Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 253

1 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 swallowingThyroid function can be normal (euthyroid), which requires regular monitoring, or hyperactive (hyperthyroid)/hypoactive (hypothyroid), which both require active treatmentThe 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)

2 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 teethFigure 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 hypoplasiaCauses may include nutritional factors (malnutrition), some diseases (such as undiagnosed and untreated coeliac disease), hypocalcaemia, infection, abnormalities in amelogenesisSecondary staining (likely to be linked to increased daily consumption of black grapes) may have made the pitting more noticeable

3 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 propylthiouracilAbrasion: use of a hard toothbrushAttrition: reduced occlusal table due to multiple missing teeth

4 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 bleedingFurthermore, 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

5 What additional risks associated with hyperthyroidism should be considered when planning extraction of the #15?The patient's hyperthyroidism is unlikely to be controlled as the diagnosis/treatment was relatively recent; it is preferable to consider initial pain/infection control using medication until the physician confirms the patient is stableHeightened patient anxiety and irritability likelyElevated blood pressure and heart rate due to the effects of thyroid hormone on sympathetic nervous system activityPatients with high arteriolar pressures may also require increased attention and a longer duration of local pressure to stop bleedingSympathetic overactivity may lead to faintingA thyroid storm may be provoked during dental treatment by the stress, administration of epinephrine, infection or traumatic surgery

6 What other factors do you need to consider in your risk assessment?SocialReliance on daughter (who works as a school teacher) for transport/to attend appointmentsMedicalRisk of cardiac arrythmiasAdditional bleeding risk associated with dabigatran (see Chapter 10.4)Gastro‐oesophageal reflux disease may be associated with positional limitationsDentalPoor oral health and irregular attenderAdvanced tooth surface lossPartially edentateOsteoporotic changes in the jaw bone secondary to hyperthyroidism

7 The patient requests dental implants to replace the missing teeth. What are the associated risks you should discuss?Poor oral health needs to be stabilised firstCompliance and need for regular dental visits and maintenanceBleeding riskInfection riskOsteoporotic changes in the mandible