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D E N T I S T R Y & M E D I C I N E ABSTRACT

Background. The thyroid gland and its


hormones play an important
role in the regulation of A D A
J
growth, development and

Management of metabolic functions of the

N
CON
body. Thyroid diseases

IO
include a group of condi-

T
patients with thyroid

A
N

I
C
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.

T predominantly among women.1 Up to 5 per- They reviewed the medical literature


cent of the U.S. female population has alter- within the scope of provision of dental care.
ations in thyroid function,2-4 and up to 6 per- Conclusions. The oral health care pro-
cent may have clinically detectable thyroid fessional can play a role in the screening of
nodules on palpation.4 An estimated 15 percent of the dental patients who have undiagnosed thy-
general population has abnormalities of thyroid roid disease. In addition, to treat patients
anatomy on physical examination, and an unknown per- who have thyroid disease, a thorough
centage of these do not complete a diagnostic evaluation. understanding of the many related path-
It has been suggested that the number ological conditions, as well as the signs
and symptoms that can occur, is needed.
Dental of people affected may be twice as many
2 Specific dental treatment protocols for these
treatment as the undetected cases. This means patients are not found in the medicodental
patients with undiagnosed hypothy-
modifications literature published between 1980 and
roidism or hyperthyroidism are seen in
may be the dental chair, where routine treat- 2000.
necessary for ment has the potential to result in Clinical Implications. As part of a
health care team, the dentist plays an
dental patients adverse outcomes.
In this article, we explore the func- important role in detecting thyroid abnor-
who are under
tion and assessment of the thyroid malities. Modifications of dental care must
medical be considered when treating patients who
gland and the impact of its dysfunction
management have thyroid disease.
on the provision of dental care.
and follow-up
for a thyroid PATHOPHYSIOLOGY
condition. The thyroid gland is formed from the palpation difficult in certain patients.
pharyngeal epithelium during the third The gland, however, is palpable in most
week of fetal development; it then healthy adults. The internal anatomy of
migrates caudally to its final position, which is posterior the thyroid gland consists of follicles that
to the cricoid and arytenoid cartilages in the neck mid- contain a mucinous colloid where the pro-
line. During this process, the thyroglossal duct is formed tein thyroglobulin is found. Thyroglobulin
(in the junction of the anterior two-thirds and posterior is the basic building block for the two
one-third of the tongue). The adult gland comprises a main hormones produced by the thyroid:
bilobular structure, which weighs between 15 and 20 triiodothyronine, or T3, and thyroxine, or
grams, and is connected by a 2-centimeterwide isthmus T4. In addition to thyroglobulin, iodine is
that is located anterior to the laryngeal cartilages. The needed for T3 and T4 synthesis.5
isthmus varies greatly in position and size, making its Iodine is transported into the thyroid

