RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH THYROID DYSFUNCTION Géza T. Terézhalmy, D.D.S., M.A. Professor ...
Thyroid Dysfunction <ul><li>Hypothalamic-pituitary-thyroid axis </li></ul><ul><ul><li>Hypothalamus </li></ul></ul><ul><ul>...
Thyroid Dysfunction <ul><li>T4 and T3 </li></ul><ul><ul><li>70% bound to thyroid binding globulin (TBG) </li></ul></ul><ul...
Thyroid Dysfunction <ul><li>T3 </li></ul><ul><ul><li>Accounts for most of the biological activity of thyroid hormones </li...
Thyroid Dysfunction <ul><li>T3 </li></ul><ul><ul><ul><li>Enhances tissue sensitivity to catecholamines </li></ul></ul></ul...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>An estimated 5% of individuals in the U.S. have ...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>May be characterized as </li></ul></ul><ul><ul><...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Euthyroidism </li></ul></ul><ul><ul><ul><li>Euth...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Euthyroidism </li></ul></ul><ul><ul><ul><li>Thyr...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Co...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Co...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Pr...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Se...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Te...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Cl...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>My...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>My...
Thyroid Dysfunction
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>My...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>My...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>My...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>C...
Thyroid Dysfunction
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>G...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>F...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>C...
Thyroid Dysfunction
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>T...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>T...
Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>T...
Thyroid Dysfunction <ul><li>Diagnosis </li></ul><ul><ul><li>Newborns  </li></ul></ul><ul><ul><ul><li>Mandatory TSH testing...
Thyroid Dysfunction <ul><li>Principles of medical management </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><...
Thyroid Dysfunction When conversion of levothyroxin, T4 to T3, is abnormal T4 and T3 replacement Liotrix  (Thyrolar®) When...
Thyroid Dysfunction <ul><li>Principles of medical management </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul>...
Thyroid Dysfunction Agranulocytosis Hepatotoxicity Urticaria Arthralgia Sialadenitis (rarely) Long-term thyroxin suppressi...
Thyroid Dysfunction Agranulocytosis Hepatotoxicity Urticaria Arthralgia Long-term thyroxin suppression OR In preparation f...
Thyroid Dysfunction Allergic reactions Adjunctive therapy to antithyroid drugs  OR  In preparation for surgery Short-term ...
Thyroid Dysfunction <ul><li>DENTAL MANAGEMENT CONSIDERATIONS </li></ul>
Thyroid Dysfunction <ul><li>Goals </li></ul><ul><ul><li>Develop and implement  timely  preventive  and therapeutic strateg...
Thyroid Dysfunction <ul><li>Functional capacity </li></ul><ul><ul><li>T3   exerts direct inotropic and chronotropic effect...
Thyroid Dysfunction <ul><li>Vital signs </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>< 180/110 mm H...
Thyroid Dysfunction <ul><li>Treatment strategies </li></ul><ul><ul><li>The physiological events associated with the thyroi...
Thyroid Dysfunction <ul><ul><li>The hypothyroid patient </li></ul></ul><ul><ul><ul><li>There is no evidence to justify def...
Thyroid Dysfunction <ul><ul><li>The use of local anesthetic agents with epinephrine </li></ul></ul><ul><ul><ul><li>The hyp...
Thyroid Dysfunction <ul><ul><li>The use of analgesics and anxiolytic agents </li></ul></ul><ul><ul><ul><li>The hypothyroid...
Thyroid Dysfunction Routine referral for medical management and risk factor modification Comprehensive care Blood pressure...
Thyroid Dysfunction Routine medical referral Limited care Blood pressure < 180/110  mm Hg AND Normal pulse pressure, rate,...
Thyroid Dysfunction <ul><li>If patient is asymptomatic </li></ul><ul><ul><li>Routine medical referral   </li></ul></ul><ul...
Thyroid Dysfunction Immediate medical referral Emergency care Establish baseline vital signs Severe hypo-thyroidism OR Thy...
Thyroid Dysfunction <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conven...
Thyroid Dysfunction <ul><li>Potential medical emergencies </li></ul><ul><ul><li>The likelihood of myxedema coma or a thyro...
Risk stratification of patients with TD <ul><li>Huber MA, Terezhalmy GT. Risk stratification and dental management of the ...
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RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ...

