Hypothyroidism

Hi Dr. Mason, I hope you are doing well!  I wanted to get your insight on a recent eval that I did.  It was for a child that is 3:9.  She had a frontal lisp on S, Z, T, D, L, N (not SH, CH, J) – which can all considered to be age appropriate.  She also rested with her tongue between her teeth (increased dental freeway space), however at times her tongue was in and her lisp were together (which suggests to me that there are no nasal breathing issues).  Her tonsils were not visible (small???).  She seemed to easily be able to breathe through her nose.  Parents report that she does snore a little.  Her cheeks were pretty “puffy” looking, but she is a young child so it seemed like it could be just a baby face.  On the inside of her mouth, her cheeks seemed really “thick”.

At this age, the buccal fat pad is still there, so this is within the normal range. Also, her palate was pretty narrow with a high appearing arch.  Her mouth appeared small (maybe due to the narrow palate), and her tongue seemed just too big for her mouth – just appeared that way when compared to her mouth/palate size.Excellent observations – and this is one time where the appearance of a large tongue in a small oral cavity makes sense, and is an accurate description. She sucked her thumb until recently and used a pacifier until age 2.  Her occlusion was normal. This indicates that the tongue forward rest posture has not as yet influenced the dentition negatively, and thankfully, the patient sits often with lips together, which is very helpful. Also, she grinds her teeth a lot, so there was wear on her teeth and her upper incisors were actually angled into a point on each corner and went upwards in the middle (together, they looked liked an upsideown V shape — they actually looked like her teeth were broken, This is most likely related to enamel hypoplasia, but her mom said she just grinds so much -only in the night time. I bet she shifts her jaw and her lower canine grind on her upper incisors to create that shape???).  What is significant is that she was born without a thyroid (aegenesis of the thyroid – there was an ultrasound that showed trace levels of thyroid).  She takes Synthroid.  She is a restless sleeper, maybe because of her medication.  My conclusion: her tongue rests forward most likely because of the shape of her palate (not enough space for her tongue to rest comfortable in her mouth).  I told that parents that the orthodontist may recommend a palatal expander when she is older.  What age do they usually do this? Anywhere from age 6 on up.  Otherwise, I do not think there is anything that needs to be done on my part until she is older, and orthodontics can open her mouth/palate, and then her forward rest posture may resolve on its own, or she may need myofunctional therapy to correct the habit. I think that everything you say here is appropriate and conservative. Same with her speech sounds. The parents were wondering if the lack of thyroid can affect anything – her tongue being forward, her palate/mouth size, and her cheeks seeming thick on the inside as well as puffy/large from the outside.Yes, the tongue may be a bit macroglossic related to the lack of thyroid. Also, what would explain/contribute to teeth grinding in a child so young?It is not at all unusual to find a teeth grinding habit in a child this young. The family dentist should monitor this and perhaps fit a soft niteguard to protect the teeth from further wear (but fortunately, these are baby teeth). Also, the dentist will check for any canine interferences. However, the excess wear and the notched incisors are very likely related to enamel hypoplasia, a characteristic of such children. Lastly, is snoring ever “normal” in a young child? Yes. As Pindborg’s description below indicates, the tendency toward macroglossia usually disappears over time with treatment. This means that the synthetic thyroid medication the physician is utilizing to counter the lack of thyroid function will also stabilize the tongue size. For now, it is very significant and positive that this youngster can sit with lips together and can breathe nasally without any apparent extra effort The first of two things I suggest that the parents do is to encourage their child to keep her lips together. This is a reasonable suggestion since you have already demonstrated that she can do this and breathe nasally. What this does is teaches the tongue to adapt to the dimensions of the oral cavity. The tongue will drop down and if a lateral cephalometric film was taken, it would reveal that the hyoid bone will be positioned lower as this adaptation occurs. This is a good thing, and seems to be what this child has been doing naturally. The second suggestion is to encourage the child to sleep on her right side. This should help to decrease the snoring. When she sleeps on her back, the tongue drops back naturally into the pharynx and snoring is facilitated. Sleeping on the side is now the preferred recommendation for sleep apnea and other sleep-related problems (rather than the specific sleep pillow and the recommendation that individuals should sleep face up). Sleeping on the right side is the healthiest position for the heart since the heart is higher and gravity aids cardiac flow.( from J.J. Pindborg’s text, Atlas of Diseases of the Oral Mucosa, W.B. Saunders, Publisher, 1980). (reply from SLP)

Wow! This is really interesting and important to know with regards to the hypothyroidism, the larger tongue, and the enamel. So, if I understand correctly:

• the hypothyroidism can cause the tongue to really be larger, but the medication should “combat this”? Yes
• with hypothyroidism, the enamel is less developed? Is there anything that can be done about this? Yes, but not recommended with baby teeth; however, stainless steel crowns are often placed to keep selected teeth from breaking off.
• Lastly, if you think it is important to encourage tongue in positioning at this age (for this particular scenario), do you think I should work with the child on this (at least for a short amount of time)? I don’t have a strong feeling one way or the other – but since the dentition is good, I guess I would just see her on a recall basis to evaluate for any changes in the dentition or tongue rest position. I wonder if the child will perceive the parents as “nagging”, but if I were to also work with the child, I can set them up on a positive reinforcement program for this and I can encourage the child as well. When I spoke with the parents, I told them to not worry about it at all now, but it seems like this was not the best recommendation! No, your recommendation was appropriate, so perhaps just seeing the child for an occasional recall would work best for now.                                                                                                                                I think they will understand, as this is a “different” and unusual case considering the thyroid, and I am blessed to be able to consult with you!!!