Emerging Trends in Neurology and Neurosurgery: Awake Craniotomy and Stereotactic Surgery

Emerging Trends in Neurology and Neurosurgery

Awake craniotomy and Stereotactic neurosurgery have become the latest trend in Neurosurgery. Some of the neurologic conditions which were treated medically can be treated successfully by these methods. At the outset I would like to state here that eventhough I am a health care professional I have not done or witnessed any of the procedures which are discussed below. These are compilations from the websites of reputed institutions where these procedures are done.

Awake Crniotomy and Stereotactic Surgery

This article gives an overview about

• Surgery for Intractable Tremor

• Surgery for Parkinson’s Disease

• Surgery for Epilepsy

• Psychiatric Neurosurgery

Surgery for Intractable Tremor

• Tremor is an involuntary rhythmical movement of the muscles
• Classification of tremor:
  Tremors at rest-tremors when the hands are in resting position
• Postural tremors-tremors when the hands held up
• Intentional tremors- tremors during movement

Essential tremor is intentional tremor which is disabling and which is not due to Parkinsonism or other neurological disorders like cerebrovascular accidents, trauma or multiple sclerosis. In these disorders patients may suffer from tremors because of injury to the cerebellar tracts. In essential tremor even though there are no other major symptoms, the tremors can be disabling and may interfere with the patient’s activities of daily living like feeding, bathing or holding objects.

Thalamotomy or Thalamic Stimulation as treatment for Essential Tremors

• In thalamotomy, a small lesion is placed in the thalamus in an effort to abolish the tremor.
• In thalamic stimulation a probe is placed and stimulated with varying intensity to control the tremors.

Patients of essential tremors with significant disability are considered for surgery when it is found that their tremors are refractory to medical treatment.

The drugs usually given for patients with essential tremors are

• propanolol
• mysoline
• and clonazepam.

The patients are considered for surgery after extensive evaluation by a team of experts and detailed investigation for a confirmation of diagnosis.

The procedure discussed here is done when the patient is awake and with local anesthesia as the full co-operaton of the patient is required. The author of this article has not witnessed such surgeries as they are done only in few very highly reputed neurologic centers in the world.

Surgery for Parkinson’s Disease

The neurosurgical treatment for Parkinson’s disease is based on the model of the role of basal ganglia in movement disorders.

• Neurosurgical treatment of Parkinson’s disease include implantation of deep brain stimulators in the globus pallidus interna (Gpi), the subthalamic nucleus (STN) or the Vim nucleus of the thalamus or the creation of small lesion in Gpi (Pallidotomy) or the Vim nucleus of the thalamus (Thalamatomy).

The patient is selected for surgery after detailed evaluation by the experts.

Parkinson’ disease is caused by a loss of dopaminergic neurons in the substantia nigra which is a part of basal ganglia. Parkinson’s disease is treated medically with precursors of dopamine like levodopa and carbidopa as dopamine does not cross the blood brain barrier. Surgery for Parkinson’s disease is considered usually when the medical therapy fails. Sedating agents and general anesthesia are avoided during the surgery to ensure full cooperation of the patient during the procedure.

Epilepsy Surgery

Seizures are a very disturbing phenomenon occurring as a result of some diseases of the brain or even without that. Seizures interfere with the functional level of the patients. People with history of seizures have to take precautions about a number of things in their daily life like driving, going near the waters and fire, to avoid deprivation of sleep, to avoid stimulants like alcohol etc. Anyone suffering from seizures would hope for a much more free life by putting an end to their sufferings.

It is observed that 20-30% of patients with intractable seizures are estimated to be because of some lesions in the brain. These lesions can be identified with the help of an MRI scan. There can also be an epileptogenic focus surrounding the lesion.

So the surgery for epilepsy may either be a removal of the structural lesion or it may be the removal of the structural lesion and the epileptogenic focus.