  1. 1. RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH THYROID DYSFUNCTION Géza T. Terézhalmy, D.D.S., M.A. Professor and Dean Emeritus School of Dental Medicine Cleveland, Ohio [email_address]
  2. 2. Thyroid Dysfunction <ul><li>Hypothalamic-pituitary-thyroid axis </li></ul><ul><ul><li>Hypothalamus </li></ul></ul><ul><ul><ul><li>Thyrotropin-releasing hormone </li></ul></ul></ul><ul><ul><li>Anterior pituitary </li></ul></ul><ul><ul><ul><li>Thyroid stimulating hormone </li></ul></ul></ul><ul><ul><li>Thyroid gland </li></ul></ul><ul><ul><ul><li>Tetraiodothyronine </li></ul></ul></ul><ul><ul><ul><li>Triiodothyronine </li></ul></ul></ul>
  3. 3. Thyroid Dysfunction <ul><li>T4 and T3 </li></ul><ul><ul><li>70% bound to thyroid binding globulin (TBG) </li></ul></ul><ul><ul><li>30% bound to transthyretin, albumin, and lipoproteins </li></ul></ul><ul><ul><li><2% circulate in an unbound free state </li></ul></ul><ul><ul><ul><li>Act to maintain physiological hormone levels </li></ul></ul></ul>
  4. 4. Thyroid Dysfunction <ul><li>T3 </li></ul><ul><ul><li>Accounts for most of the biological activity of thyroid hormones </li></ul></ul><ul><ul><ul><li>Stimulates RNA polymerase </li></ul></ul></ul><ul><ul><ul><ul><li>Transcription and translation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Growth and development </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thermoregulation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Calorigenesis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Carbohydrate, proteins, lipids metabolism </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Oxygen utilization </li></ul></ul></ul></ul></ul>
  5. 5. Thyroid Dysfunction <ul><li>T3 </li></ul><ul><ul><ul><li>Enhances tissue sensitivity to catecholamines </li></ul></ul></ul><ul><ul><ul><ul><li>  -adrenergic receptor activation </li></ul></ul></ul></ul><ul><ul><ul><li>Acts synergistically with epinephrine </li></ul></ul></ul><ul><ul><ul><ul><li> glycogenolysis </li></ul></ul></ul></ul>
  6. 6. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>An estimated 5% of individuals in the U.S. have palpable thyroid nodules </li></ul></ul><ul><ul><ul><li>95% are benign </li></ul></ul></ul><ul><ul><ul><ul><li>85% hyperplastic nodules </li></ul></ul></ul></ul><ul><ul><ul><ul><li>15% adenomas </li></ul></ul></ul></ul><ul><ul><ul><ul><li><1% cysts </li></ul></ul></ul></ul><ul><ul><ul><li>5% are malignant (30,180 cases in 2006) </li></ul></ul></ul><ul><ul><ul><ul><li>81% papillary carcinoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>14% follicular carcinoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3% medullary carcinoma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2% anaplastic forms </li></ul></ul></ul></ul>
  7. 7. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>May be characterized as </li></ul></ul><ul><ul><ul><li>Euthyroid </li></ul></ul></ul><ul><ul><ul><ul><li>Normal levels of thyroid hormones </li></ul></ul></ul></ul><ul><ul><ul><li>Hypothyroid </li></ul></ul></ul><ul><ul><ul><ul><li>Inadequate levels of thyroid hormones </li></ul></ul></ul></ul><ul><ul><ul><li>Hyperthyroid </li></ul></ul></ul><ul><ul><ul><ul><li>Excessive levels of thyroid hormones </li></ul></ul></ul></ul>
  8. 8. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Euthyroidism </li></ul></ul><ul><ul><ul><li>Euthyroid goiter (diffuse, nodular, multinodular) </li></ul></ul></ul><ul><ul><ul><li>Benign tumors </li></ul></ul></ul><ul><ul><ul><li>Malignant tumors </li></ul></ul></ul><ul><ul><ul><ul><li>Differentiated (papillary, follicular) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Undifferentiated (small cell, giant cell) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medullary </li></ul></ul></ul></ul>
  9. 9. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Euthyroidism </li></ul></ul><ul><ul><ul><li>Thyroiditis </li></ul></ul></ul><ul><ul><ul><ul><li>Acute thyroiditis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Subacute (De Quevain’s) thyroiditis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Chronic autoimmune thyroiditis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>(Hashimoto’s disease) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Postpartum thyroiditis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reidel’s thyroiditis </li></ul></ul></ul></ul>
  10. 10. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Congenital </li></ul></ul></ul><ul><ul><ul><ul><li>1:3,000-4,000 births </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Slightly  incidence in the Hispanic population </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>85% is due to sporadic thyroid dysgenesis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>15% due to autosomal recessive mode of inheritance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Recognized cause of mental retardation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Symptoms begin to appear at about the 3rd month of life (cretinism) </li></ul></ul></ul></ul></ul>
