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Dental Management of Patients with Thyroid Dysfunction

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Review Article
___________________________________________________ ____________________
J Res Adv Dent 2015; 4:1s:190-196.

Dental Management of Patients with Thyroid Dysfunction

Gautam Singh1 Neha Gupta2 Mythri P3 Amit Prakash4* Ritu Gupta5 Rahul Rishi6

1Reader,
Department of Conservative Dentistry and Endodontics, Peoples College of Dental Sciences, Bhopal, MP, India.
2SeniorLecturer, Department of Conservative Dentistry and Endodontics, Peoples College of Dental Sciences, Bhopal, MP, India.
3Reader, Department of Pedodontics, Bapuji Dental College and Hospital, Davengere, Karnataka, India.
4Senior Lecturer, Department of Orthodontics, Peoples College of Dental Sciences, Bhopal, MP, India.
5Senior Lecturer, Department of Public Health Dentistry, Divya Jyoti College of Dental Sciences, Modinagar, Gaziabad, India.
6Post Graduate Student, Department of Conservative Dentistry and Endodontics, Darshan Dental College, Udaipur, Rajasthan, India.

ABSTRACT

Background: Patients with thyroid dysfunction have become a common occurrence in dental practice all over
the world; the undetected cases are a higher risk factor as it may pose a serious threat to the patient in any of the
dental procedures being followed. Therefore, the correct and timely detection, and management of such cases is
of great importance to the dentist as well as for the total welfare of the patients. This article discusses the
characteristics, oral manifestations and the dental management of patients with hyper or hypothyroidism.

Keywords: Dental Management, Thyroid Dysfunction, Hperthyroid, Hypothyroid.

INTRODUCTION treatment should be put on hold until a complete

medical evaluation is performed. Patients with
The incidence of thyroid disease is on an history of thyroid diseases should be carefully
increase, particularly among women in this century. evaluated to determine the level of medical
This increase can be attributed to better awareness management, and they should be treated in a way
and detection of the disease in its early stages. A that limits stress and infection (2).
large number of the general population has
abnormalities of the thyroid gland. It has been Patients with Thyroid Dysfunction may be
suggested that the number of people affected may classified as euthyroid, hypothyroid, or
be twice as many as the undetected cases. This hyperthyroid depending on normal, decreased or
means patients with undiagnosed hypothyroidism hyper activity of the thyroid apparatus.
or hyperthyroidism are seen in the dental chair,
where routine treatment has the potential to result Table 1: Characteristics of thyroid disease (1)
in adverse outcomes (1). The oral health care
HYPOTHYROIDISM HYPERTHYROIDISM
professional should be familiar with the oral and
 Anemia  Abdominal pain
systemic manifestations of thyroid disease so he or
 Cardiomegaly  Cardiac
she can identify any complications and assess the
level to which the condition is controlled. This  Cold intolerance murmur
article will elaborate on the dental management of  Constipation  Diplopia
patients with thyroid dysfunction.  Cretinism  Dysrhythmias
(children)  Elevated
If a suspicion of thyroid disease arises for  Dry hair alkaline
an undiagnosed patient, all elective dental  Elevated phosphatase,
_______________________________________________________________________________________

