What precautions should be taken for tooth extractions in patients with thyroid disorders?

Tooth Extractions in Thyroid Disorders

Primary Recommendation

Patients with well-controlled thyroid disorders (both hyperthyroidism and hypothyroidism) can safely undergo routine dental extractions without special precautions, but uncontrolled hyperthyroidism requires medical stabilization before any elective dental procedure to prevent thyroid storm. 1, 2

Risk Stratification by Thyroid Status

Uncontrolled Hyperthyroidism (HIGH RISK)

• Defer all elective dental procedures, including extractions, until thyroid function is medically controlled 1, 2
• Uncontrolled hyperthyroidism poses risk of thyrotoxic crisis (thyroid storm) precipitated by dental treatment, acute infection, or surgical trauma 1
• Additional risk of hypertensive crisis if epinephrine or other vasopressors are used 1
• Emergency dental treatment only if absolutely necessary, with medical consultation and hospital setting 1, 2

Controlled Hyperthyroidism (LOW RISK)

• Routine dental extractions can proceed safely 1, 3
• Use minimal epinephrine (1:100,000 or less) with careful aspiration technique 1
• Monitor for signs of thyroid storm: fever, tachycardia, agitation, hypertension 2
• Ensure adequate stress management and anxiety control 2

Hypothyroidism - Severe/Uncontrolled (MODERATE RISK)

• Avoid central nervous system depressants, sedatives, and narcotic analgesics due to risk of significant respiratory depression 3
• Risk of myxedematous coma precipitated by CNS depressants, infection, or stressful procedures, particularly in elderly patients 3
• Defer elective extractions until thyroid replacement therapy achieves euthyroid state 3

Hypothyroidism - Well-Controlled (LOW RISK)

• No modifications to standard dental extraction protocol required 3
• All dental procedures can be offered safely 3

Procedural Bleeding Considerations

Simple Dental Extractions

• Classified as low bleeding risk procedures (2-day risk of major bleeding 0-2%) 4
• For patients on anticoagulation (unrelated to thyroid disease), simple extractions can proceed with continued anticoagulation plus local hemostatic measures 4

Multiple Tooth Extractions

• Classified as high bleeding risk procedures (2-day risk of major bleeding 2-4%) 4
• Requires more careful hemostatic planning 4
• Consider oral tranexamic acid mouthwash for local hemostasis if bleeding risk is elevated 4

Preoperative Assessment Checklist

Before any dental extraction in thyroid disorder patients, verify:

• Current thyroid function status (TSH, free T4, T3 levels) 5, 6
• Medication compliance with thyroid medications 7, 6
• Signs of uncontrolled disease:
  • Hyperthyroidism: tachycardia, tremor, heat intolerance, weight loss, anxiety 1, 2
  • Hypothyroidism: bradycardia, cold intolerance, weight gain, lethargy 3
• Cardiovascular complications: hypertension, arrhythmias, heart failure 1
• Current medications that may interact with dental anesthetics 1, 3

Anesthetic Considerations

Local Anesthesia

• In controlled hyperthyroidism: Use epinephrine-containing local anesthetics cautiously with concentration ≤1:100,000 1
• In uncontrolled hyperthyroidism: Avoid epinephrine entirely due to hypertensive crisis risk 1
• In hypothyroidism: Standard local anesthetics are safe in controlled patients 3

Sedation

• Contraindicated in severe hypothyroidism: Avoid all CNS depressants, sedatives, and narcotic analgesics 3
• In controlled thyroid disease: Standard conscious sedation protocols acceptable 3

Special Populations

Patients with MEN 2 Syndromes

• Screen for pheochromocytoma before any surgical procedure, including dental extractions 4
• Pheochromocytomas must be removed with α-adrenergic blockade (phenoxybenzamine) before any other surgery to avoid hypertensive crisis 4
• Coordinate with endocrinology before proceeding 4

Thyroiditis Patients

• Defer routine extractions during acute suppurative thyroiditis 3
• Patients with Hashimoto's thyroiditis may have transient hyperthyroid phase—avoid elective procedures during this period 3

Infection Control

• Standard universal precautions apply to all dental extractions regardless of thyroid status 4
• Extracted teeth should be handled as clinical specimens with appropriate infection control measures 4

Critical Pitfalls to Avoid

1. Never proceed with elective extractions in uncontrolled hyperthyroidism—thyroid storm can be fatal 1, 2
2. Never use epinephrine in uncontrolled hyperthyroid patients—risk of hypertensive emergency 1
3. Never use CNS depressants/narcotics in severe hypothyroidism—risk of respiratory depression and myxedematous coma 3
4. Never assume thyroid disease is controlled without recent laboratory confirmation 7, 6
5. Always screen MEN 2 patients for pheochromocytoma before any procedure 4

Communication Protocol

Bidirectional communication between dentist and endocrinologist is essential 7:

• Obtain medical clearance for uncontrolled or severe thyroid disease 7, 6
• Document current thyroid function tests and medication regimen 6
• Coordinate timing of extractions with thyroid treatment optimization 7, 3