Thyroid dysfunction and its management in dental office

CONTENTS:
 INTRODUCTION
 PATHOPHYSIOLOGY
 PREDISPOSING FACTORS
 CLINICAL MANIFESTATION
 PREVENTION
 MANAGEMENT
 CONCLUSION
2
THYROID DYSFUNCTION: CONTENTS

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

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

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

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

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

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

HYPOTHYROIDISM
 Thyroid failure usually occurs as a result of disease of
 Thyroid gland (primary hyperthyroidism)
 Pituitary gland (secondary)
 Hypothalamus (tertiary)
 Causes
Primary
9
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

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

CLINICAL MANIFESTATION:
11
THYROID DYSFUNCTION: CLINICAL MANIFESTATION
HYPERTHYROIDISM

12
HYPERTHYROIDISM

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

14
HYPOTHYROIDISM

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

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

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

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

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
MEDICATIONS USED TO MANAGE HYPOTHYROIDISM & HYPERTHYROIDISM

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

PREVENTION:
PHYSICAL EXAMINATION
Sometimes thyrotoxicosis may confused with acute anxiety
Thyrotoxicosis acute anxiety
- Has warm, sweaty hands - palms cold and clammy
21
Hypothyroidism Hyperthyroidism
no sweat
BP close to normal (diastolic ↑
slightly)
Slow heart rate
Sweaty hands
BP elevated ( systolic >diastolic)
Heart rate markedly ↑

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

PREVENTION:
PHYSICAL STATUS CLASSIFICATION OF THYROID GLANDDYSFUNCTION
23
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)

PREVENTION:
• 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

PREVENTION:
• 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

PREVENTION:
• 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

PREVENTION:
• 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

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

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

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

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

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

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

Thyroid dysfunction and its management in dental office

Thyroid dysfunction and its management in dental office

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