Copyright ©2015
 aspartate aspartate cause an indirect decrease of circulating hormone
transaminase,  transaminase (for example, surgical or pathological alteration of
alanine and alanine the hypothalamus). Congenital hypothyroidism
 transaminase transaminase refers to alteration in formation of the thyroid
and lactate levels. gland. It can be caused by dysgenesis, agenesis,
dehydrogenase  Fatigue inborn defect in hormone production or secretion.
levels.  Fine hair Defects in pituitary or hypothalamic metabolism
 Elevated  Goiter account for some cases. Acquired hypothyroidism
creatine  Heat includes idiopathic hypothyroidism, in which no
 Goiter intolerance physiological, autoimmune or biochemical
 Hyperlipidemia  Hypercalcemia abnormality is found, and it is secondary to
 Hypertelorism  Increased hypothalamic or pituitary neoplasms or surgery.
 Hypotension appetite Iatrogenic hypothyroidism can be caused by
 Inverted T  Increased surgery or radiation therapy to the gland. Endemic
waves in cardiac output hypothyroidism is found in specific populations or
electrocardiogra geographic areas and is related to a high–iodine-
 Increased pulse
m content diet. Hashimoto’s disease is an autoimmune
 Nervousness
 Lethargy thyroiditis, in which there is a lymphocytic infiltrate
 Palpitations
into the gland and the production of autoantibodies
 Low-amplitude  Proptosis
directed toward thyroglobulin and thyroid
QRS wave in  Psychosis
peroxidase. Consequently, both the building unit
electrocardiogra  Tachycardia
and the enzyme in charge of production of the
m.  Tremor thyroid hormones are blocked. A firm enlargement
 Myxedema  Warm skin of the gland (known as goiter) with antithyroid
 Paresthesia  Weight loss antibodies is pathognomonic. About 20 to 50
 Reduced cardiac
percent of women with Hashimoto’s disease present
output
initially with goiter. Hashimoto’s thyroiditis leads to
 Reduced
hypothyroidism (4). If hypothyroidism is present in
respiratory rate
infancy, it is manifested as cretinism. Characteristic
 Seizures
signs of cretinism include developmental delay,
 Bradycardia frontal bossing, short stature, protruding tongue,
 Weight gain hypertelorism, dry skin and alopecia. In adults,
hypothyroidism is manifested as myxedema and is
characterized by widespread metabolic slowdown,
HYPOTHYROIDISM
depression, overweight, generalized edema,
Hypothyroidism is defined by a deficiency diminished cardiac output, decreased pulse and
of the thyroid hormone. It can be acquired or by a respiratory rate, paresthesia, status epilepticus, skin
congenital defect (3). Hypothyroidism is defined by dryness, scalp brittleness, non-pitting skin edema,
a decrease in thyroid hormone production and periorbital edema, hoarseness and sinus
thyroid gland function. It is caused by severe iron bradycardia (1).
deficiency, chronic thyroiditis (Hashimoto’s
HYPERTHYROIDISM
disease), lack of stimulation, radioactive iodine that
causes follicle destruction, surgery and Hyperthyroidism or thyrotoxicosis is
pharmacological agents such as lithium and defined by increase in thyroid hormone production
amiodarone, the latter of which is a commonly used and thyroid gland function. It is caused by ectopic
antidysrhythmic. thyroid tissue, toxic thyroid adenoma, toxic
multinodular goiter, subacute thyroiditis, factitious
This condition can be classified into two
thyrotoxicosis and Graves’ disease and diffuse toxic
categories: primary hypothyroidism, in which the
goiter, being the most common cause of
defect is intrathyroid; or secondary
hyperthyroidism (4).
hypothyroidism, in which other pathologies can

191
 Hyperthyroidism is a condition caused by extraglandular permanent
unregulated production of thyroid hormones. thyroid tissue dentition).
Thyrotoxicosis is a serious sequela of (mainly in the  Macroglossia
hyperthyroidism that corresponds to an overt tissue lateral posterior  Micrognathia
exposure to excess circulating thyroid hormones. tongue).  Anterior open
 Periodontal bite.
It is characterized by tremor, emotional diseases.  Thick lips
instability, intolerance to heat, sinus tachycardia,
 Burning mouth  Dysgeusia
marked chronotropic and ionotropic effects,
syndrome.  Mouth
increased cardiac output (increased susceptibility
 Development of breathing
to congestive heart failure), systolic heart murmur,
connective
hypertension, increased appetite and weight loss. It
tissue diseases
can be caused by thyroid hyper function, metabolic
like Sjogren’s
imbalance or extra glandular hormone production.
syndrome or
Graves’ disease is a pathological complex produced
SLE.
by hyperthyroidism with diffuse goiter,
 Increased
ophthalmopathy and dermopathy. Not all of these
susceptibility to
signs necessarily appear together during the course
caries.
of the disease. Graves’ disease can occur at any age,
but it is discovered mostly in the third and fourth
decades of life. It is four to seven times more DENTAL MANAGEMENT
prevalent in women than in men. Antibodies also
have been detected against the TSH receptor. Controlling thyroid disease is defined by
People who have excessive thyroid-circulating length of treatment, medical follow-up, thyroid
hormones may develop cardiac abnormalities as a hormone levels and absence of symptoms.
result of the overt over stimulation of myocardial
metabolism, leading to arrhythmias and atrial Patients who have euthyroidism routinely
fibrillation. This is rare in patients younger than 40 are followed up at least twice a year. In patients
years of age unless there is a presence of long affected by hypothyroidism, history of
standing thyrotoxicosis, of note is that levothyroxine sodium dosage can be used to assess
hyperthyroid-induced atrial fibrillation can be control.
resistant to digitalis. Other findings on examination
Following are recommendations for dental
include forceful point of maximal impulse and flow
care for patients who have a known thyroid disease
murmurs. Additional physical manifestations
and are on medications. The oral health care
associated with thyrotoxicosis include oncholysis,
professional should be familiar with the oral and
fine tremor of fingers and hands, ocular signs such
systemic manifestations of thyroid disease so he or
as widened palpebral fissuring, proptosis and
she can identify any complication and assess the
infrequent blinking, and weight loss is evident. The
level to which the condition is controlled. If a
condition is characterized by cyclic phases of
suspicion of thyroid disease arises for an
remission with no predictability (1).
undiagnosed patient, all elective dental treatment
Table 2: Oral Manifestations In Thyroid Disease (3) should be put on hold until a complete medical
evaluation is performed.
HYPERTHYROIDISM HYPOTHYROIDISM
DENTAL MANAGEMENT IN HYPOTHYROIDISM
 Accelerated  Delayed
dental eruption eruption. Common oral findings in hypothyroidism
in children.  Enamel include macroglossia, dysgeusia, delayed eruption,
 Maxillary or hypoplasia in poor periodontal health and delayed wound healing.
mandibular both dentitions Before treating a patient who has a history of
osteoporosis. (being less thyroid disease, the dentist should obtain the
 Enlargement of intense in the correct diagnosis and etiology for the thyroid

