Medical problem assignment

Hyperthyroidism
** :Etiology
The thyroid gland problems of primary
significance in oral surgery is
thyrotoxicosis because thyrotoxicosis is
the mostly thyroid gland disease in which
an acute crisis can occur ,thyrotoxicosis is
the result of an excess of circulating
triidothyronin and thyroxine ,which is
caused most frequently by Graves
disease :an autoimmune disease
characterized by the presences of thyroid
.stimulating antibodies
Hyperthyroidism slowly developing
disorder that can produce an altered state
of consciousness but rarly cause
emergency ,the most common
circumstance in which an ambulatory
relatively healthy –appearing patient
develops an emergency from thyroid
. dysfunction storm occur
Thyroid storm: sudden ,sever
exacerbation of hyperthyroidism that may
or may not have been previously
diagnosed ,thyroid storm can precipitated
by infection ,surgery , trauma ,pregnancy ,
or any other physiology or emotional
stress .other causes of hyperthyroidism
are multinoduler goiter or thyroid
.adenoma
Signs and Symptoms of hyperthyroidism*
include : tachycardia ,weight loss ,
diarrhea ,elevated blood pressure ,
exophthalmos , pretibial myxedema ,
brittle hair , hyperpigmentation of skin ,
tremors ,palpitations, if it is not
recognized early the patient can suffer
. heart failure
**Diagnosis:
The dentist may be able to diagnose
previously unrecognized hyperthyroidism
by taking a complete medical history and
performing a careful examination of the
patient , including thyroid gland inspection
and palpation . If sever hyperthyroidism is
suspected from the history and inspection ,
the gland should not be palpated because
that manipulating alone can trigger a crisis.
**The diagnosis can be established
by the presence of an increased free T4,
decreased TSH,
and the presence of thyroid-stimulating
antibodies..
.Patient suspected of having
hyperthyroidism should be referred for
medical evaluation before oral surgery.
**Medical treatment :

- The treatment of hyperthyroidism may

require several approaches,
although the development of thyroid storm
mandates a rapid and aggressive approach.
Many patients with hyperthyroidism
will have been treated with radioactive
iodine or thyroidectomy, which should
render them euthyroid or even
hypothyroid., These patients provide no
additional perioperative risk.
Others may have mild hyperthyroidism
that requires beta blockers and either
propylthiouracil (PTU) or methamizole to
reduce thyroxin secretion in the
perioperative period. A significant
concern for any patient with a history of
hyperthyroidism is the potential for thyroid
storm. It can develop quickly with fever,
tachycardia, hypertension, cardiac failure,
altered mental status, and death. Treatment
requires a prompt
diagnosis and the sequential administration
of beta blockers, PTU or methamizole, and
sodium iodide. One problem is that
the signs and symptoms that present may
be confused with malignant hyperthermia
(MH), neuroleptic malignant syndrome,
or pheochromocytoma. Additional
treatment includes hyperventilation to help
manage the hypercarbia secondary to
the hypermetabolic state and rapid cooling
to manage the increasing body
temperature. Decreasing ambient
temperature, cool intravenous fluids, and
cooling blankets may also be
needed.
**Dental treatment:

For either hypothyroidism or

hyperthyroidism, elective surgery should
be delayed until the treatment makes the
patient euthyroid as determined by thyroid
hormone levels.

Emergent or urgent procedures should be

undertaken without delay and the patients
should be monitored closely. The potential
need to supplement patients with thyroid
hormone, corticosteroids, and
cardiovascular support or the need to block
the production and effects of excess
thyroid hormone should berecognized
early.
Treatment of tyhrotoxic crisis begin **
:with
termination of any and notification of *1
those outside the office able to give
emergency assistance
Venous access should be obtained , *2.
crystalloid solution should be started at a
,moderate stage rate
and the patient be kept calm as *3
. possible
Attempts may be made to cool the *4
patient until transported to a hospital
where antithyroid and sympathetic
.blocking drugs can be administered safely
Atropine and excessive amount of***
epinephrine containing solutions should
be avoided if a patient is thought to have
.incompletely treated hyperthyroidism
 :HYPOTHYROIDISM
Hypothyroidism is typically characterized
by the progressive destruction of thyroid
tissue.
It occurs in Hashimoto’s thyroiditis in
which an autoimmune lymphocytic
infiltrate develops with antithyroid
peroxidase antibodies. Subacute thyroiditis
is also autoimmune and often follows a
flulike illness and presents with jaw pain
but is usually self-limiting and resolves in
a few months. Hypothyroidism
may also be iatrogenic, resulting from the
.medical treatment of hyperthyroidism

**:Signs and Symptoms

Fatigue ,weight gain ,cold intolerance ,
constipation, facial edema, delayed deep
tendon reflexes, altered mental status,
hoarseness, headache, menstrual
.disturbances, dry skin, fingernails
**Diagnosis:
Diagnosis established by observing a
decrease free thyroxin, and elevated
thyroid stimulating hormone level.
**Medical treatment :
The treatment of hypothyroidism requires
levothyroxine.
Myxedema is the only emergent
hypothyroid condition that can develop as
a result of :infection, surgery, medications,
or any other stressful event.

The diagnosis of acute myxedema is based

on a history of hypothyroidism and the
development of altered mental status,
seizures, coma, or hypotension. Treatment
requires immediate intravenous
levothyroxine and corticosteroids.
**:Dental treatment
Any patient who presents with acute
myxedema preoperatively requires
postponement of the surgery until
appropriate treatment has been rendered
and the patient made euthyroid..

References:
**Oral Maxillofacial Surgery

**Peterson's Principles Of Oral

Maxillofacial And Surgery