Professional Documents
Culture Documents
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body. Thyroid diseases
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include a group of condi-
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patients with thyroid
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tions that can affect the U
A ING EDU 3
delivery of dental care. RT
ICLE
disease Literature Reviewed.
The authors conducted a MEDLINE search
Oral health considerations of the medical and dental literature con-
cerning thyroid disease and its manage-
ment published between 1980 and 2000.
ANDRES PINTO, D.M.D.; MICHAEL GLICK, D.M.D. The authors found eight published articles
concerning this topic in the dental litera-
ture; a few of the articles specifically
he incidence of thyroid disease is increasing, addressed thyroid disease and dental care.
by dysgenesis, agenesia, inborn defect in hormone sion, heart failure and coronary atheromas.29-34
production or secretion. Defects in pituitary or Abnormal laboratory values associated with
hypothalamic metabolism account for some cases. hypothyroidism include increased low-density
Acquired hypothyroidism includes idiopathic lipoproteins, or LDL; serum cholesterol; creatine;
hypothyroidism, in which no physiological, aspartate aminotransferase; serum lactate dehy-
autoimmune or biochemical abnormality is found, drogenase; and pernicious anemia. TSH levels are
and it is secondary to hypothalamic or pituitary elevated in primary hypothyroidism, decreased in
neoplasms or surgery. Iatrogenic hypothyroidism secondary hypothyroidism and elevated in sub-
can be caused by surgery or radiation therapy to clinical hypothyroidism. TSH levels greater than
the gland. Endemic hypothyroidism is found in 2 IU/mL are indicative of hypothyroidism. FT4 is
specific populations or geographic areas and is decreased but can be normal in subclinical states.
related to a highiodine-content diet. Interestingly, gastric antiparietal antibodies have
Hashimotos disease is an autoimmune thy- been found in some people, which explains the
roiditis, in which there is a lymphocytic infiltrate observed achlorhydria in these patients who have
into the gland and the production of autoanti- hypothyroidism. This raises questions about the
bodies directed toward thyroglobulin and thyroid possible autoimmune etiology for the condition.
peroxidase. Consequently, both the building unit Medical management. Comprehensive treat-
and the enzyme in charge of production of the ment for thyroid disorders is beyond the scope of
thyroid hormones are blocked. A firm enlarge- this review. In general, for hypothyroidism,
ment of the gland (known as goiter) with anti- levothyroxine sodium, or l-thyroxine, replacement
thyroid antibodies is pathognomonic. Between 20 is the first drug of choice and is implemented at
and 50 percent of women with Hashimotos dis- 0.25 milligrams every day and titrated according
ease present initially with goiter. to the patients response at monthly intervals.
Tissue resistance to thyroid hormones is associ- The appropriate initiating dose should be around
ated with elevated levels of FT3 and FT4, and high 1.6 micrograms per kilogram. An extra dose may
normal or elevated TSH. There is a normal TSH be required during pregnancy or when taken con-
response to TRH stimulation. Tissue resistance is currently with intake of rifampin and some anti-
believed to be caused by mutations of the thyroid convulsant medications.35 Careful monitoring by
hormone -receptors. the physician is required because of the possi-
If hypothyroidism is present in infancy, it is bility of causing iatrogenic hyperthyroidism with
manifested as cretinism. Characteristic signs of uncontrolled therapy. The hormone T3 can be
cretinism include developmental delay, frontal used in case of T3 deficiency, and there is the
bossing, short stature, protruding tongue, hyper- option of combining both T4 and T3 when severe
telorism, dry skin and alopecia. In adults, deficiency of both hormones is present. As men-
hypothyroidism is manifested as myxedema and tioned previously, l-thyroxine continues to be the
is characterized by widespread metabolic slow- preferred agent because of the undesired effects of
down, depression, overweight, generalized edema, T3 and the combined presentation in the older
diminished cardiac output, decreased pulse and population (mainly with cardiac complications).
