Thyroid gland

• Thyroid glands secrete tri-iodothyronine (T3) and thyroxine (T4). They stimulate
metabolism as they act on all the cells of the body by increasing the rate at which
food is used up and converted into heat and energy.
The thyroid gland secretion is under the control of pituitary glands which secrete
TSH. The release of TSH from pituitary gland is regulated by thyrotropin-releasing
factor (TRF) from hypothalamus.
• Negative feed back mechanism similar to the pituitary adrenal axis is also
regulating the thyroid gland secretion and the axis is called pituitary thyroid axis.
• The precise role of thyroid hormones is not known. However, excessive secretion
increases the basal metabolic rate (BMR).
Disorders of thyroid gland:
(1) Hypothyroidism:
- Etiology: the circulating level of thyroxine in the blood will fall, and there will be
a reduction in the body's metabolism. In a child, this reduction in metabolism will
slow the developmental processes leading to a stunted, mentally retarded dwarf
The clinical symptoms vary depending on the age at which the deficiency
develops:
a- In childhood (Cretinism):
- There is delayed physical, sexual and mental development, with
disproportionate body organs and abdominal protuberance.
- Delayed walking, talking and idiot infant.
- Skin: is dry and coarse and wrinkled.
- Nose: Is depressed, wide nostrils.
Oral manifestations:
• Delayed eruption of teeth. • Micrognathia.
• Macroglossia, protruded tongue, with partially opened mouth.
• Malocclusion, anterior open bite. • Puffy, enlarged, protruded lip.
b- In adults (myxedema):
Clinical manifestation:
- There is the deposition of semi-fluid material under the skin that gives the name
to this condition (myxa (Greek) = mucus; oidema = swelling).
- The skin becomes rough and coarse.
- The hair thins on the eyebrows and scalp, brittle nails and decreased sweating.
- The face and eyelids become puffy
- ▼ basal metabolic rate and body temperature, cold intolerance (hypothermia).
- The heart rate is slower: (bradycardia) and hypotension.
- Loss of appetite.
- Depressed mental functions: Crazy, Apathetic, less response to stimuli., loss of
concentration.

Management:
- Call ambulance for hospitalization.
- Artificial respiration.
- 200 mg hydrocortisone i.v.

Dental precautions:
• Myxedema coma:
Precipitating factor:
• Trauma, surgery, infection, GA.
• Sedative (diazepam), analgesic (codeine). The respiratory centre is
hypersensitive to these drugs, they should be avoided or the dose must be
reduced.

(2) Hyperthyroidism:- (Thyrotoxicosis):

Etiology: Overactivity of the thyroid gland may be due to an active tumour of the
gland itself, or excessive production of thyroid stimulating hormone releasing
factor (TSH-RF) by the hypothalamus.
Types:
a) Grave's disease: characterized by:
• Diffused enlargement of thyroid gland
• Exophthalmos
b) Nodular Goitre: characterized by:
• less severe nodular enlargement of thyroid gland
• No exophthalmos
General manifestation:
- The metabolic rate increases ► more heat production ► intolerance to heat
(prominent and significant finding.), weight loss, hot and warm sweaty skin.
- The heart beats at a faster rate, and this increase is maintained during sleep
►very light sleeper.
- Marked nervousness, emotional instability, shortness of breath, inability to sleep.
tremors of hands and tongue
- Silky hair and disturbances of the gastrointestinal tract are characteristic symp-
toms.
- The eyeballs protrude from their sockets (exophthalmos), and the upper lids fail
to follow smoothly the vertical movements of the eyes.
Oral manifestation:
• Early shedding of deciduous teeth. • Early eruption of permanent teeth.
• Osteoporosis: due to increase osteoclastic activity.
Dental precautions:
1) Treated thyrotoxic patient present no problem in dental treatment. Untreated
patient may have tachycardia and arrythemia that can lead to heart failure. The
local anesthesia should be free from adrenaline, octapressin is an alternative.
2) G.A. should be done by anaesthetist since there is risk of dangerous arrythmia.
3) Antithyroid drugs (thiocarbamides) induces agranulocytosis which may cause
oral and oropharyngeal ulceration.
4) Thyroid crisis:-
Thyroid crisis:
Definition: It is exaggerated manifestation of hyperthyroidism.
Precipitating factors: stress, infection and surgery.
How to avoid thyroid crisis?
I. Avoid stress by prescribing tranquilizers. However, low dose is prescribed
since benzodiazepine potentiate the antithyroid drugs.
II. Acute infection should be managed immediately.
Clinical manifestation:
• Thyroid crisis is manifested as:
- Nausea, vomiting. - Fever. - Profuse sweating. -
Tremor.
- Tachycardia - Hypotension - Finally heart failure and
death
- How to manage thyroid crisis?
Call ambulance for hospitalization since medical treatment will include:
a) Hydrocortisone 200 mg i.v. b) Glucose i.v. c) Ice pack,
wet pack, fans.
d) Antithyroid drugs and adrenergic antagonizer (propanolol).
- The dentist should cool the patient with cold towels and give 100-300 mg i.v.
hydrocortisone and will be ready to initiate cardiopulmonary resuscitation if
indicated.