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.