Hyperthyroidism (Graves Disease) Fact Sheet

Dan Boboia, DDS

What is it?

A hypermetabolic state that results from excess synthesis and release of thyroid hormone from the thyroid gland. This comes as a result of a disruption of the homeostatic mechanisms that normally adjust hormone secretion to meet the needs of peripheral tissues.

Epidemiology

0.5 – 1% in general population

95% of all cases in children are due to Graves Disease

Majority of cases occur during adolescence

Etiology

The cause is unknown; it results from the presence in plasma of an abnormal thyroid stimulator called the long acting thyroid stimulator or LATS; an immunoglobulin or family of immunoglobulins directed against the TSH receptor mediates thyroid over-stimulation

Graves Disease

• Most common form of hyperthyroidism
• Thyroid gland over activity
• Autoimmune disease
• 5 x more common among women than men
• Associated with eye disease (Graves opthalmia) and skin lesions (dermopathy)

**Graves opthalmia is a condition caused by inflammatory / fatty infiltrate of the orbital content resulting in a protrusion of the globe; creates a "frightened look".

**Dermopathy is a thickened layer of dermis observed over the dorsum of the legs and feet.

Hyperthyroidism

• XS intake of thyroid hormones
• Pituitary gland tumor (xs TSH secretion)
• Adenoma: masses of thyroid cells which will trap xs iodine producing xs thyroid hormones; 90% are benign
• Toxic Multinodular Goiter: also known as Plummers Disease; multiple masses of overactive thyroid glandular tissue
• Thyroiditis: inflammed thyroid
• XS Iodine intake
• Metastatic thyroid cancer

Complications / Signs / Symptoms

• Osteoporosis
• Atrial fibrillation
• Hypertension
• CHF

Thyrotoxic crisis / Thyroid Storm

• Extreme restlessness, nausea, vomiting, abdominal pain
• Fever, profuse sweating, tachycardia, cardiac arrhythmias, pulmonary edema,
• Stupor, coma
• Severe hypotension
• Death

Diagnosis

• Symptoms: rapid heart rate, intense fatigue, inability to tolerate a hot environment, irritability, nervousness
• Physical signs: weight loss, tachycardia, hand tremors, xs sweating
• Blood Tests: high levels T3 and T4 low level of circulating TSH
• Diagnostic scan: RAIU—radioactive iodine uptake test

Medical Treatment

• Antithyroid drugs: propylthiouracil, methimazole, carbimazole
• Radioactive Iodine (I-131): often results in hypothyroidism
• Thyroidectomy

Oral Findings

• Osteoporosis involving alveolar bone
• Dental caries and periodontal disease appear more rapidly in these patients
• Teeth and jaws develop more rapidly
• Premature loss of deciduous teeth with early eruption of permanent teeth
• Euthyroid infants of hyperthyroid mothers have been reported with erupted teeth at birth
• Damaged salivary gland (secondary to radioactive iodine)

Growth in children with chronic lung disease

Resident’s Name: Derek Banks Date: May 29, 2009
Article title: Growth in children with chronic lung disease
Author(s): P Davis, C Kercsmar
Journal: New England Journal of Medicine
Volume (number):
Month, Year:
Major topic: Hospital Dentistry
Minor topic(s): Growth Hormone
Type of Article: Opinion Paper
Main Purpose: Evaluate effect of chronic lung disease and its treatment on others.
Overview of method of research: Review of current literature.
Findings: In patients with severe lung disease, a trend has been noted that patients have decreased stature. Etiology of this failure to develop is not entirely known, but there are theories that the symptoms are idiopathic, others claim it may be due to inhaled or oral corticosteroids used in these patients. Still others claim that the CFTR failure might lead to the problem
Key points/Summary :
Assessment of article: Good summary.

Growth Hormone Deficiency

Resident’s Name: Derek Banks Date: May 29, 2009
Article title: Growth Hormone Deficiency
Author(s):
Journal: Pediatric Medicine Textbook
Volume (number): Page 811-814
Month, Year:
Major topic: Metabolic Disorders
Minor topic(s): Growth Hormone Deficiency
Type of Article: Textbook
Main Purpose: Discuss the implications of growth hormone deficiency
Epidemiology: Sometimes idiopathic, other times a genetic link can be found – thought to be autosomal recessive. GH deficiency is 4x more common in boys than girls, and may be linked to abnormal deliveries or history of perinatal asphyxia. Patients with GH deficiency usually appear normal at birth with appropriate weight and length. Impairment of linear growth first manifests itself in the first or second year of life. Growth of the facial bones is slowed, making size discrepancy between face and calvaria. Dental development delays can occur as well. Obesity is common among these patients.
Diagnosis: Diagnosis is based on basis of growth data. Also, serial blood draws may reveal abnormal production of Growth/other hormones at different times throughout the night. A number of chemical/metabolic stimuli exist that can elicit a release of growth hormone.
Treatment: Ask Manny, Arnold, or Lance…..
Assessment of article: Good summary.

