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University of Minnesota - School of Dentistry Thyroid Disease ______________________________________________ • Case – Katalina Korapova • Thyroid disease – Hyperthyroidism – Hypothyroidism • ASA PS level – Dental management • Algorithm • Thyroid disease – Thyroiditis – Thyroid Cancer 1 University of Minnesota - School of Dentistry Katalina Korapova ______________________________________________ • • • • • 60 yr old Caucasian Female WNWD Presents to clinic for routine exam 2 University of Minnesota - School of Dentistry Initial observations ______________________________________________ • Previous thyroid problems • History of surgery • Scar on median of neck • Thinning hair • Dry skin • Bulging eyes • Taking Levothyroxine 3 University of Minnesota - School of Dentistry 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? 4 University of Minnesota - School of Dentistry 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? 5 - School of Dentistry • 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 Hypothyroid Questions ______________________________________________ 6 University of Minnesota - School of Dentistry 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? 7 University of Minnesota - School of Dentistry Lab tests needed ______________________________________________ • Measure – – – – T4 T3 TSH TBG Normal 5 - 12 mg/dl 80 – 190 mg/d 0.5 – 4.5 mμ/L HypoDecrease Decrease Increase Decrease HyperIncrease Increase - / decrease Increase • Radioactive Iodine Uptake Test: Direct Thyroid Test – Normal RAIU = 10% – 30% (Better Indicates Hyperthyroidism) • Measurement of Autoantibodies 8 University of Minnesota 9 - School of Dentistry University of Minnesota - School of Dentistry What is going on? ______________________________________________ • Exophthalmos - sign of hyperthyroid – • Scar on neck - previous surgery – • Ms. Korpova likely had hyperthyroids problems She underwent surgery to have the mass removed Dry skin, thin hair, prescribed Levothyroxine - signs of Hypothyroid – Resulting in hypothyroidism 10 Etiology ______________________________________________ University of Minnesota - School of Dentistry Hyperthyroidism • • • • • • • • Ectopic thyroid tissue Grave’s disease Multinodular goiter Thyroid adenoma Subacute thyroiditis Ingestion of thyroid hormone Pituitary disease (anterior gland) Ingestion of food-containing thyroid hormone 11 Hyperthyroidism - Signs and Symptoms University of Minnesota - School of Dentistry ______________________________________________ • 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 12 Oral manifestations ______________________________________________ University of Minnesota - School of Dentistry Hyperthyroidism - • 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 13 Laboratory Findings ______________________________________________ University of Minnesota - School of Dentistry Hyperthyroidism - • Low TSH combined with high T4 • Low TSH, low T4 and high T3 14 University of Minnesota - School of Dentistry Hypothyroidism ______________________________________________ • Types – Primary atrophic – Secondary – Transient – Generalized resistant to thyroid hormone 15 University of Minnesota - School of Dentistry Hypothyroidism ______________________________________________ • Primary Hypothyroidism - 95% – – – – – – – – – – – – – Insufficient amount of thyroid tissue Hashimoto’s 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 16 University of Minnesota - School of Dentistry 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 17 University of Minnesota 18 - School of Dentistry Hypothyroidism – Signs and Symptoms - School of Dentistry • General University of Minnesota ______________________________________________ • Myxedema – 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 – 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 19 University of Minnesota - School of Dentistry Hypothyroidism ______________________________________________ • Treatment – Treated with synthetic drugs: sodium levothyroxine (Synthroid, LT4) or sodium liothyronine (Leotrix, LT3) • Oral complications – Adults with acquired hypothyroidism—enlarged tongue – Infants with cretinism—thick lips, enlarged tongue, delayed eruption of teeth, and resulting malocclusion 20 University of Minnesota - School of Dentistry 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 21 University of Minnesota - School of Dentistry 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 22 University of Minnesota - School of Dentistry 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 23 Patient Management - Hypothyroidism University of Minnesota - School of Dentistry ______________________________________________ • In general, well controlled hypothyroidism (even when untreated) does not interfere with dental therapy – – • May show exaggerated response to CNS depressants such as narcotic analgesics, sedatives, CNS depressants – • • • Avoid oral infections Implement normal procedures and management 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 24 University of Minnesota - School of Dentistry Dental Algorithm A ______________________________________________ • Antibiotics – No premedication, but treat infections rapidly in order to prevent thyroid storm or myxedema coma 25 University of Minnesota - School of Dentistry Dental Algorithm A ______________________________________________ • Anesthetics – Avoid Epinephrine in those with uncontrolled hyperthyroidism • Epinephrine can be administered when patient controlled 26 University of Minnesota - School of Dentistry Dental Algorithm A ______________________________________________ • Anxiety – Avoid stressful appointments as they can lead to thyroid storm 27 University of Minnesota - School of Dentistry 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 28 University of Minnesota - School of Dentistry Dental Algorithm D ______________________________________________ • Drug Interactions – Untreated hypothyroid patients may be highly sensitive to actions of narcotics, barbituates, and tranquilizers 29 - School of Dentistry Dental Algorithm E ______________________________________________ • Emergency Treatment – Be aware of signs of thyroid storm • • • • Fever Abdominal Pain Delirious Psychotic University of Minnesota – 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 30 - School of Dentistry Dental Algorithm E ______________________________________________ • Emergency Treatment – Know the signs of hypothyroid coma • • • • Hypothermia Bradycardia Hypotension Epilpetic seizures University of Minnesota – 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. 31 Thyroiditis - Types (inflammation of the thyroid gland) University of Minnesota - School of Dentistry ______________________________________________ • • • • • • • Hashimoto’s Subacute painful Subacute painless Acute suppurative Riedel’s Radiation therapy Drugs – Lithium, interlukin-2, interferons, amiodarone 32 University of Minnesota - School of Dentistry Thyroiditis Pathophysiology ______________________________________________ • Hashimoto’s – 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 • Riedel’s – fibrous infiltration of the thyroid gland of unknown origin 33 - School of Dentistry • Hashimoto’s University of Minnesota Thyroiditis Signs and Symptoms ______________________________________________ • Acute suppurative – 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 severe neck pain, fever, focal thyroid tenderness and erythema of overlying skin • Riedel’s – 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 34 University of Minnesota - School of Dentistry Thyroiditis Oral manifestations ______________________________________________ • Pain associated with subacute painful thyroiditis may radiate to the ear, jaw or occipital region • Hoarseness and dysphagia 35 Types ______________________________________________ University of Minnesota - School of Dentistry Thyroid Cancer - • Differentiated – – – – Papillary Follicular Mixed Hurthle cell carcinoma • Medullary – MEN type 2 • Anaplastic 36 Etiology ______________________________________________ University of Minnesota - School of Dentistry Thyroid Cancer - • 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 37 Signs and Symptoms ______________________________________________ University of Minnesota - School of Dentistry Thyroid Cancer • • • • • • • • • • 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 38