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RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ... RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ... Presentation Transcript

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