Pediatric responsibilities for preoperative evaluation

Resident’s Name: Derek Banks Date: May 29, 2009
Article title: Pediatric responsibilities for preoperative evaluation
Author(s): Q Fisher, M Feldman, M Wilson
Journal: Journal of Pediatrics
Volume (number): 125:675-685
Month, Year: 1994
Major topic: Hospital Dentistry
Minor topic(s): Preoperative evaluation
Type of Article: Opinion Paper
Main Purpose: To explain the role of the pediatrician in the preoperative evaluation prior to procedures under general anesthesia
Overview of method of research: Subjective review of understanding among pediatricians of their role in the preoperative evaluation and suggestions for more thorough evaluation and communication between pediatrician and anesthesia provider.
Findings: Many pediatricians do not fully understand their role in the preoperative evaluation. Many will merely write that the patient is cleared for surgery without disclosing important health information that may be essential for proper management of the pediatric patient undergoing anesthesia. One thing that can easily go unreported by a child’s pediatrician is stable or self-limiting conditions such as asthma, asymptomatic heart murmur, well-compensated hemoglobinopathy, prior exposure to chemotherapy, or mild symptoms of upper respiratory tract infection. This study cites a 1988 study showing that the risk of serious injury or death resulting from anesthesia complications in the pediatric population is around 1:20,000 to 1:100,000. This paper states that preoperative evaluation is a three-part process, including 1. evaluation of current state of health with comparison to baseline, 2. assessment made of child’s ability to handle stresses of anesthesia and proposed surgery, and 3. measures to achieve optimal medical conditions in accord with the urgency of surgery are undertaken. A thorough medical history should be done, including family history. The child should be prepared psychologically for the anesthesia experience. A multisystem physical exam should be performed by the pediatrician and pertinent information given to the anesthesia team. Some other highlights were as follows: patients with URI can sometimes be seen, if no signs of systemic illness (e.g. fever) and no signs of tracheobronchial inflammation. If these symptoms are present, tx. should be delayed at least 4 weeks. For patients with seizure disorders medications can be taken the morning of the procedure. 10-35% of patients with spina bifida become sensitized to latex. Malignant hyperthermia shows autosomal dominant tendency, so family history is very important. Patients with T21 may have atlantoaxial instability. Diabetic patients best scheduled first thing in the morning. Preoperative bloodwork is not necessary for the otherwise healthy pediatric population
Key points/Summary : That about sums it up…
Assessment of article: Good summary. We should send it to every pediatrician we know.

Cystic Fibrosis: A Current Review

Department of Pediatric Dentistry

Lutheran Medical Center

 

Resident’s Name:  Chad Abby                                    Date: 5/29/2009

Article title:  Cystic Fibrosis:  A Current Review

Author(s): Gerald Fernald, Michael Roberts, Thomas Boat

Journal:  Pediatric Dentistry

 Volume (number): Vol. 12, No. 2

Month, Year:  1990

Major topic:  Cystic Fibrosis

 Minor topic(s:  Cystic Fibrosis

Type of Article:  Theme article

Main Purpose:  To gain a better understanding of and the oral implications of cystic fibrosis

Findings:  Oral implications associated with Cystic fibrosis include enamel hypoplasia and tooth discoloration, salivary glands involvement, reduced incidence of dental caries, reservoir for potentially pathogenic respiratory bacteria, mouth breathing and anterior open bite associated with nasal and sinus obstruction.  Patients with CF require routine dental care similar to that of the general population.  Unless acutely ill, the CF patient can and should receive regular dental care.  Often children with CF do not manifest symptoms for several years, although now 70% are identified by age two.  Most infants are diagnosed because of persistent loose, bulky, oily stools, failure to thrive, and or recurrent pneumonia.  CF patients are often taking antibiotics for treatment of their lung infection and it is important to know that patients of CF are not immune deficient.  The frequency of sugar-containing food consumption generally is greater in children with CF to maintain elevated caloric and salt intake however the caries incidence is reportedly lower.  It is also observed that there is less dental plaque and gingivitis in CF patients.  The reduced caries incidence may be due to the effects of long term antibiotic and pancreatic enzyme replacement therapy on the oral microbiota.  The elevated calcium content and buffering capacity of the whole saliva may also play a role, which favors an increased prevalence of dental calculus on the teeth.  Dental appointments should be kept short and the patient may prefer to be maintained in an upright sitting position while being treated.  The use of any agent that interferes with pulmonary function, such as narcotic analgesics and sedatives, should be avoided.  Nitrous also is contraindicated in patients exhibiting evidence of emphysema and should be used only after consultation and concurrence by the patient’s physician.  Regular professional care and good home oral hygiene habits are extremely important in CF patient management. 

