"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 Surgery

1. Management of the
Patient Irradiated for
Cancer
By:
DMD4-AA
Group 2

3. • More than 1.5 million
men and women
were diagnosed with
some form of cancer
in 2010, the National
Cancer Institute
estimates.

4. • The treatment
options for most of
them probably
included
chemotherapy,
radiation therapy
and surgery.

5. •For patients, such
side effects can
take over daily
life. They can
make patients
uncomfortable at

6. best and miserable at
worst sometimes
affecting their ability
to stick to their
treatments, or making
treatments less
effective than they
could be.

8. 1. Nausea
and vomiting

9. Over half of all
patients receiving
chemotherapy will
experience these
conditions. Doctors
will usually prescribe
anti-emetics for this.

10. 2. Alopecia
(Hair loss)

11. 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.

12. On some occasions
the hair will just
become thinner and
more brittle. Hair
loss can occur in
any part of the
body.

13. 3. Fatigue

14. Most patients
receiving
chemotherapy
will experience
some degree of
fatigue.

15. This may be a
general feeling
which exists most
of the day, or may
only appear after
certain activities.

16. 4. Neutropenia (low
white blood cells)

17. When receiving
chemotherapy the
immune system will
be weakened
because the white
blood cell count will
go down.

18. Consequently,
patients become
more susceptible
to infections.

19. 5. Thrombocytopenia
(Blood clotting
problems)

20. Chemotherapy may
lower the patient's
blood platelet
count. If you are
affected you will
bruise more easily,
you will be more

21. likely to have
nosebleeds and
bleeding gums, and
if you cut yourself
it may be harder to
stop the bleeding.

22. 6. Anemia

23. Chemotherapy will
lower your red
blood cell count.
Tissues and organs
inside your body get
their oxygen from
the red blood cells.

24. If your red blood
cell count goes
down too many
parts of your body
will not get enough
oxygen and you will
develop anemia.

25. 1. Hearing impairment
2. Mucositis
(inflammation of the
mucous membrane)
3. Loss of appetite
4. Nails and skin
problems

26. 5. Cognitive problems
6. Decreased sex drive
7. Bowel movement
problems (diarrhea or
constipation)
8. Depression

27. Oral complications
are common in
cancer patients,
especially those
with head and neck
cancer.

28. Complications are
new medical
problems that occur
during or after a
disease, procedure,
or treatment and
that make recovery

29. harder. The
complications may
be side effects of
the disease or
treatment, or they
may have other
causes.

30. Chemotherapy
and radiation
therapy upset the
healthy balance
of bacteria in the
mouth.

31. It may also cause
changes in the
lining of the mouth
and the salivary
glands, which
make saliva.

32. This can upset the
healthy balance of
bacteria.
Cancer treatment
can cause mouth
and throat
problems.

34. Inflammation and
ulcers of the mucous
membranes in the
stomach or intestines.
Easy bleeding in the
mouth.
Nerve damage.

35. Oral
Complications
caused by
Radiation
Therapy to the
Head & Neck

36. Fibrosis (growth of
fibrous tissue) in the
mucous membrane
in the mouth.
Tooth decay and
gum disease.

37. Fibrosis of muscle
in the area that
receives radiation.
Breakdown of
bone in the area
that receives
radiation.

40. 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.

41. Taste changes
Dry mouth
Pain
Changes in dental
growth and development
in children.
Malnutrition caused by
being unable to eat.

42. Dehydration (not
getting the amount
of water the body
needs to be
healthy) caused by
being unable to
drink.

43. Tooth decay and gum
disease. Oral
complications may be
caused by the
treatment itself
(directly) or by side
effects of the
treatment (indirectly).

45. “Preventing and
controlling oral
complications can
help you continue
cancer treatment and
have a better quality
of life.”

46. Finding and
treating oral
problems before
cancer treatment
begins can
prevent oral
complications or
make them less
severe.

47. Problems such
as cavities, broken
teeth, loose crowns or
fillings, and gum disease
can get worse or cause
problems
during cancer treatment.

48. 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.

