Oral Manifestations of Hypothyroidism: A Case Report

DISKUSI KASUS KONTROL ODON MANDIRI

Fasilitator : drg. Feni Istikharoh, M. Biomed

Hari/Tanggal : Rabu, 10 Februari 2021

Oleh :

Octaviana Widya Pangestika

NIM : 170160100111006

PROGRAM STUDI PROFESI KEDOKTERAN GIGI

FAKULTAS KEDOKTERAN GIGI

UNIVERSITAS BRAWIJAYA MALANG

2021

Hypothy
Case Report

Oral Manifestations of roidism:

Rupesh Gupta1, Kashish Goel2, JitendeR solanKi3, saRiKa Gupta4

A Case Report
DOI: 10.7860/JCDR/2014/8905.4379

ABSTRACT
Hypothyroidism can be due to thyroid failure (primary hypothyroidism) or pituitary or hypothalamic disease (secondary hypothyroidism). A 20-year-old female
patient reported with a complaint of the presence of milk teeth in mouth since 10-12 years. Intraorally, multiple retained decidious and missing permanent teeth
were present. Macroglossia was evident. Skeletal and dental malocclusion (class II) secondary to hypothyroidism was the clinical diagnosis. A comprehensive
treatment plan was formulated. We present this case so as to make the oral health professionals aware of this condition efficiently.

Keywords: Hypothyroidism, Oral manifestations, Impacted permanent teeth, Retained teeth, Thyroid disfunction

CASE REPORT and dental malocclusion (class II) secondary to

A 20-year-old female reported with a complaint of
presence of milk teeth in her mouth since 10-12
years and wanted to get them removed. History
revealed that patient had visited a local dental
practitioner for cleaning of her teeth 1 year back,
after which she was informed about the presence of
deciduous teeth and few missing permanent teeth in
the mouth. She also gave history of bleeding gums
on brushing since 3 years, which has decreased
now. So she visited us to get her teeth treated.
Medical history revealed that the patient was a
known case of controlled hypothyroidism since 5-6
years and was on regular medication for the same
(Tab. Thyronorm® 100mg once daily). The patient
also reported that she was mediocre in academics at
school. On general physical examination, the pulse
rate 76 beats/min, respiratory rate 16 breaths/min
and blood pressure as recorded was 120/78 mm Hg.
Intraoral examination revealed multiple retained
deciduous in relation to # 55, 65, 74, 75, 85 and
missing permanent teeth in
relation to #13, 14, 23, 24, 32, 33, 34, 35,45.
[Table/Fig-1a & b]. The upper and lower lips, buccal
and labial mucosa and palate were normal on
inspection and palpation. Gingiva was mildly
inflammed. Her tongue was larger in size and
macroglossia was evident with no taste changes.
The teeth in relation to #1 3, 14, 15, 23, 24, 25,
32, 33, 34, 35, 41, and 45 were congenitally missing.
Salivary flow was normal. Based on these features,
a clinical diagnosis of skeletal
hypothyroidism was made.
INVESTIGATIONS
After clinical examination, panoramic radiography
was done. The panoramic radiograph demonstrated
multiple unerupted permanent teeth #13, 14, 23, 24,
32, 33, 34, 35,45. [Table/Fig-2].
Complete hemogram showed normal picture. The
levels of serum calcium, serum phosphorus, and
serum alkaline phosphate were also within the
normal limits. T3 test: 3.60 nmol/l (1.30-3.20), T4
test: 201.5 nmol/l (66-181), TSH: 0.321 micro IU/ml
(0.27-4.2) and Creatine kinase activity was also
increased (212 units/L).
Differential Diagnosis
• Nutritional deficiency
• Cleidocranial dysplasia
• Rickets
• Renal failure
Treatment
Patient counseling was done after which the patient
was asked to get her recent report for thyroid
function test. One month later when all the test
values were within normal limits a multidisciplinary
treatment plan was formulated. This consisted of
oral prophylaxis,
 dentistry section
[table/Fig-1a]: Intraoral photograph of maxillary arch shows multiple retained deciduous in relation to # 55, 65 and missing permanent teeth in relation to #
14, 23, 24. [table/Fig-1b]: Intraoral photograph of mandibular arch shows multiple retained deciduous in relation to # 74, 75, 85 and missing permanent teet
relation to #32, 33, 34, 35,45. [table/Fig-2]: Orthopantamograph showing multiple unerupted permanent teeth 13, 14, 23, 24, 32,
33, 34, 35,45

