5.3 Hyperthyroidism
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 54‐year‐old female presents to you for a second opinion. She is unhappy about the appearance of her teeth which she feels look rough and discoloured.
Medical History
- Graves disease/hyperthyroidism diagnosed 4 weeks ago
- Atrial fibrillation – detected at the same time as the hyperthyroidism
- Gastro‐oesophageal reflux disease
Medications
- Propylthiouracil
- Dabigatran
- Omeprazole
Dental History
- Irregular attender; only attends if there are dental problems
- Good co‐operation; history of multiple fillings and dental extractions
- Brushes twice a day using hard bristle toothbrush to remove the staining
- Highly cariogenic diet, including consumption of tea with 3 spoons of sugar 4–6 times a day
- Likes to chew/suck on citrus fruits
- Also began eating black grapes several times a day since commencing propylthiouracil as she found this helpful with her symptoms of nausea
Social History
- Widowed housewife
- Lives with eldest daughter who works as a secondary school teacher and is responsible for transportation
- No alcohol or tobacco consumption
Oral Examination
- Mild goitre (Figure 5.3.1)
- Generalised pitted hypoplastic enamel and staining present on buccal surfaces of teeth (Figure 5.3.2)
Figure 5.3.1 Mild goitre (anterior and lateral view).
Figure 5.3.2 Pitted hypoplastic enamel and staining present on buccal surfaces of the anterior teeth.
Figure 5.3.3 Generalised moderate to severe tooth surface loss on the palatal and occlusal surfaces of the maxillary dentition.
- Generalised moderate to several tooth surface loss (erosion and attrition) with possible pulpal involvement of #11 (Figure 5.3.3)
- Temporary filling in situ #15
- Caries in teeth #17, #14 and #45
- Supragingival calculus present on the lingual surfaces of the lower incisors
- Generalised gingival recession
- Missing (due to extraction) teeth #16, #24, #36 and #37
Radiological Examination
- Orthopantomogram and long cone periapical radiograph #15 undertaken (Figures 5.3.4 and 5.3.5)
- Generalised bone loss (~60–70%)
- Patchy medullary radiolucency suggestive of osteopenia/osteoporosis
- Periapical radiolucency associated with the apex of tooth #15
Structured Learning
- What is ‘goitre’ and how does it affect your dental planning?
- Goitre is an enlarged thyroid gland which causes a swelling in the front of the neck that moves up and down on swallowing
- Thyroid function can be normal (euthyroid), which requires regular monitoring, or hyperactive (hyperthyroid)/hypoactive (hypothyroid), which both require active treatment
- The impact on dental planning is dependent on any associated abnormal thyroid function and complications associated with the enlargement (e.g. respiratory obstruction, cough, voice changes, dyspnoea, tracheal deviation or dysphagia)
- The patient believes that the appearance of her teeth has worsened due to hyperthyroidism. Is she correct?
- No – she has enamel pitting; this is a form of enamel hypoplasia which would have been caused at the developmental enamel matrix formation stage of the teeth
Figure 5.3.4 Orthopantomogram demonstrating patchy medullary radiolucency suggestive of osteopenia/osteoporosis.
Figure 5.3.5 Long cone periapical radiograph demonstrating periapical radiolucency associated with the apex of tooth #15.
- Defects are divided into 4 categories: pit‐form, plane‐form, linear‐form, and localised enamel hypoplasia
- Causes may include nutritional factors (malnutrition), some diseases (such as undiagnosed and untreated coeliac disease), hypocalcaemia, infection, abnormalities in amelogenesis
- Secondary staining (likely to be linked to increased daily consumption of black grapes) may have made the pitting more noticeable
- No – she has enamel pitting; this is a form of enamel hypoplasia which would have been caused at the developmental enamel matrix formation stage of the teeth
- What factors are likely to have contributed to the tooth surface loss?
- Erosion: gastro‐oesophageal reflux disease; dietary – highly acidic/citrus fruits; nausea/vomiting due to propylthiouracil
- Abrasion: use of a hard toothbrush
- Attrition: reduced occlusal table due to multiple missing teeth
- The patient is also concerned about persistent pain from the #15 and wants it extracted at the same appointment. What risk is associated with the propylthiouracil medication?
- Propylthiouracil has anti‐vitamin K activity and can cause hypoprothrombinaemia, leading to an increased risk of bleeding
- Furthermore, it is a thionamide and hence may cause a rare reaction of agranulocytosis (0.5% of patients) that can result in oral infections and inadequate wound healing
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