192
disorder, as well as past medical complications and decreased healing and heightened susceptibility to
medical therapy. The condition’s prognosis usually infections.
is given by the time of treatment and patient
compliance. In a literature review, Johnson and
colleagues examined the effects of epinephrine in
In patients who have hypothyroidism, there patients who have hypothyroidism. No significant
is no heightened susceptibility to infection. They are interaction was observed in controlled patients who
susceptible to cardiovascular disease from had minimal cardiovascular involvement. In
arteriosclerosis and elevated LDL. Before treating patients who have cardiovascular disease (for
such patients, consult with their primary care example, congestive heart failure and atrial
providers who can provide information on their fibrillation) or who have uncertain control, local
cardiovascular statuses. anaesthetic and retraction cord with epinephrine
should be used cautiously. People who are on a
Patients who have atrial fibrillation can be stable dosage of hormone replacement for a long
on anticoagulation therapy and might require time should have no problem withstanding routine
antibiotic prophylaxis before invasive procedures, and emergent dental treatment. Haemostasis is not
depending on the severity of the arrythmia. If a concern unless the patient’s cardiovascular status
valvular pathology is present, the need for antibiotic mandates anticoagulation.For postoperative pain
prophylaxis must be assessed. control, narcotic use should be limited, owing to the
heightened susceptibility to this agents.(1)
Drug interactions of l-thyroxine include
increased metabolism due to phenytoin, rifampin Table 3: Dental management of the hypothyroid
and carbamazepine, as well as impaired absorption patient (4)
with iron sulfate, sucralfate and aluminum
hydroxide. When l-thyroxine is used, it increases the Clinical setting Hypothyroid
effects of warfarin sodium and, because of its Detection of Symptoms
gluconeogenic effects the use of oral hypoglycemic undiagnosed disease Signs
agents must be increased. Concomitant use of Refer for medical Dx and
tricyclic antidepressants elevates l-thyroxine levels. Rx
Diagnosed disease Original diagnosis and Rx
Appropriate coagulation tests should be Past treatment
available when the patient is taking an oral Current treatment
anticoagulant and thyroid hormone replacement Lack of signs and
therapy.Patients who have hypothyroidism are symptoms
sensitive to central nervous system depressants and Presence of any
barbiturates, so these medications should be used complications
sparingly. During treatment of diagnosed and Untreated or poorly Avoid surgical procedures
medicated patients who have hypothyroidism, controlled Treat oral infection
attention should focus on lethargy, which can Avoid CNS depressants
indicate an uncontrolled state and become a risk for such as narcotics,
patients (for example, aspiration of dental Barbiturate
materials), and respiratory rate. It is important to Well controlled Avoid oral infections
emphasize the possibility of an iatrogenic Implementation of normal
hyperthyroid state caused by hormone replacement procedures and
therapy used to treat hypothyroidism. Hashimoto’s Management
disease has been reported to be associated with DM Medical crisis (rare) Recognition and initial
and patients who have DM might become management of
hyperglycemic when treated with T4. When myxedematous coma
providing dental care to patients who have DM, Seek medical aid
attention should focus on complications associated Hydrocortisone (100 to
with poor glycemic control, which may cause 300 mg)

