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Original Article
Oral health status of children suffering from
thyroid disorders
Venkatesh Babu NS, Purna B. Patel
Department of Pediatric and Preventive Dentistry, VS Dental College, Bangalore, Karnataka, India
ABSTRACT
Background: Thyroid dysfunction is the second most
common disorder of the endocrine system that can
affect any system of the body. The oral cavity can be
adversely affected by either an excess or deficiency
of these hormones. Aim of the Study: To assess and
compare the oral health status of children suffering
from thyroid disorders and healthy children.
Materials and Methods: A total of 200 children
aged between 2 years and 16 years were allocated
into two groups. The study group consisted of 100
children with thyroid dysfunction (hypothyroidism/
hyperthyroidism), while the control group consisted
of 100 healthy children. Gingival index, plaque
index, DMFT (Decayed missing filled teeth Index for
permanent teeth) & Dmft index (Decayed missing
filled teeth Index for primary teeth) and modified
developmental defects of enamel (DDE) index were
recorded and data were analyzed statistically. Results:
Plaque and gingival scores were significantly higher
in the thyroid group compared to the control group.
DMFT and dmft scores were higher in the thyroid
group than the control group but the difference in score
was not statistically significant. Statistically significant
DDE score was found in the thyroid group. Apart from
increased susceptibility to caries and poor periodontal
health condition, children with thyroid disorders were
also found to have other oral manifestations such
as macroglossia, open bite, and change in eruption
pattern. Conclusion: Thyroid dysfunction (both
hypothyroidism and hyperthyroidism) has impact on
the oral health status. Children with thyroid disorders
showed high prevalence of dental caries and
periodontal disease compared to the control group.
KEYWORDS: Children, developmental defects
of enamel (DDE), DMFT and dmft index, thyroid
disorders
Introduction
The endocrine system is responsible for secretion of
various hormones and it is closely related to the central
© 2016 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. NS Venkatesh Babu,
VS Dental College, VV Puram, KR Road, Bangalore - 560 004,
Karnataka, India.
E-mail: drnsvbabu@gmail.com
Access this article online
Quick response code Website:
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DOI:
10.4103/0970-4388.180443
PMID:
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nervous system. It controls physiological functions of
body and maintains homeostasis.[1] Among various
endocrine dysfunctions, thyroid gland disorders are
most commonly encountered in the pediatric age
group, and hypothyroidism is the most common
disorder.[2] It has been estimated that in India 1 out
of 2,640 neonates suffer from thyroid disorder, when
compared with the worldwide average value of 1 in
3,800 subjects.[3]
Thyroid disorder is a general term representing
several different diseases involving thyroid
hormones and the thyroid gland. Thyroid disorders
are commonly separated into two major categories,
hyperthyroidism and hypothyroidism, depending
on whether serum thyroid hormone levels (T4
and T3) are increased or decreased, respectively.
Thyroid diseases generally may be subclassified
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How to cite this article: Venkatesh Babu NS, Patel PB. Oral
health status of children suffering from thyroid disorders. J
Indian Soc Pedod Prev Dent 2016;34:139-44.
139
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Babu and Patel: Oral health status in thyroid children
based on the etiologic factors and physiologic
abnormalities. [4]
Investigations have found an increase in the prevalence