20 Journal of Clinical and Diagnostic Research. 2014 May, Vol-

2 8(5): ZD20-ZD22
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 Primary • Autoimmune hypothyroidism: Hashimoto’s thyroiditis, atrophic thyroiditis
• Iatrogenic: 131I treatment, subtotal or total thyroidectomy, external irradiation of neck for lymphoma or cancer
• Drugs: Iodine excess (including iodine-containing contrast media and amiodarone), lithium, antithyroid drugs,
p-aminosalicyclic acid, interferon and other cytokines, aminoglutethimide
Congenital Hypothyroidism • Absent or ectopic thyroid gland
• Dyshormonogenesis,
• TSH-R mutation
• Iodine deficiency
• Infiltrative disorders: amyloidosis, sarcoidosis, hemochromatosis, scleroderma, cystinosis,
Riedel’s thyroiditis

Transient • Silent thyroiditis, including postpartum thyroiditis

• Subacute thyroiditis
• Withdrawal of thyroxine treatment in individuals with an intact thyroid after 131I treatment or subtotal thyroidectomy for Graves’ disease
Secondary • Hypopituitarism: tumours, pituitary surgery or irradiation, infiltrative disorders, Sheehan’s syndrome, trauma, genetic forms of combined pituitary hormone
deficiencies
• Isolated TSH deficiency or inactivity
• Bexarotene treatment
• Hypothalamic disease: Tumours, trauma, infiltrative disorders, idiopathic

[table/Fig-3]: Causes of the Hypothyroidism [3]

