Hashimotos and Periodontal Disease

Hashimoto's disease and Periodontitis

Jackeline Barajas, Gabriel Howe

Lamar Institute of Technology

Dental Hygiene Program

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Hashimoto's disease is an autoimmune disease that affects the thyroid gland and causes an underactive

thyroid. This autoimmune disease affects many parts of the body including the oral cavity. This research paper will

serve to educate others on how Hashimoto's disease can increase the effects and likelihood of periodontitis. This

paper will benefit clinicians by teaching them the importance of a thorough medical history review, the symptoms to

watch out for and how to manage a patient with Hashimoto’s. The images shown will picture how the dentition of a

patient with hypothyroidism might appear in an adult. In this paper we will discuss the relationship between

periodontitis and Hashimoto’s, the clinical manifestations of Hashimoto’s and how to better treat a patient with this

disease.

One of the ways people get diagnosed with Hashimoto’s disease is by getting their thyroid stimulating

hormone or “TSH” levels checked. TSH levels greater than 5.5 μIU/mL and low circulating free t 4usually indicate

hypothyroidism (Kothiwale & Panjwani, 2016, 36). Hypothyroid patients tend to be prone to infection, excessive

gingival bleeding and slow healing as a result of their high TSH levels (Kothiwale & Panjwani, 2016, 36). Increased

bleeding in hypothyroid patients is due to increased subcutaneous mucopolysaccharides which decrease the ability

of blood vessels to constrict (Kothiwale & Panjwani, 2016, 37). Another factor that influences periodontitis in

Hashimoto’s patients is the increased microbiota in the saliva due to high TSH levels (Dong et al., 2021, 13). Recent

studies have found that patients with high TSH levels have increased levels of the bacteria

Granulicatella in their saliva, which is usually found in the saliva of patients with periodontitis (Dong et al., 2021,

13). The increased susceptibility of Hashimoto’s patients to get infections explains their increased risk to getting

periodontitis, with more diverse species of bacteria in the mouth, slow healing abilities and high chance of infection

periodontitis is more likely to occur in a patient with Hashimoto’s than in a person who has normal TSH levels.

Vitamin D is an essential vitamin for patients with Hashimoto’s disease. More often than not a person with

hypothyroidism also has a vitamin D deficiency (Arik et al., 2011, 1). Vitamin D deficiency can cause a person to

have impaired wound healing and bone loss. These two factors could greatly affect the way periodontitis impacts a

person with Hashimoto’s. Vitamin D deficiency along with hypothyroidism would mean the patient would have

severe bone loss and would have delayed healing times, which would both increase the risks and severity of

periodontitis.These elements together could mean ulcers, pain, bone loss, pockets, bleeding, mobile teeth and even

eventually being edentulous. As a dental professional, it is important to know the signs and symptoms of both
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Hashimoto’s and vitamin D deficiency in order to correctly treat a patient. If a patient is Vitamin D deficient it is

important to educate them on the ways they could receive this vitamin in order to positively impact their oral health.

A dental professional must know what to look for when a patient comes in their chair presenting symptoms

of hypothyroid disease. Some general symptoms include weight gain, tiredness, intolerance to cold, dry cool skin,

puffy face and eyes, normal blood pressure but slow heart rate (Chandna & Bathla, 2011, 2). Oral manifestations in

childhood hypothyroidism include thick lips, macroglossia, malocclusion and delayed eruption of teeth (Chandna &

Bathla, 2011, 2). In adults manifestations could include macroglossa, dysgeusia, delayed eruption, poor periodontal

health, altered tooth morphology and delayed wound healing (Chandna & Bathla, 2011, 2). It is important to not

diagnose a patient who presents these signs and symptoms in the clinic and instead refer to an endocrinologist who

would be able to better assist the patient in a correct diagnosis.

