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

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CRYOSURGERY

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Cryosurgery is a technique for freezing and killing abnormal cells.• is used to treat some kinds of cancer and some precancerous or

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noncancerous conditions

•can be used both inside the body and on the skin.

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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.

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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.

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MECHANISM OF ACTIONLiquid nitrogen or argon

gas is circulated through a hollow

instrument. The doctor uses

ultrasound or MRI to guide the cryoprobe.

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A ball of ice crystals forms around the probe,

freezing nearby cells.

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ADVANTAGE OF CRYOSURGERY

1.Reduced bleeding2.Limited to the cancerous

tissue3.Reduced pain

4.low risk of infection5.Short recovery time

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6. Cryosurgery requires little time and fits easily

into the physician's office schedule

7. Minimal wound care suture removal

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8. no expensive supplies

9. treat AIDS-related Kaposi’s sarcoma

when the skin lesions are small and localized

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DISADVANTAGE

1. Scarring

2. loss of sensation

3. loss of pigmentation

4. loss of hair in the treated area

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Cryosurgery uses in Maxillofacial

surgery

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Benign Lesions• viral warts, skin tags, and

xanthelasmas• Spider naevi, pyogenic

granulomas, and Campbell de Morgan spots

• labial lentigenous macules• Labial mucoceles

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For most of the lesions mentioned

above, a single freeze cycle of 5 to

10 seconds is adequate.

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A, Seborrhoeic keratosis pretreatment.

Seborrhoeic keratosis treated with cryosurgery

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B, Post-treatment

view showing excellent cosmetic

result.

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Melanotic macules of

the lower lip

A, Preoperative view.

B, Postoperative

view.

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Premalignant and malignant Lesions

• Bowens Disease• Solar Keratosis• Actinic Cheilitis

• Basal cell carcinoma• Squamous cell

carcinoma

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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.

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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