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					                            Thyroid Disease
                          ______________________________________________

                           • Case
- School of Dentistry




                              – Katalina Korapova
                           • Thyroid disease
                              – Hyperthyroidism
                              – Hypothyroidism
                           • ASA PS level
                              – Dental management
University of Minnesota




                           • Algorithm

                           • Thyroid disease
                              – Thyroiditis
                              – Thyroid Cancer
                                                                           1
                          Katalina Korapova
                          ______________________________________________
- School of Dentistry




                                                        •   60 yr old
                                                        •   Caucasian
                                                        •   Female
                                                        •   WNWD
                                                        •   Presents to clinic for
University of Minnesota




                                                            routine exam




                                                                                     2
                          Initial observations
                          ______________________________________________
- School of Dentistry




                          • Previous thyroid
                            problems
                          • History of surgery
                          • Scar on median of
                            neck
                          • Thinning hair
University of Minnesota




                          • Dry skin
                          • Bulging eyes
                          • Taking Levothyroxine


                                                                           3
                           General Questions
                          ______________________________________________
- School of Dentistry




                                                    •   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?
University of Minnesota




                                                    •   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
                          General Thyroid Questions
                          ______________________________________________
- School of Dentistry




                             • 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?
University of Minnesota




                             • Do you often feel hot? Cold?



                                                                            5
                           Hypothyroid Questions
                          ______________________________________________

                          • Have you experienced any recent bouts of nausea or
- School of Dentistry




                            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




                                                                             6
                          Additional Information
                          ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                               medications
                             – What are her lab test results?



                                                                              7
                              Lab tests needed
                          ______________________________________________
- School of Dentistry




                          • Measure           Normal             Hypo-          Hyper-
                             –   T4          5 - 12 mg/dl       Decrease        Increase
                             –   T3        80 – 190 mg/d        Decrease        Increase
                             –   TSH        0.5 – 4.5 mμ/L      Increase        - / decrease
                             –   TBG                            Decrease        Increase

                          • Radioactive Iodine Uptake Test: Direct Thyroid Test
University of Minnesota




                             – Normal RAIU = 10% – 30% (Better Indicates Hyperthyroidism)
                          • Measurement of Autoantibodies




                                                                                            8
University of Minnesota   - School of Dentistry




9
                            What is going on?
                          ______________________________________________
- School of Dentistry




                          •    Exophthalmos - sign of hyperthyroid
                              –   Ms. Korpova likely had hyperthyroids problems
                          •    Scar on neck - previous surgery
                              –   She underwent surgery to have the mass
                                  removed
University of Minnesota




                          •    Dry skin, thin hair, prescribed
                               Levothyroxine - signs of Hypothyroid
                              –   Resulting in hypothyroidism

                                                                                  10
                          Hyperthyroidism -          Etiology
                          ______________________________________________
- School of Dentistry




                          •   Ectopic thyroid tissue
                          •   Grave’s disease
                          •   Multinodular goiter
                          •   Thyroid adenoma
                          •   Subacute thyroiditis
University of Minnesota




                          •   Ingestion of thyroid hormone
                          •   Pituitary disease (anterior gland)
                          •   Ingestion of food-containing thyroid hormone

                                                                             11
                          Hyperthyroidism - Signs and Symptoms
                          ______________________________________________
- 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
University of Minnesota




                          •   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
                          Hyperthyroidism -          Oral manifestations
                          ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                            early eruption of permanent teeth
                          • Lingual thyroid

                                                                      13
                          Hyperthyroidism -          Laboratory Findings
                          ______________________________________________
- School of Dentistry




                          • Low TSH combined with high T4
                          • Low TSH, low T4 and high T3
University of Minnesota




                                                                      14
                            Hypothyroidism
                          ______________________________________________
- School of Dentistry




                          • Types
                             – Primary atrophic
                             – Secondary
                             – Transient
                             – Generalized resistant to thyroid hormone
University of Minnesota




                                                                           15
                               Hypothyroidism
                          ______________________________________________
- School of Dentistry




                          •   Primary Hypothyroidism - 95%              •   Secondary Hypothyroidism
                              –   Insufficient amount of thyroid            –   Pituitary
                                  tissue                                    –   panhypopituitarism (neoplasm,
                              –   Hashimoto’s thyroiditis                       radiation, surgery)
                              –   Graves’ disease – end stage               –   Hypothalamic
                              –   radiation                                 –   congenital
                              –   amyloidosis, lymphoma,                    –   infection
                                  scleroderma                               –   infilitration (sarcoidosis,
                              –   Iodine 131 therapy                            granulomas)
                              –   thyroidectomy                             –   Transient Hypothyroidism
                              –   Thyroid hormone synthesis defect          –   silent and subacute thyroiditis
University of Minnesota




                              –   congenital enzyme defects                 –   thyroxine withdrawal
                              –   iodine deficiency
                              –   mutations in TSH receptor
                              –   drug induced (thionamides, lithium)
                              –   Agenesis or Dysplasia




                                                                                                                  16
                               Hypothyroidism
                          ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                              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   - School of Dentistry




18
                          Hypothyroidism –               Signs and Symptoms
                          ______________________________________________
- School of Dentistry




                          • General
                            – 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
University of Minnesota




                          • Myxedema
                            – 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
                            Hypothyroidism
                          ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                              eruption of teeth, and resulting malocclusion