  11. 11. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Congenital </li></ul></ul></ul><ul><ul><ul><ul><li>Cretinism </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Puffy face </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Large cranium </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Flat and broad nose </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Macroglossia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thick elevated lips </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Open mouth </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Altered calcification of teeth </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Delayed eruption of teeth </li></ul></ul></ul></ul></ul>
  12. 12. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Primary </li></ul></ul></ul><ul><ul><ul><ul><li>Chronic autoimmune thyroiditis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Iatrogenic (surgery, 131 I-therapy) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diffuse and nodular goiter </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe iodine deficiency </li></ul></ul></ul></ul>
  13. 13. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Secondary </li></ul></ul></ul><ul><ul><ul><ul><li>Pituitary </li></ul></ul></ul></ul>
  14. 14. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Tertiary </li></ul></ul></ul><ul><ul><ul><ul><li>Hypothalamic </li></ul></ul></ul></ul>
  15. 15. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Clear female predominance (5-10:1) </li></ul></ul></ul><ul><ul><ul><ul><li>10 million in U.S. (8 million undiagnosed) </li></ul></ul></ul></ul><ul><ul><ul><li>Myxedema </li></ul></ul></ul><ul><ul><ul><ul><li>Slow speech </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lethargy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mental impairment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased sensitivity to cold </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pitting edema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reduced rate of respiration </li></ul></ul></ul></ul>
  16. 16. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema </li></ul></ul></ul><ul><ul><ul><ul><li>Coarse facial features </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thick lips </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Puffy eyelids </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sad expression </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Dry hair </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dry and cold skin </li></ul></ul></ul></ul>
  17. 17. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema </li></ul></ul></ul><ul><ul><ul><ul><li>Muscle weakness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cardiovascular abnormalities </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Slow pulse rate, coronary artery disease, hypotension, cardiomyopathy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Laboratory abnormalities </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Aspartate transaminase </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Alanine transaminase </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> LDH </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Creatinine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Cholesterol </li></ul></ul></ul></ul></ul>
  18. 18. Thyroid Dysfunction
  19. 19. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema coma </li></ul></ul></ul><ul><ul><ul><ul><li>Precipitating factors </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Exposure to cold </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sedative drug therapy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pulmonary disease </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Congestive heart failure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gastrointestinal bleeding </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Acute thyroid trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Noncompliance with thyroid supplementation </li></ul></ul></ul></ul></ul>
  20. 20. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema coma </li></ul></ul></ul><ul><ul><ul><ul><li>Signs and symptoms </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Progressive alveolar hypoventilation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypothermia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bradycardia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decreased cardiac contractility </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hyponatremia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decreased glomerular filtration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Coma </li></ul></ul></ul></ul></ul>
