the endocrine system is responsible for hormonal secretion and is closely related to the central nervous system , as it diversifies its functions through the hypothalamus and pituitary . the thyroid gland is a bilobular structure that lies on either side of the trachea . thyroid - releasing hormone ( trh ) , secreted by the hypothalamus , induces the secretion of thyroid - stimulating hormone ( tsh ) by the anterior pituitary , which in turn stimulates thyroid hormone synthesis and secretion by the thyroid gland . thyroid dysfunction is the second most common glandular disorder of the endocrine system ( after diabetes mellitus ) and is increasing , predominantly among women . an estimated 15% of the general population have abnormalities of thyroid anatomy on physical examination and an unknown percentage of these do not complete a diagnostic evaluation . it has been suggested that the number of people affected may be twice as many as the undetected cases . this explains that the patients with undiagnosed hypothyroidism or hyperthyroidism can be seen on the dental chair , where routine treatment has the potential to result in adverse outcomes . neonatal screening programs in many areas of the world show that hypothyroidism is present in 1 of every 4000 newborns . the incidence of hypothyroidism is 10 times higher than average in iodine - deficient areas . the hypothyroidism can be divided into 3 main categories : 
 primary hypothyroidism due to permanent loss or atrophy of thyroid tissuegoitrous hypothyroidism ( hypothyroidism with compensatory thyroid enlargement due to impairment of hormone synthesis ) ; andsecondary hypothyroidism due to insufficient stimulation of a normal gland ( hypothalamic or pituitary disease or defects in the tsh molecule ) . primary hypothyroidism due to permanent loss or atrophy of thyroid tissue goitrous hypothyroidism ( hypothyroidism with compensatory thyroid enlargement due to impairment of hormone synthesis ) ; and secondary hypothyroidism due to insufficient stimulation of a normal gland ( hypothalamic or pituitary disease or defects in the tsh molecule ) . most infants with permanent congenital hypothyroidism have thyroid dysgenesis : ectopic , hypoplastic or thyroid agenesis . radiation of the thyroid gland ( radioactive iodine ) , surgical removal and excessive anti - thyroid drug therapy are responsible for the majority of these cases of acquired hypothyroidism . subclinical hypothyroidism is a common , well - defined condition that often progresses to overt disease . insufficient levels of thyroid hormone cause symptoms such as slower metabolic rate ; weight gain ; lethargy ; intolerance to cold , dry and cool skin ; puffiness of the face and eyelids . classification ( cretinism against myxedema ) by age of onset is also important , because the clinical presentations will vary substantially . childhood hypothyroidism known as cretinism is characterized by thick lips , large protruding tongue ( macroglossia ) , malocclusion and delayed eruption of teeth . neonatal cretinism is characterized by dwarfism ; overweight ; a broad , flat nose ; wide - set eyes ; thick lips ; a large , protruding tongue ; poor muscle tone ; pale skin ; stubby hands ; retarded bone age ; delayed eruption of teeth ; malocclusions ; a hoarse cry ; an umbilical hernia ; mental retardation . however , the most common reason for a delayed diagnosis of congenital hypothyroidism is the fact that in many countries , like in our country ( india ) , neonatal screening is not established yet . considering the high incidence of congenital hypothyroidism , availability of low cost therapy and a robust screening test like tsh , it is highly desirable to start a screening program nationwide to prevent the most preventable cause of mental sub - normality . congenital hypothyroidism is such an important public preventive program of international significance and the whole world is looking at india as to why they are not conducting the screening test , still as a country ? therefore , before treating a patient , who has a history of thyroid disease , the dentist should obtain the correct diagnosis and etiology for the thyroid disorder , as well as past medical complications and medical therapy . on the other hand , the dentist by detecting the early signs and symptoms of hypothyroidism can refer the patient for medical diagnosis and treatment and avoid potential complications of treating patients with uncontrolled disease . here , we are presenting a case of dental diagnosis of undetected hypothyroidism in a 13- year - old female patient by oral medicine specialists . a 13-year - old female patient came to the out - patient department of oral medicine and radiology with chief complaint of malaligned teeth . extraoral examination revealed that she had dry and cool skin ; stubby hands [ figure 2 ] ; poor muscle tone ; puffy face [ figure 3 ] ; a broad , flat nose and thick lips [ figures 3 and 4 ] . overweight , short - stature patient stubby hands of the patient puffy face ; a broad , flat nose and thick lips thick lips , macroglossia and spacing between incisors intraoral examination revealed a large , protruding tongue ( macroglossia ) [ figure 4 ] ; delayed shedding of deciduous teeth ; delayed eruption of permanent teeth and malocclusion . there were over - retained deciduous canine , first and second molars in all four quadrants of the jaw . regarding permanent teeth , only central and lateral incisors and first molars were erupted in all four quadrants . malocclusion was evident as spacing between maxillary and mandibular central incisors [ figure 4 ] . radiographic examination confirmed over - retained deciduous and unerupted permanent teeth ( i.e. retarded dental age in pa skull ) [ figure 5 ] and retarded bone age ( in pa skull and hand - wrist radiographs ) [ figures 5 and 6 ] . photograph of pa skull radiograph showing over - retained deciduous and unerupted permanent teeth photograph of hand - wrist radiograph showing retarded bone age the provisional diagnosis of hypothyroidism was made and accordingly hormonal assay was advised . the t3 and t4 levels were found to be decreased ( 0.07 ng / ml and 0.6 g / dl , respectively ) and tsh was increased ( 153.46 mu / ml ) . patient 's parents were informed about her systemic condition that required immediate attention rather than oral condition and patient was referred to the endocrinologist . patient was prescribed thyroxine sodium tablets ( thyronorm ) 50 g two times a day . after five months of treatment , the patient 's t3 , t4 and tsh levels improved ( 0.86 ng / ml , 5.6 g / dl and 14.60 mu / ml respectively ) . patient lost weight [ figures 7 and 8 ] and her facial appearance [ figure 7 ] and stubby hands also improved [ figure 8 ] . patient was to be evaluated every six months for hormone levels , but being young , she had to be on the same dosage of medication for long . following a thorough oral and periodontal examination , a treatment plan was developed that included oral hygiene instructions , mechanical debridement and orthodontic correction . five month post - treatment photograph showing loss of excessive weight and puffy face five month post - treatment photograph showing improvement in stubby hands up to 5% of the female population have alterations in the tshyroid function . in some of these cases it is caused by chronic autoimmune thyroiditis ( hashimoto 's disease ) , radioactive iodine , surgery and pharmacological agents such as lithium and amiodarone . babies who are born with underactive thyroid function have a disorder known as congenital hypothyroidism . but in our country ( india ) , the incidence is still higher ( nearly 1:1000 ) . the usual cause of this condition is the failure of the thyroid gland to develop during gestation . at birth , the infants look normal and then slowly over period of weeks , the clinical features of hypothyroidism appear . however , in our case the patient gained abnormal weight after 9 years of age and it was diagnosed to be primary hypothyroidism . the accumulation of subcutaneous fluid ( intracellularly and extracellularly ) is usually more pronounced in patients with primary ( thyroid ) hypothyroidism than in those with pituitary ( suprathyroid ) hypothyroidism . congenital hypothyroidism is characterized by dwarfism , overweight , a broad , flat nose , wide set eyes , thick lips , a large , protruding tongue , poor muscle tone , pale skin , stubby hands , retarded bone age , delayed eruption of teeth , malocclusions , a hoarse cry , an umbilical hernia and mental retardation . thickening of the lips and macroglossia is due to increased accumulation of subcutaneous mucopolysaccharides i.e. , glycosaminoglycans because of decrease in the degradation of these substances . the long - term effects of severe hypothyroidism on craniofacial growth and dental development have also included impaction of the mandibular second molars as was present in our patient . this seems to be caused by a dissociation of ramus growth and failure of normal resorption of the internal aspect of the ramus , resulting in insufficient space for proper eruption of these teeth . replacement therapy with thyroxine ( levothyroxine sodium ) is the standard approach for the treatment of hypothyroidism . thyroxin ( t4 ) is converted to the more metabolically active triiodothyronine ( t3 ) in the peripheral tissues . this returns patients to a biochemical euthyroid state , with normal levels of tsh concentration and serum - free t4 ( ft4 ) . once the euthyroid state is achieved , the patient 's tsh and ft4 levels are followed for periods of six months to one year . in our patient , improvement in levels of t3 , t4 and tsh was noted within 5 months of treatment with thyroxine . obtaining an understanding of thyroid dysfunction is of significant importance to the dentist for two reasons . first , the dentist may be the first to suspect a serious thyroid disorder and aid in early diagnosis . if a suspicion of thyroid disease arises for an undiagnosed patient , all elective dental treatment should be put on hold until a complete medical evaluation is performed . once the hypothyroid patient is under good medical care , no special problems are presented in terms of dental management , except for dealing with the malocclusion and enlarged tongue if present . our patient had come with chief complaint of malaligned teeth , but suspecting hypothyroidism , we first referred her to the endocrinologist and once the thyroid disease was under control , we planned our dental treatment . the second reason is to avoid possible dental complications resulting from treating patients with the thyroid disorders . modifications of dental care must be considered when treating patients who have diseases of thyroid gland . as the thyroid is extremely sensitive to radiation , one way the dental professional can protect the thyroid gland is to use a thyroid collar while taking patient x - rays . patients with history of thyroid diseases should be carefully evaluated to determine the level of medical management and they should be treated in a way that limits stress and infection . if an emergency dental procedure is needed in the initial weeks of thyroid treatment , close workup with the endocrinologist is needed . regular communication of the dentist with the endocrinologist is a critical component of safe and optimal treatment of thyroid patients . physicians who treat children and adults with thyroid disorders could be a good referral source of patients whose oral health care needs may not be satisfied adequately . the endocrinologist must be aware of oral manifestations of the disease and dentists must be updated on thyroid control medications to help them to maintain patient 's oral health . the dentist may be the first to detect early signs and symptoms of thyroid disorders . consultation with the patient 's primary care physician or an endocrinologist is warranted , if any sign or symptom of thyroid disease is noted on examination . in some cases , this may be life saving , whereas in other cases , the quality of life can be improved and complications of certain thyroid disorders be avoided . before treating a patient who has any thyroid disorder , the endocrinologist also needs to be familiar with the oral manifestations of thyroid dysfunctions . thus , communication of the dentist with the endocrinologist must be bidirectional , to maintain patient 's oral and thyroid health .
thyroid dysfunction is the second most common glandular disorder of the endocrine system , which may rear its head in any system in the body including the mouth . 
 the oral cavity is adversely affected by either an excess or deficiency of thyroid hormone . 
 childhood hypothyroidism known as cretinism is characterized by thick lips , large protruding tongue ( macroglossia ) , malocclusion and delayed eruption of teeth . 
 neonatal screening for congenital hypothyroidism is not performed in all countries and not every affected patient might be determined by neonatal screening alone . 
 the dentist by detecting the early signs and symptoms of hypothyroidism can refer the patient for medical diagnosis and treatment and avoid potential complications of treating patients with uncontrolled disease . 
 herein , we present a case of undetected hypothyroidism in a 13-year - old female patient based on dental features by oral medicine specialists .