193
 Cardiopulmonary
resuscitation
Haemostasis - Patients with long standing
hypothyroidism may have increased subcutaneous
mucopolysaccharides due to decrease in the
degradation of these substances. The presence of
excess subcutaneous mucopolysaccharides may
decrease the ability of small blood vessels to
constrict when cut and may result in increased
bleeding from infiltrated tissues, including mucosa
and skin. Local pressure for an extended time will
probably control the bleeding from the small
vessels adequately (2).
Susceptibility to infection - Patient with
hypothyroidism may have delayed wound healing
due to decreased metabolic activity in fibroblasts.
Delayed wound healing may be associated with an
increased risk for infection because of the longer
exposure of the unhealed tissue to pathogenic
organisms. Hypothyroid patients are not considered
to be immunocompromised (2).
A review of literature revealed no adverse
effects associated with epinephrine infusion in
patients with hypothyroidism without significant
cardiovascular disease (5).
Well controlled medically supervised
patients on thyroid replacements and patients with
mild to moderate hypothyroidism may safely
undergo routine dental care under local anesthesia
(6).
However, patients with hypothyroidism
may be hyperactive to CNS depressants, which if
indicated during the treatment protocol should be
administered with care (1)
DENTAL MANAGEMENT IN HYPERTHYROIDISM
Before treating a patient who has
hyperthyroidism, the oral health care professional
needs to be familiar with the oral manifestations of
thyrotoxicosis, including increased susceptibility to
caries, periodontal disease, enlargement of
extraglandular thyroid tissue (mainly in the lateral
posterior tongue), maxillary or mandibular
osteoporosis, accelerated dental eruption and
burning mouth syndrome.
In patients older than 70 years of age,
hyperthyroidism presents as anorexia and wasting,
atrial fibrillation and congestive heart failure. In
young patients, the main manifestation of
hyperthyroidism is Graves’ disease, while middle-
aged men and women present most commonly with
toxic nodular goitre.
Development of connective-tissue diseases
like Sjögren’s syndrome and systemic lupus
erythematosus also should be considered when
evaluating a patient who has a history of Graves’
disease. Taking a careful history and conducting a
thorough physical examination can indicate to the
oral health care professional the level of thyroid
hormone control of the patient. Patients who have
hyperthyroidism are susceptible to cardiovascular
disease from the ionotropic and chronotropic effect
of the hormone, which can lead to atrial
dysrhythmias. It is important that the dentist
address the cardiac history of these patients.
Consulting the patient’s physician before
performing any invasive procedures is indicated in
patients who have poorly controlled
hyperthyroidism. Treatment should be deferred if
the patients present with symptoms of uncontrolled
disease. These symptoms include tachycardia,
irregular pulse, sweating, hypertension, tremor,
unreliable or vague history of thyroid disease and
management, or neglect to follow physician-
initiated control for more than six months to one
year.
A decrease in circulating neutrophils has
been reported during thyroid storm crisis. Dental
treatment, however, usually is not a priority in this
state. Susceptibility to infection can increase from
drug side effects. People who have hyperthyroidism
and are treated with propyl thiouracil must be
monitored for possible agranulocytosis or
leukopenia as a side effect of therapy. Besides its
leukopenic effects, propylthiouracil can cause
sialolith formation and increase the anticoagulant
effects of warfarin. A complete blood count with a
differential will indicate if any medication induced
leukopenia may be present. Aspirin; oral
contraceptives; estrogen; and nonsteroidal anti-
inflammatory drugs, or NSAIDs, may decrease the
binding of T4 to TBG in plasma. This increases the
194
amount of circulating T4 and can lead to
thyrotoxicosis.
Aspirin, glucocorticosteroids, dopamine
and heparin can decrease levels of TSH,
complicating a correct diagnosis of primary or
pituitary hyperthyroidism. The use of epinephrine
and other sympathomimetics warrants special
consideration when treating patients who have
hyperthyroidism and are taking non-selective β-
blockers. Epinephrine acts on α-adrenergic
receptors causing vasoconstriction and on β2
receptors causing vasodilatation. Non-selective β-
blockers eliminate the vasodilatory effect,
