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Thyroid Disease. ______________________________________________. Case Katalina Korapova Thyroid disease Hyperthyroidism Hypothyroidism ASA PS level Dental management Algorithm Thyroid disease Thyroiditis Thyroid Cancer.

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Thyroid Disease


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    1. Thyroid Disease ______________________________________________ • Case • Katalina Korapova • Thyroid disease • Hyperthyroidism • Hypothyroidism • ASA PS level • Dental management • Algorithm • Thyroid disease • Thyroiditis • Thyroid Cancer University of Minnesota - School of Dentistry

    2. Katalina Korapova ______________________________________________ • 60 yr old • Caucasian • Female • WNWD • Presents to clinic for routine exam University of Minnesota - School of Dentistry

    3. Initial observations ______________________________________________ • Previous thyroid problems • History of surgery • Scar on median of neck • Thinning hair • Dry skin • Bulging eyes • Taking Levothyroxine University of Minnesota - School of Dentistry

    4. General Questions ______________________________________________ • How long ago were you prescribed Levothyroxine? • How often do you take your medications? • Have there been any changes to the type or amount of medication you are taking? • Are you taking any other medications currently? • Do you have any other medical problems I should know about? • Have you been back to your physician to be evaluated recently? • When was your last visit to a physician? University of Minnesota - School of Dentistry

    5. General Thyroid Questions ______________________________________________ • Did you have a large swelling in your neck (goiter) in the past? • Have you had any unexplained weight loss or weight gain? • Have you had any changes in your appetite? • Do you often feel hot? Cold? University of Minnesota - School of Dentistry

    6. Hypothyroid Questions ______________________________________________ • Have you experienced any recent bouts of nausea or vomitting • Have you felt tired, weak, or fatigued lately? • Have you recently experienced any muscle cramping? • Do you ever experience unexplained shortness of breath? University of Minnesota - School of Dentistry

    7. Additional Information ______________________________________________ • Pulse - rate or rhythm (slow, skip beats) • Consult with physician: • When was the surgery and what for? • History of medications • How compliant is the patient with taking her medications • What are her lab test results? University of Minnesota - School of Dentistry

    8. Lab tests needed ______________________________________________ • Measure Normal Hypo- Hyper- • T4 5 - 12 mg/dl Decrease Increase • T3 80 – 190 mg/d Decrease Increase • TSH 0.5 – 4.5 mμ/L Increase - / decrease • TBG Decrease Increase • Radioactive Iodine Uptake Test: Direct Thyroid Test • Normal RAIU = 10% – 30% (Better Indicates Hyperthyroidism) • Measurement of Autoantibodies University of Minnesota - School of Dentistry

    9. University of Minnesota - School of Dentistry

    10. What is going on? ______________________________________________ • Exophthalmos - sign of hyperthyroid • Ms. Korpova likely had hyperthyroids problems • Scar on neck - previous surgery • She underwent surgery to have the mass removed • Dry skin, thin hair, prescribed Levothyroxine - signs of Hypothyroid • Resulting in hypothyroidism University of Minnesota - School of Dentistry

    11. Hyperthyroidism - Etiology ______________________________________________ • Ectopic thyroid tissue • Grave’s disease • Multinodular goiter • Thyroid adenoma • Subacute thyroiditis • Ingestion of thyroid hormone • Pituitary disease (anterior gland) • Ingestion of food-containing thyroid hormone University of Minnesota - School of Dentistry

    12. Hyperthyroidism -Signs and Symptoms ______________________________________________ • Skeletal • osteoporosis • CV • palpitations, tachycardia, MI, arrhythmias, cardiomegaly, CHF, angina • GI • weight loss, increased appetite, pernicious anemia • CNS • anxiety, restlessness, sleep disturbances, impaired concentration, weakness, tremors • Skin • erythema, thin fine hair, soft nails • Eyes • retraction of upper lid, exophthalmos, corneal ulceration, ocular muscle weakness • Other • increased risk for diabetes, decreased cholesterol level, increased risk for thrombocytopenia, sweating University of Minnesota - School of Dentistry

    13. Hyperthyroidism -Oral manifestations ______________________________________________ • Osteoporosis involving the alveolar bone • Dental caries and periodontal disease appear rapidly in these patients • Teeth and jaws develop rapidly • Premature loss of deciduous teeth with early eruption of permanent teeth • Lingual thyroid University of Minnesota - School of Dentistry

    14. Hyperthyroidism -Laboratory Findings ______________________________________________ • Low TSH combined with high T4 • Low TSH, low T4 and high T3 University of Minnesota - School of Dentistry

    15. Hypothyroidism ______________________________________________ • Types • Primary atrophic • Secondary • Transient • Generalized resistant to thyroid hormone University of Minnesota - School of Dentistry

