3. 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
3
THYROID DYSFUNCTION: INTRODUCTION
4. 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
4
THYROID DYSFUNCTION: INTRODUCTION
5. 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 5
THYROID DYSFUNCTION: PATHOPHYSIOLOGY
6. 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
6
THYROID DYSFUNCTION: PATHOPHYSIOLOGY
7. PREDISPOSING FACTORS:
HYPERTHYROIDISM
Most often occur between 20 and 40 years of age, 8:1 ratio over males.
Causes
7
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
8. PREDISPOSING FACTORS:
HYPERTHYROIDISM
Untreated hyperthyroidism may leads to
Thyroid storm
A 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 crisis
Extreme restlessness, nausea, vomiting, abdominal pain, fever,
profuse sweating, tachycardia, cardiac arrhythmias, pulmonary
edema, congestive heart failure leading to coma
8
THYROID DYSFUNCTION: PREDISPOSING FACTORS
9. PREDISPOSING FACTORS:
HYPOTHYROIDISM
Thyroid failure usually occurs as a result of disease of
Thyroid gland (primary hyperthyroidism)
Pituitary gland (secondary)
Hypothalamus (tertiary)
Causes
Primary
9
THYROID DYSFUNCTION: PREDISPOSING FACTORS
Autoimmune hypothyroidism
Idiopathic causes
Postsurgical thyroidectomy
External radiation therapy
Radioiodine therapy
Inherited enzymatic defect
Iodine deficiency
Antithyroid drugs ( thiocyanate,
propylthiouracil, high conc. of
inorganic iodide
Lithium, phenylbutazone
10. PREDISPOSING FACTORS:
HYPOTHYROIDISM
Causes
Secondary
Pituitary tumor
Infiltrative disease (sarcoid) of pituitary
Hypothyroid patient’s are unusually sensitive to
Sedatives
Opiods (mepiridine, codeine, etc.)
Anti-anxiety drugs
As it can result in extreme overreaction
10
THYROID DYSFUNCTION: PREDISPOSING FACTORS
15. 15
SYMPTOMS
Paresthesia 92%
Loss of energy 79%
Intolerance to cold 51%
Muscular weakness 34%
Pain in muscle and joints 31%
Inability to concentrate
Drowsiness
Constipation
Forgetfulness
Depressed auditory acuity
Emotional instability
31%
30%
27%
23%
15%
15%
Headaches
dysarthria
14%
14%
SIGNS %
“pseudomyotic” reflexes
Change in menstrual pattern
Hypothermia
Dry, scaly skin
Puffy eyelids
Hoarse voice
Weight gain
Dependent edema
Sparse axillary & pubic hair
Pallor
Thinning eyebrows
Yellow skin
Loss of scalp hair
Abdominal distention
Goiter
Decreased sweating
95
86
80
79
70
56
41
30
30
24
24
23
18
18
16
10
16. 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
16
THYROID DYSFUNCTION: PREVENTION
17. 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?
17
THYROID DYSFUNCTION: PREVENTION
18. 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?
18
THYROID DYSFUNCTION: PREVENTION
20. PREVENTION:
DIALOGUE HISTORY
An 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?
20
THYROID DYSFUNCTION: PREVENTION
21. PREVENTION:
PHYSICAL EXAMINATION
Sometimes thyrotoxicosis may confused with acute anxiety
Thyrotoxicosis acute anxiety
- Has warm, sweaty hands - palms cold and clammy
21
THYROID DYSFUNCTION: PREVENTION
Hypothyroidism Hyperthyroidism
no sweat
BP close to normal (diastolic ↑
slightly)
Slow heart rate
Sweaty hands
BP elevated ( systolic >diastolic)
Heart rate markedly ↑
22. 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
22
THYROID DYSFUNCTION: PREVENTION
23. PREVENTION:
PHYSICAL STATUS CLASSIFICATION OF THYROID GLANDDYSFUNCTION
23
THYROID DYSFUNCTION: PREVENTION
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)
24. 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
24
THYROID DYSFUNCTION: PREVENTION
25. 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
25
THYROID DYSFUNCTION: PREVENTION
26. 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
26
THYROID DYSFUNCTION: PREVENTION
27. 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
27
THYROID DYSFUNCTION: PREVENTION
28. MANAGEMENT:
HYPOTHYROID
Step 1: termination of the dental procedure.
Step 2: position
supine position with legs elevated slightly
Step 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
28
THYROID DYSFUNCTION: MANAGEMENT
29. MANAGEMENT:
HYPOTHYROID
Step 4: Definitive care
Step 4a: summoning of medical assistance
Step 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
Step 4d: definitive management
includes the transport of the individual to a hospital emergency
department, administration of massive dose of IV doses of thyroid
hormones
29
THYROID DYSFUNCTION: MANAGEMENT
30. MANAGEMENT:
HYPERTHYROID
Step 1: termination of the dental procedure.
Step 2: position
supine position with legs elevated slightly
Step 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
30
THYROID DYSFUNCTION: MANAGEMENT
31. MANAGEMENT:
HYPERTHYROID
Step 4: Definitive care
Step 4a: summoning of medical assistance
Step 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
31
THYROID DYSFUNCTION: MANAGEMENT
32. MANAGEMENT:
HYPERTHYROID
Step 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
32
THYROID DYSFUNCTION: MANAGEMENT
33. CONCLUSION :
CONCLUSION
A 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.
33
THYROID DYSFUNCTION: CONCLUSION