  21. 21. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema coma </li></ul></ul></ul><ul><ul><ul><ul><li>Treatment </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prompt administration of thyroid hormone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ventilatory support </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fluid restoration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Glucose administration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Glucocorticoid administration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Mortality rates </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>20 to 60% have been reported </li></ul></ul></ul></ul></ul>
  22. 22. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Clear female predominance (5-10:1) </li></ul></ul></ul><ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>4.5 million in the U.S. (600,000 undiagnosed) </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Glandular hyperfunction </li></ul></ul></ul><ul><ul><ul><ul><li>Diffuse hyperthyroid goiter (Grave’s disease) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Multinodular hyperthyroid goiter (Plummer’s disease) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Autonomous nodule </li></ul></ul></ul></ul><ul><ul><ul><li>Thyrotoxicosis </li></ul></ul></ul><ul><ul><ul><ul><li>Exogenous thyroid hormones </li></ul></ul></ul></ul>
  23. 23. Thyroid Dysfunction
  24. 24. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Goiter </li></ul></ul></ul><ul><ul><ul><li>Exophthalmia </li></ul></ul></ul><ul><ul><ul><ul><li>Gritty sensation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Light sensitivity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased tearing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Double vision </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Felling of retroocular pressure </li></ul></ul></ul></ul>
  25. 25. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Facial flushing </li></ul></ul></ul><ul><ul><ul><li>Warm and moist skin </li></ul></ul></ul><ul><ul><ul><li>Enlarger lymph nodes </li></ul></ul></ul><ul><ul><ul><li>Tremor </li></ul></ul></ul><ul><ul><ul><li>Excitability </li></ul></ul></ul><ul><ul><ul><li>Emotional instability </li></ul></ul></ul><ul><ul><ul><li>Increased appetite with weight loss </li></ul></ul></ul><ul><ul><ul><li>Osteoporosis </li></ul></ul></ul><ul><ul><ul><li>Rapid rate of respiration </li></ul></ul></ul>
  26. 26. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Cardiovascular abnormalities </li></ul></ul></ul><ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Atrial fibrillation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Heart murmur </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul></ul><ul><ul><ul><li>Laboratory abnormalities </li></ul></ul></ul><ul><ul><ul><ul><li> Hypercalcemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li> Cholesterol </li></ul></ul></ul></ul><ul><ul><ul><ul><li> Alkaline phosphatase (heat labile-bone) </li></ul></ul></ul></ul>
  27. 27. Thyroid Dysfunction
  28. 28. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Thyroid storm </li></ul></ul></ul><ul><ul><ul><ul><li>Precipitating factors </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Non-thyroid trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Psychosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Parturition </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Myocardial infarction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Intake or radioiodide and high doses of iodine-containing compounds </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Amiodarone therapy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Discontinuation of antithyroid therapy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thyroid overdose </li></ul></ul></ul></ul></ul>
  29. 29. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Thyroid storm </li></ul></ul></ul><ul><ul><ul><ul><li>Signs and symptoms </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fever >101.3 0 F </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CNS dysfunction (agitation, confusion, delirium) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gastrointestinal dysfunction (nausea, vomiting, diarrhea) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diaphoresis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Arial fibrillation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Congestive heart failure </li></ul></ul></ul></ul></ul>
  30. 30. Thyroid Dysfunction <ul><li>Clinical manifestations </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Thyroid storm </li></ul></ul></ul><ul><ul><ul><ul><li>Treatment </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Intensive care </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>B-adrenergic blocking agents </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Propylthiouracil </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>External cooling </li></ul></ul></ul></ul></ul>