                                                                                            20
                          Hypothyroidism – Dental Implications
- School of Dentistry




                          • 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
University of Minnesota




                            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
                             ASA Physical Status
                           ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                                   –   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
                            ASA Physical Status
                          ______________________________________________
- School of Dentistry




                          • Currently has mild symptoms of
                            hypothyroidism
                            – dry skin, thinning hair
                          • Currently on levothyroxine
                            – synthetic thyroid hormone replacement to
University of Minnesota




                              control hypothyroidism
                          • Under medical management

                                                                           23
                          Patient Management - Hypothyroidism
                          ______________________________________________
- School of Dentistry




                          •   In general, well controlled hypothyroidism (even when untreated) does
                              not interfere with dental therapy
                              –   Avoid oral infections
                              –   Implement normal procedures and management

                          •   May show exaggerated response to CNS depressants such as narcotic
                              analgesics, sedatives, CNS depressants
                              –   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
University of Minnesota




                              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
                           Dental Algorithm - A
                          ______________________________________________
- School of Dentistry




                          • Antibiotics
                             – No premedication, but treat infections
                               rapidly in order to prevent thyroid storm or
                               myxedema coma
University of Minnesota




                                                                              25
                            Dental Algorithm - A
                          ______________________________________________
- School of Dentistry




                          • Anesthetics
                             – Avoid Epinephrine in those with
                               uncontrolled hyperthyroidism
                                 • Epinephrine can be administered when patient
                                   controlled
University of Minnesota




                                                                                  26
                           Dental Algorithm - A
                          ______________________________________________
- School of Dentistry




                          • Anxiety
                             – Avoid stressful appointments as they can
                               lead to thyroid storm
University of Minnesota




                                                                           27
                           Dental Algorithm – B and C
                          ______________________________________________
- School of Dentistry




                          • Bleeding
                            – Anticoagulants in combination with T4
                              therapy increases PT
                          • Complications
                            – Watch for thyrotoxicosis with patients on
University of Minnesota




                              levothyroxine (taken to treat hypothyroidism)
                          • Cardiac
                            – Watch for MI in those undergoing thyroid
                              storm
                                                                           28
                           Dental Algorithm - D
                          ______________________________________________
- School of Dentistry




                          • Drug Interactions
                             – Untreated hypothyroid patients may be
                               highly sensitive to actions of narcotics,
                               barbituates, and tranquilizers
University of Minnesota




                                                                           29
                             Dental Algorithm - E
                          ______________________________________________
- School of Dentistry




                          • Emergency Treatment
                             – Be aware of signs of thyroid storm
                                 •   Fever
                                 •   Abdominal Pain
                                 •   Delirious
                                 •   Psychotic
                             – Know how to treat thyroid storm
University of Minnesota




                                 •   Seek immediate medical aid
                                 •   Cool with cold towels, ice packs
                                 •   Hydrocortisone (100-300 mg)
                                 •   Monitor vital signs
                                 •   Start CPR if needed


                                                                           30
                            Dental Algorithm - E
                          ______________________________________________
- School of Dentistry




                          • Emergency Treatment
                             – Know the signs of hypothyroid coma
                                •   Hypothermia
                                •   Bradycardia
                                •   Hypotension
                                •   Epilpetic seizures
                             – Know how to treat hypothyroid coma
University of Minnesota




                                • 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)
                          ______________________________________________
- School of Dentistry




                          •   Hashimoto’s
                          •   Subacute painful
                          •   Subacute painless
                          •   Acute suppurative
                          •   Riedel’s
University of Minnesota




                          •   Radiation therapy
                          •   Drugs
                              – Lithium, interlukin-2, interferons, amiodarone

                                                                             32
                          Thyroiditis - Pathophysiology
                          ______________________________________________

                          • Hashimoto’s
- School of Dentistry




                           – autoimmune disorder that presents as an asymptomatic diffuse goiter

                          • Subacute painful
                           – follows upper respiratory tract viral infection

                          • Subacute painless
University of Minnesota




                           – autoimmune disorder

                          • Acute suppurative
                           – microbial infection of the thyroid

                          • Riedel’s
                           – fibrous infiltration of the thyroid gland of unknown origin
                                                                                               33
                          Thyroiditis - Signs and Symptoms
                          ______________________________________________
- School of Dentistry




                          • Hashimoto’s
                            –   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
                          • Acute suppurative
University of Minnesota




                            –   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
                          Thyroiditis - Oral manifestations
                          ______________________________________________
- School of Dentistry




                          • Pain associated with subacute painful
                            thyroiditis may radiate to the ear, jaw or
                            occipital region
                          • Hoarseness and dysphagia
University of Minnesota




                                                                           35
                            Thyroid Cancer -          Types
                          ______________________________________________
- School of Dentistry




                          • Differentiated
                           –   Papillary
                           –   Follicular
                           –   Mixed
                           –   Hurthle cell carcinoma
University of Minnesota




                          • Medullary
                           – MEN type 2
                          • Anaplastic
                                                                           36
                          Thyroid Cancer -          Etiology
                          ______________________________________________
- School of Dentistry




                          • 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
University of Minnesota




                            Chernobyl
                          • High dietary iodine intake or a very low iodine
                            intake
                          • Genetic factor
                                                                           37
                          Thyroid Cancer -             Signs and Symptoms
                              ______________________________________________
- School of Dentistry




                          •    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
University of Minnesota




                          •    Hemoptysis
                          •    Dysphagia
                          •    Stridor
                          •    hoarseness

                                                                           38

				
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