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What types of treatment are used?
If cancers of the mouth are discovered early, treatment is often quite straightforward and very effective -- which is why it is important to see a specialist with any suspicious areas that do not clear up (see previous section).
Surgery is the most common treatment for cancers of the mouth and throat. With larger cancers, some people also need radiotherapy, which is usually given from outside the body. With some small cancers, radioactive implants may work as well as surgery because they give a high dose to the cancer, but very little to surrounding areas.
Chemotherapy may be used in addition to surgery or radiotherapy, or sometimes on its own.
Your treatment programme should be decided through a joint clinic, involving a head and neck surgeon, a radiotherapist and a medical oncologist (cancer physician). Together they can advise you on the best course of action.
Your doctor will plan your treatment taking into consideration a number of factors including your age, general health, the type and size of the tumour, what it looks like under the microscope and whether or not it has spread to the lymph glands in your neck.
You may find that other people at the hospital with cancers of the mouth and throat are having different treatment from you. This will often be because their illness takes a different form and therefore they have different needs. It may also be because doctors take different views about treatment. If you have any questions about your own treatment, don't be afraid to ask your doctor or the nurse looking after you. It often helps to make a list of questions for your doctor and to take a close friend or relative with you to remind you of things you want to know but can forget so easily.
Some people find it reassuring to have another medical opinion to help them decide about their treatment. Most doctors will be pleased to refer you to another specialist for a second opinion, if you feel this will be helpful.
Surgery is usually the most effective treatment for cancers of the mouth and throat, often with radiotherapy. Very small cancers can often be treated with a simple surgical operation under local or general anaesthetic, with no need to stay in hospital overnight. Alternatively they may be treated with radiotherapy.
If you do need surgery, your doctor will discuss with you the most appropriate operation, depending on the size, site and any spread of the cancer. An operation to remove the cancer completely may be all the treatment you need. Sometimes during the operation the surgeon needs to remove some of the lymph glands on one side of the neck, especially if they are enlarged. Before any operation, make sure you have discussed it fully with your doctor so that you understand what is involved. Remember that no operation or procedure will be done without your consent.
The part of your mouth or throat which the doctor may remove depends on where the tumour is situated. As there are many different areas of the mouth and throat in which cancer can occur, it is not possible to go into details of all the operations in this booklet. It is very important that you discuss with your doctor what operation he or she plans to do and what the effects of this will be.
Sometimes when the surgeon removes the tumour he may also need to remove an area of the overlying skin. In this case the doctor may need to do a skin flap, which involves taking a layer of skin from another part of your body, such as the forearm or back, and placing it on the operation site. The thickness of the skin taken depends on the depth of the area to be covered.
If the cancer affects part of your jaw bone, the affected part may be removed with the tumour. In this case, you may need to have part of a bone from elsewhere in your body grafted onto the remainder of your jaw bone. Modern techniques enable you to move your jaw again straight after the operation.
In a few cases, in order to remove the cancer, the doctor may also need to remove some of the facial bones. This is rare, but there are now modern prostheses (false parts) available which look very realistic. If the extent of your surgery means you may need to have a prosthesis, your doctor will discuss this with you fully before you have the operation. (See the section on `Will the operation affect the way I look?'). If you have extensive surgery you will be closely checked and given intensive nursing for a few days afterwards to help you recover.
Sometimes extensive surgery to the mouth or throat may cause some swelling or bruising to the surrounding tissue which may make it difficult for you to breathe. In these cases the surgeon will create an opening called a tracheotomy (or stoma) in the lower part of the neck for you to breathe through. This will be removed when the swelling from your operation goes down.
After your operation
Many people can have their surgery entirely as a day patient. Others will need
to stay in hospital for several days. If you have a lot of surgery and
rebuilding of the tissues, you may need to stay in intensive care for a few
days. Whatever operation you have, your stay in hospital will depend on the
extent of the surgery you have had and whether a tissue graft was needed.
Many operations on the mouth and throat may make eating and drinking difficult or uncomfortable for some time. So you are likely to have an intravenous infusion (drip into a vein in your arm) of fluids and essential nutrients for a couple of days. This will be painlessly removed once you are able to eat and drink again.
