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University of Minnesota
- School of Dentistry
Thyroid
Disease
______________________________________________
• Case
– Katalina Korapova
• Thyroid disease
– Hyperthyroidism
– Hypothyroidism
• ASA PS level
– Dental management
• Algorithm
• Thyroid disease
– Thyroiditis
– Thyroid Cancer
1
University of Minnesota
- School of Dentistry
Katalina
Korapova
______________________________________________
•
•
•
•
•
60 yr old
Caucasian
Female
WNWD
Presents to clinic for
routine exam
2
University of Minnesota
- School of Dentistry
Initial
observations
______________________________________________
• Previous thyroid
problems
• History of surgery
• Scar on median of
neck
• Thinning hair
• Dry skin
• Bulging eyes
• Taking Levothyroxine
3
University of Minnesota
- School of Dentistry
General
Questions
______________________________________________
•
•
•
•
•
•
•
How long ago were you prescribed
Levothyroxine?
How often do you take your
medications?
Have there been any changes to the
type or amount of medication you are
taking?
Are you taking any other medications
currently?
Do you have any other medical
problems I should know about?
Have you been back to your
physician to be evaluated recently?
When was your last visit to a
physician?
4
University of Minnesota
- School of Dentistry
General
Thyroid
Questions
______________________________________________
• Did you have a large swelling in your neck
(goiter) in the past?
• Have you had any unexplained weight loss
or weight gain?
• Have you had any changes in your
appetite?
• Do you often feel hot? Cold?
5
- School of Dentistry
• Have you experienced any recent bouts of nausea or
vomitting
• Have you felt tired, weak, or fatigued lately?
• Have you recently experienced any muscle cramping?
• Do you ever experience unexplained shortness of
breath?
University of Minnesota
Hypothyroid
Questions
______________________________________________
6
University of Minnesota
- School of Dentistry
Additional
Information
______________________________________________
• Pulse - rate or rhythm (slow, skip beats)
• Consult with physician:
– When was the surgery and what for?
– History of medications
– How compliant is the patient with taking her
medications
– What are her lab test results?
7
University of Minnesota
- School of Dentistry
Lab
tests
needed
______________________________________________
• Measure
–
–
–
–
T4
T3
TSH
TBG
Normal
5 - 12 mg/dl
80 – 190 mg/d
0.5 – 4.5 mμ/L
HypoDecrease
Decrease
Increase
Decrease
HyperIncrease
Increase
- / decrease
Increase
• Radioactive Iodine Uptake Test: Direct Thyroid Test
– Normal RAIU = 10% – 30% (Better Indicates Hyperthyroidism)
• Measurement of Autoantibodies
8
University of Minnesota
9
- School of Dentistry
University of Minnesota
- School of Dentistry
What
is
going
on?
______________________________________________
•
Exophthalmos - sign of hyperthyroid
–
•
Scar on neck - previous surgery
–
•
Ms. Korpova likely had hyperthyroids problems
She underwent surgery to have the mass
removed
Dry skin, thin hair, prescribed
Levothyroxine - signs of Hypothyroid
–
Resulting in hypothyroidism
10
Etiology
______________________________________________
University of Minnesota
- School of Dentistry
Hyperthyroidism •
•
•
•
•
•
•
•
Ectopic thyroid tissue
Grave’s disease
Multinodular goiter
Thyroid adenoma
Subacute thyroiditis
Ingestion of thyroid hormone
Pituitary disease (anterior gland)
Ingestion of food-containing thyroid hormone
11
Hyperthyroidism - Signs and Symptoms
University of Minnesota
- School of Dentistry
______________________________________________
•
Skeletal
–
•
osteoporosis
CV
– palpitations, tachycardia, MI, arrhythmias, cardiomegaly, CHF, angina
•
GI
–
•
weight loss, increased appetite, pernicious anemia
CNS
– anxiety, restlessness, sleep disturbances, impaired concentration,
weakness, tremors
•
Skin
– erythema, thin fine hair, soft nails
•
Eyes
– retraction of upper lid, exophthalmos, corneal ulceration, ocular muscle
weakness
•
Other
– increased risk for diabetes, decreased cholesterol level, increased risk for
thrombocytopenia, sweating
12
Oral
manifestations
______________________________________________
University of Minnesota
- School of Dentistry
Hyperthyroidism -
• Osteoporosis involving the alveolar bone
• Dental caries and periodontal disease
appear rapidly in these patients
• Teeth and jaws develop rapidly
• Premature loss of deciduous teeth with
early eruption of permanent teeth
• Lingual thyroid
13
Laboratory
Findings
______________________________________________
University of Minnesota
- School of Dentistry
Hyperthyroidism -
• Low TSH combined with high T4
• Low TSH, low T4 and high T3
14
University of Minnesota
- School of Dentistry
Hypothyroidism
______________________________________________
• Types
– Primary atrophic
– Secondary
– Transient
– Generalized resistant to thyroid hormone
15
University of Minnesota
- School of Dentistry
Hypothyroidism
______________________________________________
•
Primary Hypothyroidism - 95%
–
–
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Insufficient amount of thyroid tissue
