1. Hyperactive and Hypoactive thyroid Disease
Special Needs Patients

2. Definition/prevalence
Hyperactive thyroid is when the thyroid produces an excess amount of thyroxine into the blood stream.
Thyroxine is a hormone the thyroid makes to control many bodily functions
Metabolism
Breathing
Heart rate
Many other functions.
Affects 1 out of 2,000 people
Goiter on neck due to thyroid being over worked
If you discover a goiter; Refer to MD for consult.
***NDHBE

3. Signs and Symptoms
Hyperactive thyroid -Most common characteristic is Exophthalmos (protruding eyes)***NDHBE
Rapid weight loss, decrease in appetite, nervousness, fatigue, rapid heartbeat, profuse sweating, moist skin
Eye signs:
Stared and widened palpebral fissures
Lid lag
Jerky movements of eye lids
Infrequent blinking
Patients may show emotional instability
May cry easily
Lose temper

4. Who it affects Hyperactive thyroid -Affects women 7x more then men
Genetic link
Usually affects ages years old
Some studies show that smoking increases the risk of getting the disease
No studies show that it affects one race more then the other

5. Cause of the disease
Hyperactive thyroid Most common cause is Grave’s Disease***NDHBE
Autoimmune system disorder that causes TSH to bind to receptors on thyroid gland causing an over production of thyroxine
Goiter, tachycardia, nervousness, heat intolerant, profuse sweating, moist skin, accelerated tooth eruption, exophthalmos (eyes protruding)***NDHBE

6. Diagnosis and treatment
Hyperactive thyroid can be diagnosed by your doctor
Doctor can run blood tests, which measure the levels of thyroxine in the blood stream
If blood test indicates hyperthyroidism, more tests are done to find the possible cause of the disease
Radioactive Iodine Reuptake Test
Thyroid scan
Best to consult with doctor to decide treatment plan, treatment depends on age, physical condition and severity of the disease.
Anti-thyroid medications
Beta Blockers
Radioactive Iodine by mouth
Surgery

7. Oral Manifestations Hyperactive thyroid Children Adults
Early exfoliation of primary teeth, and early eruption of permanent teeth***NDHBE
Adults
Increase risk of dental erosion
Loss of hard tissue due to acids
Increased risk for development and progression of periodontal disease and dental caries
Increase bone loss on radiographs due to increased excretion of calcium and phosphorus in urine and stools
Some medications may show mouth ulcers, or sore throat

8. Treatment Considerations
Hyperactive thyroid
Identify any oral manifestations associated with hyperthyroidism and treat aggressively
The use of topical fluoride should be used frequently to prevent dental erosion and caries
Exfoliation, and eruption should be monitored closely by dentist in children with hyperthyroidism
Use caution of local anesthetic containing epinephrine or atropine (contraindicated in patients with uncontrolled hyperthyroidism, may cause thyroid storm)***NDHBE
Stress reduction protocols
Susceptible to infection and delayed wound healing

9. Barriers to care Hyperactive thyroid
Nervous about dental appointments, put them more at risk for thyroid storm
Patients with uncontrolled thyroid may not see dentist due to risk for thyroid storm
Patients may experience burning mouth syndrome and may think its too painful to see dentist

10. Oral Hygiene instructions
Hyperactive thyroid
Educate patient on caries risk, and caries process
Educate patient on periodontal disease process
Explain proper home care to patient to prevent progression of caries and periodontal disease in patient
Explain use and benefits of fluoride to patient
Try to make goals to cut back on sugary and acidic food and drinks for those patients that may consume them
Discuss any concerns with medications that the patient may be taking causing discomfort in the oral cavity with possible referral to doctor

11. Additional information
Patients with uncontrolled hyperactive thyroid or undiagnosed hyperactive thyroid are at risk of thyroid storm
Thyroid storm can be a life threatening condition
Brought on by stress, heart attack, or infection
Thyroid storm is said to be very rare
Use emergency protocols set by your dental office is patient goes into thyroid storm

12. Comparison of hyperthyroidism vs. hypothyroidism symptoms

13. Definition and Prevalence
Underactive or hypoactive thyroid is when the thyroid gland does not produce enough thyroid hormone
This disease also produces many body functions as a result that the thyroid hormone regulates many body functions
Hypoactive thyroid affects 3.7% of the United States population