Depending on how long it is likely to be before you can eat properly again, you may have a thin tube passed via your nose and into your stomach during the operation, while you are still under the anaesthetic. This is called a nasogastric tube. The nurses on the ward will put special high-protein, high-calorie liquid food down the tube at regular times. This will help you to keep your strength up and help your body to recover from the operation. The nasogastric tube may need to stay in place for a couple of weeks until you can eat properly again.
Alternatively, sometimes a tube can be passed through the wall of your abdomen into the stomach, and liquid food can be passed through this. This is called a percutaneous endoscopic gastrostomy (PEG).
After your operation you may have some pain or discomfort for a few days. If you do have any pain it can be controlled by pain-killing drugs. There are many modern types of pain-killer available now which are very good at either relieving pain or preventing it. At first you may be given the pain-killers by injection into a muscle in your thigh or bottom, or directly into a vein through your drip. Sometimes a syringe `driver' may be used to pump a specified dose of pain-killers into a vein in your arm over a set period of time, depending on the extent of your pain. Many units allow patients to control the amount of pain-killer they receive by pressing a button attached to the syringe driver whenever they feel pain. This is called patient-controlled analgesia. Once you can eat and drink properly again, you can be given your pain-killers in tablet or liquid form.
It is very important to let your doctor or the nurses on the ward know if you do have any pain, or if your drugs are not completely relieving your pain, so that the dose can be increased or the pain-killers changed as soon as possible.
Some operations to the mouth and throat will affect the way you speak. There are several methods available to help you to adapt to this. A speech therapist will discuss with you the difficulties you may experience and the different ways of communicating once you've had your operation. Which method you use will depend on what type of surgery you have and on your individual circumstances and preference.
Usually, you will be encouraged to start walking about the ward with the help of the nurses as soon as possible after your operation.
Most people are ready to leave hospital within a few weeks, even after quite extensive operations.
Before you leave hospital you will be given an appointment to attend an out-patient clinic for check ups. This is a good time to discuss with your doctor any problems you may have after your operation.
Will the operation affect the way I
look?
It is much less common nowadays, even where very extensive surgery is needed,
for patients to be disfigured by their surgery. The scars of the surgery often
lie either in the neck or in skin creases on the face and are therefore barely
visible. The underlying bone structures can be built up to a normal shape using
bone grafts from other sites in the body.
Where facial or neck skin has to be removed completely, it can be replaced but the skin colour will not match the surrounding skin, and the scars will be visible.
Also, if the operation affects specialized structures such as the nose or lips, your appearance will be altered.
If you are going to have an operation which may affect your appearance, this section of the booklet may be helpful.
People with cancer sometimes need treatment which removes a part of their body. This is always distressing, but when the surgery affects your looks, it can be devastating.
There are many reasons for this. The face is very important for communication, and we look intently at each other when we are speaking. Watching facial expression, eye contact, nodding etc. are all ways of gathering information about what is being said. Usually, we accept this without thinking about it, but when your appearance has changed, it can sometimes feel disconcerting, as if people are staring and making judgments about you. Don't assume that this is the case. We all look at each other, and hiding your face will often draw attention to the very thing that you are trying to disguise.
Most changes to our appearance are very gradual, and it takes time to adjust to a sudden change, even when it is only small. We live in a society which puts a lot of emphasis on appearance; advertisers would have us believe that looking `perfect' means being happier, yet we all know that the relationships that are important to us, with family and friends, are not based just on the way we look.
Nevertheless, how you feel about the way you look is an important part of self esteem, and it is quite usual to worry about feeling rejected both socially and possibly even by your partner. It may help to talk to someone who has had a similar experience.
It is extremely important to have a good idea of what to expect before you have your operation. Ask your doctor to be frank about the physical effects of the surgery and try to discuss them openly with those who are close to you. If you have a partner, it may be helpful for him or her to see the doctor with you so that you can both be fully aware of what to expect after the operation. Your doctor may also be able to put you in touch with other patients, who can give the most accurate description of the operation, the procedures afterwards and the final result and effect on their life. You may also pick up good first-hand tips on how to cope with the specific problems this surgery can bring.