Hashimoto’s thyroiditis
Graves’ disease – end stage
radiation
amyloidosis, lymphoma,
scleroderma
Iodine 131 therapy
thyroidectomy
Thyroid hormone synthesis defect
congenital enzyme defects
iodine deficiency
mutations in TSH receptor
drug induced (thionamides, lithium)
Agenesis or Dysplasia
•
Secondary Hypothyroidism
–
–
–
–
–
–
–
–
–
Pituitary
panhypopituitarism (neoplasm,
radiation, surgery)
Hypothalamic
congenital
infection
infilitration (sarcoidosis,
granulomas)
Transient Hypothyroidism
silent and subacute thyroiditis
thyroxine withdrawal
16
University of Minnesota
- School of Dentistry
Hypothyroidism
______________________________________________
• Epidemiology
– 95% of hypothyroidism caused by primary and
goitrous hypothyroidism
– 2% of adult women and 0.1-0.2% of adult men in
North America are affected by acquired impairment
of thyroid function
• Laboratory Values
– Measurement of serum TSH is the most sensitive
test for hypothyroidism – high levels of TSH
indicates hypothyroidism
• normal range 0.5-4.5 mm/L
– Serum T4 is decreased in hypothyroidism
• normal range 64-154nmol/L or 5-12mg/dL
17
University of Minnesota
18
- School of Dentistry
Hypothyroidism –
Signs and Symptoms
- School of Dentistry
• General
University of Minnesota
______________________________________________
• Myxedema
– dry, thick skin; dry hair; fatigue; edema (puffy hand, face, eyes); cold
intolerance; weight gain; hoarseness; sluggishness; headache;
constipation; shortness of breath; bradycardia; arthritis; muscle
cramps
• Neonatal cretinism
– Symptoms - developmental impairment of skeletal system and CNS;
dwarfism; broad flat nose; wide-set eyes; thick lips; protruding tongue;
poor muscle tone; pale skin; umbilical hernia; delayed eruption of
teeth; malocclusions; hoarse voice
– hypothyroidism developing in older children and adults
• Symptoms
– generalized apathy and sluggishness; puffy eyelids; dry, rough skin;
dry, brittle, and coarse hair; cold intolerant; congestive heart failure;
constipation; slurred, hoarse speech; anemia; weight gain
– serum cholesterol levels are elevated
– may develop fatal hypothermic coma
19
University of Minnesota
- School of Dentistry
Hypothyroidism
______________________________________________
• Treatment
– Treated with synthetic drugs: sodium levothyroxine (Synthroid,
LT4) or sodium liothyronine (Leotrix, LT3)
• Oral complications
– Adults with acquired hypothyroidism—enlarged tongue
– Infants with cretinism—thick lips, enlarged tongue, delayed
eruption of teeth, and resulting malocclusion
20
University of Minnesota
- School of Dentistry
Hypothyroidism – Dental Implications
• Hypothyroid patients under good care pose no threat to dental
treatment
• Hypothyroid patients treated with T4 and taking warfarin may be at
risk for hemorrhage
• Untreated hypothyroid patients are sensitive to narcotics and
barbiturates
• Stress, infection, trauma, CNS depressants may precipitate a
hypothyroid (myxedema) coma, especially in elderly patients; if a
myxedema coma occurs, call for medical aid, inject 100-300mg
hydrocortisone, cover patient to conserve heat, CPR as needed
• Severe myxedema, bradycardia, and hypotension may be present
• Head and neck exam palpation of the thyroid is important and may
lead to medical referral leading to a diagnosis of thyroiditis or
hypothyroidism
21
University of Minnesota
- School of Dentistry
ASA
Physical
Status
______________________________________________
• ASA PS level II
• Ms. Korapova was likely treated for hyperthyroidism in the past
– It is possible that she went through subtotal thyroidectomy due
to a large goiter
•
•
Resulting in large scar in the median of her neck
With remaining exophthalmos
–
Usually irreversible regardless of anti-thyroid treatment
– Patient likely has post-operative hypothyroidism
•
A common complication of thyroidectomy
• Must consult physician to determine level of control of
hypothyroidism prior to dental tx
22
University of Minnesota
- School of Dentistry
ASA
Physical
Status
______________________________________________
• Currently has mild symptoms of
hypothyroidism
– dry skin, thinning hair
• Currently on levothyroxine
– synthetic thyroid hormone replacement to
control hypothyroidism
• Under medical management
23
Patient Management - Hypothyroidism
University of Minnesota
- School of Dentistry
______________________________________________
•
In general, well controlled hypothyroidism (even when untreated) does
not interfere with dental therapy
–
–
•
May show exaggerated response to CNS depressants such as narcotic
analgesics, sedatives, CNS depressants
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•
•
•
Avoid oral infections
Implement normal procedures and management
Avoid in severe hypothyroidism, reduce dosage in mild hypothyroidism
Hypothyroid patients being treated with levothyroxine receiving warfarin
or other oral anticoagulants may have even further prolongation of
prothrombin time and could be at risk for hemorrhage
Hypothyroid patients with diabetes with decreased need for insulin or