respiratory rate, paresthesia, status epilepticus, People who have angina pectoris (symptomatic
skin dryness, scalp brittleness, nonpitting skin ischemic heart disease) should take l-thyroxine in
edema, periorbital edema, hoarseness and sinus the morning; at least 30 minutes or more before
bradycardia24-26 (Box 1). breakfast; and at least one hour before or after
Medical conditions associated with hypothy- taking iron supplements, antacids or sucralfate.19
roidism include hypercholesterolemia, hypona- Hormone dose is increased 0.25 mg every three
tremia and anemia. Mild or subclinical hypothy- weeks until a 1 mg/day dosage is reached. Thy-
roidism27,28 refers to elevations of TSH in roid function tests are performed at six weeks
association with normal levels of FT4. Subclinical after treatment is initiated. Effectiveness of
hypothyroidism has been linked with high choles- therapy is measured by a sensitive TSH assay, in
terol levels, atrial fibrillation and osteoporosis in which an elevated value indicates insufficient
females. Recently, subclinical hypothyroidism has treatment. Hormone levels may need to be
been considered to be an important risk factor for titrated in cases of immune-mediated hypothy-
coronary heart disease in women. Cardiac-specific roidism and in relation to interactions with cer-
findings are sinus bradycardia, pericardial effu- tain medications.
There is evidence that certain people who have are used to control the symptoms associated with
hyperthyroidism can be susceptible to developing thyrotoxicosis such as sweating, tremor, anxiety
asthma and that euthyroid states positively influ- and tachycardia. Subtotal thyroidectomy (partial
ence asthmatic control. Underlying mechanisms removal of the thyroid gland) is being used less
that could explain this relationship include owing to the efficacy of iodine treatment, but it
increased sensitivity to catecholamines, super- persists as an option in young patients who are
oxide production and increase production of bron- resistant to pharmacological treatment and in
choconstrictive prostaglandins (known as PGE some people who have thyroid neoplasms.
and PGF) in hyperthyroidism.41 During pregnancy, pharmacological manage-
Other thyroid conditions. Thyroid nodules ment should consist of the lowest dose that can
represent growth of the thyroid gland with corre- maintain the euthyroid state. Propylthiouracil
sponding elevation of hormone synthesis. Toxic has been preferred over methimazole, presumably
goiter (uni- or multinodular) is a disease found because the former did not cross the placenta, but
mostly among elderly people, arising from long- research has found evidence to the contrary.42
standing simple goiter, with formation of Thyroid storm is the main complication of
autonomous nodules. Other conditions involving persistent hyperthyroidism. It is defined as the
the thyroid gland include pyogenic thyroiditis, bodys response to maintained thyrotoxicosis.
Riedels thyroiditis, subacute granulomatous thy- Thyroid storm commonly is expressed as extreme
roiditis and several neoplasms such as adenomas. irritability and delirium, a temperature of higher
Medical management. Treatment for hyper- than 41 C, tachycardia, hypotension, vomiting
thyroidism includes administration of propyl- and diarrhea. Thyroid storm is the bodys
thiouracil (300-600 mg/day total at eight-hour response to maintained thyrotoxicosis. This is
intervals) or methimazole (30-60 mg/day total, common in postoperative states in patients who
administered in two doses), which are thioamides have uncontrolled or undiagnosed hyperthy-
that inhibit hormone biosynthesis by aborting the roidism. It also can be triggered by a surgical
iodotyrosine residue coupling. Starting dose for emergency, sepsis and trauma. Some case reports
the propylthiouracil is 100 mg every six to eight describe acute renal failure, lactic acidosis and
hours. Methimazole is more effective than propyl- absence of fever.43 The initiating stimulus for thy-
thiouracil but with more side effects. The main roid storm is unknown. It has been hypothesized
purpose of this therapy is to limit the circulating that it is not caused by glandular hyperfunction
hormone. Surgery and radiotherapy (iodine 131, but rather by a decrease in protein binding
or I-131) are other options, but they are associ- capacity. Severe cardiac dysrhythmias and block-
ated with the risk of creating permanent hypothy- ages can occur secondary to long-term exposure to
roidism. Radioactive iodine therapy is used for thyroid hormones.
