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Thyroid dysfunction and its management in dental office

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  • 1. CONTENTS:  INTRODUCTION  PATHOPHYSIOLOGY  PREDISPOSING FACTORS  CLINICAL MANIFESTATION  PREVENTION  MANAGEMENT  CONCLUSION 2 THYROID DYSFUNCTION: CONTENTS
  • 2. INTRODUCTION:  Thyroid gland is composed of two elongated lobes on either side of the trachea that are joined by a thin isthmus of thyroid tissue located at or below the level of the thyroid cartilage  Secretes- ― THYROXIN (T₄) ― TRI-IODOTHYRONINE (T₃) ― CALCITONIN 3 THYROID DYSFUNCTION: INTRODUCTION
  • 3. INTRODUCTION: • THYROID HORMONE HAS * Effect on growth * Effect on carbohydrate metabolism * Effect on fat metabolism * Effect on vitamin metabolism * Effect on basal metabolic rate * Effect on cardiovascular system * Effect on the function of the muscle 4 THYROID DYSFUNCTION: INTRODUCTION
  • 4. PATHOPHYSIOLOGY: • Thyroid dysfunction may result due to hypo/hyper-function of thyroid gland • Thyroid dysfunction is the second most common glandular disorder of the endocrine system and is increasing, predominantly among women 1. THYROTOXICOSIS / HYPERTHYROIDISM  May be due to  Autoimmunity TSI (immunoglobulin antibody) induce continual activation of cAMP system of the cells, with resultant development of hyperthyroidism  Adenoma localized adenoma in the thyroid tissue & secretes large quantities of thyroid hormone 5 THYROID DYSFUNCTION: PATHOPHYSIOLOGY
  • 5. PATHOPHYSIOLOGY: 2. HYPOTHYROIDISM  Autoimmune  Thyroiditis precedes the autoimmune destruction of the thyroid gland  This cause progressive deterioration and finally fibrosis of the gland, with resultant diminished or absent secretion of thyroid hormone 6 THYROID DYSFUNCTION: PATHOPHYSIOLOGY
  • 6. PREDISPOSING FACTORS: HYPERTHYROIDISM  Most often occur between 20 and 40 years of age, 8:1 ratio over males.  Causes 7 THYROID DYSFUNCTION: PREDISPOSING FACTORS  Toxic diffuse goiter (Grave’s disease)  Toxic multi-nodular goiter  Toxic uni-locular goiter  Factitious Thyrotoxicosis  T₃ Thyrotoxicosis  Thyrotoxicosis associated with Thyroiditis  Hashimoto’s Thyroiditis  Sub-acute Thyroiditis  Jod-Basedow phenomenon  Metastatic follicular carcinoma  Malignancies with circulating thyroid stimulators  TSH producing pituitary tumor  Hypothalamic hyperthyroidism
  • 7. PREDISPOSING FACTORS: HYPERTHYROIDISM  Untreated hyperthyroidism may leads to  Thyroid storm A sudden and severe exacerbation of the signs and symptoms of thyrotoxicosis usually accompanied by hyperpyrexia and precipitated by some form of stress, inter-current disease, infection, trauma, thyroid surgery or radioactive iodine administration  Thyroid crisis Extreme restlessness, nausea, vomiting, abdominal pain, fever, profuse sweating, tachycardia, cardiac arrhythmias, pulmonary edema, congestive heart failure leading to coma 8 THYROID DYSFUNCTION: PREDISPOSING FACTORS
  • 8. PREDISPOSING FACTORS: HYPOTHYROIDISM  Thyroid failure usually occurs as a result of disease of  Thyroid gland (primary hyperthyroidism)  Pituitary gland (secondary)  Hypothalamus (tertiary)  Causes Primary 9 THYROID DYSFUNCTION: PREDISPOSING FACTORS Autoimmune hypothyroidism Idiopathic causes Postsurgical thyroidectomy External radiation therapy Radioiodine therapy Inherited enzymatic defect Iodine deficiency Antithyroid drugs ( thiocyanate, propylthiouracil, high conc. of inorganic iodide Lithium, phenylbutazone
  • 9. PREDISPOSING FACTORS: HYPOTHYROIDISM  Causes Secondary  Pituitary tumor  Infiltrative disease (sarcoid) of pituitary  Hypothyroid patient’s are unusually sensitive to  Sedatives  Opiods (mepiridine, codeine, etc.)  Anti-anxiety drugs As it can result in extreme overreaction 10 THYROID DYSFUNCTION: PREDISPOSING FACTORS
  • 10. CLINICAL MANIFESTATION: 11 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPERTHYROIDISM
  • 11. CLINICAL MANIFESTATION: 12 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPERTHYROIDISM
  • 12. 13 SYMPTOMS Common Weight loss <20 lb 72-100% 20-40 lb upto 14% >40 lb 27-36% Palpitation Nervousness Tremor Less common Chest pain Dyspnea Edema Disorientation Diarrhea/hyper-defecation Abdominal pain SIGNS Fever <103⁰F 57-70% >103⁰F 30-43% ‐tachycardia 100-139 beats/min 24% 140-169 beats/min 62% 170-200 beats/min 14% Sinus tachycardia Dysrhythmia Wide pulse pressure Tremor Thyrotoxic state & eyelid retraction Hyperkinesis Heart failure Weakness Coma Tender liver Infiltrated ophthalmopathy Somnolence or obtundence Psychosis jaundice