serial extraction and interceptive orthodontic procedures. Special

considerations were taken while prescribing medicines, for the
danger of precipitating myxoedema coma due to opioid
analgesics. Blood pressure was monitored on every visit and
povidine iodine was avoided. Keeping all these points in view full
mouth oral prophylaxis were performed for the patient followed
by serial extraction of deciduous teeth under strict observation of
a paedodontist, oral and maxillofacial surgeon and an
orthodontist.
Outcome and Follow-Up
Once the patient recovered and healing had taken place,
interceptive orthodontic procedures were started. The patient is
on a regular visit to his physician for the treatment of
hypothyroidism.
DISCUSSION
Deficient thyroid hormone secretion leads to common oral findings like the
characteristic macroglossia, dysgeusia, delayed eruption, poor
periodontal health, altered tooth morphology and delayed wound
healing [1]. Childhood hypothyroidism known as cretinisim is
characterized by thick lips, large protruding tongue
(macroglossia), malocclusion and delayed eruption of teeth.
Macroglossia is due to increased accumulation of subcutaneous
mucopolysaccharides i.e., glycosaminoglycans due to the
decrease in the degradation of these substances [2].
Hypothyroidism has been frequently attributed to autoimmune
reaction, but it can transpire after the removal of excessive
thyroid tissue in the treatment of hyperthyroidism. Transient
hypothyroidism may occur in silent or subacute thyroiditis.
Subclinical (or mild) hypothyroidism is a state of normal thyroid
hormone levels and mild elevation of TSH; despite the name,
some patients may have minor symptoms. As the TSH level
increase and T4 level lowers the clinical symptoms of
hypothyroidism become more readily apparent. In areas of iodine
sufficiency, autoimmune disease and iatrogenic causes are most
common [Table/Fig-3] [3].
According to “UK Guidelines for the Use of Thyroid Function
Tests” in women, the prevalence of newly diagnosed overt
hypothyroidism increases from 0.3% in younger women to 2% in
women over 60 years [3].
Severe hypothyroidism, such as in the present case can have
deleterious effects on tooth development and eruption, and lead
to prolonged retention of the primary dentition, subnormal growth
of the maxilla and mandible with a marked reduction in the
dimensions of the facial complex, and a lack of coordination
between mandibular growth and dental development [4]. The
radiograph of the patient indicates that the growth of the
mandible and the maxilla was severely impaired. The effect on
the dentition to a great extent was limited to: retained primary
teeth, delayed eruption of permanent teeth and
distortion of the roots of the lateral incisors and first permanent molars.
On general examination, rough skin, delayed relaxation phase of
deep tendon reflex, hoarse speech and palor were noted. Similar
findings were seen in other case reports [5-7]. According to a study,
macroglossia, dry skin, constipation and forgetfulness were seen
in 82%, 97%, 66% and 61% patients respectively, suffering from
hypothyroidism [7]. All these findings were also seen in our patient.
Many studies have reported about weight gain, peripheral
oedema, puffy eyelids and diastolic hypertension [5-8]. None of these
findings were seen in our patient. This can be due to the fact that the
patient is a controlled hypothyroid and is regularly under
medication since years. There is reported literature on the
psychological symptoms or cognitive dysfunction, that patients
experience on long term intake of L-Thyroxine [9]. None of these
symptoms were reported by our patient. Keeping the assumption
that hypothyroidism will have typical signs and symptoms can be
hazardous since these are present in only 25-70% patients [7,8].
CONCLUSION
Oral manifestation of hypothyroidism is rare and dentists are
usually unaware of such conditions leading to misdiagnosis and
improper patient care. When such cases are encountered in
routine practice, hypothyroidism can be considered as a
differential diagnosis for commonly encountered nutritional deficiency
or rickets. Various factors such as lack of awareness about
hypothyroidism among the primary health care practitioners, the
unavailability and higher cost of the laboratory investigations play
vital role in limited diagnosis and management of
hypothyroidism.
REFERENCES
[1] Young ER. The thyroid gland and the dental practitioner. J Can Dent
Assoc.1989;55:903–7.
[2] Loevy HT, Aduss H, Rosenthal IM. Tooth eruption and craniofacial
development in congenital hypothyroidism: Report of case. J Am Dent
Assoc.1987;115:429–31.
[3] Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL.
Harrison’s Manual of Medicine. 16th ed. Endocrinology and metabolism. The
McGraw-Hill Companies, Inc. The United States of America. 2005; 815-22.
[4] Bedi R, Brook AH. Changes in general, craniofacial and dental development
in juvenile hypothyroidism. Br Dent J. 1984;157:58-60.
[5] Bhuvana G, Guha K, Alan P. The Diagnosis and Management of Hypothyroidism.
Southern Medical Journal. 2002; 95(5):475-80.
[6] Little JW. Thyroid disorders. Part II: hypothyroidism and thyroiditis. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology.
2006; 102(2): 148-53.
[7] Hueston WJ. Treatment of Hypothyroidism. American Family Physician. 2001;
64(10): 1717-24.
[8] Tachman ML, Gordon P. Guthrie JR. Hypothyroidism: Diversity of Presentation.
Endocrine reviews. 1984; 5(3): 456.
[9] Samuels MH, Schuff KG, Carlson NE, Carello P, Janowsky JS. Health Status,
Psychological Symptoms, Mood, and Cognition in L-Thyroxine-Treated
Hypothyroid Subjects. Thyroid. 2007;17(3): 249-58.
 Rupesh Gupta et al., Oral Manifestations of Hypothyroidism
Journal of Clinical and Diagnostic Research. 2014 May, Vol-8(5): ZD20-ZD22 21
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Rupesh Gupta et al., Oral Manifestations of Hypothyroidism