Key points/Summary :  Cystic fibrosis is the most common of the severe genetic disorders seen in Caucasians.  Defective exocrine gland secretions due to abnormal water and electrolyte transport across epithelial cells, result in chronic disease of the respiratory and gastrointestinal systems.  CF is an autosomal recessive disorder ranging from 1:1700 in incidence.  The classic CF phenotype includes chronic progressive pulmonary disease, pancreatic insufficiency with steatorrhea and failure to thrive, excess sweat electrolyte content, male sterility and decreased female fertility.  Most of the clinical manifestations of CF are produced by abnormal secretions causing sticky or thickened mucous secretions that can lead to respiratory malfunction or obstruction.  Inadequate hydration is partly responsible for problems with clearance of mucous from airways.  Respiratory failure is the most common cause of death.  The diagnostic criteria for CF include a sweat chloride level grater than 60 meq/L, chronic obstructive pulmonary disease, exocrine pancreatic insufficiency, and a familial history of CF.  At least two of these criteria are necessary for diagnosis. 

Assessment of article:   Great overview of cystic fibrosis

Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Department of Pediatric Dentistry

Lutheran Medical Center

 

Resident’s Name:  Chad Abby                                    Date: 5/29/2009

Article title:  Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Author(s): Howard Needleman, Sandhya Harpavat, Sam Wu, Elizabeth Allred, Charles Berde

Journal:  Pediatric Dentistry

 Volume (number): Vol. 30, No. 2

Month, Year:  2008

Major topic:  General Anesthesia

 Minor topic(s:  Postoperative pain of dental rehabilitation performed on children under GA

Type of Article:  Scientific Article

Main Purpose:  The purpose of this study was to determine the prevalence, severity and variables influencing postoperative pain and other sequelae in children undergoing dental rehabilitation under general anesthesia. 

Methods:  Healthy children scheduled for dental rehabilitation having treatment only on primary teeth were included in the study.  General anesthesia protocol was standardized and patients did not receive local anesthesia intraoperatively.  Pain and other postoperative sequelae were recorded for seven days postoperatively. 

Findings:  95% of the 90 children had postoperative pain which was moderate in intensity and highest immediately postoperatively.  Children who had an extraction or were at least 4 years old and had more then 12 procedures experienced, increased postoperative pain.  The most common postoperative symptoms other than pain were agitation, need for analgesics, and sleepiness.  Longer operative times resulted in increased postoperative sleepiness.  Children whose tracheal intubations were traumatic were more likely to report sore throats.  Children who were at least 4 years old required more analgesics, experienced more postoperative sleepiness and had nausea more frequently.  All postoperative problems significantly decreased by day 2 postoperatively and ceased by day four to five. 

Key points/Summary :  Children undergoing dental rehabilitation under general anesthesia commonly experience postoperative symptoms such as pain, agitation, need for analgesics, and sleepiness.  Children who have longer operative times are more likely to experience postoperative sleepiness.  This study used no intraoperative local anesthesia nor were there any standard orders for the use of postoperative analgesics to be given in the recovery room, which may explain why the children in this study had the highest rate of reported pain compared with other previous studies.  It was also found that children of less-educated parents were more likely to report pain in both the preoperative and PACU periods. 

Assessment of article:  Dentists often have limited contact with children immediately following treatment under general anesthesia so it is important to explain to parents what to expect and how to manage and reduce children’s postoperative emotional and physical distress.  The results were somewhat surprising to me considering how few parents tell us there children have postoperative pain or nausea following dental rehabilitation after general anesthesia.  Possibly parents feel more comfortable expressing pain or discomfort on questionnaires they fill out?  This is something the article mentioned in that the type of pain scale used was more of a self assessment scale. 

Impact of Advances in Diabetes Care on Dental Treatment of the Diabetic Patient

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Anna Haritos Date: May 29, 2009
Article title: Impact of Advances in Diabetes Care on Dental Treatment of the Diabetic Patient
Author(s): Mealey, Brian L.
Journal: Compendium
Volume (number): 19 (1)
Month, Year: Jan 1998
Major topic: dental treatment and diabetes
Minor topic(s):
Type of Article: review
Main Purpose(s): 1) to review findings of the Diabetes Control and Complications Trial(DCCT) 2) diabetes treatment regimens that might be encountered in a dental practice 3) and potential alterations to dental treatment protocols
Findings: DCCT began in 1985 as a prospective, randomized, controlled, multi-center clinical trial; DCCT was designed to compare the effects of intensive insulin therapy with the effects of conventional insulin therapy on microvascular complications of insulin-dependent DM. The patients were followed 6.5 years on average. The results of the study found that intensive insulin treatment could lad to improved glycemic control which could then inhibit the onset and delay the progression of microvascular complications of insulin-dependent DM. The DCCT result caused physicians to intensify insulin regiments for insulin dependent DM patients.
Sulfonylureas - stimulate pancreatic beta cells to secrete insulin; patient must eat properly to avoid hypoglycemia;
Metformin, lowers blood glucose by preventing liver conversion of glycogen to glucose; rarely causes hypoglycemia.
Troglitazone, increases tissue sensitivity to insulin; hypoglycemia is rarely associated with hypoglycemia
Acarbose, an alpha-glucosidase inhibitor, slows the digestion and uptake of carbs from the gut.
Daily insulin routines encountered by dental practitioner include (1) single injection of intermediate acting insulin; (2) single injection of intermediate acting insulin mixed with regular or lispro insulin (3) twice daily injection of intermediate acting insulin or (4) twice daily injections of intermediate-acting insulin mixed with regular or lispro insulin
Dentist should ask patients to bring their glucometer to the dental office to check their blood glucose prior to starting the appointment. Patients on intensive treatment plans may test their blood glucose 4 or more times daily; a low reading indicates the need for a snack, a high reading indicates a need for insulin injection. If patient has a low or at the low end of normal blood glucose reading (below 60 mg/dl), it might be important for them to have a carbohydrate before starting, especially if the appointment will be lengthy.
Signs and symptoms of hypoglycemia: confusion, shakiness, tremors, agitation, sweating, tachycardia
Treatment for hypoglycemia: 15 g of oral carbohydrate (4-6 oz of juice or soda), tube of icing;
Hyperglycemic crisis is much less common in dental office – prolonged hyperglycemia may result in diabetic ketoacidosis in insulin dependent patients or hyperosmolar nonketotic diabetic acidosis.
Key points/Summary: : Healthy persons have blood glucose levels within range of 60 mg/dl to 150 mg/dl. Five complications classically associated with DM include retinopathy, nephropathy, neuropathy, macrovascular disease, and impaired wound healing. Primary assay of long term DM control is HbA1c, which reflects blood glucose concentrations over the past 6-8 weeks. Most common complication of DM insulin regimens: hypoglycemia. Most common causes of hypoglycemia: excess insulin injection, skipping meals/snacks, increasing exercise without adjusting food or insulin, consuming alcohol and confusing hypoglycemia signs with intoxication and stress.
Assessment of article: very good resource article