of dental caries and severity of periodontal disease in
the patients with thyroid dysfunction. Several causes
were proposed, such as the disease process itself,
surgical treatment (thyroidectomy), or the medication
taken, which can lead to the increase in the severity of
oral and dental diseases.[5]
The present study is undertaken to evaluate the
oral health status of children suffering from thyroid
disorders and to compare it with that of the healthy
children.
Materials and Methods
In the present study, a of total 200 children were
included who are in the age range of 2-16 years.
The study group consisted of 100 diagnosed
cases of thyroid disorder (hypothyroidism/
hyperthyroidism). All the children were evaluated
before inclusion in the study by pediatric
endocrinologist and the data were collected by using
a specially designed pro forma to obtain information
regarding their personal details, demographic
characteristics, type of thyroid disease, medication
history, and family history. The control group
consisted of 100 healthy children who visited the
Department of Pediatric and Preventive Dentistry
for a routine dental checkup. Ethical clearance was
obtained from the Institutional Ethical Committee.
Clinical assessment was carried out using the plaque
index by Silness P and Loe H 1967, gingival index by
Loe H and Silness P 1963, DMFT and dmft index by
the World Health Organization (WHO) criteria 1997,
and the modified developmental defects of enamel
(DDE) Index (DDE score) by the Federation Dentaire
Internationale (FDI) 1992. Information regarding oral
hygiene practices, including the frequency of dental
checkups and use of toothbrush, was obtained from
parents.
Each child and parent were educated about the severity
and prognosis of the dental aspects of thyroid disease
and motivated about the importance of maintaining of
good oral hygiene. During the study, all the children
were given comprehensive dental treatment with
emphasis on preventive measures.
Table 1: Comparison of dmft and DMFT indices between the thyroid and control groups
Parameter Group Mean Std. dev
DMFT Thyroid 0.760 1.296
Control 0.420 0.755
Dmft Thyroid 2.250 2.231
Control 1.970 2.037
140 Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2016 | Vol 34 | Issue 2 |
Results
Results were analyzed using Statistical Package
for the Social Sciences (SPSS) version 15.0
(SPSS-Inc., Chicago,  IL). The data were expressed
as mean  ±  standard deviation (SD). The Z-test was
used for intergroup comparisons of parameters
such as DMFT, dmft, plaque index, gingival index,
and modified DDE index. The χ² test was used for
intergroup comparison of brushing habits and prior
dental visit.
Out of 100 diagnosed children with thyroid
disorder, 73% children suffered from congenital
hypothyroidism (38% had hypothyroidism due to
thyroid agenesis and 35% had hypothyroidism due
to thyroid dyshormonogenesis), 17% from secondary
hypothyroidism, 2% from thyroiditis, and 3% from
Grave’s disease [Graph 1].
Mean value for DMFT and dmft score of THE thyroid
group (0.76 and 2.25, respectively) were higher than
the control group (0.48 and 1.97 respectively) but there
was no significant difference observed between two
groups [Table 1 and Graph 2].
Higher mean gingival index and plaque index scores
were recorded in the thyroid group (1.417 and 0.987,
respectively) compared to the control group (0.874
and 0.450, respectively) and the difference in the mean
gingival index and plaque index between the two
groups was found to be statistically significant with
P value < 0.001 [Table 2 and Graph 3].
Graph 1: Type of thyroid disorder in the thyroid group
SE of mean Mean difference Z P-value
0.130 0.340 −1.210 0.226
0.075
0.223 0.280 −0.822 0.411
0.204
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Babu and Patel: Oral health status in thyroid children