sulfonylurea may become hypoglycemic when treated with levothyroxine
No special problems in terms of dental management once the patient is
under good medical care. Follow up with current treatment, lack of signs
and symptoms of disease, presence of any complications
24
University of Minnesota
- School of Dentistry
Dental
Algorithm
A
______________________________________________
• Antibiotics
– No premedication, but treat infections
rapidly in order to prevent thyroid storm or
myxedema coma
25
University of Minnesota
- School of Dentistry
Dental
Algorithm
A
______________________________________________
• Anesthetics
– Avoid Epinephrine in those with
uncontrolled hyperthyroidism
• Epinephrine can be administered when patient
controlled
26
University of Minnesota
- School of Dentistry
Dental
Algorithm
A
______________________________________________
• Anxiety
– Avoid stressful appointments as they can
lead to thyroid storm
27
University of Minnesota
- School of Dentistry
Dental
Algorithm
–
B
and
C
______________________________________________
• Bleeding
– Anticoagulants in combination with T4
therapy increases PT
• Complications
– Watch for thyrotoxicosis with patients on
levothyroxine (taken to treat hypothyroidism)
• Cardiac
– Watch for MI in those undergoing thyroid
storm
28
University of Minnesota
- School of Dentistry
Dental
Algorithm
D
______________________________________________
• Drug Interactions
– Untreated hypothyroid patients may be
highly sensitive to actions of narcotics,
barbituates, and tranquilizers
29
- School of Dentistry
Dental
Algorithm
E
______________________________________________
• Emergency Treatment
– Be aware of signs of thyroid storm
•
•
•
•
Fever
Abdominal Pain
Delirious
Psychotic
University of Minnesota
– Know how to treat thyroid storm
•
•
•
•
•
Seek immediate medical aid
Cool with cold towels, ice packs
Hydrocortisone (100-300 mg)
Monitor vital signs
Start CPR if needed
30
- School of Dentistry
Dental
Algorithm
E
______________________________________________
• Emergency Treatment
– Know the signs of hypothyroid coma
•
•
•
•
Hypothermia
Bradycardia
Hypotension
Epilpetic seizures
University of Minnesota
– Know how to treat hypothyroid coma
• Immediate medical help
• Hydrocortisone (100-300 mg)
• CPR if needed
– This said, thyroid storm and myxedema coma are very rare.
31
Thyroiditis -
Types
(inflammation of the thyroid gland)
University of Minnesota
- School of Dentistry
______________________________________________
•
•
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Hashimoto’s
Subacute painful
Subacute painless
Acute suppurative
Riedel’s
Radiation therapy
Drugs
– Lithium, interlukin-2, interferons, amiodarone
32
University of Minnesota
- School of Dentistry
Thyroiditis
Pathophysiology
______________________________________________
• Hashimoto’s
– autoimmune disorder that presents as an asymptomatic diffuse goiter
• Subacute painful
– follows upper respiratory tract viral infection
• Subacute painless
– autoimmune disorder
• Acute suppurative
– microbial infection of the thyroid
• Riedel’s
– fibrous infiltration of the thyroid gland of unknown origin
33
- School of Dentistry
• Hashimoto’s
University of Minnesota
Thyroiditis
Signs
and
Symptoms
______________________________________________
• Acute suppurative
–
moderately sized goiter, rubbery and firm in consistency, moveable,
hypothyroidism
• Subacute painful
–
enlarged, painful, tender gland with signs and symptoms of hyperthyroidism
• Subacute painless
–
–
present with signs and symptoms of hyperthyroidism without thyroid pain or
tenderness or fever
severe neck pain, fever, focal thyroid tenderness and erythema of overlying
skin
• Riedel’s
–
slowly enlarging stony neck mass which may extend beyond the thyroid gland
causing compressive symptoms such as dyspnea, dysphagia, hoarseness and
a sensation of choking
34
University of Minnesota
- School of Dentistry
Thyroiditis
Oral
manifestations
______________________________________________
• Pain associated with subacute painful
thyroiditis may radiate to the ear, jaw or
occipital region
• Hoarseness and dysphagia
35
Types
______________________________________________
University of Minnesota
- School of Dentistry
Thyroid Cancer -
• Differentiated
–
–
–
–
Papillary
Follicular
Mixed
Hurthle cell carcinoma
• Medullary
– MEN type 2
• Anaplastic
36
Etiology
______________________________________________
University of Minnesota
- School of Dentistry
Thyroid Cancer -
• External radiation to cervical region
• Children who have undergone thymic irradiation
• Teenagers with acne who were treated with
irradiation
• Children exposed to radioactive fallout from
Chernobyl
• High dietary iodine intake or a very low iodine
intake
• Genetic factor
37
Signs
and
Symptoms
______________________________________________
University of Minnesota
- School of Dentistry
Thyroid Cancer •
•
•
•
•
•
•
•
•
•
Lump in the region of the gland
Dominant nodule(s) in multinodular goiter
Hard painless mass
Fixation to adjacent structures
Enlarged cervical lymph nodes
Rapidly growing mass
Hemoptysis
Dysphagia
Stridor
hoarseness
38