Recurrence of Early Childhood Caries after Comprehensive Treatment with General Anesthesia and Follow-up

Resident’s Name: Laura Randazzo Sabnani Date: 5/29/2009

Article title: Recurrence of Early Childhood Caries after Comprehensive Treatment with General Anesthesia and Follow-up

Author(s):  Forester, T et el.

Journal: J. Dent for Children

Volume (number): 73:1

Month, Year:  2006

Major topic / Main purpose: To determine the likelihood of new caries in children with ECC after comprehensive treatment under GA.  Also, to determine if immediate follow-up can prevent relapse.  

Methods and Materials:  193 patients who had returned for at least one 6 MRC visit or appeared for an emergency visit 6-24 months following the surgery.  

Results:  53.4% of the children had developed new carious lesions in the 6-24 month postoperative period.  46.6% had new caries in only the primary dentition 12% had new caries in only the permanent dentition, and 5% had caries that involved both dentitions.  New carious lesions were less likely in patients that returned for their immediate two week follow-up 19.7% vs. children who did not attend 33.7% although this association was found not to be statistically significant.  

Keypoints/Summary:  Following treatment in the O.R 61% of children failed to show up for the post operative appointment.  53% of the children developed new caries within 2 years.  

Assessment of article:  Interesting...It seems like we are fighting a losing battle.

The Efficacy of Preoperative Analgesic Administration for Postoperative Pain Management of Pediatric Dental Patients

Resident’s Name: Laura Randazzo Sabnani Date:5/29/2009

Article title:The Efficacy of Preoperative Analgesic Administration for Postoperative Pain Management of Pediatric Dental Patients

Author(s): Primosch, R et al.

Journal: Anesthesia and Pain Control in Dentistry

Volume (number):2, No 2

Month, Year:  1993

Major topic :  Preoperative pain management in children

 Main purpose: To access the effectiveness of preoperative administration of acetominophen  upon post operative pain and to access the frequency of postoperative analgesics used following various dental procedures in children aged 4-10 years. 

 Methods and Materials:  60 patients were split equally into resorative and extraction procedures and then each group was subdivided into a preoperative acetominophen group and a placebo group.   Inclusion criteria was no history of mental or systemic illness, currently not taking any medications, age 4-10 years, at least one dental extraction or restorative procedure needed, and parent or guardian available to evaluate postoperative condition for atleast 6 hours following procedure.  The parents were asked to wait one hour before reporting and then reported every hour for six hours following the procedure whether or not pain related behaviors were observed and timing of analgesic administration if given. 

Result/Summary:  The results showed that regardless of the procedure being performed there was a high prevalence of post operative pain.  There was not a statistically significant difference in the acetaminophen group vs. the placebo group given preoperativelly for postoperative pain.  

