Transcript Thyroid storm

THYROID GLAND
DISEASE
ANATOMY
It is composed of 2 lobes linked by isthmus lying over the second,
third and fourth tracheal rings. WT is about 20 to 25 gm.
PHYSIOLOGY
The T.G secretes 3 hormones:

Thyroxin T4

Tri-iodothyronine T3

Calcitonin (regulates Ca and ph. Levels)
An adequate supply of iodine is required
for the synthesis of these hormones (100
microgram). The most common source is
table salt and fish.
The functions of thyroid H are
1- Growth and development
2- Carbohydrate, protein and fat metabolism
3- Vitamin metabolism
4- Basal metabolic rate
5- Effect on the cardiovascular system
6- Increase oxygen consumption by the tissue
7- Increase oxygen release from Hb
8- Effect on muscle function
9- Increase oxidative phosphorylation
10- Induce hyperglycemia.
11- Augmentation of adrenalin and noradrenalin
function
REGULATION OF SECRETION IS THROUGH THE
HYPOTHALAMIC-PITUITARY- THYROID AXIS.
•Metabolic
demands
•Drugs
• Infection
• Surgery
•Trauma
•Low temperature
•Pit. disorders
•Age
•stress
•Sleep
HYPOTHALAMUS
Thyrotropin releasing hormone (TRH)
PITUITARY
Thyroid stimulating hormone (TSH)
THYROID
GLAND
Secretes T4 (main hormone) and T3.
-VE FEEDBACK
MECHANISM
THYROID FUNCTION TESTS
A- Hormone measurement
1- Total T3 1.2 to 2.8 nmol\L
2- Total T4 150 nmol\L
3- TSH
0.5 to 5 mU\L
B- Measurement of thyroid-pituitary-hypothalamic axis
C-Thyroid scanning: use of RAI131 then the gland is
scanned to see its uptake.
D- Biopsy
E-Imaging study
1-Ultrasound
2-MRI
3- CT scan.
THYROID DYSFUNCTION
Due to either hypo- or hyper function of
gland
 They are the second most common
endocrine disorder – mostly in woman

THYROID GLAND DISEASES





Congenital (Agenesis ,Ectopic)
Hypofunction (hypothyroidism)
Hyperfunction (thyrotoxicosis)
Thyroiditis.
Thyroid gland neoplasm.
ANY ENLARGEMENT OF THE T.G IS
TERMED GOITRE.
The enlargement may be diffuse,
nodular, singular, functional or nonfunctional.
TERMS
 Hyperthyroidism
 Hypothyroidism
 Euthyroid
(normal levels)
HYPOTHYROIDISM
Failure of thyroid gland to produce adequate level
of H.
It is either
1- Congenital
2-Acquired ( primary or secondary)
In adults called myxedema
In children called cretinism
Hypothyroidism
A- Idiopathic (spontaneous)
B- Autoimmune
C- Thyroiditis
C- Surgery (partial, sub-total or total )
D- Radioactive iodine
E- Drugs (thiocyanate, propyl-thiouracil -PTU, lithium,
phenylbutazone.
F- Post- thyroiditis (Hashimotos)
G- Iodine deficiency
H- Secondary to pituitary gland failure.
Treatment is replacement therapy (Levothyroxine)
HYPERTHYROIDISM - THYROTOXICOSIS
The commonest causes are
 Primary hyperthyroidism –toxic diffuse goiter - (Graves disease)
 Toxic nodular goiter
 Toxic solitary nodule
 Hashimotos thyroiditis
 Jud-basedow syndrome (excessive iodine intake)
 Factitious Thyrotoxicosis (excessive thyroxin intake)
 Ectopic thyroid H secretion (teratoma)
 Thyroid carcinoma
 Malignancies with thyroid stimulators
 Pitutary adenoma stimulating TSH (Thyroid - stimulating hormone)
THYROTOXICOSIS
IMPORTANT NOTE
1- Thyrotoxicosis may be confused with
acute anxiety
2- In thyrotoxicosis, hands are sweaty and
warm
3- In acute anxiety, palms are cold and
clammy
TREATMENT OF THYROTOXICOSIS
1-Anti-thyroid drugs
Inhibit synthesis of thyroxin by
interference with trapping, oxidation and
coupling of iodide.
 Most commonly used drugs are
carbimazole and propylthiouracil (PTU)