Twenty-two children showed different types of enamel
defects. Eight children were found to have white spots,
seven children had diffuse type of opacity, five children
had combination of diffuse and demarcated opacity, and
two children had obvious enamel hypoplasia. Modified
DDE score of the thyroid group (0.500) was higher than
that of the control group (0.150) [Table 3 and Graph 4].
Anterior open bite was seen in 23 children (23%),
whereas 3 children (3%) had posterior cross bite. All of
them had hypothyroidism either due to thyroid gland
agenesis or thyroid dyshormonogenesis [Graph 5].
Macroglossia was observed in 46 children (46%) [Graph
6]. Delayed eruption was found in 33 children (33%) with
hypothyroidism, whereas 4 children (4%) with Grave’s
disease and thyroiditis showed early eruption [Graph 7].

Graph 2: Comparison of mean DMFT and mean dmft between two

Graph 3: Comparison of mean Plaque Index and Mean Gingival Index
groups
between two groups

Graph 4: Comparison of mean modified developmental defects of

enamel index between two groups Graph 5: Distribution of open bite in thyroid group

Table 2: Comparison of plaque index and gingival index

Parameter Group Mean Std. dev. SE of mean Mean difference Z P-value
PI Thyroid 1.417 0.707 0.071 0.542 −5.965 <0.001*
Control 0.874 0.571 0.057
GI Thyroid 0.987 0.724 0.072 0.537 −4.354 <0.001*
Control 0.450 0.484 0.050
P - value <0.001 = Statistically significant

Table 3: Comparison of modified developmental defects of enamel index

Parameter Group Mean Std. dev. SE of mean Mean difference Z P-Value
DDE Thyroid 0.500 1.330 0.133 0.350 −2.136 0.033*
Control 0.150 0.609 0.061
P - value <0.001 = statistically significant

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Babu and Patel: Oral health status in thyroid children

Graph 6: Distribution of Macroglossia in Thyroid group Graph 7: Eruption distribution in thyroid group

Statistically significant association was observed in Table 4: Frequency of brushing

frequency of brushing between the two groups (P value
Time of brushing Thyroid Control χ2 P-value
< 0.001). In the thyroid group 81% of children brushed
N (%) N (%)
their teeth once daily and 3% of children twice daily,
whereas in the control group 71% of children brushed 0 15 15 3 3 27.032 <0.001*
their teeth once daily and 16% of children twice daily. 1 82 82 71 71
Fifteen percent of the children in the thyroid group did 2 3 3 26 26
not brush compared to only 3% in the control group Total 100 100 100 100
[Table 4]. Seven percent of the children in the thyroid P - value <0.001 = statistically significant
group had visited dentist before, compared to 51%
children in the control group. The difference between Table 5: Prior dental visit
the two groups was found to be statistically significant
Prior dental visit Thyroid Control χ2 P-value
[Table 5].
N (%) N (%)
1 7 7 51 51 47.013 <0.001*
Discussion 2 93 93 49 49
Total 100 100 100 100
Thyroid hormones influence the growth and maturation P - value <0.001 = statistically significant
of tissues, energy metabolism, and turnover of both
cells and nutrients.[1] Available literature on the overall
health status and treatment needs of the children In the present study, the mean DMFT and dmft values
with thyroid disorders is very sparse. People with in the thyroid group were 0.76 and 2.25, respectively.
thyroid disorders constitute a very large proportion When compared to the control group mean values of
of the population, although there are very few studies both DMFT and dmft were higher in the thyroid group
concerning the dental aspects of the disease. but the difference was not statistically significant.
Yamana et al.[5] also recorded higher value of DMFT in
Congenital hypothyroidism (CH) is the most common the adult thyroid group compared to the control group
metabolic disorder in the newborn. In our study, but this difference was statistically significant.
we observed that out of 100 children, 73% children
suffered from CH. This data were comparable with The plaque and gingival scores were significantly
the study done by Desai et al.[3,6] who also found higher in the study group (0.987 and 1.417, respectively)
high prevalence (78%) of CH. With the institution compared to that in the control group (0.450 and 0.847,
of neonatal screening for hypothyroidism in the respectively) with statistically significant P value of
most developed countries, instances of CH are <0.001. These results are comparable to the results
now recognized shortly after birth and are treated obtained by Yamana et al.[5] who stated that moderate
immediately to avoid mentally handicapping type of gingival inflammation was found to be the most
conditions and growth disorders.[7] Also, the dental common among the patients with thyroid dysfunction.
abnormalities of hypothyroidism can be prevented. Similar results were also obtained by Kadhim et al.[9]
Although the American Academy of Pediatrics (AAP) who found that the patients with thyroid disorders
recommends a heel prick sample after 48 h of life, it is have poor periodontal health and more clinical
not routinely followed in our country.[8] Umbilical or attachment loss compared with healthy individuals.
heel prick sampling should be made compulsory for Scardina et al.[10] suggested the possible association
all newborns. of thyroid dysfunction and periodontitis. Decrease in

