|Year : 2016 | Volume
| Issue : 2 | Page : 139-144
Oral health status of children suffering from thyroid disorders
NS Venkatesh Babu, Purna B Patel
Department of Pediatric and Preventive Dentistry, VS Dental College, Bangalore, Karnataka, India
|Date of Web Publication||14-Apr-2016|
Dr. N S Venkatesh Babu
VS Dental College, VV Puram, KR Road, Bangalore - 560 004, Karnataka
Source of Support: None, Conflict of Interest: None
| 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
|How to cite this article:|
Venkatesh Babu N S, Patel PB. Oral health status of children suffering from thyroid disorders. J Indian Soc Pedod Prev Dent 2016;34:139-44
|How to cite this URL:|
Venkatesh Babu N S, Patel PB. Oral health status of children suffering from thyroid disorders. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2021 Apr 15];34:139-44. Available from: https://www.jisppd.com/text.asp?2016/34/2/139/180443
| Introduction|| |
The endocrine system is responsible for secretion of various hormones and it is closely related to the central nervous system. It controls physiological functions of body and maintains homeostasis.  Among various endocrine dysfunctions, thyroid gland disorders are most commonly encountered in the pediatric age group, and hypothyroidism is the most common disorder.  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. 
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 based on the etiologic factors and physiologic abnormalities. 
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. 
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.
| 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].
|Table 1: Comparison of dmft and DMFT indices between the thyroid and control groups |
Click here to view
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].
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].
Statistically significant association was observed in frequency of brushing between the two groups (P value < 0.001). 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 the thyroid group did not brush compared to only 3% in the control group [Table 4]. Seven percent of the children in the thyroid group had visited dentist before, compared to 51% children in the control group. The difference between the two groups was found to be statistically significant [Table 5].
| Discussion|| |
Thyroid hormones influence the growth and maturation of tissues, energy metabolism, and turnover of both cells and nutrients.  Available literature on the overall health status and treatment needs of the children with thyroid disorders is very sparse. People with thyroid disorders constitute a very large proportion of the population, although there are very few studies concerning the dental aspects of the disease.
Congenital hypothyroidism (CH) is the most common metabolic disorder in the newborn. In our study, we observed that out of 100 children, 73% children suffered from CH. This data were comparable with the study done by Desai et al. , who also found high prevalence (78%) of CH. With the institution of neonatal screening for hypothyroidism in the most developed countries, instances of CH are now recognized shortly after birth and are treated immediately to avoid mentally handicapping conditions and growth disorders.  Also, the dental abnormalities of hypothyroidism can be prevented. Although the American Academy of Pediatrics (AAP) recommends a heel prick sample after 48 h of life, it is not routinely followed in our country.  Umbilical or heel prick sampling should be made compulsory for all newborns.
In the present study, the mean DMFT and dmft values in the thyroid group were 0.76 and 2.25, respectively. When compared to the control group mean values of both DMFT and dmft were higher in the thyroid group but the difference was not statistically significant. Yamana et al. also recorded higher value of DMFT in the adult thyroid group compared to the control group but this difference was statistically significant.
The plaque and gingival scores were significantly higher in the study group (0.987 and 1.417, respectively) compared to that in the control group (0.450 and 0.847, respectively) with statistically significant P value of <0.001. These results are comparable to the results obtained by Yamana et al. who stated that moderate type of gingival inflammation was found to be the most common among the patients with thyroid dysfunction. Similar results were also obtained by Kadhim et al. who found that the patients with thyroid disorders have poor periodontal health and more clinical attachment loss compared with healthy individuals. Scardina et al. suggested the possible association of thyroid dysfunction and periodontitis. Decrease in 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.  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 bite in 3%) were the most prevalent oral manifestations observed in the study [Figure 1] and [Figure 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. 
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.,  Loevy et al.,  and Buket et al.  have also reported delay in tooth eruption in children suffering from CH.
|Figure 3: Ten-year-old child suffering from hypothyroidism with delayed eruption and exfoliation|
Click here to view
|Figure 4: Eight-year-old child suffering from hyperthyroidism with early eruption of premolars and second molars|
Click here to view
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 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Carlos Fabue L, Jiménez Soriano Y, Sarrión Pérez MG. Dental management of patients with endocrine disorders. J Clin Exp Dent 2010;2:e196-203.
Desai MP. Thyroid function in children. J Assoc Physicians India 2011;59(Suppl):35-42.
Desai MP. Disorders of thyroid gland in India. Indian J Pediatr 1997;64:11-20.
De Ruiter J. Thyroid hormone tutorial: Thyroid pathology. Endocrine Module (P4pp25260) Thyroid Section, spring 2002. p. 1-30.
Al-Rubbaey YA, El-Samarrai SK. Oral health status and dental treatment needs in relation to salivary constituents and parameters among a group of patients with thyroid dysfunction. J Bagh College Dentistry 2010;22:65-72.
Desai MP, Karandikar S. Autoimmune Thyroid disease in childhood: A study of children and their families. Indian Pediatr 1999;36:659-68.
Kapoor S, Kapoor D, Kapoor VK. Congenital hypothyroidism: It′s profile in infancy. Thyroid Res Pract 2013;10:47-55.
John M. Burden of thyroid disease in India: Need for aggressive diagnosis. Medicine Update 2008;18:334-41.
Hanau KJ, Naoom E, Mahammed HO. CPITN in Iraqi females with thyroid dysfunction. Mustansiryia Dent J 2012;9:99-106.
Scardina GA, Messina P. Modifications of interdental papilla microcirculation: A possible cause of periodontal disease in Hashimoto′s Thyroiditis? Ann Anat 2008;190:258-63.
Monea A, Elod N, Sitaru A, Stoica A, Monea M. Can thyroid dysfunction induce periodontal disease? Eur Sci J 2014;10:74-83.
Chandna S, Bathla M. Oral manifestations of thyroid disorders and its management. Indian J Endocrinol Metab 2011;15(Suppl 2):S113-6.
Vitalle MS, Weiler RM, Niskier SR, Braga AJ. Delayed tooth eruption in adolescents with hypothyroidism. Rev Paul Pediatr 2012;30:613-6.
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.
Ayna B, Tumen DS, Celenk S, Bolgul B. Dental treatment way of congenital hypothyroidism: Case report. Int Dent Med Disord 2008;1:34-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]