When you come round from the operation you will probably be anxious to know what you look like, but at the same time frightened of what you might see. Once you have recovered physically from the operation -- after 7-8 days perhaps -- try to pluck up the courage to look at your face, perhaps with a doctor or nurse the first time. Even if you had a good idea of what to expect, you may still feel shocked and distressed when you look at your face for the first time. If your face feels different, for example numb or swollen, this can add to the initial sense of unfamiliarity. You may be extremely upset and perhaps wish you had never agreed to the operation. Give yourself time. These are very strong emotions and part of you needs to grieve for your old looks even as you look ahead to the future. The staff looking after you will be aware of this, and will help you, and you can get advice and help from organizations such as Changing Faces or Let's Face It, which specialize in helping people to develop the skills for coping with changed appearance.
There are now many ways of helping to minimise facial disfigurement caused by cancer surgery. Depending on the extent of the operation, you may be offered an artificial part called a prosthesis or camouflage make-up. Modern prostheses are made of soft plastic and are designed to suit the needs of each patient. If you are likely to need a prosthesis, your doctor will discuss this with you before the operation.
Camouflage make-up is suitable for both men and women. It consists of specially designed creams to disguise scars and other facial disfigurements, and the ranges available are suitable for all skin types and colours. The British Association of Skin Camouflage and the British Red Cross Society offer a special service providing camouflage make-up and individual teaching sessions on how to apply it for the best effect. Some types of camouflage make-up can be applied to facial prostheses to improve the colour match of the skin. This can be useful in the summer when the skin with tone changes. If the prosthesis needs colouring it should be referred back to the person or organisation that supplied it.
Even if it is difficult, it is best to keep looking at your face -- perhaps helping to change dressings, or to care for your prosthesis -- as soon as possible. The more you look at ease with yourself, the easier you will find it to deal with the reactions of others. Your friends and family may feel unsure about what to say and how to behave, worried about saying the wrong thing. The staff looking after you will be able to give them advice about what to expect and how to support you.
As you and the people close to you become more familiar with your changed appearance, you will want to think about seeing other people, going back to work etc. If you avoid social situations, you may find yourself wanting to go out less and less. It is best to start by going somewhere familiar with someone else. You may find that people take far less notice of you than you anticipated. Some people may seem intrusive, however. They may make remarks; small children are often openly curious and may ask why you look different. Decide in advance how you will answer. A simple sentence saying that you have had an operation will be enough. You do not have to elaborate.
Learning to deal effectively with other people is often a case of taking the initiative in putting the other person at ease. They will soon respond to you and not to your appearance. You can get lots more information about these kinds of `social skills' from Changing Faces or Let's Face It. They are not difficult to learn, they simply require practice and the confidence that you are managing social situations in an effective way.
Worried about meeting people after
having surgery on your face? Help is available
Remember that personality, interests and sense of humour are often more important to those who know you. These are the qualities that your friends and family value, and these things have not changed. People who are close to you are likely to be less concerned about the change in your appearance and more about how the change is affecting you. Be open about your fears of rejection. If given the chance, most people will welcome the chance to reassure you of their continuing love for you.
If you think it could help, a trained counsellor can help both by listening to your particular difficulties, and by providing information about how others have managed in a similar situation. Some of the organisations on mentioned later provide counselling. CancerBACUP's Cancer Support Service provides counselling at its London and Glasgow offices, and can give you the addresses of people to contact. Alternatively, you could ask your doctor to refer you.
Self confidence is the key to coping successfully with unfamiliar situations, and this itself comes from gradually building up your activities, especially in social settings. Hold onto anything that makes you feel good about yourself or that will help you to accept the change in how you look. Joining a group specially for people with facial disfigurements may take away the feeling of having to cope alone, and put you in touch with people who really understand what you are going through from their own experience.
Never be afraid to ask for help. There are many people both in hospital and outside who can listen, and who have the experience to help you in very practical ways to live a full and happy life again.
Radiotherapy treats cancer by using carefully targeted doses of high energy rays to destroy the cancer cells while doing as little harm as possible to normal cells. Radiotherapy may be used particularly to treat larger cancers of the mouth and throat. It may be used alone or together with surgery or chemotherapy.
Radiotherapy can be given in one of two ways -- either from outside the body as external beam radiotherapy, which is a beam of X-rays from a large machine or, for small cancers of the mouth and throat, as a radioactive implant (internal radiotherapy).
