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Thyroid Disease• Case

– Katalina Korapova• Thyroid disease

– Hyperthyroidism– Hypothyroidism

• ASA PS level– Dental management

• Algorithm

• Thyroid disease– Thyroiditis– Thyroid Cancer

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Katalina Korapova

• 60 yr old• Caucasian • Female• WNWD• Presents to clinic for

routine exam

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Initial observations

• Previous thyroid problems

• History of surgery• Scar on median of neck• Thinning hair• Dry skin• Bulging eyes• Taking Levothyroxine

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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?

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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?

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Hypothyroid Questions• 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?

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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?

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Lab tests needed

• Measure Normal Hypo- Hyper-– T4 5 - 12 mg/dl Decrease Increase– T3 80 – 190 mg/d Decrease Increase– TSH 0.5 – 4.5 mμ/L Increase - / decrease– TBG Decrease Increase

• Radioactive Iodine Uptake Test: Direct Thyroid Test– Normal RAIU = 10% – 30% (Better Indicates Hyperthyroidism)

• Measurement of Autoantibodies

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What is going on?

• Exophthalmos - sign of hyperthyroid– Ms. Korpova likely had hyperthyroids problems

• Scar on neck - previous surgery– She underwent surgery to have the mass

removed

• Dry skin, thin hair, prescribed Levothyroxine - signs of Hypothyroid

– Resulting in hypothyroidism

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Hyperthyroidism - Etiology

• 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

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Hyperthyroidism - Signs and Symptoms

• 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

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Hyperthyroidism - Oral manifestations

• 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

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Hyperthyroidism - Laboratory Findings

• Low TSH combined with high T4

• Low TSH, low T4 and high T3

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Hypothyroidism

• Types– Primary atrophic– Secondary– Transient– Generalized resistant to thyroid hormone

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Hypothyroidism • Primary Hypothyroidism - 95%

– 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

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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

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Hypothyroidism – Signs and Symptoms

• General– 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

• Myxedema – 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

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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

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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

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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

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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

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Patient Management - Hypothyroidism

• In general, well controlled hypothyroidism (even when untreated) does not interfere with dental therapy– Avoid oral infections– Implement normal procedures and management

• May show exaggerated response to CNS depressants such as narcotic analgesics, sedatives, CNS depressants– 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

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Dental Algorithm - A

• Antibiotics – No premedication, but treat infections

rapidly in order to prevent thyroid storm or myxedema coma

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Dental Algorithm - A

• Anesthetics– Avoid Epinephrine in those with

uncontrolled hyperthyroidism• Epinephrine can be administered when patient

controlled

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Dental Algorithm - A

• Anxiety – Avoid stressful appointments as they can

lead to thyroid storm

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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

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Dental Algorithm - D

• Drug Interactions– Untreated hypothyroid patients may be

highly sensitive to actions of narcotics, barbituates, and tranquilizers

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Dental Algorithm - E

• Emergency Treatment – Be aware of signs of thyroid storm

• Fever

• Abdominal Pain

• Delirious

• Psychotic

– 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

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Dental Algorithm - E

• Emergency Treatment– Know the signs of hypothyroid coma

• Hypothermia

• Bradycardia

• Hypotension

• Epilpetic seizures

– 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.

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Thyroiditis - Types(inflammation of the thyroid gland)

• Hashimoto’s • Subacute painful• Subacute painless• Acute suppurative• Riedel’s• Radiation therapy• Drugs

– Lithium, interlukin-2, interferons, amiodarone

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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

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Thyroiditis - Signs and Symptoms

• Hashimoto’s – 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

• Acute suppurative – 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

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Thyroiditis - Oral manifestations

• Pain associated with subacute painful thyroiditis may radiate to the ear, jaw or occipital region

• Hoarseness and dysphagia

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Thyroid Cancer - Types

• Differentiated– Papillary– Follicular– Mixed– Hurthle cell carcinoma

• Medullary– MEN type 2

• Anaplastic

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Thyroid Cancer - Etiology

• 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

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Thyroid Cancer - Signs and Symptoms

• 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

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