Leptospirosis– A Case Scenario

• Mr. M 56 years is a farmer. He has three acres of paddy cultivation and two acres of land cultivating vegetables. Though he has people working in his fields, he makes regular visits to the paddy field and vegetable cultivations.
• Mr. M was apparently normal except that he is a known case of diabetes mellitus for the past ten years. He was on oral hypoglycemic agents and his blood sugar was under control.
• He developed fever six days back. Fever was low grade and intermittent. When the fever was high occasionally, he developed chills and rigor.
• Along with fever, he had loose stools and vomiting. Two to three episodes of loose stools per day were there. There was no abdominal pain or abdominal fullness. Loose stools also started six day back
• Patient developed cough with expectoration three days back. He had breathlessness from yesterday for which he sought medical treatment
• Patient was admitted yesterday and the all the routine blood and urine investigations were sent. Blood is also sent for serology tests to rule out scrub typhus and typhoid
• On examination, he had red conjunctiva and cracks on his heels and feet. All vital signs were normal except that he had mild fever.
• Results of the blood show that he has abnormal liver function.

Provisional diagnosis is made for leptospirosis

Pancreatic Cancer

• Pancreatic cancer is difficult to diagnose at early stages.
•  Patients may have only non -specific symptoms in the beginning. By the time it is diagnosed often, the cancer has spread to distant organs.
• Although the incidence of pancreatic cancer is less compared to other cancers, the mortality (number of deaths) from pancreatic cancer is very high
• Surgery is the primary mode of treatment for pancreatic cancer
• Neo adjuvant therapy-using chemotherapy or radiation therapy prior to surgery may be useful as it may be better tolerated by some patients and also because the size of the tumor reduces with these therapies and resection of the tumor becomes easy
• Red meat consumption increases the risk of pancreatic cancer
• Laboratory findings will be non-specific Serum amylase and lipase may be high. In obstructive jaundice, bilirubin levels will be very high. Tumor markers like CA 19 and CEA may be high
• Alcohlic patients may develop chronic pancreatitis and it may be difficult to differentiate from pancreatic carcinoma

Will Exercise Reduce Obesity?

Obesity and overweight are commonly seen now. Truly speaking I don’t see many morbidly obese people often, but I can say that every other person I meet may be a bit overweight.  In fact, four years ago I did a small study in our hometown measuring many people’s BMI. Most of them were looking average built, but were overweight.

When more was asked about their dietary habits, I noticed that they did not overeat. Their staple food was rice. For breakfast there was idly, dosa, upma etc. Lunch included two or three big spoons of rice, vegetable curry and fish curry.

Plain Dosa

Their diet was not overwhelmingly energy rich or fat rich. In addition to that because of the religious disciplines, most of them observed moderation in diet.

Idly

Then what could be the reason for overweight?

Overweight was mainly because of lack of physical activity. They did minimum work. Their ancesotrs had to work in the field, produce paddy, and make rice out of the paddy by boiling it at home and even husking the paddy at home. In olden days, most of the vegetables were cultivated in their own courtyard.

But now the situation has changed. Paddy fields are disappearing. They are land filled and new houses are built. Rice is bought from the market. So no effort is put in boiling the paddy and husking it. Generally people had less physical activity with the use of machines like mixer grinder, washing machines, dish washer etc.

So I went back and suggested each one of them to increase their physical activities. People have large squares of land and it was suggested to engage in more of gardening which might help them to reduce weight

Questionnaire on Spirituality at Workplace 

Thamasoma Jyothirgamaya

Demographic Proforma

1.     Gender:

a.    Female

b.    Male

2.     Marital Status:

a.     Unmarried

b.    Married

c.     Divorced

d.    Widowed

3.     Number of children:       

4.     Current position/Job Title:

5.     Qualification: 

6.     Age:

 QUESTIONNAIRE ON THE ROLE OF SPIRITUALITY IN THE WORKPLACE

All responses to this questionnaire will be held and treated in strict confidence. You are requested to encircle the response which you feel appropriate.

