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Thyroid Disease

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Presents to clinic for routine exam. University of Minnesota - School of Dentistry ... 95% of hypothyroidism caused by primary and goitrous hypothyroidism ... – PowerPoint PPT presentation

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Title: Thyroid Disease


1
Thyroid Disease
______________________________________________
  • Case
  • Katalina Korapova
  • Thyroid disease
  • Hyperthyroidism
  • Hypothyroidism
  • ASA PS level
  • Dental management
  • Algorithm
  • Thyroid disease
  • Thyroiditis
  • Thyroid Cancer

University of Minnesota - School of
Dentistry
2
Katalina Korapova
______________________________________________
  • 60 yr old
  • Caucasian
  • Female
  • WNWD
  • Presents to clinic for routine exam

University of Minnesota - School of
Dentistry
3
Initial observations
______________________________________________
  • Previous thyroid problems
  • History of surgery
  • Scar on median of neck
  • Thinning hair
  • Dry skin
  • Bulging eyes
  • Taking Levothyroxine

University of Minnesota - School of
Dentistry
4
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?

University of Minnesota - School of
Dentistry
5
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?

University of Minnesota - School of
Dentistry
6
Hypothyroid Questions
______________________________________________
  • 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 - School of
Dentistry
7
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?

University of Minnesota - School of
Dentistry
8
Lab tests needed
______________________________________________
  • 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
  • Normal RAIU 10 30 (Better Indicates
    Hyperthyroidism)
  • Measurement of Autoantibodies

University of Minnesota - School of
Dentistry
9
University of Minnesota - School of
Dentistry
10
What is going on?
______________________________________________
  • Exophthalmos - sign of hyperthyroid
  • Ms. Korpova likely had hyperthyroids problems
  • Scar on neck - previous surgery
  • She underwent surgery to have the mass removed
  • Dry skin, thin hair, prescribed Levothyroxine -
    signs of Hypothyroid
  • Resulting in hypothyroidism

University of Minnesota - School of
Dentistry
11
Hyperthyroidism - Etiology
______________________________________________
  • Ectopic thyroid tissue
  • Graves disease
  • Multinodular goiter
  • Thyroid adenoma
  • Subacute thyroiditis
  • Ingestion of thyroid hormone
  • Pituitary disease (anterior gland)
  • Ingestion of food-containing thyroid hormone

University of Minnesota - School of
Dentistry
12
Hyperthyroidism - Signs and Symptoms
______________________________________________
  • 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

University of Minnesota - School of
Dentistry
13
Hyperthyroidism - Oral manifestations
______________________________________________
  • 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

University of Minnesota - School of
Dentistry
14
Hyperthyroidism - Laboratory Findings
______________________________________________
  • Low TSH combined with high T4
  • Low TSH, low T4 and high T3

University of Minnesota - School of
Dentistry
15
Hypothyroidism
______________________________________________
  • Types
  • Primary atrophic
  • Secondary
  • Transient
  • Generalized resistant to thyroid hormone

University of Minnesota - School of
Dentistry
16
Hypothyroidism
______________________________________________
  • Primary Hypothyroidism - 95
  • Insufficient amount of thyroid tissue
  • Hashimotos 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

University of Minnesota - School of
Dentistry
17
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

University of Minnesota - School of
Dentistry
18
University of Minnesota - School of
Dentistry
19
Hypothyroidism Signs and Symptoms
______________________________________________
  • 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
  • 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

University of Minnesota - School of
Dentistry
20
Hypothyroidism
______________________________________________
  • Treatment
  • Treated with synthetic drugs sodium
    levothyroxine (Synthroid, LT4) or sodium
    liothyronine (Leotrix, LT3)
  • Oral complications
  • Adults with acquired hypothyroidismenlarged
    tongue
  • Infants with cretinismthick lips, enlarged
    tongue, delayed eruption of teeth, and resulting
    malocclusion

University of Minnesota - School of
Dentistry
21
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

University of Minnesota - School of
Dentistry
22
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

University of Minnesota - School of
Dentistry
23
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

University of Minnesota - School of
Dentistry
24
Patient Management - Hypothyroidism
______________________________________________
  • 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 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

University of Minnesota - School of
Dentistry
25
Dental Algorithm - A
______________________________________________
  • Antibiotics
  • No premedication, but treat infections rapidly in
    order to prevent thyroid storm or myxedema coma

University of Minnesota - School of
Dentistry
26
Dental Algorithm - A
______________________________________________
  • Anesthetics
  • Avoid Epinephrine in those with uncontrolled
    hyperthyroidism
  • Epinephrine can be administered when patient
    controlled

University of Minnesota - School of
Dentistry
27
Dental Algorithm - A
______________________________________________
  • Anxiety
  • Avoid stressful appointments as they can lead to
    thyroid storm

University of Minnesota - School of
Dentistry
28
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

University of Minnesota - School of
Dentistry
29
Dental Algorithm - D
______________________________________________
  • Drug Interactions
  • Untreated hypothyroid patients may be highly
    sensitive to actions of narcotics, barbituates,
    and tranquilizers

University of Minnesota - School of
Dentistry
30
Dental Algorithm - E
______________________________________________
  • Emergency Treatment
  • Be aware of signs of thyroid storm
  • Fever
  • Abdominal Pain
  • Delirious
  • Psychotic
  • 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

University of Minnesota - School of
Dentistry
31
Dental Algorithm - E
______________________________________________
  • Emergency Treatment
  • Know the signs of hypothyroid coma
  • Hypothermia
  • Bradycardia
  • Hypotension
  • Epilpetic seizures
  • 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.

University of Minnesota - School of
Dentistry
32
Thyroiditis - Types(inflammation of the thyroid
gland)
______________________________________________
  • Hashimotos
  • Subacute painful
  • Subacute painless
  • Acute suppurative
  • Riedels
  • Radiation therapy
  • Drugs
  • Lithium, interlukin-2, interferons, amiodarone

University of Minnesota - School of
Dentistry
33
Thyroiditis - Pathophysiology
______________________________________________
  • Hashimotos
  • 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
  • Riedels
  • fibrous infiltration of the thyroid gland of
    unknown origin

University of Minnesota - School of
Dentistry
34
Thyroiditis - Signs and Symptoms
______________________________________________
  • Hashimotos
  • 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
  • severe neck pain, fever, focal thyroid tenderness
    and erythema of overlying skin
  • Riedels
  • 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

University of Minnesota - School of
Dentistry
35
Thyroiditis - Oral manifestations
______________________________________________
  • Pain associated with subacute painful thyroiditis
    may radiate to the ear, jaw or occipital region
  • Hoarseness and dysphagia

University of Minnesota - School of
Dentistry
36
Thyroid Cancer - Types
______________________________________________
  • Differentiated
  • Papillary
  • Follicular
  • Mixed
  • Hurthle cell carcinoma
  • Medullary
  • MEN type 2
  • Anaplastic

University of Minnesota - School of
Dentistry
37
Thyroid Cancer - Etiology
______________________________________________
  • 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

University of Minnesota - School of
Dentistry
38
Thyroid Cancer - Signs and Symptoms
______________________________________________
  • 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

University of Minnesota - School of
Dentistry
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