  31. 31. Thyroid Dysfunction <ul><li>Diagnosis </li></ul><ul><ul><li>Newborns </li></ul></ul><ul><ul><ul><li>Mandatory TSH testing </li></ul></ul></ul><ul><ul><li>Adults, serum TSH concentrations </li></ul></ul><ul><ul><ul><li>Hypothyroidism </li></ul></ul></ul><ul><ul><ul><ul><li> TSH and  free T4 </li></ul></ul></ul></ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul><ul><ul><ul><ul><li> TSH and  free T4 </li></ul></ul></ul></ul><ul><ul><li>Specialized testing </li></ul></ul><ul><ul><ul><li>Anti-thyroglobulin antibody (TgAb) </li></ul></ul></ul><ul><ul><ul><li>Anti-thyroid peroxidase antibody (TPOAb) </li></ul></ul></ul><ul><ul><ul><li>Anti-thyroid receptor antibody (TRAAb) </li></ul></ul></ul>
  32. 32. Thyroid Dysfunction <ul><li>Principles of medical management </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Purified or synthetic thyroid preparations </li></ul></ul></ul><ul><ul><ul><ul><li>Daily dosages, 0.05 to 0.15 mg, or its equivalent </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inadequate replacement therapy is associated with continued clinical features of hypothyroidism </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Substantial over-treatment results in clinical manifestations of hyperthyroidism </li></ul></ul></ul></ul></ul>
  33. 33. Thyroid Dysfunction When conversion of levothyroxin, T4 to T3, is abnormal T4 and T3 replacement Liotrix (Thyrolar®) When absorption of levothyroxin is inadequate T3 replacement Liothyronine (Cytomel ® , Triostat ® ) Hyper-thyroidism in overdose Drug of choice T4 and T3 replacement Levothyroxin (Levoxyl ® , Levothyroxin ® , Synthroid ® ) ADEs Indication Mechanisms of action Drug
  34. 34. Thyroid Dysfunction <ul><li>Principles of medical management </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Antithyroid drugs </li></ul></ul></ul><ul><ul><ul><ul><li>Primary treatment, therapy is stopped or tapered after 12 to 18 months of therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lifelong follow-up is required as spontaneous hypothyroidism may develop decades later </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>OR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Preparative therapy before surgery or radioiodine therapy </li></ul></ul></ul></ul><ul><ul><ul><li>Iodine or iodide preparations </li></ul></ul></ul><ul><ul><ul><ul><li>Short-term benefits </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decrease vascularity and size of the thyroid gland in preparation to surgery </li></ul></ul></ul></ul></ul>
  35. 35. Thyroid Dysfunction Agranulocytosis Hepatotoxicity Urticaria Arthralgia Sialadenitis (rarely) Long-term thyroxin suppression OR In preparation for surgery or radioiodine therapy Inhibits the transformation of inorganic iodine to organic iodine Methimazole ( Tapazole ® ) ADEs Indication Mechanisms of action Drug
  36. 36. Thyroid Dysfunction Agranulocytosis Hepatotoxicity Urticaria Arthralgia Long-term thyroxin suppression OR In preparation for surgery or radioiodine therapy Inhibits the transformation of inorganic iodine to organic iodine AND Blocks the conversion of T4 to T3 Propyl- thiouracil ADEs Indication Mechanisms of action Drug
  37. 37. Thyroid Dysfunction Allergic reactions Adjunctive therapy to antithyroid drugs OR In preparation for surgery Short-term inhibition of thyroxine release Iodine OR Iodide ADEs Indication Mechanisms of action Drug
  38. 38. Thyroid Dysfunction <ul><li>DENTAL MANAGEMENT CONSIDERATIONS </li></ul>
  39. 39. Thyroid Dysfunction <ul><li>Goals </li></ul><ul><ul><li>Develop and implement timely preventive and therapeutic strategies compatible with the patients’ physical and emotional ability to undergo and respond to dental care </li></ul></ul><ul><li>Medical history </li></ul><ul><ul><li>Review of organ systems </li></ul></ul><ul><ul><li>Drug History </li></ul></ul>
  40. 40. Thyroid Dysfunction <ul><li>Functional capacity </li></ul><ul><ul><li>T3 exerts direct inotropic and chronotropic effects on cardiac muscle </li></ul></ul><ul><ul><li>T3 is synergistic with epinephrine </li></ul></ul><ul><ul><li>Metabolic equivalents (METs) </li></ul></ul><ul><ul><ul><li>Ability of the CV system to meet metabolic demand for oxygen </li></ul></ul></ul><ul><ul><ul><ul><li>Poor functional capacity </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>< 4 METs </li></ul></ul></ul></ul></ul>
  41. 41. Thyroid Dysfunction <ul><li>Vital signs </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>< 180/110 mm Hg </li></ul></ul></ul><ul><ul><ul><ul><li>Not an independent risk factor for cardiovascular risk in association with non-cardiac procedures </li></ul></ul></ul></ul><ul><ul><ul><li>> 180/110 mm Hg constitutes a medical emergency </li></ul></ul></ul><ul><ul><ul><li>< 90/50 mm Hg reliable sign of shock </li></ul></ul></ul><ul><ul><li>Pulse pressure, rate, and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor to either rule out or confirm significant CVD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate </li></ul></ul></ul><ul><ul><ul><ul><li><50 or >100 beats/min constitutes a medical emergency </li></ul></ul></ul></ul>