JADA, Vol. 133, July 2002 849


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

thyroid receptors have been described11-15 as and


Hypothalamus
. -receptors are found in myocardial cells, and
-receptors are responsible for hormone
+ (TRH) hemostasis and feedback mechanism. Thyroid
function, like many hormonal somatic regulators,
- is controlled by feedback mechanisms (Figure), in
Anterior Pituitary Gland which the thyroid hormones act as direct
inhibitors of TRH, thus regulating their own pro-
+ Thyroxine duction. A deficiency of either T4 or T3 can affect
adversely the growth and development of the
+ infant and will decrease metabolic function in the
(TSH)
adult. An overproduction or excess availability of
thyroid hormones can cause serious and life-
threatening complications if not discovered and
managed in time.
Thyroid
EVALUATION OF THYROID DISEASE
Figure. The hypothalamus releases thyrotropin-releasing The American Thyroid Associations Guidelines
hormone, or TRH, which acts on the anterior pituitary
gland, releasing thyroid-stimulating hormone, or TSH, or for Detection of Thyroid Dysfunction16-19 suggest a
thyrotropin, a glycoprotein that binds to TSH receptors screening model for all patients. It is recom-
on the thyroid gland. This binding initiates thyroid
activity, resulting both in hypertrophy and hyperplasia, mended that patients have a serum thyroid-stim-
as well as the production of thyroid hormones. ulating hormone, or TSH, level screen starting
at age 35 years and every five years after that,
follicular cells and is combined with thyroglobulin regardless of sex. People from families with his-
to form the thyroid hormone precursors tory of and risk factors for thyroid disease may be
monoiodotyrosine and diiodotyrosine. These pre- followed more closely. Risk factors include perni-
cursors are transformed into T3 and T4 and later cious anemia; diabetes mellitus, or DM; previous
released into the bloodstream. T4 is produced only surgery or radiation to the head and neck region;
in the thyroid, while T3 also can be produced in vitiligo; family history of thyroid disorders;
extraglandular tissues. Once in the plasma, T4 is autoimmune disease; and intake of iodine-
bound primarily to T4-binding globulin, or TBG, containing medications (for example, contrast
and less efficiently to T4-binding prealbumin media for imaging purposes).16
(transthyretin) and albumin.5-9 The initial screening for thyroid dysfunction is
Thyroid hormones influence the growth and performed as part of a head and neck examina-
maturation of tissue, energy metabolism, and tion. During a screening, the thyroid gland is
turnover of both cells and nutrients. T4 is at least examined with the patients head extended to one
25 times more concentrated than T3 and is deion- side. The examiner uses the fingers of both hands
ized in the extraglandular sites to T3 (about 80 to palpate the thyroid gland. Next, the patient is
percent of T3 is produced in this form). Approxi- instructed to swallow, during which time the
mately 40 percent of T4 is deionized to reverse T3 examiner can evaluate the anatomical extent of
in a similar manner. Reverse T3 is not biologically the lobules using the last three fingers of one
active. hand. It is important to remember that the right
T3 is the main metabolic effector, with a 10-fold lobule usually is larger than the left and that on
greater affinity over T4 or nuclear thyroid relaxation the thyroid outline cannot be observed
receptor proteins. The action of this hormone at a in a healthy patient. Any anatomical abnormality
molecular level includes the activation of genetic of the thyroid gland is defined by its consistency,
material (mainly transcription and formation of size, tenderness and growth. If an abnormal
messenger ribonucleic acid) and translation to finding is discovered, hormone and function
proteins coding for multiple hormonal and con- studies need to follow.
stituent tissues such as growth hormone; thy- Laboratory studies. Laboratory studies of
rotropin-releasing hormone, or TRH; malic thyroid function tests are used to confirm a diag-
enzyme; myosin; and the calcium pump complex nosis of hypo- or hyperthyroidism in symptomatic
of the sarcoplasmic reticulum.10 Tissue-specific patients. As thyroid function tests may reflect on

850 JADA, Vol. 133, July 2002


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

nonthyroid pathology, such TABLE 1


as hypothalamic or pitu-
itary disease, the interpre-
THYROID FUNCTION SCREENING TESTS.
tation of these tests needs PRESUMPTIVE THYROID-STIMULATING FREE THYROXINE*
DIAGNOSIS HORMONE
to be put in perspective
(Table). Primary Hyperthyroidism - +
Due to the negative Secondary +/N +
feedback mechanism regu- Hyperthyroidism
(Pituitary/Other)
lating thyroid hormone
secretion, the measure- Primary Hypothyroidism + -
ment of serum TSH is the Secondary -/N -
best test to determine thy- Hypothyroidism
(Pituitary/Other)
roid function.11,16 Owing, in
part, to the sensitivity of Subclinical Hypothyroidism + N
TSH assays, the use of the Subclinical Hyperthyroidism - N
traditional TRH-stimulated
Euthyroid State N N
test has been revised.
People who have pri- * Free thyroxine, or FT4, determines thyroid function and presumptive diagnosis of hypothyroidism or
mary hypothyroidism will hyperthyroidism. It is correlated with other thyroid function tests to confirm diagnosis levels of FT4.
-: Decreased hormone levels.
have increased TSH con- +: Increased hormone levels.
centration as a result of N: Normal hormone levels.

