the treated area
131
Cryosurgery uses in Maxillofacial
surgery
132
Benign Lesions• viral warts, skin tags, and
xanthelasmas• Spider naevi, pyogenic
granulomas, and Campbell de Morgan spots
• labial lentigenous macules• Labial mucoceles
133
For most of the lesions mentioned
above, a single freeze cycle of 5 to
10 seconds is adequate.
134
A, Seborrhoeic keratosis pretreatment.
Seborrhoeic keratosis treated with cryosurgery
135
B, Post-treatment
view showing excellent cosmetic
result.
136
Melanotic macules of
the lower lip
A, Preoperative view.
B, Postoperative
view.
137
Premalignant and malignant Lesions
• Bowens Disease• Solar Keratosis• Actinic Cheilitis
• Basal cell carcinoma• Squamous cell
carcinoma
138
Auricular basal cell carcinoma.
A, Preoperative view of basal cell carcinoma of the ear. B, Basal cellcarcinoma of the ear 1 week post-
treatmentC, Left ear 6 weeks post-treatment.
139
Complications• 24 and 72 hours following cryotherapythere is edema
and sometimes blister formation
• hemorrhage and ulceration.• Pigmentary changes are the
most common.
Lasers in Oral & Maxillofacial
Surgery
L ight
A mplification by
S timulated
E mission of
R adiation
LASER stands for:
•Albert Einstein – 1917 – Quantum theory
•Theodore Maiman – 1960 – 1st Laser using
Ruby crystal
•Leon Goldman – 1963 – Father of modern lasers
HISTORICAL BACKGROUND
TISSUE EFFECTSTemperat
ureVisual
ChangeBiological changes
37-60˚C No change Warming, welding
60-65 ˚C Blanching Coagulation
65-90 ˚C White/gray
Protein denaturization
, necrosis
Temperature
Visual Change
Biological changes
90-100 ˚C Puckering Drying
100-150 ˚C
Plume Vaporization
150-210 ˚C
Carbonization
Potential Scar
COMPLICATIONS
1.Herpes Simplex
2.Dyschromias
3.Scarring
4.Eye and Teeth Injuries
COMMONLY USED LASERS
TYPE USE1) Erbium:YAG
(pulsed)(2490 nm)
Ablative skin resurfacing,
epidermal lesions
2) Nd: YAG, frequency-doubled
(532 nm)
Pigmented Lesions,
red/orange/yellow tattoos
TYPE USE
Nd : YAG (1064 nm)QS
Normal mode
Pigmented lesions, blue/black tattoosHair removal, leg
veins, non-ablative dermal remodelling
Nd: YAG, long- pulsed
(1320 nm)
Non-ablative dermal remodelling
3) Alexandrite (755 nm)
QSNormal mode
Pigmented lesions, blue/black/green tattoosHair removal, leg veins
4) Pulsed dye (510 nm) (585-595 nm)
Pigmented lesions Vascular lesions, hypertrophic/keloid scars, striae,
FIRST LASER
PRESENT LASERS
HAND PIECE
Advantages
1.Principles – simple
2.Technique – easy
3.Applications – unique
4.Results – outstanding
5.remote application6.precise cutting
7.hemostasis 8.low cicatrization
9.reduced postoperative pain and
swelling,
Disadvantages
1. Thermal alteration around the zone of laser tissue ablation.
2. One major is the lack of haptic feedback during laser surgery.
3. no option for switching between different
wavelengths.4.laser surgery systems are
bulky, which particularly limits their use in the
narrow space of the oral cavity.
5. no flexible light guide
Use of Laser in Maxillofacial
Surgery
Oral Tumorssquamous cell carcinoma is the
most common oral cancer. Laser used :
CO2 and Er-YAG-lasersNd:YAG lasers
KTP lasers (potassium titanyl phosphate laser)
FACIAL SKIN RESURFACING
Indications:
1.Photo damage: Dyschromias & Rhytides
2.Atrophic (depressed) scars : Post acne
Mechanism: Thermal ablation of Epidermis &
papillary dermis
Lasers
a) Single pass CO2
b) Modulated Er : YAG
PHOTO DAMAGE
DEPRESSED SCARS
VASCULAR LESIONS
• Chromophore – Oxyhaemoglobin
• Absorption wavelengths – 418, 542, 577 nm
• Laser of Choice : FPPDL – wavelength – 585, 590, 595, 680 nm
PORTWINE HAEMANGIOMA
Nasal Telangiectasias
• HYPERTROPHIC SCARS, KELOIDS & STRIAE DISTANSAE
• FPPDL (585nm) – Laser of Choice
• Sessions – 4-6 weekly intervals
• Future
• Atrophic scars : Non-ablative lasers
POST TRAUMATIC SCAR
POST SURGICAL SCAR
NASOLABIAL SCAR
PIGMENTED LESIONS
QS Nd: YAG
QS ALEXANDRITE
PERIORBITAL PIGMENTATIONS
Seborrheic Keratosis
Tattoos
1.Black pigment
QS ALEXANDRITE
2. Blue & green pigments
QS ALEXANDRITE (755 nm)
3. Red, orange & yellow
FPPDL (510nm)
AMATEUR TATTOO
PROFESSIONAL TATTOO
MULTICOLOURED TATTOO
• HAIR REMOVAL
• Hair follicle thermal relaxation time : 10-100
milli seconds
• Lasers & IPL (600-1200nm)
• QS & LP Nd:YAG (1064 nm)
• IPL (590-1200 nm)
HAIR REMOVAL
HAIR REMOVAL