Assessment of article:  Good article 

An update in diabetes mellitus

Department of Pediatric Dentistry
St Joseph Hospital

Resident’s Name: Craig Elice Date: May 29, 2009
Article title: An update in diabetes mellitus
Author(s): Dahms, WT
Journal: Pediatric Dentistry
Volume (number): 13(2)
Month, Year: 1991
Major topic: Discussion of dental implications of diabetes
Minor topic(s): n/a
Type of Article: review article
Main Purpose: Reviews concepts of Diabetes Mellitus and its treatment and implications in dentistry
Overview of method of research: Type I (aka Insulin Dependent Diabetes Mellitus-IDDM) affects mostly children with only 10% having onset over 21. It affects 1 in 700 children at 16 years of age. Treatment consists of two injections of NPH or insulin per day. The Beta cells of the islets in the pancreas are destroyed by the body’s autoimmune system over at least several years before symptoms appear. Symptoms include significant variables in blood sugars and both hypoglycemia and ketoacidosis.
Type II or adult onset diabetes is more common affecting 5 % of the population, mostly affecting patients over 40, and is related to obesity and a positive family history. It can be controlled by diet or hypoglycemic agents. Normal number of islets are noted but they are sluggish.
Several advances in the management of diabetes have occurred. Self blood glucose monitoring allows patients to monitor blood glucose levels during daily activity. Insulin pumps permit more predictable blood glucose control. Highly purified insulin prevents allergic reactions. Different techniques have been developed to determine the success of regulating blood glucose control. These include blood glycosylated hemoglobin in the form of total glycosylated hemoglobin, GgA1c, and HgA1. Treatment investigations under review include immuno-suppression to prevent an autoimmune response.
Dental implications: Diabetes does not increase the risk of dental decay. However, the frequency and severity of periodontal disease increased with age. Gingival inflammation appears related to patients with diabetes who have poor metabolic control. It is uncertain if chronic inflammation is related to decreased salivary flow, elevated salivary glucose concentration, or poor oral hygiene. There is some speculation that hyperglycemia can produce neutrophil dysfunction. Patients with diabetes have chronic hyperglycemia which causes poor neutrophil function and may make the diabetic patient more susceptible to periodontal disease.
Dental Treatment: In case of limited ability to eat, patients should have ready access to rapidly acting carbohydrates like sugar, orange juice, candy bars, etc. In general anesthesia cases, modifications should be made in cases of long periods of fasting like early AM surgeries, larger bedtime snacks, or less NPH before dinner and lastly postponement of AM insulin until after surgery.
Assessment of article: good summary, but needs updating.

Hypothyroidism

Kris Hendricks, LMC/St. Joseph Hospital
Literature Review

Hypothyroidism Facts Sheet

Primary

• 95% of cases
  
• Congenital hypothryoidism
  
• Thyroid agenesis
  
• Dysplasia
  
• Cretenism affects 1 in 3500 newborns
  

Acquired primary hypothryoidism

• Hashimoto thyroiditis autoimmune disease--most common cause after age 8
  
• Teratogenic drug induced
  
• Iodine deficiency: very common in developing countries
  
• Radiation destruction
  
• Surgical removal
  
• Idiopathic
  

Secondary

• 5% of cases
  
• Pituitary or hypothalmic dysfunction
  
• congenital hypopituitarism
  
• Pituitary necrosis
  

Course of disease

• Generalized reduction in metabolic function, most often manifested as slowed physical and mental activity
  
• In very young infants, it can cause irreversible mental retardation and slowed physical growth

Prognosis: 

good, with very early treatment, but 3 of 4 infants with hypothyroidism will have lower IQ later in life despite early treatment.

Complications

• myxedema coma, mental dysfunction, stupor, cardiovascular collagse
  
• anemia, dilutional hyponatremia, hyperlipidemia
  
• impact on growth and development affecting CNS, skeletal, GI, repoductive, etc. 
  

Diagnosis:

• Good med hx and assay of TSH and free T4 levels. 
  
• Congenital usually first found in neonatal screenings, but lab errors--or lack of neonatal screenings could lead to later diagnosis relying on clinical signs. 
  
• Acquired is usually presents with growth deceleration first or maybe goiter
  

Treatment:

• Depends on underlying cause
  
• Replacement thyroxine (levothyroxine), orally
  

Oral Findings:

• enlarged tongue
  
• delayed dental development and eruption
  
• malocclusion
  
• gingival edema
  
• delayed skeletal development
  
• protruding tongue and thick lips
  

Dental management:

• Good medical history
  
• sensitivity to stress, infection, surgery
  
• sensitivity to some drugs like sedatives and opioid analgesics
  
• myxedema coma signs include hypothermia, bradycardia, hypotension, seizures
  
• consult with physician
  

Hyperthyroidism (Graves Disease) Fact Sheet

Hyperthyroidism (Graves Disease) Fact Sheet

Dan Boboia, DDS

 

What is it?

 

A hypermetabolic state that results from excess synthesis and release of thyroid hormone from the thyroid gland.  This comes as a result of a disruption of the homeostatic mechanisms that normally adjust hormone secretion to meet the needs of peripheral tissues.