  • 13. CLINICAL MANIFESTATION: 14 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPOTHYROIDISM
  • 14. 15 SYMPTOMS Paresthesia 92% Loss of energy 79% Intolerance to cold 51% Muscular weakness 34% Pain in muscle and joints 31% Inability to concentrate Drowsiness Constipation Forgetfulness Depressed auditory acuity Emotional instability 31% 30% 27% 23% 15% 15% Headaches dysarthria 14% 14% SIGNS % “pseudomyotic” reflexes Change in menstrual pattern Hypothermia Dry, scaly skin Puffy eyelids Hoarse voice Weight gain Dependent edema Sparse axillary & pubic hair Pallor Thinning eyebrows Yellow skin Loss of scalp hair Abdominal distention Goiter Decreased sweating 95 86 80 79 70 56 41 30 30 24 24 23 18 18 16 10
  • 15. PREVENTION: Two goals are essential in the management of patients with thyroid dysfunction 1. Prevention of the occurrence of the life-threatening situations myedema coma and thyroid storm 2. Prevention of the exacerbation of complications associated with thyroid dysfunction, notably cardiovascular disease Prevention is through • Medical history questionnaire • Dialogue history • Physical examination 16 THYROID DYSFUNCTION: PREVENTION
  • 16. PREVENTION: MEDICAL HISTORY QUESTIONNAIRE (university of the pacific school of dentistry medical history) • Section III – Q49. Do you have or have you had thyroid, adrenal disease? • Section I: – Q1. Is your general health good? – Q2. Has there been a change in your health within the last year? – Q3. Have you been hospitalized or had a serious illness in the last 3 years? If yes, why? – Q4. Yes/No: Are you being treated by a physician now? For what? Date of last medical exam? 17 THYROID DYSFUNCTION: PREVENTION
  • 17. PREVENTION: • Section II – Q10. Have you experienced weight loss, fever, night sweats? • Section IV – Q52. Have you experienced radiation treatments? – Q58. Have you experienced surgeries? • Section V – Q62. are you taking drugs, medications, over-the-counter medicines (including aspirin), natural remedies? 18 THYROID DYSFUNCTION: PREVENTION
  • 18. HYPOTHYROIDISM THYROTOXICOSIS Generic Proprietary Generic Proprietary Thyroid USP (desiccated) Armour Thyroid, Thyroid strong, Westhroid Propylthiouracil Propyl-Thyracil Levothyroxine (T₄) Leo-T, Levoxine, Synthroid, Eltroxin Methimazole Tapazole Liothyronine (T₃) Cytomel Carbimazole Liotrix Euthyroid, Thyrolar Propranolol Inderal PREVENTION: 19 THYROID DYSFUNCTION: PREVENTION MEDICATIONS USED TO MANAGE HYPOTHYROIDISM & HYPERTHYROIDISM
  • 19. PREVENTION: DIALOGUE HISTORY An in-depth dialogue history is indicated when the medical history questionnaire indicates a positive history of thyroid disease.  Q. What is the nature of the thyroid dysfunction– hypo/hyperfunction?  Q. How do you manage the disorder?  Q. Have you unexpectedly gained or lost weight recently?  Q. Are you unusually sensitive to cold temperatures or pain-relieving medications?  Q. Are you unusually sensitive to heat?  Q. Have you become increasingly irritable or tense? 20 THYROID DYSFUNCTION: PREVENTION
  • 20. PREVENTION: PHYSICAL EXAMINATION Sometimes thyrotoxicosis may confused with acute anxiety Thyrotoxicosis acute anxiety - Has warm, sweaty hands - palms cold and clammy 21 THYROID DYSFUNCTION: PREVENTION Hypothyroidism Hyperthyroidism no sweat BP close to normal (diastolic ↑ slightly) Slow heart rate Sweaty hands BP elevated ( systolic >diastolic) Heart rate markedly ↑
  • 21. PREVENTION: DENTAL CONSIDERATION • EUTHYROID – Those who are receiving therapy to treat the condition, have normal levels of thyroid hormone and have no symptoms, represent euthyroid – They represent ASA II (next slide) risks and may be managed normally during dental treatment – If mild manifestations of either hypo/hyper are present • Elective dental treatment may proceed although certain treatment modifications should be considered • They represent ASA III risk 22 THYROID DYSFUNCTION: PREVENTION
  • 22. PREVENTION: PHYSICAL STATUS CLASSIFICATION OF THYROID GLANDDYSFUNCTION 23 THYROID DYSFUNCTION: PREVENTION DEGREE OF THYROID DYSFUNCTION ASA PHYSICAL STATUS COSIDERATIONS Hypo/hyper-functioning Pt. receiving medical therapy; no signs or symptoms of dysfunction evident II Usual ASA II considerations Hypo/hyper-function; signs & symptoms of dysfunction evident III Usual ASA III considerations, including avoidance of vasopressors(hyper) or CNS depressants (hypo)