potentiating an α-adrenergic increase in blood
pressure. This mechanism applies to any patient
who is taking non-selective β-blockers, and it is
relevant in patients who have hyperthyroidism
because of the possible cardiovascular
complications that can arise. If the patient does not
have any cardiovascular disease or is not receiving
anticoagulation therapy, haemostatic
considerations should not represent a concern for
invasive oral procedures (1)
Oral health care professionals should
recognize the signs and symptoms of a thyroid
storm, as the patient could present for dental care
during its initial phase or when undiagnosed.
Patients who have hyperthyroidism have increased
levels of anxiety, and stress or surgery can trigger a
thyrotoxic crisis. Epinephrine is contraindicated,
and elective dental care should be deferred for
patients who have hyperthyroidism and exhibit
signs or symptoms of thyrotoxicosis. Brief
appointments and stress management are
important for patients who have hyperthyroidism.
Treatment should be discontinued if signs or
symptoms of a thyrotoxic crisis develop and access
to emergency medical services should be available
(4). After treatment, proper postoperative analgesia
is indicated. NSAIDs should be used with caution in
the patients who have hyperthyroidism and who
take β-blockers, as the former can decrease the
efficiency of the latter. Pain, however, can
complicate cardiac function in patients who have
hyperthyroidism and symptomatic disease, and
alternative pain medications need to be instituted. It
is important that patients continue taking their
thyroid medication as prescribed. If an emergent
procedure is needed in the initial weeks of thyroid
treatment, close work-up with the endocrinologist
is needed (1)
Haemostasis - Patients with hyperthyroidism may
have elevated blood pressure and heart rate on the
basis of the effects of thyroid hormone on
sympathetic nervous system activity. Patients with
high arteriolar pressures may require increased
attention and a longer duration of local pressure to
stop bleeding. Hyperthyroid patients who are on
warfarin sodium have increased metabolism of this
drug, leading to alteration in previously therapeutic
coagulation indices.
Anti-thyroid drugs namely propylthiouracil
(PTU) has anti-vitamin K activity and can cause
hypoprothrombinemia and bleeding that poses a
risk for hemorrhage. Thus, patients taking PTU
must be carefully evaluated before surgery or
invasive dental treatment (2).
Susceptibility to infection - Thionamides may
cause a very rare reaction of agranulocytosis (0.5%
of patients) that can result in oral infections and
inadequate wound healing. These post-operative
complications could be prevented if clinicians
carefully follow precautions stated with
thionamides (2).
Fluoride was used as a drug to treat
hyperthyroidism because it reduces thyroid activity
quite effectively. This is due to the ability of fluoride
to mimic the action of thyrotropin (TSH). Excess
fluoride correlates with the other thyroid-related
issues such as iodine deficiency. Fluorine and
iodine, both being members of the halogen group of
atoms, have an antagonistic relationship. When
there is excess of fluoride in the body it can
interfere with the function of the thyroid gland.
Thus, fluoride has been linked to thyroid problems.
Patient who wish to avoid the effect of fluoride on
their thyroid can utilize fluoride free toothpaste (2).
Table 4: Summary of dental treatment alterations
for thyroid disease.
Hyperthyroidism Hypothyroidism
 Avoid the use of  A complete blood
adrenaline and control count before
the spread of infection. performing dental
 Patient treated with surgery is
propylthiouracil, a recommended.
195
 complete blood count  Avoid the use of with any kind of thyroid dysfunction, proper and
should be done. adrenaline, control timely consultation is mandatory for the well being
 NSAID’s should be oral infection and do of the patient and to avoid any complications during
used with caution. not use central the dental treatment procedures being planned in
 Treatment should be nervous depressant the dental office.
discontinued if signs or drugs.
CONFLICT OF INTEREST
symptoms of a  Dentist should have
thyrotoxic crisis knowledge of drug No potential conflict of interest relevant to this
develop. interactions of article was reported.
 These patients are thyroxine.
susceptible to central  If myxedatous coma REFERENCES
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196

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