patients who have Graves disease, as well as
severe cardiac compromise, toxic uni- or multi- DENTAL MANAGEMENT OF PATIENTS WHO
HAVE THYROID DISEASE
nodular goiter or severe reaction to antithyroid
drugs. Contraindications for radiotherapy are Controlling thyroid disease is defined by length of
pregnancy, breast-feeding or acute ophthal- treatment, medical follow-up, thyroid hormone
mopathy. Methimazole should precede iodine levels and absence of symptoms. Patients who
treatment in patients who have severe hyperthy- have euthyroidism routinely are followed up at
roidism or a large goiter to stop exacerbation of least twice a year. In patients affected by
the hyperthyroid state secondary to radiation.41 hypothyroidism, history of levothyroxine sodium
The prevalence of hypothyroidism induced by dosage can be used to assess control.
I-131 is between 2 and 3 percent of patients Following are recommendations for dental care
treated with this modality.26,41 If hypothyroidism for patients who have a known thyroid disease
persists for more than six months after therapy, and are on medications. The oral health care pro-
hormone replacement must be implemented. The fessional should be familiar with the oral and sys-
use of I-131 therapy in children, however, is con- temic manifestations of thyroid disease so he or
troversial and has been linked with glandular she can identify any complication and assess the
oncogenesis. Glucocorticosteroids, such as dexam- level to which the condition is controlled. If a sus-
ethasone, can be used in cases of severe thyrotoxi- picion of thyroid disease arises for an undiag-
cosis. Adrenergic antagonists such as propanolol nosed patient, all elective dental treatment
should be put on hold until a complete medical glycemic when treated with T4. When providing
evaluation is performed. dental care to patients who have DM, attention
Hypothyroidism. Common oral findings in should focus on complications associated with
hypothyroidism include macroglossia, dysgeusia, poor glycemic control, which may cause de-
delayed eruption, poor periodontal health and creased healing and heightened susceptibility
delayed wound healing.44 Before treating a to infections.39,44
patient who has a history of thyroid disease, the In a literature review, Johnson and colleagues15
dentist should obtain the correct diagnosis and examined the effects of epinephrine in patients
etiology for the thyroid disorder, as well as past who have hypothyroidism. No significant interac-
medical complications and medical therapy. Fur- tion was observed in controlled patients who had
ther inquiry regarding past dental treatment is minimal cardiovascular involvement. In patients
justified. The conditions prognosis usually is who have cardiovascular disease (for example,
given by the time of treatment and patient congestive heart failure and atrial fibrillation) or
compliance. who have uncertain control, local anesthetic and
In patients who have hypothyroidism, there is retraction cord with epinephrine should be used
no heightened susceptibility to infection. They are cautiously. People who are on a stable dosage of
susceptible to cardiovascular disease from arte- hormone replacement for a long time should have
riosclerosis and elevated LDL. Before treating no problem withstanding routine and emergent
such patients, consult with their primary care dental treatment. Hemostasis is not a concern
providers who can provide information on their unless the patients cardiovascular status man-
cardiovascular statuses. Patients who have atrial dates anticoagulation.
fibrillation can be on anticoagulation therapy and For postoperative pain control, narcotic use
might require antibiotic prophylaxis before inva- should be limited, owing to the heightened sus-
sive procedures, depending on the severity of the ceptibility to these agents.