Before the treatment starts, you will be given an appointment to see a dentist and hygienist, who will give you advice on care of your teeth and gums as any damaged or decayed teeth may have to be removed before radiotherapy treatment is started.
External radiotherapy
This treatment is usually given in five sessions from Monday to Friday, with a
rest at the weekend.
The length of your treatment course will depend on the type and size of the tumour and whether surgery and chemotherapy have been used or are planned in the future. A course of external radiotherapy will usually last for three to seven weeks. In some hospitals radiotherapy is given several times a day over a shorter period, such as 2-3 weeks. Your doctor will discuss the treatment plan with you before you start.
Planning the treatment
To ensure that you receive maximum benefit from your radiotherapy, careful and accurate planning is necessary.
Your radiotherapy needs to be directed accurately at the same place in the mouth or throat each time it is given and it is often difficult to keep your head still, even for a short time, when you are lying down. So, to help you stay in exactly the same position during each radiotherapy treatment, a plastic head support is made for you. This is called a shell.
The shell is made by taking an impression of your face with quick-setting plaster of Paris. Your skin is protected from the plaster by fine netting and holes are left around your eyes and mouth and nostrils so that you can breathe. If you have a beard you will need to shave it off before the impression is taken. The impression only takes a few minutes to set and is then lifted off.
Marks can be drawn onto the shell to pinpoint the area which will be given the radiotherapy. This means that marks will probably not need to be drawn onto your skin.
You will then be asked to lie under a large machine called a simulator which takes X-rays of the area around the cancer. Treatment planning is a very important part of radiotherapy and it may take several visits before the radiotherapist (the doctor who plans your treatment) is satisfied with the plan.
When the plan is ready you will start the radiation treatment. The radiographer (the person who controls the treatment machine) will position you carefully on the couch and make sure you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room but you will be able to talk to the radiographer who will be watching you carefully from an adjoining room, either directly through a viewing window or on a TV monitor screen.
Radiotherapy is not at all painful. It is very similar to having an X-ray but takes a little longer. You will need to lie very still for several minutes while your treatment is being given.
Side effects
Soreness: Your mouth and throat will very probably become sore after a
couple of weeks of treatment and swallowing solid foods may become difficult.
For this reason, your doctor will encourage you to eat soft food
and to avoid smoking, drinking spirits and eating hot or spicy foods. Drinking
plenty of bland fluids like tea, milk and water will help keep your mouth moist.
Once the radiotherapy
course has finished, your mouth will heal, probably within four weeks or so.
If you do develop reactions to the radiotherapy you will be given special mouth washes and medicines to help relieve the discomfort.
During treatment you may develop bad breath. This may be helped by regular mouth care and mouth washes. Your doctor or nurse will be able to advise you on how to do this effectively. Your doctor may also prescribe an antibiotic medication which can help.
Many patients either lose their sense of taste or find that everything tastes the same (usually rather metallic). It may take some months for your taste to return to normal after the treatment.
Dry mouth: you may notice that you cannot produce as much saliva as before the treatment. This can make your mouth quite dry. People who have a dry mouth need to take special care of their teeth. You should brush regularly with a soft toothbrush and visit a specialist dentist every three months. You will usually be asked to apply fluoride gel to your teeth every day, either as a mouthwash or in special shields. To reduce the feeling of dryness, you may find it helpful to use an artificial saliva spray or tablets, or to wipe butter on the inside of your cheeks. The tablets are available on prescription from your GP. CancerBACUP has a factsheet on dry mouth which we would be happy to send you.
Diet: it is very important during the treatment to eat as well as possible despite these side effects. Well nourished people tend to heal and get back to good health more quickly. Rather than missing meals because of a sore mouth, it is a good idea to supplement meals with high-calorie drinks such as Complan or Build-up (available from your chemist) or even with baby foods which are soft but also high in protein and calories. CancerBACUP has a booklet called Diet and the Cancer Patient which has helpful tips on how to eat well when you have a sore or dry mouth. Your doctor can refer you to the hospital dietitian who can give you individual advice.
Skin: the skin in the treatment area may gradually redden from the third week of treatment onwards and become dry, scaly or sore. Rarely, this side effect is so severe that the skin in the treated area may break down and `weep'. The radiotherapy team can give you detailed advice on this.