7.     What are the top 3 aspects that have the most meaning for you in yourjob? (Check only the top three)

a.     Realizing my full potential as a person

b.    Producing quality students

c.     Being associated with an ethical organization

d.    Having good colleagues

e.     Interesting or meaningful work

f.     Service to the humanity

g.    Earning money

h.     Security

i.      Bringing your whole self to work

j.      Being creative

8.     To what extentdoes your work add to the meaning of your life?

a.     Not at All

b.    A bit

c.     Quite a lot

d.    Very much

9.     How apprehensive are you of losing your job?

a.     Not at All

b.    A bit

c.     Quite a lot

d.    Very much

10.  How often do you pray or meditate at home?

a.     Never

b.    Rarely

c.     2-3 times a week

d.     Every Day

11.   How important is spirituality in your life?

a.     Not at All

b.    A bit

c.     Quite a lot

d.    Very much

12.  How relevant is the role of spirituality at workplace?

a.     Irrelevant

b.    Rarely relevant

c.     Mostly relevant

d.     Relevant

13.  What is your opinion of spirituality as a topic of discussion at work

a.     Inappropriate

b.    Moderatelyappropriate

c.     Very appropriate

d.    Highly appropriate

14.  What is the role of philosophical values in the workplace?

a.     Irrelevant

b.    Hardly  relevant

c.     Highly  relevant

d.     Relevant

15.  To what extentdo you consider work as a form of worship?

a.     Not at All

b.    A bit

c.     Quite a lot

d.    Very much

16.  Do you believe in God, a Deity or a Higher Power?

a.     Indifferent

b.    Disbelieve

c.     Believe

d.    Strongly Believe

17.  Have you ever felt the presence of God, a Deity or a Higher Power at work?

a.     Never

b.    Rarely

c.     Few times

d.    Often

18.  Have you ever discussed issues of spirituality with co-workers?

a.     Never

b.    Rarely

c.     Few times

d.    Often

19.  How often do you pray or meditate at work?

a.     Never

b.    Rarely

c.     Few times

d.    Often

20.  To what extentdo you draw satisfactionfrom work by considering it as service to humanity?

a.     Not at All

b.    A bit

c.     Quite a lot

d.    Very much

21.   Briefly describe the main differences between religion and spirituality:Spirituality is an individual concern,while religion is just a social concern.

Scoring: Each item’s frequency and percentage will be calculated

 Low energy helium neon laser in the prevention of oral Mucositis

Introduction:

Effectiveness of cancer therapies designed to improve cure rates and to extend survival time, including chemotherapy and radiotherapy is tempered by side effects that may become life threatening. Oral complications are one such side effect category and include chemotherapy and radiation therapy related stomatitis (oral mucositis) and associated pain, xerostomia and oral infection.¹

Stomatitis (oral mucositis) is an inflammation of the mucous membranes of the oral cavity and oropharynx characterized by tissue erythema, edema, and atrophy often progressing to ulceration. The clinical significance of  radiation therapy related stomatitis is widely recognized.¹Stomatitis is virtually universal when radiation therapy includes the oropharyngeal area, with the severity dependent upon the type of ionizing radiation, volume of irradiatd tissue, dose per day, cumulative dose and duration of radiation therapy.¹ 

Radiation therapy for head and neck cancers has a range of sequelae in the oral cavity. This includes caries, mucositis, trismus, xerostomia, osteoradionecrosis and secondary oral and fungal infections.²

Radiotherapy-induced oral mucositis represents a therapeutic challenge frequently encountered in cancer patients. This side effect causes significant morbidity and may delay the treatment plan, as well as increase therapeutic expenses.³

Side effects of radiation therapy to the head and neck may be noted as early as the first week.⁴ A syndrome of pain, swelling and tenderness after irradiation of major salivary lands begin a few after small doses of radiation are given. The pain may be severe.⁵ Severe reduction in the volume of saliva and the alteration of its composition may cause serious complications. Dryness of mouth and difficulty in swallowing and mastication are common The changes in salivary flow, volume and viscosity may be related to vascular damages to the salivary glands and may persist for years. The recovery of a normal production of saliva will depend on the characteristics of each patient and the salivary gland irradiated percentage. Many investigators have observed, however that within hours of low dose radiation therapy, dryness of mouth and the elevation of serum amylase develop.⁵

The xerostomia appears soon after the beginning of the RT, becoming more evident after 20Gy doses. Initially, the saliva becomes thicker and its elimination rate decreases⁶

This xerostomia may be irreversible, although there is a tendency of recovering up to 50% of the initial salivary volume, if both the irradiated parotid volume and the final irradiation dose remain in the lowest possible values^(7-11).

Research findings to date based upon animal, human and most notably cellular studies have enhanced the establishment of low intensity laser treatment  as an effective means of biostimulation for the wound healing process. The most popular laser in studies on cell irradiation to date has been the helium – neon laser with a wavelength of 632.8nm. Using embryonic foreskin fibroblasts and adult human skin fibroblasts , Boulton and Marshall (1986) reported an increase in cell proliferation following irradiation with a He-Ne laser.  Lyons et al 1987 have found out that laser irradiation stimulates the production of collagen by fibroblasts, which in turn is an important component of scar tissue formation. Myofibroblasts are modified fibroblasts that are directly involved in granulation tissue contraction. A study by Pourreau Schneider et al (1990) found that He-Ne laser irradiation of fibroblasts transforms the cells into myofibroblasts , which the author suggests may set into motion the acceleration of the wound healing process which is typically observed in clinical practice after He-Ne laser treatment¹².