arrythmia.45 If valvular pathology is present, the Hyperthyroidism. Before treating a patient
need for antibiotic prophylaxis must be assessed. who has hyperthyroidism, the oral health care
Drug interactions of l-thyroxine include increased professional needs to be familiar with the oral
metabolism due to phenytoin, rifampin and car- manifestations of thyrotoxicosis, including
bamazepine, as well as impaired absorption with increased susceptibility to caries, periodontal dis-
iron sulfate, sucralfate and aluminum hydroxide. ease, enlargement of extraglandular thyroid
When l-thyroxine is used, it increases the effects tissue (mainly in the lateral posterior tongue),
of warfarin sodium and, because of its gluco- maxillary or mandibular osteoporosis, accelerated
neogenic effects, the use of oral hypoglycemic dental eruption46 and burning mouth syndrome
agents must be increased. Concomitant use of tri- (Box 2). In patients older than 70 years of age,
cyclic antidepressants elevates l-thyroxine levels. hyperthyroidism presents as anorexia and
Appropriate coagulation tests should be available wasting, atrial fibrillation and congestive heart
when the patient is taking an oral anticoagulant failure. In young patients, the main manifesta-
and thyroid hormone replacement therapy. tion of hyperthyroidism is Graves disease, while
Patients who have hypothyroidism are sensitive middle-aged men and women present most com-
to central nervous system depressants and barbi- monly with toxic nodular goiter. Development of
turates, so these medications should be used connective-tissue diseases like Sjgrens syn-
sparingly.12,44 drome and systemic lupus erythematosus also
During treatment of diagnosed and medicated should be considered when evaluating a patient
patients who have hypothyroidism, attention who has a history of Graves disease.
should focus on lethargy, which can indicate an Taking a careful history and conducting a thor-
uncontrolled state and become a risk for patients ough physical examination can indicate to the
(for example, aspiration of dental materials), and oral health care professional the level of thyroid
respiratory rate. It is important to emphasize the hormone control of the patient. Patients who have
possibility of an iatrogenic hyperthyroid state hyperthyroidism are susceptible to cardiovascular
caused by hormone replacement therapy used to disease from the ionotropic and chronotropic
treat hypothyroidism. Hashimotos disease has effect of the hormone, which can lead to atrial
been reported to be associated with DM,1,21 and dysrhythmias.31,32,45,46 It is important that the den-
patients who have DM might become hyper- tist address the cardiac history of these patients.
BOX 2
unreliable or vague history
ORAL MANIFESTATIONS OF THYROID DISEASE. of thyroid disease and man-
agement, or neglect to follow
HYPERTHYROIDISM HYPOTHYROIDISM
physician-initiated control
dIncreased susceptibility to dSalivary gland enlargement
caries dMacroglossia for more than six months to
dPeriodontal disease dGlossitis one year.
dPresence of extraglandular dDelayed dental eruption
thyroid tissue (struma dCompromised periodontal A decrease in circulating
ovariimainly in lateral healthdelayed bone neutrophils has been
posterior tongue) resorption
dAccelerated dental eruption dDysgeusia reported during thyroid
dBurning mouth syndrome storm crisis. Dental treat-
ment, however, usually is
BOX 3 not a priority in this state.
CONSIDERATIONS FOR DENTAL TREATMENT. Susceptibility to infection
can increase from drug side
BEFORE TREATMENT: ASSESSMENT OF THYROID FUNCTION effects. People who have
dEstablish type of thyroid condition. hyperthyroidism and are
dIs there a presence of cardiovascular disease? If yes, assess
cardiovascular status.
treated with propyl-
dAre there symptoms of thyroid disease? If yes, defer elective thiouracil must be moni-
treatment and consult a physician.
dObtain baseline thyroid-stimulating hormone, or TSH. Control is
tored for possible agranulo-
indicated by hormone levels, length of therapy and medical cytosis or leukopenia as a
monitoring. If the patient has received no medical supervision
for more than one year, consult a physician.
side effect of therapy.
dObtain baseline complete blood count. Give attention to drug- Besides its leukopenic
induced leukopenia and anemia.
dAssess medication and interactions with thyroxine and TSH.
effects, propylthiouracil can
Make proper treatment modifications if the patient is receiving cause sialolith formation
anticoagulation therapy.
dTake blood pressure and heart rate. If blood pressure is elevated
and increase the anti-
in three different readings or there are signs of coagulant effects of war-
tachycardia/bradycardia, defer elective treatment and consult a
physician.
farin. A complete blood
count with a differential will
DURING TREATMENT
indicate if any medication-
dOral examination should include salivary glands. Give attention
to oral manifestations. induced leukopenia may be
dMonitor vital signs during procedure: present. Aspirin; oral con-
Is the patient euthyroid? If yes, there is no contraindication to
local anesthetic with epinephrine. traceptives; estrogen; and
Use caution with epinephrine if the patient taking nonselective nonsteroidal anti-
-blockers.