14. Signs and symptoms Vary on degree of hormone deficiency
Signs and symptoms include: fatigue, unexplained weigh gain, puffy face, weak muscles, dry skin, cold intolerance,***NDHBE bradycardia
Adult onset; Advanced hypothyroidism aka myxedema***NDHBE symptoms include: low blood pressure, decreased breathing and body temperature, unresponsiveness, and worst possible result myxedema coma
Cretinism: early onset in children
Congential hypothyroidism results in:
severe growth retardation, lack of muscle development,
macroglossia, delayed tooth eruption and mental deficiency.
***NDHBE

15. Who it affects Most common in whites, and least common in blacks
Two to eight times more likely in women, than men
Common in women 60 years and older
Someone with and autoimmune disease or family background of an autoimmune disease
Past treatment of radioactive iodine
Anti-thyroid medications
Radiation to head or neck
Thyroid surgery
Been pregnant or delivered baby within past 6 months

16. Causes of disease
In United States most common cause is from Hashimoto thyroiditis – body sees thyroid as antigen and chronic immune reaction occurs, resulting in destruction of thyroid gland and under production of the hormone
Other causes of disease but not as common are:
Treatment of hyperthyroidism
Thyroid surgery
Radiation to head or neck
Medications
Pituitary disease
Pregnancy
Congenital disease
Congenital thyroiditis is caused by defect in genes that determine how the thyroid synthesizes the hormone

17. Diagnosis and treatment
Hypothyroidism
Older women may have screenings at regular annual exams
Some doctors recommend screenings on women or are pregnant or plan on becoming pregnant
If patient displays and signs or symptoms they may be screened
Diagnosed through blood tests that measure thyroxine in bloodstream called TSH test
Most common treatment is through synthetic hormone called levothyroxine (synthroid)***NDHBE
Treatment is typically lifelong, and over time will decrease the symptoms of the disease
Doctor will continue to do annual TSH tests to help manage dosage of medication

18. Signs and symptoms and Oral manifestations
May affect head and mouth
Can cause edema of face, and lips, enlarged gingival tissue, and macroglossia
Patient may experience pharyngeal edema, causing coarse, raspy voice
Delayed exfoliation of primary teeth, and delayed eruption of primary and permanent teeth.

19. Treatment considerations
Hypothyroidism
Etiology of gingival edema should be evaluated, if no caused is found a referral should be made to patients doctor
Delayed exfoliated and eruption may cause pseudodontia, consult with dentist for further treatment options
Patients are susceptible to infection, and poor healing. Monitor patients on healing and tissue response
Patients are sensitive to barbiturates, and CNS depressants, if the medications are indicated use with caution

20. Barriers to care Hypothyroidism
Patients may state they are too tired to come to dental visits
Patients may also state they are too tired to perform proper home care
Patients may experience weakness throughout body which may cause them to not care for their teeth properly
Gingival enlargement may cause fear or hesitation to see dentist

21. Oral hygiene instructions
Hypothyroidism
Discuss and find cause of gingival overgrowth
Educate patient on proper care of gingival tissue to prevent colonization of bacteria
Educate on periodontal disease, and caries processes
Discuss importance of good homecare even if patient may be too tired to do so
Discuss the importance of cleaning tongue and all sides of teeth if swollen tongue may get in the way

22. References
Chandna, S., & Bathla, M. (2011, July 1). Oral manifestations of thyroid disorders and its management. Retrieved May 16, 2015, from
DeLong, L., & Burkhart, N. (2013). Endocrine Disorders. In Oral Pathology for the Dental Hygienist (2nd ed., pp ). Philadelphia, Pennsylvania: Christopher Johnson.
Hyperthyroidism (overactive thyroid). (2012, November 20). Retrieved May 15, 2015, from conditions/hyperthyroidism/basics/definition/con
Hypothyroidism (underactive thyroid). (2012, December 1). Retrieved May 15, 2015, from conditions/hypothyroidism/basics/treatment/con
Little, J., Falace, D., Miller, C., & Rhodus, N. (2013). Thyroid Diseases. In Dental Management of the Medically Compromised Patient (8th ed., pp ). St. Louis, Missouri: Mosby Elsevier