 PARTICULARS OF CONTRIBUTORS:
1. EX-PG Student, Department of Orthodontics, Kothiwal Dental College, Moradabad, Uttarpardesh, India.
2. EX-PG Student, Department of Prosthodontics, Kothiwal Dental College Moradabad, Uttarpardesh, India.
3. Assistant Professor, Department of Public Health Dentistry, Vyas Dental College & Hospital, Kudi Haud, Pali Road Jodhpur, Rajasthan, India.
4. PG Student, Department of Oral Medicine and Radiology, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Jitender Solanki,
Assistant Professor, Department of Public Health Dentistry, Vyas Dental College & Hospital, Kudi Haud, Pali Road,
Jodhpur, Rajasthan-342005, India. Date of Submission: Feb 12,
Phone: 91-9571580558, Email: solankijitender@gmail.com 2014 Date of Peer Review: Feb
FINANCIAL OR OTHER COMPETING INTERESTS: None. 13, 2014 Date of Acceptance: Feb
26, 2014
Date of Publishing: May 15, 2014

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 MANIFESTASI ORAL PASIEN DENGAN HIPOTIROIDISME: SEBUAH LAPORAN KASUS

ABSTRAK

Hipotiroidisme dapat disebabkan oleh kegagalan tiroid (hipotiroidisme primer) atau penyakit pituitari
atau hipotalamus (hipotiroidisme sekunder). Seorang pasien wanita berusia 20 tahun dilaporkan
dengan keluhan adanya gigi susu di mulut sejak 10-12 tahun. Secara intraoral, terdapat beberapa gigi
sulung yang tertinggal dan gigi permanen yang hilang, terlihat jelas lidah makroglossia. Diagnosis
klinis yang didapat adalah maloklusi skeletal dan dental (Klas II) akibat hipotiroidisme. Rencana
pengobatan yang komprehensif telah dirancang. Kami menyajikan kasus ini agar para profesional
kesehatan mulut mengetahui kondisi ini secara efisien.

Kata Kunci: Hipotiroidisme, Manifestasi Oral, Impaksi Gigi Permanen, Retensi Gigi, Disfungsi Tiroid

LAPORAN KASUS
Seorang wanita berusia 20 tahun melaporkan dengan keluhan adanya gigi susu di mulutnya sejak 10-
12 tahun dan ingin mencabutnya. Riwayat mengungkapkan bahwa pasien telah mengunjungi dokter
gigi terdekat untuk membersihkan giginya 1 tahun yang lalu, setelah itu dia diberitahu tentang adanya
gigi sulung dan beberapa gigi permanen yang hilang di mulutnya. Ia juga menceritakan riwayat gusi
berdarah saat menyikat gigi sejak 3 tahun, yang kini semakin berkurang. Jadi dia mengunjungi kami
untuk merawat giginya. Riwayat medis mengungkapkan bahwa pasien adalah kasus hipotiroidisme
terkontrol yang diketahui sejak 5-6 tahun dan menjalani pengobatan reguler untuk hal penyakit
tersebut (Tab. Thyronorm® 100mg sekali sehari). Pasien juga melaporkan bahwa bidang akademik di
sekolahnya termasuk kategori sedang. Pada pemeriksaan fisik secara umum, denyut nadi (PR)
76x/menit, frekuensi napas (RR) 16x/menit dan tekanan darah (BP) 120/78 mmHg. Pemeriksaan
intraoral menunjukkan beberapa retensi gigi sulung (55, 65, 74, 75, 85) dan kehilangan gigi permanen
(13, 14, 23, 24, 32, 33, 34, 35,45) [Tabel / Gambar-1a & b]. Pada pemeriksaan inspeksi dan palpasi
didapatkan bibir atas dan bawah, mukosa bukal dan labial dan palatum normal. Gingiva mengalami
radang ringan. Lidahnya berukuran lebih besar dan makroglossia terlihat jelas tanpa perubahan rasa.
Gigi 13, 14, 15, 23, 24, 25,32, 33, 34, 35, 41, 45 hilang kongenital. Aliran saliva normal. Berdasarkan
tampilan klinis ini, dibuat diagnosis klinis yaitu maloklusi skeletal dan dental (kelas II) akibat
hipotiroidisme.