If the patients hyperthyroidism is not controlled, avoid inflammatory drugs, or
epinephrine; only emergent procedures should be performed. NSAIDs, may decrease the
dMinimize stressappointments should be brief.
dDiscontinue treatment if there are symptoms of thyroid binding of T4 to TBG in
disease. plasma. This increases the
dMake pertinent modifications if end-organ disease is present
(diabetes, cardiovascular disease, asthma). amount of circulating T4 and
can lead to thyrotoxicosis.
AFTER TREATMENT
Aspirin, glucocortico-
dPatients who have hypothyroidism are sensitive to central
nervous system depressants and barbiturates. steroids, dopamine and hep-
dControl pain. arin can decrease levels of
dUse precaution with nonsteroidal anti-inflammatory drugs for
patients who have hyperthyroidism, avoid aspirin. TSH, complicating a correct
dContinue hormone replacement therapy or antithyroid drugs as diagnosis of primary or pitu-
prescribed.
itary hyperthyroidism.
The use of epinephrine
Consulting the patients physicians before per- and other sympathomimetics warrants special
forming any invasive procedures is indicated in consideration when treating patients who have
patients who have poorly controlled hyperthy- hyperthyroidism and are taking nonselective
roidism. Treatment should be deferred if the -blockers.37 Epinephrine acts on -adrenergic
patients present with symptoms of uncontrolled receptors causing vasoconstriction and on 2
disease. These symptoms include tachycardia, receptors causing vasodilation. Nonselective
irregular pulse, sweating, hypertension, tremor, -blockers eliminate the vasodilatory effect,
hormone receptor beta-deficient mice. Endocrinology 1998;139:4945-52. 32. Vanderpump MP, Turnbridge WM, French JM, et al. The inci-
15. Johnson AB, Webber J, Mansell P, Gallan I, Allison SP, Mac- dence of thyroid disorders in the community: a 20-year follow up of the
donald I. Cardiovascular and metabolic responses to adrenaline infu- Wickham Survey. Clin Endocrinol 1995;43(1):55-68.
sion in patients with short-term hypothyroidism. Clin Endocrinol 33. Fowler PB. Risk in cardiovascular disease: subclinical hypothy-
1995;43:747-51. roidism is risk factor for coronary heart disease. BMJ
16. Ladenson PW, Singer PA, Ain KB, et al. American Thyroid Asso- 2000;321(7254):175.
ciation guidelines for detection of thyroid dysfunction. Arch Intern Med 34. Skinner GR, Thomas R, Taylor M, et al. Thyroxine should be tried
2000;160:1573-5. in clinically hypothyroid but biochemically euthyroid patients. BMJ
17. Wartofsky L. Update in endocrinology. Ann Intern Med 2001;135: 1997;314(7096):1764.
601-9. 35. Mandel SJ, Brent GA, Larsen PR. Levothyroxine therapy in
18. Bagchi N, Brown TR, Parish RF. Thyroid dysfunction in adults patients with thyroid disease. Ann Intern Med 1993;119:492-502.
over age 55 years: a study in an urban US community. Ach Intern Med 36. Sherman RG, Lasseter DH. Pharmacologic management of
1990;150:785-7. patients with diseases of the endocrine system. Dent Clin North Am
19. Singer PA, Cooper DS, Levy EG, et al. Treatment guidelines for 1996;40:727-52.
patients with hyperthyroidism and hypothyroidism. JAMA 1995; 37. Yagiela JA. Adverse drug interactions in dental practice: interac-
273:808-12. tions associated with vasoconstrictors: part V of a series. JADA
20. Biondi B, Fazio S, Cuocolo A, et al. Impaired cardiac reserve and 1999;130(5):701-9.
exercise capacity in patients receiving long-term thyrotropin suppres- 38. Mealey BL. Impact of advances in diabetes care on dental treat-
sive therapy with levothyroxine. J Clin Endocrinol Metab 1996;81: ment of the diabetic patient. Compend Contin Educ Dent 1998;19(1):
4224-8. 41-60.
