Thyroid dysfunction and its management in dental office

THYROID DYSFUNCTION: ITS MANAGEMENT IN ORAL SURGEY

Prese

nted by:

HEMAM SHANKAR SINGH

FINAL YEAR BDS

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CONTENTS:

INTRODUCTION PATHOPHYSIOLOGY PREDISPOSING FACTORS CLINICAL MANIFESTATION PREVENTION MANAGEMENT CONCLUSION

THYROID DYSFUNCTION: CONTENTS

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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

THYROID DYSFUNCTION: INTRODUCTION

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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

THYROID DYSFUNCTION: INTRODUCTION

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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

THYROID DYSFUNCTION: PATHOPHYSIOLOGY

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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

THYROID DYSFUNCTION: PATHOPHYSIOLOGY

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PREDISPOSING FACTORS:

HYPERTHYROIDISM Most often occur between 20 and 40 years of age, 8:1 ratio over males. Causes

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

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HYPERTHYROIDISM Untreated hyperthyroidism may leads to

Thyroid stormA 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 crisisExtreme restlessness, nausea, vomiting, abdominal pain, fever, profuse sweating, tachycardia, cardiac arrhythmias, pulmonary edema, congestive heart failure leading to coma


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HYPOTHYROIDISM Thyroid failure usually occurs as a result of disease of

Thyroid gland (primary hyperthyroidism) Pituitary gland (secondary) Hypothalamus (tertiary)

CausesPrimary


Autoimmune hypothyroidismIdiopathic causesPostsurgical thyroidectomyExternal radiation therapyRadioiodine therapyInherited enzymatic defectIodine deficiency

Antithyroid drugs ( thiocyanate, propylthiouracil, high conc. of inorganic iodideLithium, phenylbutazone

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HYPOTHYROIDISM Causes

Secondary Pituitary tumor Infiltrative disease (sarcoid) of pituitary

Hypothyroid patient’s are unusually sensitive to Sedatives Opiods (mepiridine, codeine, etc.) Anti-anxiety drugsAs it can result in extreme overreaction


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CLINICAL MANIFESTATION:

THYROID DYSFUNCTION: CLINICAL MANIFESTATION

HYPERTHYROIDISM

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HYPERTHYROIDISM

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SYMPTOMS Common

Weight loss <20 lb 72-100%20-40 lb upto 14%>40 lb 27-36%

PalpitationNervousnessTremor

Less common

Chest painDyspneaEdema

DisorientationDiarrhea/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 tachycardiaDysrhythmiaWide pulse pressureTremorThyrotoxic state & eyelid retractionHyperkinesisHeart failureWeaknessComaTender liverInfiltrated ophthalmopathySomnolence or obtundencePsychosisjaundice

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HYPOTHYROIDISM

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SYMPTOMS

Paresthesia 92%

Loss of energy 79%

Intolerance to cold 51%

Muscular weakness 34%

Pain in muscle and joints 31%

Inability to concentrateDrowsinessConstipationForgetfulnessDepressed auditory acuityEmotional instability

31%30%27%23%15%15%

Headachesdysarthria

14%14%

SIGNS %

“pseudomyotic” reflexesChange in menstrual patternHypothermiaDry, scaly skinPuffy eyelidsHoarse voiceWeight gainDependent edemaSparse axillary & pubic hairPallorThinning eyebrowsYellow skinLoss of scalp hairAbdominal distentionGoiterDecreased sweating

95868079705641303024242318181610

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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

THYROID DYSFUNCTION: PREVENTION

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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?


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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?


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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:


MEDICATIONS USED TO MANAGE HYPOTHYROIDISM & HYPERTHYROIDISM

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PREVENTION:

DIALOGUE HISTORYAn 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?


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PREVENTION:

PHYSICAL EXAMINATION

Sometimes thyrotoxicosis may confused with acute anxietyThyrotoxicosis acute anxiety- Has warm, sweaty hands - palms cold and clammy


Hypothyroidism Hyperthyroidismno sweatBP close to normal (diastolic ↑ slightly)Slow heart rate

Sweaty handsBP elevated ( systolic >diastolic)

Heart rate markedly ↑

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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


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PREVENTION:

PHYSICAL STATUS CLASSIFICATION OF THYROID GLANDDYSFUNCTION


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)

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PREVENTION:

DENTAL CONSIDERATION• 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


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PREVENTION:

DENTAL CONSIDERATION• 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


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PREVENTION:

DENTAL CONSIDERATION• 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


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PREVENTION:

DENTAL CONSIDERATION• 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


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MANAGEMENT:

HYPOTHYROIDStep 1: termination of the dental procedure.Step 2: position

supine position with legs elevated slightlyStep 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

THYROID DYSFUNCTION: MANAGEMENT

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MANAGEMENT:

HYPOTHYROIDStep 4: Definitive careStep 4a: summoning of medical assistanceStep 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 O₂Step 4d: definitive management

includes the transport of the individual to a hospital emergency department, administration of massive dose of IV doses of thyroid hormones


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MANAGEMENT:

HYPERTHYROIDStep 1: termination of the dental procedure.Step 2: position

supine position with legs elevated slightlyStep 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


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MANAGEMENT:

HYPERTHYROIDStep 4: Definitive careStep 4a: summoning of medical assistanceStep 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


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MANAGEMENT:

HYPERTHYROIDStep 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


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CONCLUSION :

CONCLUSIONA 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.

THYROID DYSFUNCTION: CONCLUSION

THANK YOU

Health & Medicine

Thyroid dysfunction and its management in dental office