INVESTIGASI
Setelah pemeriksaan klinis kemudian dilakukan radiografi panoramik. Radiografi panoramik
menunjukkan beberapa gigi permanen yang tidak erupsi (13, 14, 23, 24, 32, 33, 34, 35, 45)
[Tabel/Gambar-2]. Hasil hemogram lengkap menunjukkan gambaran normal. Kadar kalsium serum,
fosfor serum, dan alkali fosfat serum juga dalam batas normal. Uji T3: 3,60 nmol / l (1,30-3,20), uji
T4: 201,5 nmol / l (66-181), TSH: 0,321 mikro IU / ml (0,27-4,2) dan aktivitas Creatinin kinase
meningkat (212 unit / L) ).

Gambar 1-a: Foto intraoral lengkung rahang atas menunjukkan beberapa

retensi gigi sulung (55,65) dan kehilangan gigi permanen (13,14,23,24)
Gambar 1-b: Foto intraoral lengkung rahang atas menunjukkan beberapa
retensi gigi sulung (74,75,85) dan kehilangan gigi permanen (32,33,34,35,45)
Gambar 2: Ortopantamograf menunjukkan beberapa gigi permanen tidak
erupsi (13,14,23,24,32,33,34,35,45)

Differential Diagnosis
• Defisiensi nutrisi
• Cleidocranial dysplasia
• Rickets/Rakhitis
• Gagal ginjal

Perawatan
Konseling pasien dilakukan setelah pasien diminta untuk mendapatkan laporan terbaru untuk tes fungsi
tiroidnya. Satu bulan kemudian ketika semua nilai tes berada dalam batas normal, rencana perawatan
multidisiplin dirancang. Ini terdiri dari profilaksis oral, ekstraksi serial dan prosedur ortodontik
interseptif. Pertimbangan khusus diambil saat meresepkan obat, untuk bahaya memicu koma
miksedema akibat analgesik opioid. Tekanan darah dipantau pada setiap kunjungan dan povidine
iodine dihindari. Menjaga semua poin ini dalam pandangan profilaksis mulut penuh, dilakukan untuk
pasien, diikuti dengan ekstraksi serial gigi sulung di bawah pengawasan ketat oleh pedodontis, ahli
bedah mulut dan maksilofasial dan ortodontis.

Hasil dan Follow Up

Setelah pasien pulih dan terjadi penyembuhan, prosedur ortodontik interseptif dimulai. Pasien secara
teratur mengunjungi dokternya untuk pengobatan hipotiroidisme.
 DISKUSI
Sekresi hormon tiroid yang kurang menyebabkan temuan oral yang umum seperti karakteristik
makroglossia, dysgeusia, delay erupsi, kesehatan periodontal yang buruk, morfologi gigi yang berubah
dan penyembuhan luka yang tertunda. Hipotiroidisme pada masa kanak-kanak dikenal sebagai
kretinisme, ditandai dengan bibir tebal, lidah menonjol besar (makroglossia), maloklusi, dan delay
erupsi gigi. Makroglossia disebabkan oleh peningkatan akumulasi mukopolisakarida subkutan yaitu,
glikosaminoglikan karena penurunan degradasi zat ini.

Hipotiroidisme sering dikaitkan dengan reaksi autoimun, tetapi dapat terjadi setelah pengangkatan
jaringan tiroid yang berlebihan dalam pengobatan hipertiroidisme. Hipotiroidisme sementara dapat
terjadi pada tiroiditis non aktif atau subakut. Hipotiroidisme subklinis (atau ringan) adalah keadaan
kadar hormon tiroid normal dan sedikit peningkatan TSH; terlepas dari namanya, beberapa pasien
mungkin memiliki gejala ringan. Ketika tingkat TSH meningkat dan tingkat T4 menurun, gejala klinis
hipotiroidisme menjadi lebih jelas. Pada kondisi kadar iodine cukup, penyakit autoimun dan penyebab
iatrogenik adalah yang paling umum [Tabel / Gambar-3]. Menurut “UK Guidelines for the Use of
Thyroid Function Tests” pada wanita, prevalensi hipotiroidisme yang baru didiagnosis meningkat dari
0,3% pada wanita yang lebih muda, menjadi 2% pada wanita di atas 60 tahun.

