Thyroid dysfunction and its management in dental office

1. THYROID DYSFUNCTION: ITS MANAGEMENT IN ORAL SURGEY Presented by: HEMAM SHANKAR SINGH FINAL YEAR BDS

2. CONTENTS: INTRODUCTION PATHOPHYSIOLOGY PREDISPOSING FACTORS CLINICAL MANIFESTATION PREVENTION MANAGEMENT CONCLUSION 2 THYROID DYSFUNCTION: CONTENTS

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 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: 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

11. CLINICAL MANIFESTATION: 11 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPERTHYROIDISM

12. CLINICAL MANIFESTATION: 12 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPERTHYROIDISM

13. 13 SYMPTOMS Common Weight loss <20 lb 72-100% 20-40 lb upto 14% >40 lb 27-36% Palpitation Nervousness Tremor Less common Chest pain Dyspnea Edema Disorientation Diarrhea/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 tachycardia Dysrhythmia Wide pulse pressure Tremor Thyrotoxic state & eyelid retraction Hyperkinesis Heart failure Weakness Coma Tender liver Infiltrated ophthalmopathy Somnolence or obtundence Psychosis jaundice

14. CLINICAL MANIFESTATION: 14 THYROID DYSFUNCTION: CLINICAL MANIFESTATION HYPOTHYROIDISM

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 Prevention of the occurrence of the life-threatening situations myedema coma and thyroid storm 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

19. 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: 19 THYROID DYSFUNCTION: PREVENTION MEDICATIONS USED TO MANAGE HYPOTHYROIDISM & HYPERTHYROIDISM

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

34. THANK YOU