49. If dental problems
are treated before
cancer treatments
begin, there may
be fewer or
milder oral
complications.

50.  Prevention of Oral
Complications
includes a healthy
diet, good oral
care, and dental
checkups

51. Eat a wellbalanced diet. Healthy
eating can help the
body stand the stress of
cancer treatment, help
keep up your energy,
fight infection, and
rebuild tissue.

52. Keep your mouth
and teeth clean. This
helps prevent
cavities, mouth
sores, and
infections.
Have a complete
oral health exam.

53. “It is important
that patients who
have head or
neck cancer stop
smoking.”

54. 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.

56. 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.

57. 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.

58. Swishing ice chips
in the mouth for 30
minutes, beginning 5
minutes before
patients
receive fluorouracil,
may help prevent
mucositis. Patients

59. who receive high-dose
chemotherapy and
stem cell transplant
may be
given medicine to help
prevent mucositis or
keep it from lasting as
long.

60. Pain
A cancer patient's pain may
come from the following:
- The cancer.
- Side effects of cancer
treatments.
- Other
medical conditions not
related to the cancer.

61. Non-drug treatments may
also help, including the
following:
Physical therapy.
TENS (transcutaneous
electrical nerve
stimulation).
Applying cold or heat.

62. Hypnosis.
Acupuncture. (See
the PDQ summary
on Acupuncture.)
Distraction.
Relaxation
therapy or imagery.

63. Cognitive
behavioral
therapy.
Music or
drama therapy.
Counseling.

64. Infection
Infections 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

65. 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

66. be given drugs to help
prevent fungal
infections from
occurring.
e. Giving antiviral drugs
before treatment starts
can lower the risk of
viral infections.

67. Bleeding
Bleeding may occur
when anticancer drugs
make the blood less able
to clot.
Most patients can safely
brush and floss while
blood counts are low.

68. 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.

69. 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

70. 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.

71. Dry Mouth
“Dry mouth (xerostomia)
occurs when the salivary
glands don't make
enough saliva.”
Salivary glands usually
return to normal after
chemotherapy ends.

72. 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.”

73. 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.

74. 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).

75. 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

76. 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.

77. Taste Changes
Changes in taste
(dysguesia) are common
during chemotherapy and
radiation therapy.
In most patients receiving
chemotherapy and in
some patients receiving
radiation therapy, taste

78. 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.

79. Zinc sulfate
supplements may
help some patients
recover their sense
of taste.

80. Malnutrition
Loss of appetite
can lead to
malnutrition.
Nutrition support may
include liquid diets
and tube feeding.

81. 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.

82. • Eat between-meal snacks
to
add calories and nutrients
• Eat foods high in calories
and protein.
• Take supplements to
get vitamins, minerals,
and calories.

83. Swallowing Problems
Pain 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

84. 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.

85. • 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

86. 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.

87. 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.

88. 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

89. 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

90. 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.

91. 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.

92. • Use topical antibiotics.
• Use painkillers as
prescribed.
• Surgery to remove dead
bone or to rebuild bones
of the mouth and jaw.
• Hyperbaric
oxygen therapy

94. I. DEFINITION:
•Medical use of
oxygen at a level
higher than
atmospheric
pressure

95. • It involves breathing
pure oxygen in a
pressurized room
• During treatment,
patients can
breathe 100%
oxygen

96. II. HISTORY:
• First proposed as
a treatment for
cancer and other
conditions in the
1960s

97. • 1970's:
- treating damage
of the maxilla and
mandible occurring
during radiation
treatments

98. III. PROCESSES:
Monoplace
Chambers
Multiplace
Chambers

99. Monoplace Chambers
• single patient is placed
in a pressurized clear,
acrylic chamber, about
seven feet long, while
pure oxygen is
compressed into the
chamber

100. • Chamber is comfortable,
with an atmosphere
similar to that of an
airplane
• Chamber pressures
typically rise to two-anda-half times the normal
atmospheric pressure

101. • Session can last
anywhere from thirty
minutes to two hours
• Cost less to operate
• Internal environment
is maintained at
100% oxygen

102. Monoplace Chambers

103. Multiplace
Chambers
• large tanks able to
accommodate
anywhere from
two to fourteen
people

104. • Allows patients
to be directly
cared for by
staff within the
chamber

105. • Chamber is filled
with compressed air,
and patients breathe
100% oxygen
through a facemask,
head hood, or
endotracheal tube.