  42. 42. Thyroid Dysfunction <ul><li>Treatment strategies </li></ul><ul><ul><li>The physiological events associated with the thyroid dysfunction and the “stress” of a procedure can affect cardiac function (myocardial ischemia) </li></ul></ul><ul><ul><ul><li>Procedure-specific variables </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid shifts or </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duration of the procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physiological stress </li></ul></ul></ul></ul><ul><ul><ul><li>Dental procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Very low risk </li></ul></ul></ul></ul><ul><li>* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46 </li></ul><ul><li>*Arch Intern Med </li></ul><ul><li>2001;161:1509-1512 </li></ul><ul><li>*JADA 2001;132:1570-1579 </li></ul>
  43. 43. Thyroid Dysfunction <ul><ul><li>The hypothyroid patient </li></ul></ul><ul><ul><ul><li>There is no evidence to justify deferring needed surgery in patients with mild to moderate hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>*Am J Med 1983;14:893-897 </li></ul></ul></ul><ul><ul><ul><li>* Am J Med 1984:77:261-266 </li></ul></ul></ul><ul><ul><li>The hyperthyroid patient </li></ul></ul><ul><ul><ul><li>The effects of undiagnosed or undertreated hyperthyroidism on the heart carries perioperative risks </li></ul></ul></ul><ul><ul><ul><ul><li>Increased cardiac output may limit cardiac reserve during surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>*N Engl J Med 2001;344:501-509 </li></ul></ul></ul></ul>
  44. 44. Thyroid Dysfunction <ul><ul><li>The use of local anesthetic agents with epinephrine </li></ul></ul><ul><ul><ul><li>The hypothyroid patient </li></ul></ul></ul><ul><ul><ul><ul><li>No evidence of adverse effects associated with epinephrine infusion in patients with hypothyroidism </li></ul></ul></ul></ul><ul><ul><ul><li>*Clin Endocrinol 1995;43:747-751 </li></ul></ul></ul><ul><ul><ul><li>The hyperthyroid patient </li></ul></ul></ul><ul><ul><ul><ul><li>Thyroid hormones act synergistically with epinephrine </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Use epinephrine with caution </li></ul></ul></ul></ul></ul>
  45. 45. Thyroid Dysfunction <ul><ul><li>The use of analgesics and anxiolytic agents </li></ul></ul><ul><ul><ul><li>The hypothyroid patient </li></ul></ul></ul><ul><ul><ul><ul><li>Hyper-reactive to CNS depressants </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Use judiciously </li></ul></ul></ul></ul></ul><ul><ul><ul><li>The hyperthyroid patient </li></ul></ul></ul><ul><ul><ul><ul><li>ASA displaces thyroid hormones from their protein binding sites </li></ul></ul></ul></ul>
  46. 46. Thyroid Dysfunction Routine referral for medical management and risk factor modification Comprehensive care Blood pressure < 180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity > 4 METs Euthyroid OR Mild to moderate thyroid dysfunction AND/OR Minor or intermediate predictors of CV risk Consultation or referral Treatment options Physical examination Predictors of risk
  47. 47. Thyroid Dysfunction Routine medical referral Limited care Blood pressure < 180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity < 4 METs Euthyroid OR Mild to moderate thyroid dysfunction AND/OR No major predictors of CV risk Consultation or referral Treatment options Physical examination Predictors of risk
  48. 48. Thyroid Dysfunction <ul><li>If patient is asymptomatic </li></ul><ul><ul><li>Routine medical referral </li></ul></ul><ul><li>If patient is symptomatic </li></ul><ul><ul><li>Immediate medical referral </li></ul></ul>Emergency care BP > 180/110 mm Hg OR Systolic BP < 90 mm Hg AND/OR Abnormal pulse pressure, rate, and rhythm Euthyroid OR Mild to moderate thyroid dysfunction AND/OR No major predictors of CV risk Consultation or referral Treatment options Physical examination Predictors of risk
  49. 49. Thyroid Dysfunction Immediate medical referral Emergency care Establish baseline vital signs Severe hypo-thyroidism OR Thyrotoxicosis AND/OR Major predictors of CV risk Consultation or referral Treatment options Physical examination Predictors of risk
  50. 50. Thyroid Dysfunction <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conventional vs. electromechanical toothbrushes </li></ul></ul></ul><ul><ul><li>Antibacterial mouthwashes </li></ul></ul><ul><ul><li>Topical fluorides </li></ul></ul><ul><ul><li>Sialagogues </li></ul></ul><ul><ul><ul><li>Pilocarpine (Salagen) </li></ul></ul></ul><ul><ul><ul><li>Cevimeline (Evoxac) </li></ul></ul></ul>
  51. 51. Thyroid Dysfunction <ul><li>Potential medical emergencies </li></ul><ul><ul><li>The likelihood of myxedema coma or a thyroid crisis in the oral health care setting is extremely remote </li></ul></ul><ul><ul><ul><li>Other medical emergencies may be anticipated based on the patient’s medical history and vital signs </li></ul></ul></ul>
  52. 52. Risk stratification of patients with TD <ul><li>Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction. Quintessence Int 2008;39:139-150. </li></ul><ul><li>Pickett FA, Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2 nd ed. Baltimore: Wolters Kluwer Health / Lippincott Williams & Wilkins, 2009. </li></ul>
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