RISK STARTIFICATION RISK STARTIFICATION AND DENTAL AND DENTAL
MANAGEMENT OF MANAGEMENT OF PATIENTS WITH THYROID PATIENTS WITH THYROID
DYSFUNCTIONDYSFUNCTION
Géza T. Terézhalmy, D.D.S., M.A. Géza T. Terézhalmy, D.D.S., M.A. Professor and Dean Emeritus Professor and Dean Emeritus
School of Dental Medicine School of Dental Medicine Cleveland, Ohio Cleveland, Ohio
[email protected]@uthscsa.edu
Terezhalmy 204/12/23
Thyroid DysfunctionThyroid Dysfunction
• Hypothalamic-pituitary-thyroid axis– Hypothalamus
• Thyrotropin-releasing hormone
– Anterior pituitary• Thyroid stimulating
hormone
– Thyroid gland• Tetraiodothyronine • Triiodothyronine
Terezhalmy 304/12/23
Thyroid DysfunctionThyroid Dysfunction
• T4 and T3– 70% bound to
thyroid binding globulin (TBG)
– 30% bound to transthyretin, albumin, and lipoproteins
– <2% circulate in an unbound free state• Act to maintain
physiological hormone levels
Terezhalmy 404/12/23
Thyroid DysfunctionThyroid Dysfunction
• T3– Accounts for most of the biological
activity of thyroid hormones• Stimulates RNA polymerase
– Transcription and translation» Growth and development» Thermoregulation» Calorigenesis» Carbohydrate, proteins, lipids metabolism» Oxygen utilization
Terezhalmy 504/12/23
Thyroid DysfunctionThyroid Dysfunction
• T3• Enhances tissue sensitivity to
catecholamines -adrenergic receptor activation
• Acts synergistically with epinephrine glycogenolysis
Terezhalmy 604/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– An estimated 5% of individuals in the
U.S. have palpable thyroid nodules• 95% are benign
– 85% hyperplastic nodules– 15% adenomas– <1% cysts
• 5% are malignant (30,180 cases in 2006)– 81% papillary carcinoma– 14% follicular carcinoma– 3% medullary carcinoma– 2% anaplastic forms
Terezhalmy 704/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– May be characterized as
• Euthyroid– Normal levels of thyroid hormones
• Hypothyroid– Inadequate levels of thyroid hormones
• Hyperthyroid– Excessive levels of thyroid hormones
Terezhalmy 804/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Euthyroidism
• Euthyroid goiter (diffuse, nodular, multinodular)
• Benign tumors• Malignant tumors
– Differentiated (papillary, follicular)– Undifferentiated (small cell, giant cell)– Medullary
Terezhalmy 904/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Euthyroidism
• Thyroiditis– Acute thyroiditis– Subacute (De Quevain’s) thyroiditis– Chronic autoimmune thyroiditis
» (Hashimoto’s disease)– Postpartum thyroiditis– Reidel’s thyroiditis
Terezhalmy 1004/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Congenital– 1:3,000-4,000 births
» Slightly incidence in the Hispanic population
» 85% is due to sporadic thyroid dysgenesis» 15% due to autosomal recessive mode of
inheritance– Recognized cause of mental retardation
» Symptoms begin to appear at about the 3rd month of life (cretinism)
Terezhalmy 1104/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Congenital– Cretinism
» Puffy face» Large cranium» Flat and broad nose» Macroglossia» Thick elevated lips» Open mouth» Altered calcification of teeth» Delayed eruption of teeth
Terezhalmy 1204/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Primary – Chronic
autoimmune thyroiditis
– Iatrogenic (surgery, 131I-therapy)
– Diffuse and nodular goiter
– Severe iodine deficiency
Terezhalmy 1304/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Secondary– Pituitary
Terezhalmy 1404/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Tertiary– Hypothalamic
Terezhalmy 1504/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Clear female predominance (5-10:1)– 10 million in U.S. (8 million undiagnosed)