106. Multiplace
Chambers

107. IV. USES:
This therapy can be
used on patients
having/ suffering from:
• Air or gas embolism
• Cyanide poisoning
• Crush injury

108. • Decompression
sickness
• Enhancement of
healing wounds
• Exceptional blood loss
• Gas gangrene
• Necrotizing Soft
tissues infection

109. •Actinomycosis
•Skin grafts or flaps
•Osteomyelitis
•Radiation necrosis
•Acute Thermal
Burn Injury

110. This therapy can
also be applied as:
• Adjunctive
treatment with
maxillofacial
reconstructive
procedures such as

111. dental
extractions,
dental implants
and jaw
reconstruction in
the radiated
patient.

112. V. ADVANTAGES:
• help promote a wellvascularized wound
• enhancing healing
and the
reconstructive
process

113. • painless
• increased oxygen delivery
to injured tissue
• improved infection control
•preservation of damaged
tissue
• elimination and reduced
effects of toxic
substances

114. VI. COMPLICATIONS:
• patients often feel light
headedness and
tiredness
• Milder problems:
– claustrophobia
– fatigue
– headache

115. Serious problems:
– myopia (short
sightedness) that can
last for weeks or
months
– sinus damage
– ruptured middle ear
– lung damage

116. • Major
complications:
– Oxygen toxicity
– convulsions
–fluid in the lungs
–respiratory failure

117. • Severe
complications:
– central nervous
system (CNS)
toxicity
– pulmonary
toxicity

119. 119

120. Cryosurgery is a
technique for freezing
and killing abnormal
cells.
• is used to treat some
kinds of cancer and
some precancerous or
120

121. noncancerous
conditions
• can be used both
inside the body
and on the skin.
121

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.
122

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.
123

124. 124

125. MECHANISM OF ACTION
Liquid nitrogen or
argon gas is
circulated through a
hollow instrument.
The doctor uses
ultrasound or MRI to
guide the cryoprobe.
125

126. A ball of ice crystals
forms around the
probe, freezing nearby
cells.
126

127. ADVANTAGE OF
CRYOSURGERY
1.Reduced bleeding
2.Limited to the
cancerous tissue
3.Reduced pain
4.low risk of infection
5.Short recovery time
127

128. 6. Cryosurgery requires
little time and fits
easily into the
physician's office
schedule
7. Minimal wound care
suture removal
128

129. 8. no expensive
supplies
9. treat AIDS-related
Kaposi’s sarcoma
when the skin
lesions are small
and localized
129

130. DISADVANTAGE
1. Scarring
2. loss of sensation
3. loss of pigmentation
4. loss of hair in the
treated area
130

131. 131

132. Benign Lesions
• viral warts, skin tags, and
xanthelasmas
• Spider naevi, pyogenic
granulomas, and Campbell
de Morgan spots
• labial lentigenous
macules
• Labial mucoceles
132

133. For most of the
lesions mentioned
above, a single
freeze cycle of 5
to 10 seconds is
adequate.
133

134. Seborrhoeic keratosis
treated with cryosurgery
A, Seborrhoeic keratosis
pretreatment.
134

135. B, Post-
treatment
view
showing
excellent
cosmetic
result.
135

136. Melanotic
macules of
the lower lip
A,
Preoperative
view.
B,
Postoperative
view.
136

137. Premalignant and
malignant Lesions
• Bowens Disease
• Solar Keratosis
• Actinic Cheilitis
• Basal cell carcinoma
• Squamous cell
carcinoma
137

138. Auricular basal cell
carcinoma.
A, Preoperative view of basal cell
carcinoma of the ear. B, Basal cell
carcinoma of the ear 1 week posttreatment
C, Left ear 6 weeks post-treatment.
138

139. Complications
• 24 and 72 hours following
cryotherapythere is
edema and sometimes
blister formation
• hemorrhage and
ulceration.
• Pigmentary changes are
the most common.
139