 

Epidemiology

 

0.5 – 1% in general population

 

 

Etiology

The cause is unknown; it results from the presence in plasma of an abnormal thyroid stimulator called the long acting thyroid stimulator or LATS; an immunoglobulin or family of immunoglobulins directed against the TSH receptor mediates thyroid over-stimulation

 

Graves Disease

• Most common form of hyperthyroidism
• Thyroid gland over activity
• Autoimmune disease
• 5 x more common among women than men
• Associated with eye disease (Graves opthalmia) and skin lesions (dermopathy)

Hyperthyroidism

• XS intake of thyroid hormones
• Pituitary gland tumor (xs TSH secretion)
• Adenoma
• Toxic Multinodular Goiter
• Thyroiditis
• XS Iodine intake
• Metastatic thyroid cancer

 

Complications / Signs / Symptoms

• Osteoporosis
• Atrial fibrillation
• Hypertension
• CHF

 Thyrotoxic crisis:

• Extreme restlessness, nausea, vomiting, abdominal pain
• Fever, profuse sweating, tachycardia, cardiac arrhythmias, pulmonary edema,
• Stupor, coma
• Severe hypotension
• Death

Diagnosis

• Symptoms: rapid heart rate, intense fatigue, inability to tolerate a hot environment, irritability, nervousness
• Physical signs: weight loss, tachycardia, hand tremors, xs sweating
• Blood Tests: high levels T3 and T4 low level of circulating TSH
• Diagnostic scan: RAIU—radioactive iodine uptake test

Medical Treatment

 

• Antithyroid drugs
• Radioactive Iodine
• Thyroidectomy

 

Oral Findings

• Osteoporosis involving alveolar bone
• Dental caries and periodontal disease appear more rapidly in these patients
• Teeth and jaws develop more rapidly
• Premature loss of deciduous teeth with early eruption of permanent teeth
• Euthyroid infants of hyperthyroid mothers have been reported with erupted teeth at birth
• Damaged salivary gland (secondary to radioactive iodine)

 

 

Reasons for Repeat Dental Treatment Under GA

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Anna Haritos Date: May 22, 2009
Article title: Reasons for Repeat Dental Treatment Under General Anesthesia for the Healthy Child
Author(s): Sheller, et al
Journal: Pediatic Dentistry
Volume (number): 25:6
Month, Year: Nov-Dec, 2003
Major topic: Repeat GA-based dental treatment
Minor topic(s): n/a
Type of Article: Research
Main Purpose: to investigate the reasons why healthy children required repeat dental treatment under GA
Overview of method of research: A retrospective chart review of 23 patients (ASA I, II, two GA-dental tx) was conducted between Jan 19990 and Mar 2000; these charts were labeled subjects and were matched demographically with 23 ‘control’ charts of one-time GA-dental tx patients; Parents/guardians of these subjects and controls were recruited for questionnaire/interview session – 11 subject parents and 9 control parents participated;
Findings: The chart review found that repeat patients were mostly male, with mean age of first GA-treatment at 2.6 yrs, and mean age second GA-treatment 4.7 years. For both subjects and controls, Medicaid was the most common method of payment. At the initial visit, prior to any GA, no subjects cooperated for radiographs, while 40% of controls cooperated for radiographs. All of the subjects received central incisor treatment under GA while 76% of the controls received central incisor treatment. 7% of subjects versus 43% of controls returned for post-op visits. 39% of subjects developed caries on previously untreated/unerupted teeth versus 2% of the controls. Success of SSC were similar in both groups. Interview responses by parents revealed that subject patients had a hard time with injections in the medical setting versus controls; At the time of the first GA, more subjects than controls were bottle-fed with non-water fluids. All controls had an adult brushing their teeth at the time of the first GA versus 55% of the subjects. After the first GA treatment, 45% of subjects continued to use non-water bottle-feeding at nap and bedtime versus 11% of controls. Both subject and control parents did not change frequency of type of snacks given to their child before versus after GA treatment.
Key points/Summary: patient factors associated with need for second session of GA-dental treatment: 1)100% involvement of maxillary central incisors at time of initial GA; 2)continued use of the bottle at the time of GA; 3)poor cooperation in the medical/dental setting; 4) difficult personality as described by parent; 5) parents not brushing child’s teeth; 6) parent/child had dysfunctional social situation; 7) parents failed to bring child back for post-op visit;
Assessment of article : very good article

Perioperative Approach To Children

Department of Pediatric Dentistry
Lutheran Medical Center
Date: 05/22/2009
Article title: Perioperative Approach To Children
Author(s): Zuckerberg Aaron L.
Journal: Pediatric Anesthesia
Volume (number): 41 number 1
Month, Year: Feb 1994
Major topic: Pediatric Anesthesia
Minor topics: Outpatient surgery
Type of Article: Professional Paper

Main Purpose:
Review the importance of child management in the perioperative period.
Overview of method of research: Professional paper with review of literature.

Findings:
The current trend toward treating pediatric patients under general anesthesia in outpatient clinics means that anesthesiologists often have little contact with the patient outside of the OR. Therefore, the responsibility of the perioperative care falls on the pediatrician and referring doctor. Psychological preparation of the child and family is extremely important.

Key points/Summary :
Parental Anxieties: many things that are routine to health care providers can be very frightening to parents. It’s important to establish trust with parents and provide them factual help to allay fears.

Childhood anxieties: children have many strange ideas about what may happen to them when they are in surgery. Being “put to sleep” also has negative connotations for children ranging from punishment to their pet’s euthanasia. Using play and imagination to help the child manage the situation can be helpful.

Psychological consequences of anesthesia and surgery
acute: emergence can range from calm to very wild. Data show that children who have a calm induction are more likely to emerge quietly.
chronic: some children can experience behavior changes after surgery and anesthesia. This is not a concern unless it persists beyond 2 weeks. Anxiety is the most common behavior changes, but regression, interpersonal disturbances, sleep anxiety and eating disturbances have all been recognized.