Primary • Autoimmune hypothyroidism: Hashimoto’s thyroiditis, atrophic thyroiditis

• Iatrogenic: 131I treatment, subtotal or total thyroidectomy, external irradiation of neck for lymphoma or cancer
• Drugs: Iodine excess (including iodine-containing contrast media and amiodarone), lithium, antithyroid drugs,
p-aminosalicyclic acid, interferon and other cytokines, aminoglutethimide
Congenital Hypothyroidism • Absent or ectopic thyroid gland
• Dyshormonogenesis,
• TSH-R mutation
• Iodine deficiency
• Infiltrative disorders: amyloidosis, sarcoidosis, hemochromatosis, scleroderma, cystinosis,
Riedel’s thyroiditis

Transient • Silent thyroiditis, including postpartum thyroiditis

• Subacute thyroiditis
• Withdrawal of thyroxine treatment in individuals with an intact thyroid after 131I treatment or subtotal thyroidectomy for Graves’ disease
Secondary • Hypopituitarism: tumours, pituitary surgery or irradiation, infiltrative disorders, Sheehan’s syndrome, trauma, genetic forms of combined pituitary hormone
deficiencies
• Isolated TSH deficiency or inactivity
• Bexarotene treatment
• Hypothalamic disease: Tumours, trauma, infiltrative disorders, idiopathic

[table/Fig-3]: Penyebab Hipotiroidisme[3]

Hipotiroidisme yang parah, seperti pada kasus ini dapat memiliki efek merusak pada perkembangan
dan erupsi gigi, dan menyebabkan retensi yang berkepanjangan pada gigi sulung, pertumbuhan di
bawah normal dari rahang atas dan rahang bawah, dengan penurunan yang nyata pada dimensi
kompleks wajah, dan kurangnya koordinasi antara pertumbuhan mandibula dan perkembangan gigi.
Radiografi pasien menunjukkan bahwa pertumbuhan mandibula dan rahang atas sangat terganggu.
Efek pada gigi sebagian besar terbatas pada: retensi gigi sulung, delay erupsi gigi permanen dan
distorsi akar gigi permanen insisif lateral dan molar pertama. Pada pemeriksaan umum, kulit kasar,
fase relaksasi tertunda dari refleks tendon dalam, suara serak, dan wajah pucat telah dicatat. Temuan
serupa terlihat dalam laporan kasus lain. Menurut sebuah penelitian, makroglossia, kulit kering,
sembelit dan ingatan yang mudah lupa terlihat masing-masing pada 82%, 97%, 66% dan 61% pasien
yang menderita hipotiroidisme. Semua temuan ini juga terlihat pada pasien ini. Banyak penelitian telah
melaporkan tentang penambahan berat badan, edema perifer, kelopak mata bengkak dan hipertensi
diastolik. Namun, tak satu pun dari temuan tersebut terlihat pada pasien ini. Hal ini dapat disebabkan
oleh fakta bahwa pasien adalah hipotiroid yang terkontrol dan secara teratur menjalani pengobatan
selama bertahun-tahun. Ada literatur yang melaporkan tentang gejala psikologis atau disfungsi
kognitif, yang dialami pasien pada asupan L-Tiroksin jangka panjang. Tak satu pun dari gejala ini
dilaporkan oleh pasien ini. Mempertahankan asumsi bahwa hipotiroidisme memiliki tanda dan gejala
yang khas dapat berbahaya karena hanya terjadi pada 25-70% pasien.

KESIMPULAN
Manifestasi oral dari hipotiroidisme jarang terjadi dan dokter gigi biasanya tidak menyadari kondisi
tersebut yang menyebabkan kesalahan diagnosis dan perawatan pasien yang tidak tepat. Ketika kasus
seperti itu ditemui dalam praktik rutin, hipotiroidisme dapat dianggap sebagai diagnosis banding untuk
defisiensi nutrisi atau rakhitis yang biasa sering ditemui. Berbagai faktor seperti kurangnya kesadaran
tentang hipotiroidisme di antara praktisi perawatan kesehatan primer, tidak tersedianya pemeriksaan
laboratorium dan biaya laboratorium lebih tinggi memainkan peran penting dalam keterbatasan
mendiagnosis dan pengelolaan hipotiroidisme.