            Iijima K et al observed that repeated irradiation with low power He-Ne laser is an effective and safe therapy for post herpetic neuralgia. They have irradiated 18 patients with severe postherpetic neuralgia. The efficacy of low power He-Ne laser was evaluated using a four grade estimation visual analog scale and modified McGill pain questionnaire after every 10 of as many as 50 irradiations. The efficacy rate using a four grade estimation at the end of 50 treatments was 94.4%. VAS decreased from 6.2 before irradiation therapy to 3.6 after 50 treatments.¹³

Maiya GA, Sagar MS & Fernandes Donald has reported that low energy He-Ne laser was effective in preventing and treating oral mucositis among head and neck cancer patients receiving radiotherapy.  The patients with carcinoma of oral cavity with stages II-IV a being uniformly treated with curative total tumour dose of 66 Gy in 33 fractions over 6 wk were selected for the study. The patients were divided based on computer generated randomisation into laser (study group) and control groups with 25 patients in each group. Both study and control groups were comparable in terms of site of the lesion, stage of the cancer and histology. The study group patients were treated with He-Ne laser (wavelength 632.8 nm and output of 10mW) and control group patients were given oral analgesics, local application of anaesthetics, 0.9 per cent saline and povidine wash during

the course of radiotherapy. All patients tolerated the laser treatment without any adverse effect or reactions. The result showed a significant difference in pain and mucositis 

Use of the low-energy helium-neon laser (LEL) appears to be a simple atraumatic technique for the prevention and treatment of mucositis of various origins. Preliminary findings, and significant results obtained for chemotherapy-induced mucositis in a previous phase III study, prompted a randomized multicenter double-blind trial to evaluate LEL in the prevention of acute radiation-induced stomatitis. Irradiation by LEL corresponds to local application of a high-photon-density monochromatic light source. Activation of epithelial healing for LEL-treated surfaces, the most commonly recognized effect, has been confirmed by numerous in vitro studies. The mechanism of action at a molecular and enzymatic level is presently being studied. From September 1994 to March 1998, 30 patients were randomized. Technical specification: 60 mW (25 mW at Reims, 1 patient), He-Ne, wavelength 632.8 nm. The trial was open to patients with carcinoma of the oropharynx, hypopharynx and oral cavity, treated by radiotherapy alone (65 Gy at a rate of 2 Gy/fraction, 5 fractions per week) without prior surgery or concomitant chemotherapy. The malignant tumor had to be located outside the tested laser application areas (9 points): posterior third of the internal surfaces of the cheeks, soft palate and anterior tonsillar pillars. Patients were randomized to LEL or placebo light treatment, starting on the first day of radiotherapy and before each session. The treatment time (t) for each application point was given by the equation : t (s)=energy (J/cm²)2surface (cm²)/Power (W). Objective assessment of the degree of mucositis was recorded weekly by a physician blinded to the type of treatment, using the WHO scale for grading of mucositis and a segmented visual analogue scale for pain evaluation. Protocol feasibility and compliance were excellent. Grade 3 mucositis occured with a frequency of 35.2% without LEL and of 7.6% with LEL

Carlos et al has conducted a study to verify if the use of InGaAIP laser with 685 nm wave length can reduce the xerostomy incidence, the oral mucositis severity and the pain related to mucositis in patients with head and neck cancer submitted to radiotherapy.
Sixty patients presenting head and neck carcinoma were submitted to radiotherapy with daily doses of 1.8 to 2.0 Gy and a final dose of 45 to 72 Gy. The salivary volume was evaluated in the first and fifteenth days, at the end of the treatment and after 15 and 30 days. The oral mucositis was evaluated on a weekly basis. Twenty-nine patients were submitted to radiotherapy without laser and 31 were submitted to radiotherapy and laser with daily doses of 2 joules/cm² in predetermined areas of the oral mucosa and the parotid and submandibular glands. In the group submitted to radiotherapy and laser the incidence of mucositis (p < 0.001) and pain (p < 0.016) was significantly lower and the salivary volume (p < 0.001) was kept higher during and after the treatment.
The group of patients submitted to radiotherapy and laser had lower incidence of xerostomy, oral mucositis and pain when compared to the group treated with radioteraphy without laser, producing statistically significant results.