the bodys attempt to pro-


duce more thyroid hormone. Normal values range T4 in cases in which the thyroid pathology is of
between 0.7 milli-International Units per autoimmune etiology. A diagnosis of hyperthy-
milliliter and 5.3 mIU/mL for adults. Low or roidism is confirmed by obtaining a TSH level less
undetectable TSH levels generally suggest hyper- than 0.1 mIU/mL. In both primary and secondary
thyroidism. Normal TSH levels in the presence of hyperthyroidism, FT4 levels are elevated.
abnormal T3 or T4 concentrations indicate a non- Several imaging techniques are useful for eval-
thyroid pathology. uating an apparent abnormal thyroid gland. Mag-
The total concentration of T4 is determined by netic resonance imaging and sonography can
the ratio of T4 secreted by the thyroid, the amount detect the presence and extent of tumors or
of T4 cleared and the serum concentration of TBG. masses. Fine-needle biopsy can be useful when
Patients with hyperthyroidism have increased malignancy is suspected or to rule out
levels of T4 or decreased TBG. Low serum concen- cystic pathology.
tration of T4 and increased TBG indicate a
hypothyroid state. To assess the serum concentra- HYPOTHYROIDISM
tion of free T4, or FT4, an assay is performed that Hypothyroidism is defined by a decrease in thy-
determines the rate of T4 binding to serum pro- roid hormone production and thyroid gland func-
teins. Range values for FT4 are 60 to 150 tion. It is caused by severe iron deficiency, chronic
nanomoles per liter, and 0 to 3 nmol/L for free T3, thyroiditis (Hashimotos disease), lack of stimula-
or FT3 . The thyroid hormone binding ratio, also tion, radioactive iodine that causes follicle
known as the T3 resin uptake test, measures the destruction, surgery and pharmacological agents
unoccupied binding sites for T4. The direct testing such as lithium and amiodarone, the latter of
of thyroid function involves in vivo administration which is a commonly used antidysrhythmic.20-24
of radioactive iodine, usually iodine 123. The thy- This condition can be classified into two cate-
roid radioactive iodine uptake is the most gories: primary hypothyroidism, in which the
common direct assay; the range for normal is defect is intrathyroid; or secondary hypothy-
wide, between 10 and 30 percent uptake of the roidism, in which other pathologies can cause an
administered dose. indirect decrease of circulating hormone (for
The TRH stimulation test is useful in con- example, surgical or pathological alteration of the
firming states of thyrotoxicosis, as it tests the hypothalamus).
response to elevated TRH. Other available tests Congenital hypothyroidism refers to alteration
include the detection of antibodies against T3 or in formation of the thyroid gland. It can be caused

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Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

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.

852 JADA, Vol. 133, July 2002


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

Once the euthyroid state BOX 1


is achieved, the patients CHARACTERISTICS OF THYROID DISEASE.
TSH and FT4 levels are fol-
lowed for periods of six HYPOTHYROIDISM HYPERTHYROIDISM
months to one year. In dAnemia dAbdominal pain
dCardiac murmur
infantile or neonatal states, dCardiomegaly
dCold intolerance dDiplopia
therapy should start as dConstipation dDysrhythmias
dCretinism (children) dElevated alkaline
soon as possible owing to dDry hair phosphatase, aspartate
the risk of developmental dElevated aspartate transaminase and alanine
transaminase, alanine transaminase levels
delay. In cases of pituitary transaminase and lactate dFatigue
or hypothalamic hypothy- dehydrogenase levels dFine hair
dElevated creatine dGoiter
roidism, however, corticos- dGoiter dHeat intolerance
teroid treatment should dHyperlipidemia dHypercalcemia
dHypertelorism dIncreased appetite
precede thyroid hormone dHypotension dIncreased cardiac output
therapy to avoid the possi- dInverted T waves in dIncreased pulse
electrocardiogram dNervousness
bility of adrenal dLethargy dPalpitations
insufficiency. dLow-amplitude QRS wave dProptosis
in electrocardiogram dPsychosis
A complication of dMyxedema dTachycardia
myxedema is the myxede- dParesthesia dTremor
dReduced cardiac output dWarm skin
matous coma, manifested dReduced respiratory rate dWeight loss
as hypothermia, brady- dSeizures
dTachycardia
cardia and severe hypoten- dWeight gain
sion. Persistent myxedema
can lead to cardiomegaly.36
Another complication of the hypothyroid state is also is an important genetic component to Graves
the syndrome of inappropriate adrenal stimu- disease with increased human leukocyte antigen
lating hormone secretion, defined as persistent haplotypes B8 and DRw3 among Caucasians,
hyponatremia and serum hypo-osmolality. If not Bw36 among Japanese and Bw46 among
treated, it can cause serious neurological Chinese.1 Antibodies also have been detected
sequelae. against the TSH receptor.
It is not always necessary to be able to palpate
HYPERTHYROIDISM the thyroid gland in the presence of clinical signs
Hyperthyroidism is a condition caused by unregu- and symptoms of hyperthyroidism. This can be
lated production of thyroid hormones. Thyrotoxi- explained by the presence of extrathyroid glan-
cosis is a serious sequela of hyperthyroidism that dular tissue that cannot be palpated on
corresponds to an overt tissue exposure to excess examination.
circulating thyroid hormones. It is characterized People who have excessive thyroid-circulating
by tremor, emotional instability, intolerance to hormones may develop cardiac abnormalities as a
heat, sinus tachycardia, marked chronotropic and result of the overt overstimulation of myocardial
ionotropic effects, increased cardiac output metabolism, leading to arrhythmias and atrial
(increased susceptibility to congestive heart fibrillation. This is rare in patients younger than
failure), systolic heart murmur, hypertension, 40 years of age unless there is a presence of long-
increased appetite and weight loss.10,37,38 It can be standing thyrotoxicosis. Of note is that
caused by thyroid hyperfunction, metabolic imbal- hyperthyroid-induced atrial fibrillation can be
ance or extraglandular hormone production. resistant to digitalis. Other findings on examina-
Graves disease is a pathological complex pro- tion include forceful point of maximal impulse
duced by hyperthyroidism with diffuse goiter, and flow murmurs. Additional physical manifes-
ophthalmopathy and dermopathy. Not all of these tations associated with thyrotoxicosis include
signs necessarily appear together during the oncholysis, fine tremor of fingers and hands,
course of the disease. Graves disease can occur at ocular signs such as widened palpebral fissuring,
any age, but it is discovered mostly in the third proptosis and infrequent blinking, and weight
and fourth decades of life. It is four to seven times loss is evident. The condition is characterized by
39,40
more prevalent in women than in men. There cyclic phases of remission with no predictability.