• Myxedema– Slow speech– Lethargy – Mental impairment– Depression– Increased sensitivity to cold– Pitting edema– Reduced rate of respiration
Terezhalmy 1604/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Myxedema– Coarse facial
features» Thick lips» Puffy eyelids» Sad
expression– Dry hair– Dry and cold skin
Terezhalmy 1704/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Myxedema– Muscle weakness– Cardiovascular abnormalities
» Slow pulse rate, coronary artery disease, hypotension, cardiomyopathy
– Laboratory abnormalities Aspartate transaminase Alanine transaminase LDH Creatinine Cholesterol
Terezhalmy 1804/12/23
Thyroid DysfunctionThyroid Dysfunction
Terezhalmy 1904/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Myxedema coma– Precipitating factors
» Infection» Exposure to cold» Sedative drug therapy» Pulmonary disease» Congestive heart failure» Gastrointestinal bleeding» Acute thyroid trauma» Noncompliance with thyroid supplementation
Terezhalmy 2004/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Myxedema coma– Signs and symptoms
» Progressive alveolar hypoventilation» Hypothermia» Bradycardia» Decreased cardiac contractility» Hyponatremia» Decreased glomerular filtration» Coma
Terezhalmy 2104/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hypothyroidism
• Myxedema coma– Treatment
» Prompt administration of thyroid hormone» Ventilatory support» Fluid restoration» Glucose administration» Glucocorticoid administration
– Mortality rates» 20 to 60% have been reported
Terezhalmy 2204/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Clear female predominance (5-10:1)– Hyperthyroidism
» 4.5 million in the U.S. (600,000 undiagnosed)• Glandular hyperfunction
– Diffuse hyperthyroid goiter (Grave’s disease)– Multinodular hyperthyroid goiter (Plummer’s
disease)– Autonomous nodule
• Thyrotoxicosis– Exogenous thyroid hormones
Terezhalmy 2304/12/23
Thyroid Dysfunction
Terezhalmy 2404/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Goiter• Exophthalmia
– Gritty sensation– Light sensitivity– Increased
tearing– Double vision– Felling of
retroocular pressure
Terezhalmy 2504/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Facial flushing • Warm and moist skin• Enlarger lymph nodes• Tremor • Excitability • Emotional instability• Increased appetite with weight loss• Osteoporosis• Rapid rate of respiration
Terezhalmy 2604/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Cardiovascular abnormalities– Tachycardia– Atrial fibrillation– Heart murmur– Hypertension
• Laboratory abnormalities Hypercalcemia Cholesterol Alkaline phosphatase (heat labile-bone)
Terezhalmy 2704/12/23
Thyroid DysfunctionThyroid Dysfunction
Terezhalmy 2804/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Thyroid storm– Precipitating factors
» Infection» Non-thyroid trauma» Psychosis» Parturition» Myocardial infarction» Intake or radioiodide and high doses of
iodine-containing compounds» Amiodarone therapy» Discontinuation of antithyroid therapy» Thyroid overdose
Terezhalmy 2904/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Thyroid storm– Signs and symptoms
» Fever >101.30F» Tachycardia» CNS dysfunction (agitation, confusion,
delirium)» Gastrointestinal dysfunction (nausea,
vomiting, diarrhea)» Diaphoresis» Arial fibrillation» Congestive heart failure
Terezhalmy 3004/12/23
Thyroid DysfunctionThyroid Dysfunction
• Clinical manifestations– Hyperthyroidism
• Thyroid storm– Treatment
» Intensive care» B-adrenergic blocking agents» Propylthiouracil» External cooling
Terezhalmy 3104/12/23
Thyroid DysfunctionThyroid Dysfunction
• Diagnosis– Newborns
• Mandatory TSH testing– Adults, serum TSH concentrations
• Hypothyroidism TSH and free T4
• Hyperthyroidism TSH and free T4