Need for the study:

Helium neon laser and its ability to improve salivary flow is not studied yet. There are not many studies done on helium neon lasers and the degree of salivary flow which helps to prevent oral mucositis in India. Although nurses are taking care of such patients every day, nurse’s role is hidden within. Keeping all these in mind, the researcher has decided to undertake this study collaborating different categories of personnel.

Purpose of the study:

            The overall purpose of the study is to test whether helium neon laser increases the salivary flow which is already reduced due to the effect of radiotherapy. If the salivary flow increases with helium neon laser it will help to considerably reduce oral pain and oral mucositis. In further studies, the mechanism of action of increase in salivary flow can be studied.

Assumptions:

The researcher assumes that

1. helium neon laser increases salivary flow
2. Helium neon laser will reduce the incidence of oral mucositis and oral pain.
3. Patients will willingly participate in the study.

Problem statement:

A study to determine the effectiveness of low energy helium neon laser in the prevention of oral complications of cancer therapy among cancer patients admitted to a selected hospital in India.

Objectives:

1. To determine the incidence of oral mucositis among patients undergoing radiation therapy.
2. To assess the severity of oral mucositis among patients undergoing radiation therapy as measured by mucositis grading scale.
3. To correlate the dose of radiation and the severity of oral mucositis.
4. To find out the effectiveness of low energy helium neon laser in reducing the severity of oral mucositis among patients undergoing radiation therapy   as measured by mucositis grading scale.
5. To determine the incidence of oral pain among patients undergoing radiation therapy.
6. To assess the severity of oral pain among patients undergoing radiation therapy as measured by visual analog scale.
7. To correlate the dose of radiation and the severity of oral pain.
8. To determine the effectiveness of low energy helium neon laser in reducing the severity of oral pain among patients undergoing radiation therapy   as measured by visual analog scale.
9. To determine the incidence of salivary dysfunction among patients undergoing radiation therapy.
10. To assess the severity of salivary dysfunction among patients undergoing radiation therapy as measured un stimulated salivary flow
11. To correlate the dose of radiation and the severity of salivary dysfunction.
12. To determine the effectiveness of low energy helium neon laser in reducing the severity of salivary dysfunction among patients undergoing radiation therapy   as measured by un stimulated salivary flow
13. To determine the association between oral complications of cancer therapy and selected demographic variables ;age, gender, associated chronic illnesses

Definition of terms:

Oral complications of cancer therapy

In this study oral complications of cancer therapy refers to salivary dysfunction, oral pain and the development of oral mucositis following   radiotherapy.

Cancer therapy

In this study, cancer therapy refers to radiotherapy used to treat head and neck cancer patients.

Cancer

In this study, cancer refers to cancers of the head and neck region.

Variables:

Dependent variable:  Helium neon laser therapy of 632.8nm wavelength

Independent variables: Oral mucositis, oral pain, salivary dysfunction.

Selected demographic variables: age, gender, associated chronic illnesses

Hypotheses:

1. There will be significant difference in the severity of oral mucositis among patients undergoing radiation therapy who are treated with low energy helium neon laser and  not treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

2. There will be significant difference in the severity of oral pain among patients undergoing radiation therapy who are treated with low energy helium neon laser and   not   treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

3. There will be significant difference in the severity of salivary dysfunction among patients undergoing radiation therapy who are treated with low energy helium neon laser and not treated with helium neon laser as measured by mucositis grading scale at 0.05 level of significance.

Research methodology:

Research approach: The study uses survey approach and evaluative approach.

Research design:  Experimental.

Population: Head and Neck Cancer patients undergoing radiotherapy.

Sample size:100

Sampling techniquePurposive sampling.

Sampling criteria:

The study was performed in a group of

1. Voluntary patients aged above 21 years,
2.  Bearing head and neck carcinomas and not submitted to previous RT in the affected region.
3.  Patients whose the irradiation fields include the salivary glands.
4. The patients with hospital numbers bearing odd numbers will be denominated "control", receiving RT without laser
5. Patients with hospital numbers bearing even numbers will be submitted to RT and laser therapy.

