|Year : 2016 | Volume
| Issue : 1 | Page : 34-37
Impact of thyroid hormone dysfunction on periodontal disease
Shaila Kothiwale, Vishal Panjwani
Department of Periodontics, KLE's VK Institute of Dental Sciences, KLE University, Belgaum, Karnataka, India
|Date of Web Publication||2-Feb-2016|
Department of Periodontics, KLE's VK Institute of Dental Sciences, KLE University, Nehru Nagar, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Thyroid hormones play an important role in the regulation of physiologic processes. Thyroid dysfunction is the second most common glandular disorder of the endocrine system and is increasing predominantly among women. Thyroid disease can lead to imbalance in the homeostasis of the body and affect the healing capacity of tissues. However, limited data are available regarding the relationship between thyroid hormone imbalance and periodontal health. This case report presents the influence of thyroid hormone dysfunction and its impact on periodontal disease progression, systemic health of the patient, and the management of periodontal disease. The report emphasizes the need for frequent professional evaluations, patient education, and consistent educational reinforcement by health care providers in patients with hypothyroidism.
Keywords: Hypothyroidism, oral healthcare, periodontitis, thyroid hormone
|How to cite this article:|
Kothiwale S, Panjwani V. Impact of thyroid hormone dysfunction on periodontal disease. J Sci Soc 2016;43:34-7
| Introduction|| |
Inflammation is a primary pathologic feature of periodontal disease. A number of risk factors including systemic diseases influence individual susceptibility to periodontitis. Periodontal infections influence overall health and the course of several systemic diseases such as diabetes, cardiovascular disease, respiratory diseases, and preterm low birth weight. It is thus, a two-way road with systemic host factors and periodontal inflammation generating widespread effects with the potential to induce adverse systemic outcomes.
Thyroid hormones play an important role in the regulation of growth, development, and metabolic functions of the body. Thyroid disease can lead to imbalance in the homeostasis of the body and affect the healing capacity of tissues.  The common oral findings in hypothyroidism include the characteristic macroglossia, dysgeusia, delayed eruption, altered tooth morphology, and delayed wound healing. 
However, limited data are available regarding the relationship between thyroid hormone imbalance and periodontal health. This case report presents a patient with periodontal destruction that is associated and influenced by hypothyroidism.
| Case report|| |
A 30-year-old female patient reported to the department of periodontics with the chief complaint of bleeding gums and an increase the size of gums since 6 months.
The patient was apparently normal 6 months earlier, after which she noticed spontaneous episodes of bleeding from the gums that was sudden in onset and had gradually progressed since then.
She also noticed a gradual increase in the size of gums to an extent that it was aesthetically displeasing. The patient complained of oral malodor. The past dental history revealed that the patient had undergone oral prophylaxis twice. Nevertheless, the removal of local factors did not result in any decrease in gingival swelling and bleeding.
On intraoral examination, the oral hygiene index score suggested that the status of oral hygiene was fair.  There was generalized gingival inflammation seen with a reddish pink color of the gingiva with rolled out margins and blunt interdental papillae. The interdental and marginal gingivae in the mandibular anterior region were deflected away from teeth [as seen in [Figure 1] and [Figure 2].
|Figure 1: Preoperative photograph showing marked gingival inflammation with minimal amounts of plaque and calculus|
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|Figure 2: Photograph showing interdental and marginal gingiva defl ected away from the mandibular anterior teeth|
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On clinical examination, there was minimal local deposits, generalized grade II type of inflammatory enlargement with loss of stippling, spontaneous bleeding, and the presence of periodontal pockets of 5-7 mm. 
The radiovisiograph presented with horizontal and vertical bone loss with generalized 10-40% of bone reduction [as seen in [Figure 3]]. The fremitus test was positive with the presence of horizontal as well as angular types of wear facets in relation to the mandibular anterior teeth.
The patient had a systemic history hypothyroidism since the past 2 years and was apparently on systemic thyroxine (100 mg/day). She had discontinued the medication since the past 4-5 months. Since the patient showed a lack of compliance with systemic treatment, a blood examination was carried out to review the systemic thyroid hormone levels. On chemiluminescent immunoassay, increased thyroid stimulating hormone (TSH) levels more the 150 μIU/mL were seen. Thus, increase in the severity of hypothyroidism was noted. On further counseling, she also revealed an increase in body weight, along with increased puffiness of the face since the past 6 months.