    16. Primary Hypothyroidism - 95% Insufficient amount of thyroid tissue Hashimoto’s thyroiditis Graves’ disease – end stage radiation amyloidosis, lymphoma, scleroderma Iodine 131 therapy thyroidectomy Thyroid hormone synthesis defect congenital enzyme defects iodine deficiency mutations in TSH receptor drug induced (thionamides, lithium) Agenesis or Dysplasia Secondary Hypothyroidism Pituitary panhypopituitarism (neoplasm, radiation, surgery) Hypothalamic congenital infection infilitration (sarcoidosis, granulomas) Transient Hypothyroidism silent and subacute thyroiditis thyroxine withdrawal Hypothyroidism ______________________________________________ University of Minnesota - School of Dentistry

    17. Hypothyroidism ______________________________________________ • Epidemiology • 95% of hypothyroidism caused by primary and goitrous hypothyroidism • 2% of adult women and 0.1-0.2% of adult men in North America are affected by acquired impairment of thyroid function • Laboratory Values • Measurement of serum TSH is the most sensitive test for hypothyroidism – high levels of TSH indicates hypothyroidism • normal range 0.5-4.5 mm/L • Serum T4 is decreased in hypothyroidism • normal range 64-154nmol/L or 5-12mg/dL University of Minnesota - School of Dentistry

    18. University of Minnesota - School of Dentistry

    19. Hypothyroidism – Signs and Symptoms ______________________________________________ • General • dry, thick skin; dry hair; fatigue; edema (puffy hand, face, eyes); cold intolerance; weight gain; hoarseness; sluggishness; headache; constipation; shortness of breath; bradycardia; arthritis; muscle cramps • Neonatal cretinism • Symptoms - developmental impairment of skeletal system and CNS; dwarfism; broad flat nose; wide-set eyes; thick lips; protruding tongue; poor muscle tone; pale skin; umbilical hernia; delayed eruption of teeth; malocclusions; hoarse voice • Myxedema • hypothyroidism developing in older children and adults • Symptoms • generalized apathy and sluggishness; puffy eyelids; dry, rough skin; dry, brittle, and coarse hair; cold intolerant; congestive heart failure; constipation; slurred, hoarse speech; anemia; weight gain • serum cholesterol levels are elevated • may develop fatal hypothermic coma University of Minnesota - School of Dentistry

    20. Hypothyroidism ______________________________________________ • Treatment • Treated with synthetic drugs: sodium levothyroxine (Synthroid, LT4) or sodium liothyronine (Leotrix, LT3) • Oral complications • Adults with acquired hypothyroidism—enlarged tongue • Infants with cretinism—thick lips, enlarged tongue, delayed eruption of teeth, and resulting malocclusion University of Minnesota - School of Dentistry

    21. Hypothyroidism – Dental Implications • Hypothyroid patients under good care pose no threat to dental treatment • Hypothyroid patients treated with T4 and taking warfarin may be at risk for hemorrhage • Untreated hypothyroid patients are sensitive to narcotics and barbiturates • Stress, infection, trauma, CNS depressants may precipitate a hypothyroid (myxedema) coma, especially in elderly patients; if a myxedema coma occurs, call for medical aid, inject 100-300mg hydrocortisone, cover patient to conserve heat, CPR as needed • Severe myxedema, bradycardia, and hypotension may be present • Head and neck exam palpation of the thyroid is important and may lead to medical referral leading to a diagnosis of thyroiditis or hypothyroidism University of Minnesota - School of Dentistry

    22. ASA Physical Status ______________________________________________ • ASA PS level II • Ms. Korapova was likely treated for hyperthyroidism in the past • It is possible that she went through subtotal thyroidectomy due to a large goiter • Resulting in large scar in the median of her neck • With remaining exophthalmos • Usually irreversible regardless of anti-thyroid treatment • Patient likely has post-operative hypothyroidism • A common complication of thyroidectomy • Must consult physician to determine level of control of hypothyroidism prior to dental tx University of Minnesota - School of Dentistry

    23. ASA Physical Status ______________________________________________ • Currently has mild symptoms of hypothyroidism • dry skin, thinning hair • Currently on levothyroxine • synthetic thyroid hormone replacement to control hypothyroidism • Under medical management University of Minnesota - School of Dentistry

    24. Patient Management - Hypothyroidism ______________________________________________ • In general, well controlled hypothyroidism (even when untreated) does not interfere with dental therapy • Avoid oral infections • Implement normal procedures and management • May show exaggerated response to CNS depressants such as narcotic analgesics, sedatives, CNS depressants • Avoid in severe hypothyroidism, reduce dosage in mild hypothyroidism • Hypothyroid patients being treated with levothyroxine receiving warfarin or other oral anticoagulants may have even further prolongation of prothrombin time and could be at risk for hemorrhage • Hypothyroid patients with diabetes with decreased need for insulin or sulfonylurea may become hypoglycemic when treated with levothyroxine • No special problems in terms of dental management once the patient is under good medical care. Follow up with current treatment, lack of signs and symptoms of disease, presence of any complications University of Minnesota - School of Dentistry