Exclusion criteria:

Head and neck cancer patients who receive combination treatment.

Data collection instruments:

Patient profile, oral mucositis grading scale, visual analog scale for pain, Scale to assess the salivary flow.

Ethical considerations

Plan for data analysis: t test, chi – square, anova, odds ratio and path analysis for relationship

Work plan

Conceptual framework:

This study incorporates the quality caring model developed by Deffy J.The Quality-Caring Model exposes and demonstrates the value of nursing within the evidence-based practice milieu of modern health care. It favors a process, or way of being, that challenges modernist conventions and highlights the power of relationships. By reaffirming the nature of nursing's work as relationship-centered, the blended model describes the 2 dominant relationships that comprise professional encounters. Relationships characterized by caring are theorized to influence positive outcomes for patients/families, health care providers, and health care systems.

References:

1. Devita VT Jr. Oral complications. In: Cancer: principles and practice of oncology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001; 2523 – 2533, 2881–2888.  
2. Berger. M. Ann, Zlotolow. M. Ian. Oral manifestations and complications of cancer therapy. In:Principles and practice of paliative care and supportive oncology. 2^nd ed. Philadelphia, PA: Lippincot Williams & Wilkins, 2002; 282 – 298.
3. Kostler JW. Hejna M. Wensel C. & Zeilinzki CC. Oral mucositis complicating chemotherapy/radiotherapy CA A cancer journal for clinicians. 2001; 51:290-315
4. Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. NIH Consens Statement 1989 Apr 17-19;7(7):1-11.
5. Fajardo LF, Berthrong M,  Anderson RE.Salivary glands In: Fajardo LF, Bertrong M, Anderson RE, editors,Radiation pathology.Minnesota:  Oxford University Press. 2001. 265 – 270.
6. Semba SE, Mealy BL, Hallmon WW. The head and neck radiotherapy patient: Part 1 – oral manifestations of radiation therapy. Compend Contin Educ Dent 1994;15:252 – 260.CROSS REFERENCE FROM  Carlos de oliviera. Low level laser therapy in the prevention of radiation therapy induced xerstomia and oral mucositis.
7. Chao KS, Deasy Jo, Markmon J et al, A prospective study of salivary function sparing in patients with head and neck cancers receiving intensity modulated or three dimensional radiation therapy: initial results. Int J Radiat Oncol Biol Phys 2001; 49:907 – 916. 
8. Burlage FR, Coppes RP, Meertens H et al. Parotid and submandibular/sublingual salivary flow during high dose radiotherapy. Radiother Oncol 2001;61: 271 – 274 
9. Roesnik JM, Moerland MA, Batterman JJ, et al. Quantitative dose volume respose analysis of changes in parotid gland function after radiotherapy in the head and neck region. Int J Radiat Oncol Biol Phys 2001; 51: 938 – 946. 
10. Maes A, Weltens C, Flamen P, et al. Preservation of parotid function with uncomplicated conformal radiotherapy. Radiother Oncol 2002;63:203 – 211. 
11. Cheng VST, Downs J, Herbert D, Aramany M. The function of the parotid gland following radiation therapy for head and neck cancer. Int J Radiat Oncol Biol Phys1981; 7:253–258. 
12. Baxter GD. Therapeutic lasers theory & practice. Churchill Livingstone. Edinburgh. 1994; 89 – 182.
13. Iijima K,Shimoyama N,Shimoyama M, & Mizuguchi T. Evaluation of analgesic effect of low power He-Ne laser on postherpetic neuralgia using VAS and modified MC Gill pain questionnaire. J Clin Laser Med Sug. 1991 Apr;9(2):121-6.
14. Maiya AG, Sagar MS & Fernandes D. Effect of low level helium neon laser therapy in the prevention and treatment of radiation induced mucositis in head and neck cancer patients. Indian J Med Res 124, October 2006, pp 399-402
15. R. J. Bensadoun et al.Low energy helium neon laser in the prevention of radiation induced oral mucositis. Supportive care in cancer.7(4).June, 1999.
16. Oliveira et al. Low level laser therapy in the prevention of radiotherapy induced xerostomia and oral mucositis. Radiologia Brasileria. 39(2). Mar/Apr. 2006.