141. LASER stands for:
L ight
A mplification by
S timulated
E mission of
R adiation

142. HISTORICAL BACKGROUND
• Albert Einstein – 1917 –
Quantum theory
• Theodore Maiman –
1960 – 1st Laser using
Ruby crystal
• Leon Goldman – 1963 –
Father of modern lasers

144. TISSUE EFFECTS
Temperat
Visual
ure
Change
37-60˚C No change
Biological
changes
Warming,
welding
60-65 ˚C
Blanching
Coagulation
65-90 ˚C
White/
gray
Protein
denaturizatio
n, necrosis

145. Tempera
ture
Visual
Change
Biological
changes
90-100 ˚C
Puckering
Drying
100-150
˚C
Plume
Vaporization
150-210
˚C
Carbonizati Potential Scar
on

146. COMPLICATIONS
1.Herpes Simplex
2.Dyschromias
3.Scarring
4.Eye and Teeth
Injuries

147. COMMONLY USED LASERS
TYPE
1) Erbium:YAG
(pulsed)
(2490 nm)
USE
Ablative skin
resurfacing,
epidermal
lesions
2) Nd: YAG,
Pigmented
frequencyLesions,
doubled (532 nm) red/orange/yello
w tattoos

148. TYPE
Nd : YAG (1064 nm)
QS
Normal mode
Nd: YAG, longpulsed
(1320 nm)
USE
Pigmented lesions,
blue/black tattoos
Hair removal, leg
veins, non-ablative
dermal
remodelling
Non-ablative dermal
remodelling

149. 3) Alexandrite (755
nm)
QSNormal mode
Pigmented
lesions,
blue/black/green
tattoos
Hair removal, leg
veins
4) Pulsed dye (510
nm)
(585-595 nm)
Pigmented
lesions
Vascular lesions,
hypertrophic/kelo
id scars, striae,

150. FIRST LASER

151. PRESENT LASERS

152. HAND PIECE

153. Advantages
1.Principles – simple
2.Technique – easy
3.Applications – unique
4.Results – outstanding

154. 5.remote application
6.precise cutting
7.hemostasis
8.low cicatrization
9.reduced
postoperative pain
and swelling,

155. Disadvantages
1. Thermal alteration
around the zone of
laser tissue ablation.
2. One major is the lack
of haptic feedback
during laser surgery.

156. 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

158. Oral Tumors
squamous cell carcinoma is
the most common oral
cancer.
Laser used :
CO2 and Er-YAG-lasers
Nd:YAG lasers
KTP lasers (potassium
titanyl phosphate laser)

159. FACIAL SKIN
RESURFACING
Indications:
1.Photo damage:
Dyschromias & Rhytides
2.Atrophic (depressed)
scars : Post acne

160. Mechanism: Thermal
ablation of Epidermis &
papillary dermis
Lasers
a) Single pass CO2
b) Modulated Er : YAG

161. PHOTO DAMAGE

162. DEPRESSED SCARS

163. VASCULAR LESIONS
• Chromophore –
Oxyhaemoglobin
• Absorption wavelengths
– 418, 542, 577 nm
• Laser of Choice : FPPDL
– wavelength – 585, 590,
595, 680 nm

164. PORTWINE HAEMANGIOMA

165. Nasal Telangiectasias

166. • HYPERTROPHIC SCARS,
KELOIDS & STRIAE DISTANSAE
• FPPDL (585nm) – Laser of
Choice
• Sessions – 4-6 weekly intervals
• Future
• Atrophic scars : Non-ablative
lasers

167. POST TRAUMATIC SCAR

168. POST SURGICAL SCAR

169. NASOLABIAL SCAR

170. PIGMENTED LESIONS
QS Nd: YAG
QS ALEXANDRITE

171. PERIORBITAL
PIGMENTATIONS

172. Seborrheic Keratosis

173. Tattoos
1.Black pigment
QS ALEXANDRITE
2. Blue & green pigments
QS ALEXANDRITE (755
nm)
3. Red, orange & yellow
FPPDL (510nm)

174. AMATEUR TATTOO

175. PROFESSIONAL TATTOO

176. MULTICOLOURED
TATTOO

177. • 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)

178. HAIR REMOVAL

179. HAIR REMOVAL