Advantages of outpatient surgery: cost, minimal parent-child separation, rapid return to daily life, restoration of parental control, reduction of nosocomial infections.

The limitations of outpatient surgery: parents struggle to take time off work and may be poor at providing post-operative care. Fear of the unknown is less because the child spends more time in the hospital.

Induction: in most settings, parents are present for induction. Having the parent wear a gown and hat can help the child wear his own gown and hat. The anesthesiologist can also use time before the induction to create a relationship with the child. The author recommends puppet shows, magic tricks and creation of balloon animals.

Perioperative sedation: in the past nearly every child was premedicated. Having parent present for induction basically obviates the need for premedication. Also you want a good airway for induction, which is another reason not to premedicate. The anesthesiologists should also tailor the induction to account for any limiting factors.

Postoperative period: parents want to be with their children as soon as they come out of surgery to verify to themselves that the child has survived and to support the child in recovery. Usually parents are allowed to be involved once anesthesia has turned the child over to PACU. Adequate post surgery analgesia must also be accounted for.

Assessment of article: Good review of many factors involved in taking care of patients when any level of sedation is involved.

A survey of parents whose children had full-mouth rehabilitation under general anesthesia regarding subsequent preventative dental care

St. Joseph’s Lit. Review / 5-22-09

Dr. Dan Boboia

 

Title:

A survey of parents whose children had full-mouth rehabilitation under general anesthesia regarding subsequent preventative dental care

 

Authors:

Shehy, Evelyn et al.

 

Main purpose:

To evaluate by telephone interview the self-reported compliance of families with preventative dental care, including follow-up visits, for their children who had full-mouth rehabilitation under GA.

 

Methods and Materials:

77 patients who attended New England Medical center in Boston for dental treatment under GA were included in the survey.  Prior to GA preventive dental care and was given to parents and children.  Follow up was scheduled 1 week and 6 months after treatment.  44 of the 77 patients were interviewed by one investigator.  The remaining parents could not be contacted.  Data was collected from these 44 patient records.

 

Results:

• 30 males / 14 females
• Mean age was 4.5  years
• 24 patients had a history of nursing caries, 12 had behavioral management problems or patients requiring extensive treatment, and 8 patients were medically compromised

Dental Visits Following GA:

• 34 (77%) had regular 6-month dental appointments after GA
• 10 (23%) had not returned for a visit
• Whether the patient returned for recall was significantly related to the type of payment received (cash vs. Medicaid)
• 10 (23%) patients needed fillings or extractions since the GA procedure

Dietary Habits Since GA:

• 34 (77%) reported reducing the frequency of sugar consumption

• 10 (23%) reported no change

OH Practices Since GA:

• 30 (68%) Parents reported carrying out daily tooth brushing for their children

• 14 (32%) were allowed to brush their own teeth without help (unbelievable)

Discussion / Conclusions:

• Of the ten patients that required restorations or extractions at follow-up visits none required GA for treatment

• 77% of children surveyed returned for routine 6-month F/U
• More cash/insurance patients returned for routine recall visits than Medicaid (contrary to the findings to Enger who found no significant differences between these two groups in a previous study)
• 77% of parents reported reducing sugar consumption after treatment under GA
• 32% of the children were reported to brush teeth by themselves; it is generally accepted that preschool children lack the ability to brush their teeth adequately and that parental involvement is essential to improve efficiency
• 30% living in fluoridated areas used daily rinses or gels
• 21% of children surveyed used bottle and tap water for drinking purposes
• Caries risk patients identified from this study are patients who continued unfavorable eating patterns, had marginal fluoride exposure, and had unsupervised daily tooth brushing

 

 

Neutropenia

Resident’s Name: Chad Abby Date: 5/13/2009
Neutropenia:
Neutropenia is a hematological disorder characterized by an abnormally low number of a type of white blood cell called a neutrophil. Neutrophils usually make up 50-70% of circulating white blood cells and serve as the primary defense against infections by destroying bacteria in the blood. Hence, patients with neutropenia are more susceptible to bacterial infections and, without prompt medical attention, the condition may become life-threatening. A patient has chronic neutropenia if the condition lasts for longer than 3 months. It is sometimes used interchangeably with the term leukopenia. There are three general guidelines used to classify the severity of neutropenia based on the absolute neutrophil count (ANC) measured in cells per microliter of blood:
Mild neutropenia (1000 <= ANC < 1500) — minimal risk of infection
Moderate neutropenia (500 <= ANC < 1000) — moderate risk of infection
Severe neutropenia (ANC < 500) — severe risk of infection
Some common symptoms of neutropenia include fevers and frequent infections. These infections can result in conditions such as mouth ulcers, diarrhea, a burning sensation when urinating, unusual redness, pain, or swelling around a wound, or a sore throat. Causes can be divided into the following groups:
Decreased production in the bone marrow:
aplastic anemia
cancer, particularly blood cancers
certain medications
hereditary disorders (e.g. congenital neutropenia, cyclic neutropenia)
radiation
Vitamin B12 or folate deficiency.
Increased destruction:
autoimmune neutropenia.
chemotherapy treatments, such as for cancer and autoimmune diseases
Marginalisation and sequestration:
Hemodialysis
There is often a mild neutropenia in viral infections.
People with neutropenia are sometimes given antibiotics before they have major dental treatment. This helps protect them from infections. Generally, if your neutrophil count is less than 1,000, you will need antibiotics. Sometimes you may have to take the antibiotics for several days after treatment as well. If you have neutropenia or are taking medicines that can cause neutropenia, give your dentist an updated copy of your blood test results every time you visit.If there is a history of neutropenia or any of the conditions are occurring as expressed above then a blood test should be ordered before starting any dental treatment. According to hospital protocol any non-routine orders must be ordered by the child’s physician. It is necessary that you work closely with the child’s physician to avoid any unnecessary possible life threatening conditions.

