2022 Thyroid Health: Check the Neck Even in Adolescents & Young Adults
Abstract: 2021 Thyroid health: check the neck even in adolescents & Young adults
The evaluation and treatment of thyroid nodules is similar in both adolescents and adults, however the management may be more difficult in a younger population. Interprofessional management involving the endocrine oncology and dental home will help mitigate surgical and radiodine (I-131) side effects. This review emphases the role of the dental professional in detection and management of thyroid carcinoma.
Thyroid Health Introduction
Thyroid carcinoma can be diagnosed in any age, sex or race although it is more commonly seen in females (3:1)2. American Cancer Society estimates about 52,890 new cases in 20202. In fifteen to thirty-nine-year-old American females, thyroid carcinoma is the diagnosis responsible for the most new cases of cancer per year, from 2013-20177. This diagnosis also has the fifth highest incidence in both sexes in the 0-19 age group bracket in the United States (following Lymphoid Leukemia, Astrocytoma, Hodgkin and Non-Hodgkin lymphoma 6. Factors that may play a role in the development of thyroid carcinoma include exposure to radiation (higher dose and younger age increases risk), having a first degree relative with thyroid cancer and the amount of iodine in the diet 2. Based on studies from Atomic bomb survivors, it was determined that children are “ten times more sensitive than adults to the induction of cancer” 5. Although the incidence may seem concerning, the five year survival rate in is 99.3% in children, and 98.3% in adults 3, 6.
During dental extraoral exam, healthcare providers can locate the thyroid, below the laryngeal prominence of the thyroid cartilage (“Adam’s Apple”) and above the collarbones. It is important to check for symmetry, and the presence of any protrusions upon swallowing. Carcinoma is more likely when there is a nodule which is large, hard, irregular, fixed, or accompanied by cervical lymphadenopathy, and they will carry a greater risk of malignancy compared to those in adults 10, 8. Children with thyroid carcinoma often present with higher rate of distant metastasis to the lung, bone or liver compared to adults 11. Early comprehensive examination, referral and therapy are paramount.
Although there is safeguards like rectangular collimation, aprons, thyroid collars, shields, lined gloves and dosimetry monitoring devices, they must be properly maintained for optimum efficacy. For example, hanging the apron properly will prevent cracks from forming. One study demonstrated that a loose thyroid collar during CBCT scans will not effectively reduce radiation dose, however when used tightly around the neck it can offer 46.5% dose reduction 9. Education (ALARA Principle) and a commitment to safety is necessary for every dental professional to minimize exposure to iodizing radiation.
Thyroid ultrasound and fine needle aspiration are useful diagnostic tools
Thyroidectomy (complete thyroid removal) or Lobectomy (Partial removal) surgery is a treatment option for “growing nodules or those exceeding four centimeters and causing compressive symptoms” 11. Total thyroidectomy is also performed in patients’ with Graves Disease (hyperthyroidism).
Surgery is often followed by single, or multiple adjuvant treatments with I-131 to achieve complete ablation of thyroid remnants11. The I-131 should be administered in combination with an antiemetic medication due to gastrointestinal upset which develops four to twelve hours after, and typically resolves in two days 11, 12. Baking soda rinse has been shown to increase the intraoral pH level to counteract the gastric acid bathing tooth enamel.
The I-131 therapy can lead to sialaodenitis, temporary loss of salivary flow and change of taste (e.g. unpleasant, bitter) 11, 12. Side effects seen in in the salivary glands occur in approximately 67% of patients, and typically resolve within a few hours to three days 12. There are select cases in which these symptoms may persist for longer than three months 12. Patients with xerostomia will be at high caries risk and three-month recall visits, supplemental fluoride and diet modification should be considered 1. Patients that are on low-iodine diets are often able to have kosher salt, but are on restricted amounts of other types of salt. It is common to see an increase of cariogenic snacks during this time (jams, honey, gummies, raisins, maple syrup). Oral health recommendations should include hydrating with water, sugar free lozenges, sialagogues and xylitol gum to help stimulate salivary flow.
Another promising adjunctive therapy includes supplemental Vitamin E for one week before, to four weeks after, a single dose of I-131 4. This has been shown to have a protective effect against radiation-induced dysfunction in salivary glands in patients with thyroid carcinoma 4. Encourage families to maintain optimism and a routine follow up schedule with their medical and dental team to aid in timely detection of disease reoccurrence or post-treatment sequalae. There is a need for more studies on the dental complications seen in the adolescent and young adult population. As of today, no long-term studies have been done to ascertain the risk of stunted tooth root growth or dental anomalies following I-131 therapy during adolescence.
In the wise words of Madame Curie, “Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.”
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About the Authors
- Robertzon Guloy, DMD, CAGS is an orthodontist local to Pinellas County, Florida. Before obtaining his Orthodontic Certificate, he practiced as a general dentist for over ten years. He has detected a number of thyroid carcinomas and has referred for suspicious palpable nodules found during routine Head and Neck exams.
- Dorothy Cataldo, DMD, CAGS is a pediatric dentist local to Pinellas County, Florida. She is passionate about raising awareness about Thyroid Carcinoma to bridge the gap between medical and dental care, especially during the month of September which is “Thyroid Cancer Awareness Month.” She is active in thyroid cancer support groups and wants other oral health professionals to appreciate the role they can play in the early detection of cancer.
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