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D E N T I S T R Y & M E D I C I N E

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

854 JADA, Vol. 133, July 2002


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

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.

JADA, Vol. 133, July 2002 855


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

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,

856 JADA, Vol. 133, July 2002


Copyright 2002 American Dental Association. All rights reserved.
D E N T I S T R Y & M E D I C I N E

potentiating an -adrenergic increase in blood tant in under-


pressure. This mechanism applies to any patient standing the
who is taking nonselective -blockers, and it is possible modifi-
relevant in patients who have hyperthyroidism cations needed
because of the possible cardiovascular complica- for dental treat-
tions that can arise. Knowledge of the described ment. Length
interactions should alert the clinician for any pos- and current Dr. Pinto is an assis- Dr. Glick is a professor,

sible complication. state of therapy ment of Oral Medicine, Department


tant professor, Depart- of Diag-
nostic Sciences, Univer-
During treatment, heightened awareness are important in University of Pennsyl- sity of Medicine and
vania School of Dental Dentistry of New Jersey,
toward oral soft- and hard-tissue manifestations, understanding Medicine, 4001 Spruce Newark.
as described previously, should be emphasized.47 the metabolic St., Philadelphia, Pa.
19104, e-mail
Oral examination should include inspection and control of apipa1008@aol.com.
palpation of salivary glands. If the patient does patients. The Address reprint
requests to Dr. Pinto.
not have any cardiovascular disease or is not main complica-
receiving anticoagulation therapy, hemostatic tions of both
considerations should not represent a concern for patients with hyperthyroidism and hypothy-
invasive oral procedures. Management of the roidism are associated with cardiac comorbidity.
patient receiving anticoagulation therapy has Other comorbid conditions are DM and asthma.
been described in the literature.48 Consultation with the patients primary care
Oral health care professionals should recognize physician or an endocrinologist is warranted if
the signs and symptoms of a thyroid storm, as the any sign or symptom of thyroid disease is noted
patient could present for dental care during its on examination.
initial phase or when undiagnosed. Patients who Dental treatment modifications may be neces-
have hyperthyroidism have increased levels of sary for dental patients who are under medical
anxiety, and stress or surgery can trigger a thyro- management and follow-up for a thyroid condition
toxic crisis. Epinephrine is contraindicated, and even if there are no comorbid conditions. Stress
elective dental care should be deferred for reduction, awareness of drug side effects or inter-
patients who have hyperthyroidism and exhibit actions, and vigilance for appearance of signs or
signs or symptoms of thyrotoxicosis. Brief symptoms of hormone toxicity are among the
appointments and stress management are impor- responsibilities of the oral health care provider.
tant for patients who have hyperthyroidism.
Treatment should be discontinued if signs or 1. Larsen PR, Davies TF, Hay ID. The thyroid. In: Williams RH,
symptoms of a thyrotoxic crisis develop and Wilson JD, Foster DW, Kronenberg HM, eds. Williams textbook of
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858 JADA, Vol. 133, July 2002


Copyright 2002 American Dental Association. All rights reserved.