Outside of being aware of these symptoms and referring your patient to an endocrinologist, treatment starts

with you. Hashimoto’s is caused by hypothyroidism, and this is the most common hormone disorder that presents

itself in humans. With this in mind, as a dental professional, some patients can be asymptomatic and have no idea

the lack of this hormone is an issue, so it is your responsibility to take measures with every patient regardless of

their medical history (Aldulaijan). These measures consist of basic treatment procedures such as using the thyroid

collar when taking x-rays, ensuring a low stress level to your patient, knowing the oral appearance of symptoms, and

knowing what past medical experiences on their medical history that could reflect thyroid issues. However, if there

are any concerns that an undiagnosed patient may present this disorder, postponing treatment until there is a further

diagnosis with a physician or endocrinologist is the action that should be taken (Chandna & Bathla, 2011, 5).

Of course, what works for one patient doesn’t necessarily work for another, so when it comes to treatment

plans, your role in being able to describe side effects of medications and herbal supplements is extremely

important. Especially when each patient will have different dosages and prescriptions to suit their specific diagnosis.

One of the most common medications, known as thyroxine, causes increased metabolism due to phenytoin,

rifampicin and carbamazepine, as well as impaired absorption with iron sulfate, sucralfate and aluminum hydroxide.

The effects of warfarin sodium are also increased with the use of thyroxine. You will also see that patients who have

hypothyroidism are sensitive to central nervous system depressants and barbiturates, so it is best to use the

medications in moderation (Chandna & Bathla, 2011, 5).

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In spite of having common medications to treat thyroid disorders and hashimoto’s, it is not uncommon for

patient’s to stray from these medications and use unprescribed medications/ supplements to treat their disorder.

Three out of four people with thyroid disorders actually prefer using alternative treatments. In doing so, many of

these patient’s find better improvement with symptoms such as weight gain, fatigue, and overall health. One of the

most popular alternative treatments that has surfaced is the use of desiccated thyroid extract, or DTE. DTE is

derived from dehydrated pig thyroid glands, which is better known as armour thyroid, and is used by 10%-25% of

people with thyroid disorders. Although it is not typically what is prescribed by health care providers at this time,

due to its growing popularity and effectiveness, many health care professionals suggest DTE to their patients with

thyroid disorders even though it is not yet an approved treatment (Widner, 2020, 1).

As a dental professional, a patient’s overall health is just as important as their oral health. Many patients

you see will have other conditions that go hand and hand with your treatment plan. It is of the utmost importance to

be able to understand these conditions/disorders, understand their effects on the oral cavity, and comprehend the side

effects of medications your patient’s may be taking in order to provide the best treatment for any and every patient.

With these skills and understanding, when it comes to patients like those who have thyroid disorders, you will be

able to implement patient treatment at the highest standards.

Bibliography

Aldulaijan, Hajer A., et al. (2019, Sep 26). Relationship between Hypothyroidism and Periodontitis: A Scoping

Review. Wiley Online Library, John Wiley & Sons, Ltd. Retrieved on April 14, 2020 from

onlinelibrary.wiley.com/doi/full/10.1002/cre2.247.
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Arik, S., Tamer, I., & Coksert, D. (2011). Relative Vitamin D Insufficiency in Hashimoto's Thyroiditis. Mary Anne

Liebert, Inc., 21(8), 1. Thyroid. 10.1089/thy.2009.0200

Chandna, S., & Bathla, M. (2011). Oral manifestations of thyroid disorders and its management. Indian Journal of

Endocrinology and Metabolism, 2, 1-8. NCBI. 10.4103/2230-8210.83343

Dong, T., Zhao, F., Yuan, K., Zhu, X., Wang, N., Xia, F., Lu, Y., & Huang, Z. (2021, 02 26). Association Between

Serum Thyroid-Stimulating Hormone Levels and Salivary Microbiome Shifts. Frontiers in cellular and

infection microbiology, 11(1), 1-26. NCBI. 10.3389/fcimb.2021.603291

Kothiwale, S., & Panjwani, V. (2016, February 02). impact of thyroid hormone dysfunction on periodontal disease.

Journal of The Scientific Study, 43(1), 34-37. jscisociety.com. 10.4103/0974-5009.175456

Widner, Amy. (2020, April 1). Research Shows Hypothyroidism Patients Who Choose Alternative Therapies Cite

Effectiveness, Improved Symptoms. UAMS News. Retrieved on April 14, 2021 from

news.uams.edu/2020/03/30/research-shows-hypothyroidism-patients-who-choose-alternative-therapies-cit

e-effectivness-improved-symptoms/.
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