The Clinical Presentation of Tuberculous Disease in Children

Department of Pediatric Dentistry
Lutheran Medical Center
Date: 05/14/2009
Article title: The Clinical Presentation of Tuberculous Disease in Children
Author(s): Waagner, DC
Journal: Pediatric Annals
Volume (number): vol 22:10
Month, Year: 1993
Major topic: Tuberculous
Minor topics: N/A
Type of Article: Review

Main Purpose: Review the differing presentations of tuberculous disease seen in children.

Overview of method of research: Not research, per se, rather a textbook style review. Perhaps a review of literature.

Findings:
In 1993, tuberculosis was on the rise. It must always be accounted for in the differential diagnosis of children with pulmonary infection. It should also always be considered when children present with persistent fever, wight loss, malaise, or failure to thrive.

Key points/Summary :
Early diagnosis is key to start therapy before the disease process begins.
Many patients remain asymptomatic in the early stages of the disease and are only diagnosed through a positive skin hypersensitivity test.
Even if asymptomatic, early chemotherapy and contact investigations should be initiated before disease progresses.
Endothoracic lymphadenopathy and endobronchial disease: chest xray shows collapse-consolidation lesions (segmental fan-shaped opacification)
Progressive primary pulmonary tuberculosis: a pulmonary focus enlarges into a caseous mass, children are usually very ill. Frequently moist rales are heard over the infected area.
Chronic pulmonary tuberculosis: uncommon in kids (mostly seen in adults) kids have cachectic appearance, supraclavicular adenopathy and moist rales ausculated over the pulmonary apical areas.
Pleural effusion: 8% of children, symptoms of fever, cough and weight loss, followed by acute onset of chest pain and shortness of breath. Fever is elevated for 1-2weeks and drops in the 3rd.

Extrapumonary tuberculosis
Miliary tuberculosis: most severe hematogenous tb. Infants are at highest risk. Symptoms vary but child is usually acutely ill and choroidal tubercles can be seen on ophthalmic exam in 13-87% of patients.
Tuberculous meningitis: most grave complication. Usually occurs over 3 weeks. Most patients exhibit resistance to neck flexion and may have bulging anterior fontanelle.
Superficial tuberculous lymphadenitis:most common extrapulmonary tb. Early complication occuring within 6 months of infection.
Skeletal tuberculosis: can be a complication of the primary infection, but may not manifest until 2-3 years afterward.
Most chronic pulmonary cases occur in children acquiring the primary infection after age 7.

Assessment of article: Great review, especially in light of our recent scares in the clinic

Etiology of Oral Habits

Resident’s Name: Joanne Lewis Date: May 1, 2009
Article title: Etiology of Oral Habits
Author(s): Ruben E. Bayardo, DDS, MS, et al
Journal: Journal of Dentistry for Children
Volume (number): 350
Month, Year: September/October 1996
Major topic: Oral habits in children
Type of Article: Chart review
Main Purpose: To determine general epidemiologic data of oral habits and some possible factors associated with them.
Overview of method of research: 1600 parental questionnaires regarding patients 2 to 15 years of age who were seen in a private pediatric dental practice in Guadalajara, Mexico from 1977 to 1992 were analyzed. Oral habits were classified by type: digital sucking, lip or tongue sucking, bruxism, onychophagia (nail biting), mouth breathing, and other. Other information, such as family structure and past and present illnesses, was also gathered and classified.
Findings: 56.8% of patients demonstrated some type of oral habit, with 23.7% presenting with onychophagia, 23.6% with bruxism, 11.7% with mouth breathing, 11.3% with digital sucking, 6.9% with lip or tongue sucking, and 2.4% with other habits. Girls showed a greater susceptibility towards the development of oral habits, as did only children. There was a statistically significant correlation between poor physical health, especially chronic conditions such as allergies, and oral habits.
Key points/Summary: Prevention and treatment of oral habits should be perceived as a behavior problem that affects the oral cavity. This problem is significantly influenced by family, social, environmental and biological factors and should be treated with a multidisciplinary approach.
Assessment of article: Large sample size makes for a good epidemiological study.