>>Hello. Welcome to the session of endocrine disorders.

So you heard Dr. Kim last time spoke about thyroid cancer and osteoporosis.

Let's start with thyroid.

Even through your practice is oral cavity,

how does your extra oral exam involve thyroid?

Do you palpate for it and why?

>>Most dentists during their extraoral head and

neck examination will palpate not only lymph glands and salivary glands,

but they'll palpate a thyroid gland.

Now it's not so easy to detect a nodule per se unless it's somewhat large.

But you should be able to palpate if a thyroid is significantly enlarged enough to

prompt the consultation to the patient's primary care physician for further evaluation.

>>Is this something that's done, should be done on a routine basis in

all dental offices or is it done only with the department of oral medicine?

>>Oh, that's a good question. So, I think since we know

that thyroid cancer seems to be on the rise,

I think it is certainly within

the purview of a dentist to be able to palpate the thyroid gland,

once again, determine whether or not

it is enlarged and then make the appropriate referral.

It seems like it would be a very good thing for

general dentists so and dental specialists to go

ahead and do that routinely on their extraoral examination.

>>So, Dr. Kim also discussed the rise in the rates of thyroid cancer.

But what was your perspective?

Do you see it in your practice and if there is a rise why is it happening?

>>So, it's a very good question.

And yes, we do see it.

We see certainly patients with thyromegaly in which

we have referred and have later determined that these patients had a thyroid cancer.

So, we are seeing it both independently of Dr. Kim's practice.

But also remember we're at a large medical center so we also

see some of the patients that come back after they've had thyroid treatment,

whether it be surgery or more commonly after

they've had radioactive iodine therapy to treat the thyroid cancer.

>>So, if the detected an enlargement of thyroid,

what questions would you ask the patient to believe that

cancer or malignant growth may be a possibility?

>>I think that's more of a difficult question to answer.

I don't think we can just palpate and be able to tell if somebody has a thyroid cancer.

It's often followed up with evaluation from

the primary care physician including blood tests,

but even more appropriately an ultrasound of the thyroid.

And during that ultrasound examination of the thyroid there are

certain subtle changes that can be seen on

the ultrasound that are more suggestive of a cancer than others.

Finally, a thyroid cancer is ultimately detected by

a fine needle aspiration or a cytology smear and be able to see those cancer cells.

>>I think it's important for oral healthcare providers to

recognize any potential signs of pathology or abnormalities.

And if detected on examination,

these patients should be promptly referred to their healthcare providers.

>>I assume that the treatment of thyroid cancer

has potential implications on the oral cavity and dental management.

So, could you elaborate on that please.

>>Oh sure. So patients that are treated with or treated for thyroid cancer,

often it is with the combination of surgery, neck surgery.

And then followed if in fact the tissue type is suggestive of a more aggressive type of

a thyroid cancer or if it has certain characteristics on

biopsy or if it has gone beyond the thyroid capsule,

patients are treated with radioactive iodine therapy.

The radioactive iodine therapy is interesting in so far as it hones in on thyroid tissue.

It also tends to hone in on salivary gland tissue.

So, with the destruction of

any potential thyroid cancerous cells in and

around the thyroid bed or in the lymph nodes or in other areas,

it will very effectively treat and kill those thyroid cancer cells.

Unfortunately, it has a similar effect on the salivary gland structure.

So, it'll cause two things.

It'll cause the destruction of the cells that actually make saliva,

and it'll cause some level of destruction on the cells that carry

the saliva from where the saliva is produced out to the oral cavity.

So it'll have a profound effect on both the.

Well, it'll have profound effect resulting in xerostomia.

>>Okay, so for those viewers who are not familiar well with dentistry,

could you please explain why xerostomia or dry mouth is detrimental to oral health?

>>Sure. Did you want to take it?

>>Sure. So dry mouth can be very deleterious

to the health of the oral cavity due to the fact that when patients make saliva,

there are elements, proteins and

other enzymes in the saliva that help protect the teeth from

things like dental caries and also protects the oral environment

from fungal infections, namely oral candidiasis.

And so, when patients do develop dry mouth secondary

to radioactive iodine therapy to treat thyroid cancer,

we certainly see increases in the rates of dental caries,

severity of dental caries as well as increased rates of

oral fungal infections which can be symptomatic and difficult to treat.

>>So, when you work with endocrinologist like Dr. Kim,

what type of preventive measures do you

take before the treatment starts, if there are any,

and what type of treatment do you render if indeed

some of the caries and other complications have occurred?

>>If the patient is indicated for radioactive iodine therapy,

that decision is primarily left to the endocrinologist such as Dr. Kim.

I think education is critically important for the patient

to understand that following the radioactive iodine therapy,

there may be a relative risk of dry mouth.

And so if patients understand that before the therapy,

I think that really is important for possible complications afterwards.

When patients are referred to us for management of dry mouth from endocrinology,

often we will recommend a salivary substitute over-the-counter,

products that help lubricate the oral tissues,

make the patient feel more comfortable.

Also we will recommend increased strength for fluoride application

or prescription fluoride to protect the teeth from the increased risk of dental caries.

If we need to treat a patient for oral fungal infections

we'll certainly provide that antifungal medication.

There are medicines to stimulate salivary flow.

One is Pilocarpine another one is the Cevimeline.

These are medications that can potentially be prescribed depending on a variety of

factors to help stimulate salivary flow for patients with these conditions.

>>And the only thing I might just add is occasionally we'll have patients perform

salivary gland massage as a method to have

salivary gland constantly stimulated mechanically.

So, patients we'll explain to them to massage

their either parotid gland or

their submandibular gland in order to help mechanically stimulate.

It's interesting though the patients don't initially perceive

a dryness until usually about the sixth month mark.

They will get a swelling during the time of

the radioactive iodine treatment that usually dissipates within a couple of weeks,

and then at around the six-month mark they'll notice

some dryness and perhaps even some swelling in the parotid gland area.

>>Okay. Thank you.

Well, the other conditions that we discussed was the one osteoporosis.

So, first of all the big question,

this is essentially known as condition that affects women.

Are men affected as well by osteoporosis?

>>I believe men can be affected by the condition as well,

although at lower rates and incidents compared to females.

But certainly it can occur in males.

>>And that was the reasons is?

Why are women more affected by this condition?

>>It has to do with the female sex hormones estrogen and

progesterone which have an effect on bone metabolism and bone health.

And so when females enter middle age perimenopausal time frame,

these hormone levels fluctuate and therefore can have an effect on bone health.

>>So, let's discuss the treatment of osteoporosis.

>>So, as previously discussed,

osteoporosis often is treated with medications known as Bisphosphonates

or antiresorptive medications which can certainly

have an effect on the maxillofacial bones.

Patients are at a relative increased risk of

developing osteonecrosis of their jaw bones when taking these medications.

So, it certainly is important for oral healthcare providers to be aware

of patients who are taking these types of medicines to treat osteoporosis.

>>Okay. All right, thank you.

Oral medicine perspectives on endocrine conditions - Dr. Tom Sollecito, Dr. Eric Stoopler

The Oral Cavity: Portal to Health and Disease

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