  • 23. PREVENTION: DENTAL CONSIDERATION • HYPOTHYROID – Medical consultation considered prior to start of any dental procedure – Caution must be exercised when prescribing CNS depressant • Sedative-hypnotics (barbiturates) • Opiod analgesic & • Other anti-anxiety drugs – Administration of a “normal” dose may produce an overdose, leading to respiratory or cardiovascular depression or both – Dental treatment should be postponed until consultation or definitive management of the clinical manifestation is achieved 24 THYROID DYSFUNCTION: PREVENTION
  • 24. PREVENTION: DENTAL CONSIDERATION • HYPERTHYROID – Mild degree of hyper-function may show • Acute anxiety, with little ↑ in clinical risk • However, various cardiovascular disorders, 1⁰ly angina pectoris, are exaggerated during dental procedure , the management protocol for that specific situations should be followed – Severe hyper-function should receiving immediate medical consultation • Dental procedure should be postponed – Atropine should be avoided • Causes an ↑ in heart rate & may be a factor in precipitating thyroid storm 25 THYROID DYSFUNCTION: PREVENTION
  • 25. PREVENTION: DENTAL CONSIDERATION • HYPERTHYROID – Epinephrine & other vasopressors should be used with caution – Vasopressors stimulate the cardiovascular system & can precipitate cardiac dysrhythmias, tachycardia, & thyroid storm in hyperthyroid patients whose cardiovascular system have already been sebsitized 26 THYROID DYSFUNCTION: PREVENTION
  • 26. PREVENTION: DENTAL CONSIDERATION • HYPERTHYROID – However, LA with vasoconstrictors may be used when the following precautions are taken: • Used the least-concentrated effective solution of epinephrine (1:200,000 is preferred to 1:100,000 which is preferred to 1:50,000) • Injecting the smallest effective volume of anesthetics/vasopressors • Aspiration prior to any injection 27 THYROID DYSFUNCTION: PREVENTION
  • 27. MANAGEMENT: HYPOTHYROID Step 1: termination of the dental procedure. Step 2: position supine position with legs elevated slightly Step 3: A-B-C, basic life support, as needed myxedema coma must be considered, management includes establishment of a patent airway (head-tilt-chin-lift), assessment of breathing, administration of O₂, & assessment of adequacy of circulation 28 THYROID DYSFUNCTION: MANAGEMENT
  • 28. MANAGEMENT: HYPOTHYROID Step 4: Definitive care Step 4a: summoning of medical assistance Step 4b: establishment of an IV line if available, an IV line of 5% dextrose & water or normal saline may be started before the arreval of medical personnel Step 4c: administration of O₂ Step 4d: definitive management includes the transport of the individual to a hospital emergency department, administration of massive dose of IV doses of thyroid hormones 29 THYROID DYSFUNCTION: MANAGEMENT
  • 29. MANAGEMENT: HYPERTHYROID Step 1: termination of the dental procedure. Step 2: position supine position with legs elevated slightly Step 3: A-B-C, basic life support, as needed thyroid storm must be considered, management includes establishment of a patent airway (head-tilt-chin-lift), assessment of breathing, administration of O₂, & assessment of adequacy of circulation 30 THYROID DYSFUNCTION: MANAGEMENT
  • 30. MANAGEMENT: HYPERTHYROID Step 4: Definitive care Step 4a: summoning of medical assistance Step 4b: establishment of an IV line if available, an IV line of 5% dextrose & water or normal saline may be started before the arreval of medical personnel Step 4c: administration of O₂ 31 THYROID DYSFUNCTION: MANAGEMENT
  • 31. MANAGEMENT: HYPERTHYROID Step 4d: definitive management • includes the transport of the individual to a hospital emergency department, administration of large dose of anti-thyroid drugs (e.g. propylthiouracil) • Additional includes administration of propranolol to block the adrenergic- mediated effects of thyroid hormone • Large doses of glucocorticoids to prevent acute adrenal insufficiency • Other measures – O₂ – Cold packs – Sedation careful monitoring of hydration & electrolyte balance 32 THYROID DYSFUNCTION: MANAGEMENT
  • 32. CONCLUSION : CONCLUSION A patient with either hyperthyroidism or hypothyroidism may enter the Dental clinic for any dental procedure which required your attention. For implementation of any dental procedure to this patient required a good knowledge regarding their signs and symptoms as a pre-procedure diagnosis can made. 33 THYROID DYSFUNCTION: CONCLUSION

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