In the present clinical scenario, the female patient was systemically compromised presenting an uncontrolled state of hypothyroidism with levels of thyroid-stimulating hormone (TSH) greater than 150 μIU/mL. Hence, she was referred to an endocrinologist prior to the commencement of any dental treatment. Accordingly, she was prescribed 150 mg of systemic thyroxine per day. After consultation, the etiotropic phase was initiated that comprised a thorough ultrasonic scaling with patient education and motivation regarding oral hygiene. She was then kept on a through maintenance program for a period of 8 weeks to evaluate her compliance with systemic therapy as well as oral hygiene maintenance. Also, as mentioned in the clinical findings it was appreciated that the gingival status with severe and spontaneous bleeding from the tooth supporting tissues did not correlate with the presence of local deposits. Similarly, at the end of 8 weeks it was noticed that there was a further improvement in the oral hygiene maintenance but the gingival bleeding scores did not improve significantly. At the end of 12 weeks, there was an improvement in the thyroid hormone levels within the normal range, along with distinct reduction in the bleeding scores. The periodontal charting at the end of 12 weeks showed that there was a marked improvement in the gingival status, with persisting periodontal pockets only in the maxillary posterior teeth. Hence, a surgical therapy was planned comprising pocket reduction in relation to the posterior quadrants. Coronoplasty was done with respect to the mandibular anterior teeth to relieve the trauma [as seen in [Figure 4]].
As there is a delayed response of tissues to healing, the patient was educated regarding the complication of delayed healing that is encountered in a state of hypothyroidism and was simultaneously motivated to follow a stringent maintenance program hereafter. She was then scheduled for a recall program every 6 weeks, keeping a check on the systemic thyroid hormone levels and her compliance with the supportive periodontal therapy. In addition, the patient optimistically mentioned about reduced puffiness noticed in the facial region, along with reduction in the body weight. She also showed a positive inclination toward improvement in oral health-related quality of life and expressed the desire to maintain a regular maintainance recall visit.
| Discussion|| |
Hypothyroidism is a clinical disease state occurring when there is insufficient thyroid hormone available to the target tissues. Serum TSH concentrations represent the most reliable indicators of thyroid status. The American thyroid association recommends that all patients should obtain a serum TSH determination at the age of 35 years and be followed up every 5 years. 
In general, results demonstrating elevated TSH (>5.5 μIU/mL) and low circulating free t 4 levels are indicative of hypothyroidism.  It is also a commonly prevailing disorder in the adult Indian population and is common among females.  Hence, the determination of the influence of thyroid hormone imbalance in periodontitis may be important for the prevention of morbidity related to this condition.
In the present clinical scenario, the patient complained about bleeding gums with minimal amount of local factors. As the therapy for periodontitis and hypothyroidism (the restoration of thyroid hormone levels within normal limits and TSH levels at the baseline that were 150 μIU/mL were reduced to 5 μIU/mL) was initiated, there was an improvement in the oral hygiene status and immense reduction in the bleeding scores. This finding of increased gingival bleeding with minimal local factors may be due to the susceptibility of hypothyroid patients to infection. In hypothyroidism, delayed wound healing occurs due to decrease in the metabolic activity of the fibroblasts. , Delayed wound healing may be associated with an increased risk for infection due to the longer exposure of the unhealed tissue to pathogenic organisms manifesting clinically with increased gingival bleeding.
Patients with hypothyroidism have increased subcutaneous mucopolysaccharides due to decrease in the degradation of these substances. The presence of excess subcutaneous mucpolysaccharides may decrease the ability of small blood vessels to constrict and may result in increased bleeding from infiltrated tissues including the mucosa and skin.  However, in this case, we could not elicit increased bleeding during the periodontal surgery, probably because the surgical therapy was initiated after the restoration of thyroid hormones within the normal limits and after thorough etiotropic phase.
Hence, when treating patients with thyroid dysfunction in the oral healthcare setting, the goal should be to develop and implement timely preventive and therapeutic strategies compatible with the patient's physical and emotional ability to undergo and respond to dental care.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]