21. Little JW, Falace DA, Miller CS, Rhodus NL. Thyroid disease. In: 39. Hall R. Hyperthyroidism and Graves disease. In: Besser GM,
Little JW, ed. Dental management of the medically compromised Thorner MO, eds. Clinical endocrinology. 2nd ed. London: Mosby Wolfe;
patient. 5th ed. St. Louis: Mosby; 1997:419-33. 1994:1-24.
22. Harjai KJ, Licata AA. Effects of amiodarone on thyroid function. 40. Tuttle RM, Patience T, Budd S. Treatment with propylthiouracil
Ann Intern Med 1997;126(1):63-73. before radioactive iodine therapy is associated with higher treatment
23. Newman CM, Price A, Davies DW, Gray TA, Weetman AP. Amio- failure rate than therapy with radioactive iodine alone in Graves dis-
darone and the thyroid: a practical guide to the management of thyroid ease. Thyroid 1995;5:243-7.
dysfunction induced by amiodarone therapy. Heart 1998;79(2):121-7. 41. Luong KV, Nguyen LT. Hyperthyroidism and asthma. J Asthma
24. Danese MD, Powe NR, Sawin CT, Ladenson PW. Screening for 2000;37(2):125-30.
mild thyroid failure at the periodic health examination: a decision and 42. Mortimer RH, Cannell GR, Addison RS, Johnson LP, Roberts MS,
cost-effectiveness analysis. JAMA 1996;276:285-92. Bernus I. Methimazole and propylthiouracil equally cross the perfused
25. Babb RR. Associations between diseases of the thyroid and the human term placental lobule. J Clin Endocrinol Metab 1997;82:
liver. Am J Gastroenterol 1984;79:421-3. 3099-102.
26. Woeber KA. Update on the management of hyperthyroidism and 43. Jiang YZ, Hutchinson KA, Bartelloni P, Manthous CA. Thyroid
hypothyroidism. Arch Fam Med 2000;9:743-7. storm presenting as multiple organ dysfunction syndrome. Chest
27. Woeber KA. Subclinical thyroid dysfunction. Arch Intern Med 2000;118:877-89.
1997;157:1065-8. 44. Young ER. The thyroid gland and the dental practitioner. J Can
28. Hak AE, Pols HA, Visser TJ, Drexhage HA, Hofman A, Witteman Dent Assoc 1989;55:903-7.
JC. Subclinical hypothyroidism is an independent risk factor for 45. Muzyka BC. Atrial fibrillation and its relationship to dental care.
atherosclerosis and myocardial infarction in elderly women: the Rot- JADA 1999;130:1080-5.
terdam Study. Ann Intern Med 2000;132:270-8. 46. Poumpros E, Loberg E, Engstrom C. Thyroid function and root
29. Hart IR. Management decisions in subclinical thyroid disease. resorption. Angle Orthod 1994;64:389-94.
Hosp Pract 1995;30(1):43-50. 47. Greenspan SL, Greenspan FS. The effect of thyroid hormone on
30. Toft AD, Boon NA. Thyroid disease and the heart. Heart skeletal integrity. Ann Intern Med 1999;130:750-8.
2000;84:455-60. 48. Webster K, Wilde J. Management of anticoagulation in patients
31. Woeber KA. Thyrotoxicosis and the heart. N Engl J Med with prosthetic heart valves undergoing oral and maxillofacial opera-
1992;327:94-8. tions. Br J Oral Maxillofac Surg 2000;38(2):124-6.