2- Radioactive iodine:
I131 is commonest isotope used and the
aim is to destroy the thyroid tissue.
3- Surgery :
The aim is to remove the thyroid tissue by
Subtotal thyroidectomy (Preserves about 4g
(10%) of thyroid tissue). Patients must be
euthyroid prior to operation
DENTAL MANAGEMENT OF THYROTOXIC
PATIENT
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Detection of undiagnosed disease
Symptoms
Signs
Referral
Patient with diagnosed disease
Determine original disease
Past therapy
Current medication
Assessment of clinical status
Referral if necessary
TWO GOALS IN MANAGEMENT
Prevent the occurrence of life threatening
situations ( Myxedema coma or thyroid
storm)
 Prevent the exacerbation of complications
associated with them as cardiovascular
diseases

DENTAL MANAGEMENT OF THYROTOXIC
PATIENT
Avoidance of the following in untreated or
poorly treated patients:
 Surgical procedures
 Acute infection
 Epinephrine in local anesthetic solutions and
gingival retraction cords
Patient under good medical treatment:

Supine position
Patient on PTU should be given stress management
medications as diazepam, lorazepam
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For local anesthesia, use mepivicaine only
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If patient is off the anti-thyroid drug, THEN you can use
lidocaine,prilocaine , bupivicaine (max= 2 carpules)
Epinephrine concentration as low as possible (1:200.000)
over (1:100.000) over (1:50.000)
In block injections, aspiration before injection
Implement normal procedures and management
Avoid atropine since it may lead to increase in heart rate
and precipitate a thyroid storm
Patient under good medical treatment

Avoid acute infection

Treat all chronic infections

Patient on PTU causes agranulocytosis,
thrombocytopenia and has an anti-vitamin k
activity

Always check the complete blood picture
(CBC), platelet count , prothrombin time and NR
(normalized ratio)
Thyroid storm
Life-threatening exacerbation of
thyrotoxicosis. Has a mortality of 50%.
Precipitating factors
Thyroid surgery, Radioiodine ,Withdrawal of
antithyroid drugs, Acute illness (e.g.
stroke, infection, trauma)
Clinical features
Severe thyrotoxicosis, fever, delirium
,seizure or coma, tachycardia, congestive
heart disease, profuse sweating, .
Treatment
ABC (BASIC LIFE SUPPORT)

Patency of airway (Head tilt-chin lift)

Assessment of breathing

Administration of O2 ( 100% - FLOW RATE 10L/ MIN)
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Assessment of adequacy of circulation

If available , establish an IV LINE for 5% dextrose and water or
normal saline
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Wet or ice packs
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Medical assistance at once

High antithyroid drugs, beta- blockers, 200-300mg hydrocortisone
to prevent adrenal insufficiency

Sedation, hydration and electrolyte balance
DENTAL MANAGEMENT OF HYPOTHYROID
PATIENT










Detection of undiagnosed disease
Symptoms
Signs
Referral
Patient with diagnosed disease
Determine original diagnosis
Past therapy
Current medication
Assessment of clinical status
Referral if necessary
DENTAL MANAGEMENT OF HYPOTHYROID
PATIENT
Avoidance of the following in untreated or
poorly treated patients
 Surgical procedures
 Acute infection
 CNS depressants (opioid analgesics, sedative
hypnotics as barbiturates and other anianxiety
drugs
 Administration of such drugs may become an
overdose---- respiratory / or cardiovascular
depression
DENTAL MANAGEMENT OF HYPOTHYROID
PATIENT
Patient under good medical
treatment:


Avoid acute infection
Implement normal procedures and
management
Myxedematous crisis:
An exacerbation of hypothyroid signs
and symptoms
 Usually in old people
 Seek medical aid
 Basic life support measures (BLS)
 Oxygen – 100%- flow rate 10L/Min)
 I.V or i.m Hydrocortisone (100-300mg)

ORAL COMPLICATIONS
Thyrotoxicosis
Osteoporosis of alveolar
bone
Dental caries and PDD
Teeth and jaw develop
rapidly
Hypothyroidism
Infants with hypothyroidism
may demonstrate thick lips,
enlarged tongue, delayed
eruption of teeth, malocclusion
Premature loss of
deciduous teeth
Early eruption of permanent
teeth
Lingual thyroid
In adults there is
macroglossia