Thyroid Disease

1
Thyroid Disease
______________________________________________

• Case
• Katalina Korapova
• Thyroid disease
• Hyperthyroidism
• Hypothyroidism
• ASA PS level
• Dental management
• Algorithm
• Thyroid disease
• Thyroiditis
• Thyroid Cancer

University of Minnesota - School of
Dentistry
2
Katalina Korapova
______________________________________________

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

University of Minnesota - School of
Dentistry
3
Initial observations
______________________________________________

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

University of Minnesota - School of
Dentistry
4
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?

University of Minnesota - School of
Dentistry
5
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?

University of Minnesota - School of
Dentistry
6
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?

University of Minnesota - School of
Dentistry
7
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?

University of Minnesota - School of
Dentistry
8
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

University of Minnesota - School of
Dentistry
9
University of Minnesota - School of
Dentistry
10
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

University of Minnesota - School of
Dentistry
11
Hyperthyroidism - Etiology
______________________________________________

• Ectopic thyroid tissue
• Graves disease
• Multinodular goiter
• Thyroid adenoma
• Subacute thyroiditis
• Ingestion of thyroid hormone
• Pituitary disease (anterior gland)
• Ingestion of food-containing thyroid hormone

University of Minnesota - School of
Dentistry
12
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

University of Minnesota - School of
Dentistry
13
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

University of Minnesota - School of
Dentistry
14
Hyperthyroidism - Laboratory Findings
______________________________________________

• Low TSH combined with high T4
• Low TSH, low T4 and high T3

University of Minnesota - School of
Dentistry
15
Hypothyroidism
______________________________________________

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

University of Minnesota - School of
Dentistry
16
Hypothyroidism
______________________________________________

• Primary Hypothyroidism - 95
• Insufficient amount of thyroid tissue
• Hashimotos 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

University of Minnesota - School of
Dentistry
17
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

University of Minnesota - School of
Dentistry
18
University of Minnesota - School of
Dentistry
19
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

University of Minnesota - School of
Dentistry
20
Hypothyroidism
______________________________________________

• Treatment
• Treated with synthetic drugs sodium
  levothyroxine (Synthroid, LT4) or sodium
  liothyronine (Leotrix, LT3)
• Oral complications
• Adults with acquired hypothyroidismenlarged
  tongue
• Infants with cretinismthick lips, enlarged
  tongue, delayed eruption of teeth, and resulting
  malocclusion

University of Minnesota - School of
Dentistry
21
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

University of Minnesota - School of
Dentistry
22
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

University of Minnesota - School of
Dentistry
23
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

University of Minnesota - School of
Dentistry
24
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

University of Minnesota - School of
Dentistry
25
Dental Algorithm - A
______________________________________________

• Antibiotics
• No premedication, but treat infections rapidly in
  order to prevent thyroid storm or myxedema coma

University of Minnesota - School of
Dentistry
26
Dental Algorithm - A
______________________________________________

• Anesthetics
• Avoid Epinephrine in those with uncontrolled
  hyperthyroidism
• Epinephrine can be administered when patient
  controlled

University of Minnesota - School of
Dentistry
27
Dental Algorithm - A
______________________________________________

• Anxiety
• Avoid stressful appointments as they can lead to
  thyroid storm

University of Minnesota - School of
Dentistry
28
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

University of Minnesota - School of
Dentistry
29
Dental Algorithm - D
______________________________________________

• Drug Interactions
• Untreated hypothyroid patients may be highly
  sensitive to actions of narcotics, barbituates,
  and tranquilizers

University of Minnesota - School of
Dentistry
30
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

University of Minnesota - School of
Dentistry
31
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.

University of Minnesota - School of
Dentistry
32
Thyroiditis - Types(inflammation of the thyroid
gland)
______________________________________________

• Hashimotos
• Subacute painful
• Subacute painless
• Acute suppurative
• Riedels
• Radiation therapy
• Drugs
• Lithium, interlukin-2, interferons, amiodarone

University of Minnesota - School of
Dentistry
33
Thyroiditis - Pathophysiology
______________________________________________

• Hashimotos
• 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
• Riedels
• fibrous infiltration of the thyroid gland of
  unknown origin

University of Minnesota - School of
Dentistry
34
Thyroiditis - Signs and Symptoms
______________________________________________

• Hashimotos
• 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
• Riedels
• 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

University of Minnesota - School of
Dentistry
35
Thyroiditis - Oral manifestations
______________________________________________

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

University of Minnesota - School of
Dentistry
36
Thyroid Cancer - Types
______________________________________________

• Differentiated
• Papillary
• Follicular
• Mixed
• Hurthle cell carcinoma
• Medullary
• MEN type 2
• Anaplastic

University of Minnesota - School of
Dentistry
37
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

University of Minnesota - School of
Dentistry
38
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

University of Minnesota - School of
Dentistry