– Specialized testing• Anti-thyroglobulin antibody (TgAb)• Anti-thyroid peroxidase antibody (TPOAb)• Anti-thyroid receptor antibody (TRAAb)
Terezhalmy 3204/12/23
Thyroid DysfunctionThyroid Dysfunction
• Principles of medical management– Hypothyroidism
• Purified or synthetic thyroid preparations– Daily dosages, 0.05 to 0.15 mg, or its
equivalent» Inadequate replacement therapy is associated
with continued clinical features of hypothyroidism
» Substantial over-treatment results in clinical manifestations of hyperthyroidism
Terezhalmy 3304/12/23
Thyroid DysfunctionThyroid Dysfunction
Drug Mechanisms of action Indication ADEs
Levothyroxin (Levoxyl®, Levothyroxin®, Synthroid®)
T4 and T3 replacement Drug of choice
Hyper-thyroidism
in overdose
Liothyronine (Cytomel®, Triostat®)
T3 replacement
When absorption of levothyroxin is inadequate
Liotrix (Thyrolar®)
T4 and T3 replacement
When conversion of levothyroxin, T4 to T3, is abnormal
Terezhalmy 3404/12/23
Thyroid DysfunctionThyroid Dysfunction
• Principles of medical management– Hyperthyroidism
• Antithyroid drugs– Primary treatment, therapy is stopped or tapered
after 12 to 18 months of therapy» Lifelong follow-up is required as spontaneous
hypothyroidism may develop decades later OR Preparative therapy before surgery or radioiodine
therapy• Iodine or iodide preparations
– Short-term benefits » Decrease vascularity and size of the thyroid
gland in preparation to surgery
Terezhalmy 3504/12/23
Thyroid DysfunctionThyroid Dysfunction
Drug Mechanisms of action Indication ADEs
Methimazole (Tapazole®)
Inhibits the transformation of inorganic iodine to organic iodine
Long-term thyroxin suppressionORIn preparation for surgery or radioiodine therapy
AgranulocytosisHepatotoxicityUrticaria ArthralgiaSialadenitis (rarely)
Terezhalmy 3604/12/23
Thyroid DysfunctionThyroid Dysfunction
Drug Mechanisms of action Indication ADEs
Propyl- thiouracil
Inhibits the transformation of inorganic iodine to organic iodineANDBlocks the conversion of T4 to T3
Long-term thyroxin suppressionORIn preparation for surgery or radioiodine therapy
AgranulocytosisHepatotoxicityUrticariaArthralgia
Terezhalmy 3704/12/23
Thyroid DysfunctionThyroid Dysfunction
Drug Mechanisms of action Indication ADEs
IodineORIodide
Short-term inhibition of thyroxine release
Adjunctive therapy to antithyroid drugs OR In preparation for surgery
Allergic reactions
Terezhalmy 3804/12/23
Thyroid DysfunctionThyroid Dysfunction
DENTAL MANAGEMENT
CONSIDERATIONS
Terezhalmy 3904/12/23
Thyroid DysfunctionThyroid Dysfunction
• Goals– Develop and
implement timely preventive and therapeutic strategies compatible with the patients’ physical and emotional ability to undergo and respond to dental care
• Medical history– Review of organ
systems– Drug History
Terezhalmy 4004/12/23
Thyroid DysfunctionThyroid Dysfunction
• Functional capacity– T3 exerts direct
inotropic and chronotropic effects on cardiac muscle
– T3 is synergistic with epinephrine
– Metabolic equivalents (METs)• Ability of the CV
system to meet metabolic demand for oxygen– Poor functional
capacity» < 4 METs
Terezhalmy 4104/12/23
Thyroid DysfunctionThyroid Dysfunction
• Vital signs– Blood pressure
• < 180/110 mm Hg– Not an
independent risk factor for cardiovascular risk in association with non-cardiac procedures
• > 180/110 mm Hg constitutes a medical emergency
• < 90/50 mm Hg reliable sign of shock
– Pulse pressure, rate, and rhythm• Pulse pressure
correlates closely with systolic BP– Reliable
cofactor to either rule out or confirm significant CVD
• Pulse rate – <50 or >100
beats/min constitutes a medical emergency
Terezhalmy 4204/12/23
Thyroid DysfunctionThyroid Dysfunction
• Treatment strategies– The physiological