Hair loss: in most cases, radiotherapy for cancers of the mouth and throat will not cause any hair loss, or the amount of hair lost will be very slight. Hair loss only occurs where the treatment beam enters and leaves your body, and only the hair very close to the tumour is likely to be permanently lost. Otherwise, any hair loss is temporary and hair will start to grow back some weeks after the treatment finishes. Radiotherapy for cancers of the mouth and throat usually only causes hair loss in the beard area.
Tiredness: this is quite a common side effect with radiotherapy to the mouth or throat. During your treatment you should try to get as much rest as you can, especially if you have to travel a long way each day for your treatment.
Feelings of sickness (nausea): this side effect is uncommon, but your doctor can prescribe anti-sickness tablets or medicines (anti-emetics) if it is a problem.
Stiff jaw: if the radiotherapy is to the back of the throat (nasopharynx), the muscles used to open and close the mouth can become stiff. It is important to practise mouth opening exercises once or twice a day. Your specialist dentist will advise on this.
Reducing side effects: your doctor will advise you to look after your teeth (see above) and to avoid smoking. Smoking may worsen radiation reactions in the mouth and throat.
All these side effects can be distressing and discouraging at the time. It may help to know, however, that they are temporary and will gradually disappear once your course of treatment has finished.
External radiotherapy does not make you radioactive, and you need not worry about being in contact with other people, including children.
Radiotherapy does not make you radioactive
Internal radiotherapy
In selected cases internalradiotherapy
may be used. This is given by inserting radioactive needles or wires into the
cancer while you are under a general anaesthetic. Over a few days, the needles
or wires give a high dose of radiotherapy directly to the tumour from the
inside, rather than a lower daily dose of external radiotherapy, which is given
over a longer period of time.
While you are having internal radiotherapy you will need to be cared for in a single room in hospital for a few days until the radioactive needles or wires have been removed from your body by the doctor. Although it will be perfectly all right for your family and close friends to visit you for short periods, it is not advisable to have children or pregnant women visit you while you are having this type of radiotherapy. The reason for this is to avoid any chance of them being exposed to the very small dose of radioactivity given off outside your body by the needles or wires. The doctors and nurses caring for you will also only be able to stay in your room for short periods at a time. This is because they may be looking after several people having internal radiotherapy treatment and they must keep their exposure to the low level of radioactivity to a minimum.
These precautions and restricted visiting times can make you feel isolated and rather lonely. It may help to know that you will only need to be cared for separately for the few days that the radioactive needles or wires are in place.
Side effects
Soreness will develop 5-10 days after the needles or wires have been removed and
may last for several weeks. During this time, you may find it easier to eat a
soft diet (see CancerBACUP's Diet
and the Cancer Patient booklet) and you should avoid smoking, drinking
spirits and eating hot or spicy foods. Drinking fluids like tea, milk and water
will help to keep your mouth moist. Your doctor can prescribe special
mouthwashes and medicines to help relieve the discomfort.
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Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of cancer cells. As the drugs circulate in the bloodstream, they can reach the cancer cells all over the body. Chemotherapy may be used before or after surgery or radiotherapy to try and increase their effectiveness. Sometimes chemotherapy may be given at the same time as radiotherapy, as they can work well together. If the cancer has come back after surgery or radiotherapy, or has spread to other parts of the body, chemotherapy may be used on its own. It may also be used as part of a clinical trial. If chemotherapy is suggested for you, you might find it helpful to get a copy of a booklet, Understanding chemotherapy. Side effects Other side effects may include feelings of sickness, being sick, diarrhoea and hair loss. Some drugs also make your mouth sore and cause small mouth ulcers. Regular mouthwashes are important and the nurses will show you how to do these properly. If you don't feel like eating, you can supplement or replace your meals with nutritious, high-calorie drinks which are available on prescription from your doctor. There are also medicines available from your doctor to help you stop feeling sick (anti-emetics). CancerBACUP has a booklet called Diet and the Cancer Patient. |
| Contact Information for our Dentist in Milton Keynes | |
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Dentist |
Dr David Gilmartin |
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Postal address |
MK Dental Care, 159 Ramsons Avenue, Conniburrow, Milton Keynes, Buckinghamshire, MK14 7BE, England. |
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Phone |
01908 690326 |
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Fax |
01908 676880 |
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Electronic mail | |
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