    25. Dental Algorithm - A ______________________________________________ University of Minnesota - School of Dentistry • Antibiotics • No premedication, but treat infections rapidly in order to prevent thyroid storm or myxedema coma

    26. Dental Algorithm - A ______________________________________________ University of Minnesota - School of Dentistry • Anesthetics • Avoid Epinephrine in those with uncontrolled hyperthyroidism • Epinephrine can be administered when patient controlled

    27. Dental Algorithm - A ______________________________________________ University of Minnesota - School of Dentistry • Anxiety • Avoid stressful appointments as they can lead to thyroid storm

    28. Dental Algorithm – B and C ______________________________________________ University of Minnesota - School of Dentistry • Bleeding • Anticoagulants in combination with T4 therapy increases PT • Complications • Watch for thyrotoxicosis with patients on levothyroxine (taken to treat hypothyroidism) • Cardiac • Watch for MI in those undergoing thyroid storm

    29. Dental Algorithm - D ______________________________________________ University of Minnesota - School of Dentistry • Drug Interactions • Untreated hypothyroid patients may be highly sensitive to actions of narcotics, barbituates, and tranquilizers

    30. Dental Algorithm - E ______________________________________________ University of Minnesota - School of Dentistry • Emergency Treatment • Be aware of signs of thyroid storm • Fever • Abdominal Pain • Delirious • Psychotic • Know how to treat thyroid storm • Seek immediate medical aid • Cool with cold towels, ice packs • Hydrocortisone (100-300 mg) • Monitor vital signs • Start CPR if needed

    31. Dental Algorithm - E ______________________________________________ University of Minnesota - School of Dentistry • Emergency Treatment • Know the signs of hypothyroid coma • Hypothermia • Bradycardia • Hypotension • Epilpetic seizures • Know how to treat hypothyroid coma • Immediate medical help • Hydrocortisone (100-300 mg) • CPR if needed • This said, thyroid storm and myxedema coma are very rare.

    32. Thyroiditis - Types(inflammation of the thyroid gland) ______________________________________________ • Hashimoto’s • Subacute painful • Subacute painless • Acute suppurative • Riedel’s • Radiation therapy • Drugs • Lithium, interlukin-2, interferons, amiodarone University of Minnesota - School of Dentistry

    33. Thyroiditis -Pathophysiology ______________________________________________ • Hashimoto’s • autoimmune disorder that presents as an asymptomatic diffuse goiter • Subacute painful • follows upper respiratory tract viral infection • Subacute painless • autoimmune disorder • Acute suppurative • microbial infection of the thyroid • Riedel’s • fibrous infiltration of the thyroid gland of unknown origin University of Minnesota - School of Dentistry

    34. Thyroiditis -Signs and Symptoms ______________________________________________ • Hashimoto’s • moderately sized goiter, rubbery and firm in consistency, moveable, hypothyroidism • Subacute painful • enlarged, painful, tender gland with signs and symptoms of hyperthyroidism • Subacute painless • present with signs and symptoms of hyperthyroidism without thyroid pain or tenderness or fever • Acute suppurative • severe neck pain, fever, focal thyroid tenderness and erythema of overlying skin • Riedel’s • slowly enlarging stony neck mass which may extend beyond the thyroid gland causing compressive symptoms such as dyspnea, dysphagia, hoarseness and a sensation of choking University of Minnesota - School of Dentistry

    35. Thyroiditis -Oral manifestations ______________________________________________ • Pain associated with subacute painful thyroiditis may radiate to the ear, jaw or occipital region • Hoarseness and dysphagia University of Minnesota - School of Dentistry

    36. Thyroid Cancer - Types ______________________________________________ • Differentiated • Papillary • Follicular • Mixed • Hurthle cell carcinoma • Medullary • MEN type 2 • Anaplastic University of Minnesota - School of Dentistry

    37. Thyroid Cancer - Etiology ______________________________________________ • External radiation to cervical region • Children who have undergone thymic irradiation • Teenagers with acne who were treated with irradiation • Children exposed to radioactive fallout from Chernobyl • High dietary iodine intake or a very low iodine intake • Genetic factor University of Minnesota - School of Dentistry

    38. Thyroid Cancer -Signs and Symptoms ______________________________________________ • Lump in the region of the gland • Dominant nodule(s) in multinodular goiter • Hard painless mass • Fixation to adjacent structures • Enlarged cervical lymph nodes • Rapidly growing mass • Hemoptysis • Dysphagia • Stridor • hoarseness University of Minnesota - School of Dentistry