events associated with the thyroid dysfunction and the “stress” of a procedure can affect cardiac function (myocardial ischemia)
• Procedure-specific variables– Fluid shifts or– Blood loss– Duration
of the procedure
– Physiological stress
• Dental procedures– Very low risk
* Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1996;82:42-46*Arch Intern Med
2001;161:1509-1512*JADA
2001;132:1570-1579
Terezhalmy 4304/12/23
Thyroid DysfunctionThyroid Dysfunction
– The hypothyroid patient• There is no
evidence to justify deferring needed surgery in patients with mild to moderate hypothyroidism
*Am J Med 1983;14:893-897
*Am J Med 1984:77:261-266
– The hyperthyroid patient• The effects of
undiagnosed or undertreated hyperthyroidism on the heart carries perioperative risks– Increased
cardiac output may limit cardiac reserve during surgery
*N Engl J Med 2001;344:501-509
Terezhalmy 4404/12/23
Thyroid DysfunctionThyroid Dysfunction
– The use of local anesthetic agents with epinephrine• The hypothyroid
patient– No evidence of
adverse effects associated with epinephrine infusion in patients with hypothyroidism
*Clin Endocrinol 1995;43:747-751
• The hyperthyroid patient– Thyroid
hormones act synergistically with epinephrine» Use
epinephrine with caution
Terezhalmy 4504/12/23
Thyroid DysfunctionThyroid Dysfunction
– The use of analgesics and anxiolytic agents• The hypothyroid
patient– Hyper-reactive
to CNS depressants» Use
judiciously
• The hyperthyroid patient– ASA displaces
thyroid hormones from their protein binding sites
Terezhalmy 4604/12/23
Thyroid DysfunctionThyroid Dysfunction
Predictors of risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORMinor or
intermediate predictors of CV risk
Blood pressure < 180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity > 4 METs
Comprehensive care
Routine referral for medical management and risk factor modification
Terezhalmy 4704/12/23
Thyroid DysfunctionThyroid Dysfunction
Predictors of risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORNo major
predictors of CV risk
Blood pressure < 180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity < 4 METs
Limited careRoutine medical referral
Terezhalmy 4804/12/23
Thyroid DysfunctionThyroid Dysfunction
Predictors of risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORNo major
predictors of CV risk
BP > 180/110 mm Hg ORSystolic BP < 90 mm HgAND/ORAbnormal pulse pressure, rate, and rhythm
Emergencycare
If patient is asymptomatic
Routine medical referral
If patient is symptomatic
Immediate medical referral
Terezhalmy 4904/12/23
Thyroid DysfunctionThyroid Dysfunction
Predictors of risk
Physical examination
Treatment options
Consultation or referral
Severe hypo-thyroidism
ORThyrotoxicosisAND/ORMajor
predictors of CV risk
Establish baseline vital signs
Emergency care
Immediate medical referral
Terezhalmy 5004/12/23
Thyroid DysfunctionThyroid Dysfunction
• Preventive strategies– Oral hygiene
• Conventional vs. electromechanical toothbrushes
– Antibacterial mouthwashes– Topical fluorides– Sialagogues
• Pilocarpine (Salagen)• Cevimeline (Evoxac)
Terezhalmy 5104/12/23
Thyroid DysfunctionThyroid Dysfunction
• Potential medical emergencies– The likelihood of
myxedema coma or a thyroid crisis in the oral health care setting is extremely remote• Other medical
emergencies may be anticipated based on the patient’s medical history and vital signs
Terezhalmy 5204/12/23
Risk stratification of patients with TDRisk stratification of patients with TD
• Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction. Quintessence Int 2008;39:139-150.
• Pickett FA, Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2nd ed. Baltimore: Wolters Kluwer Health / Lippincott Williams & Wilkins, 2009.