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serum level of thyroid hormone can induce a low-grade
inflammation by impaired nitric oxide availability and
increased serum prostaglandins, cytokines, and matrix
metalloproteinases (MMPs) ultimately leading to poor
periodontal health status and alveolar bone resorption.
Adriana et al.[11] stated that serum and salivary levels
of proinflammatory cytokines, such as tumor necrosis
factor (TNF)-α and Interleukin (IL)-6, play important
role in thyroid hormone-related periodontitis.
Enamel defects can be observed in the patients with
thyroid dysfunction. These enamel defects can range
from small white spots to diffuse or demarcated
opacity. Presence of enamel defects is attributed to
change in thyroid hormone levels when the teeth are in
mineralization phase. In the present study, statistically
significant DDE score was found in the thyroid group
(0.500) compared to the control group (0.150). Enamel
defects were observed both in primary and permanent
dentitions.
Apart from increased susceptibility to caries and poor
periodontal health condition, these children also had
other oral manifestations such as macroglossia, open bite,
and changes in eruption pattern. Macroglossia (46%) and
open bite (anterior open bite in 23% and posterior cross
Figure 1: Macroglossia observed in child with congenital
hypothyroidism
Figure 3: Ten-year-old child suffering from hypothyroidism with
delayed eruption and exfoliation
Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2016 | Vol 34 | Issue 2 |
Babu and Patel: Oral health status in thyroid children
bite in 3%) were the most prevalent oral manifestations
observed in the study [Figures  1 and 2]. Increased
accumulation of subcutaneous mucopolysaccharides
(i.e. glycosaminoglycans) in tongue due to decrease
in the degradation of these substances can lead to
macroglossia and open bite.[12]
Change in eruption pattern was another important
observation noted. Delayed eruption was found in
33 children (33%) with hypothyroidism [Figure 3].
Early eruption was observed in 4 children (4%) with
hyperthyroidism [Figure 4]. Maria et al.,[13] Loevy
et al.,[14] and Buket et al.[15] have also reported delay in
tooth eruption in children suffering from CH.
These children with thyroid disorders are at higher
risk of poor oral hygiene due to regular long-term
medications that may contain sugar, and some of
them also suffer from mental and/or motor disorder
due to which effective oral hygiene can be difficult
to achieve for children with these impairments. The
present study showed that in the thyroid group, 81%
of children brushed their teeth once daily and 3% of
children twice daily, whereas in the control group 71%
of children brushed their teeth once daily and 16% of
children twice daily. Fifteen percent of the children in
Figure 2: Anterior open bite
Figure 4: Eight-year-old child suffering from hyperthyroidism with
early eruption of premolars and second molars
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Babu and Patel: Oral health status in thyroid children
the thyroid group did not brush compared to only 3%
in the control group. It is recommended that children,
parents, and caretakers should be educated regarding
maintenance of proper oral hygiene. Children with
thyroid disorders have high caries prevalence and
poor periodontal health compared to the healthy
children. Hence, regular oral health care and periodic
dental visits are a must for this group of children.
In the present study, only 7% of thyroid children had
prior dental visit, compared to 51% children in the
control group. Children with thyroid disorders do
not tend to attend dental problems unless they have
severe toothache or swelling. This is due to inadequate
knowledge and awareness about importance of oral
health care among these children and their caretakers.
Parents should be advised about the importance of
oral care. Preventive care should be delivered as early
as possible and reinforced at every dental visit, so that
the need for active treatment is minimal.
As a part of the health-care team, the pediatric
dentist plays an important role in detecting thyroid
abnormalities and its early diagnosis. Dental
management of children with thyroid disorders
begins with prevention of dental diseases and
thus maintaining a caries free dentition. Adequate
knowledge also helps the clinician to avoid possible
dental complications resulting from treating patients
with the thyroid disorders. Modifications of dental
care must be considered when treating children with
thyroid disorders.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for
his/her/ their images and other clinical information
to be reported in the journal. The patients understand
that their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
144 Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2016 | Vol 34 | Issue 2 |
Conflicts of interest
There are no conflicts of interest.
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