Endocrine disorders

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Endocrine disorders and their oral manifestations

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Endocrine disorders

  1. 1. and their Oral Manifestations
  2. 2. Endocrine system - together with the nervous system, acts as the body´s communication network - it is composed of various endocrine glands and endocrine cells - the glands are capable of synthesizing and releasing special chemical messengers – - hormones
  3. 3. Hormones - substances which are secreted by specialised cells in very low concentrations and they are able to influence • secreted cell itself (autocrine influence), • adjacent cells (paracrine influence) or • remote cells (hormonal influence)
  4. 4. The main groups of hormones Classic hormones (produced by specialised glands) are divided into three groups: 1. low molecular (amine) hormones (catecholamines, thyroid hormones, prostaglandins, leucotrienes, dopamine, serotonin, GABA, melatonin ) 2. steroid hormones (e.g.gluco- and mineralocorticoids) 3. polypeptidic and protein hormones (e.g. insulin, leptin)
  5. 5. General characteristic of hormones 1. they have specific rates and patterns of secretion (diurnal, pulsatile, cyclic patterns, pattern that depends on the level of circulating substrates) 2. they operate within feedback systems, either positive(rare) or negative, to maintain an optimal internal environment 3. they affect only cells with appropriate receptors  specific cell function(s) is initiated 4. they are excreted by the kidney, deactivated by the liver or by other mechanisms.
  6. 6. Some general effects of hormones Hormones regulate the transport of ions, substrates and metabolites across the cell membrane: - they stimulate transport of glucose and amino acids - they influence of ionic transport across the cell membrane - they influence of epithelial transporting mechanisms - they stimulate or inhibit of cellular enzymes - they influence the cells genetic information
  7. 7. The pituitary gland is divided into 2 functional units.  Anterior pituitary or adeno hypophysis  Posterior pituitary or neuro hypophysis Adeno hypophysis include Pars Anterior, Pars Intermedia & Pars Tuberalis. Neuro hypophysis includes Pars Posterior, Infundibular Stem and Median eminence.
  8. 8. Growth hormone (GH,Somatotropin)- Accelerate body growth. Adrenocorticotrophic hormone(ACTH)-Stimulates secretion & growth of zona fasciculata & zona reticularis of adrenal cortex. Thyroid stimulating hormone(TSH) -Stimulates T3 and T4 secretion and growth of thyroid gland. Follicle stimulating hormone(FSH)-Stimulates ovarian follicle, spermatogenesis
  9. 9. Leutinizing hormone(LH)-Stimulates ovulation & leutinization of ovarian follicle, testosterone secretion. Prolactin(leutotrophic hormone)Stimulates secretion of milk and maternal behavior and maintains corpus luteum.
  10. 10. • Alpha & beta melanocyte stimulating hormone Stimulates melanin synthesis in melanocytes in humans.
  11. 11. Vasopressin (Antidiuretic hormone)- promotes water retention. Oxytocin- Causes milk ejection.
  12. 12. Four characteristic elements in the regulation of pituitary hormone levels have been identified1) Specific hypothalamic neurons release small peptides into the anterior pituitary. 2) Secretory cells in the pituitary coordinate the release of larger peptides into the systemic circulation. 3) Resultant changes in specific endocrine organs, which act as a target tissue for the pituitary hormones, have been linked to specific pituitary hormones.
  13. 13. 4) A well-documented negative feedback by the hormone product of the target organ has been demonstrated upon the secretory pituitary cell and upon hypothalamic neuronal secretions. In the central nervous system, peptidergic neurons in the hypothalamus release small peptides (3–8 amino acids) that specifically signal secretory cells in the pituitary to produce and release larger peptides (20 to > 1,000 amino acids) into the systemic circulation
  14. 14. • Gigantism • Acromegaly • Hypopituitarism
  15. 15. HYPERPITUITARISM • It results from hyperfunction of anterior lobe of pituitary gland, most significantly with increased production of growth hormone. • Cause of this condition is a benign, functioning tumor of the eosinophilic cells in the anterior lobe of the pituitary gland. • GH acts directly on some tissue but most of its biological effects are accounted by stimulation of secretion of insulin like growth factor I (IGF-I) and its binding proteins from the lower.
  16. 16. Types • Gigantism — If the increase occurs before the epiphysis of the long bone are closed. • Acromegaly — if the increase occurs later in life after epiphysis closure.
  17. 17. • TALL SKELETON • MUSCLES AND VISCERA – LARGE.
  18. 18. • Generalized overgrowth of most tissue in childhood. • Stature of individual — Excessive generalized skeletal growth. Patient may often have height of 7 to8 feet. Patients achieve monstrous size. • Symptoms — later in life it may show genital underdevelopment and excessive perspiration • Complain of headache, lassitude, fatigue, muscle and joints pain and hot flashes.
  19. 19. • Skull — There is increase in size of calvarium which may lead to change in the hat size. • Pituitary tumors may also induce deficiency of other pituitary hormones causing signs of hypogonadism including decreased libido and menstrual problems in women.
  20. 20. Teeth • Teeth in gigantism are proportional to the size of jaw and the rest of the body and root may be longer than normal. • The teeth become spaced, partly because of enlargement of the tongue and party because upper teeth are situated on the inner aspect of the lower dental arch, due to disproportionate enlargement of the two jaws
  21. 21. Jaw bone • Mandibular condylar growth is very prominent. The growth at the condyle may exceed that of the alveolar processes, so that increase in vertical depth of the ramus is greater than that of the body of the jaw, consequently the upper and lower teeth fail to come into proper occlusion. • Overgrowth of mandible leading to prognathism. • Class III malocclusion.
  22. 22. • Palate — the palatal vault is usually flattened and the tongue increase in size and may cause crenation on its lateral border. • Lips — the lips become thick and Negroid. • In edentulous patients' enlargement of the alveolus may prevent the comfortable fit of complete dentures.
  23. 23. • Radiographically, the cortical plate is radiodense and the condyles appear large in diameter. • Deposition of cementum on the roots of the teeth is increased (hypercementosis). • Hoarseness, stridor and dyspnoea are signs of thickening of the pharyngeal and laryngeal (vocal cords) soft tissues. • Reduced airway diameter makes these patients more susceptible to upper airway obstruction. • Enlargement of the major salivary glands is possible.
  24. 24. • CEREBRAL GIGANTISM (SOTO’S syndrome) • Cause is not known. Clinical features include  Large elongated head.  Prominent forehead.  Large ears and jaws.  Elongated chin.  Antimongoloid slant to the eyes.  Coarse facial features.  Subnormal intelligence and impaired co-ordination.
  25. 25. • PRIMARY. Pituitary tumor. Pituitary hyperplasia. • SECONDARY. Ectopic GH/GRH secreting tumor. MEN syndromes (association).
  26. 26. CLINICAL FEATURES • Age and sex — it is more common in males and occurs most frequently in 3rd decade. • Facial features — bone overgrowth and thickening of the soft tissue cause a characteristic coarsening of facial features termed acromegaly. • Symptoms — there is temporal headache, photo phobia and reduction in vision.
  27. 27. • Increased Intrasellar tension. • Compression of neighbouring structures.
  28. 28. • Enlarged hands and feet with clubbing of the toes and fingers due to enlargement of the tufts of the terminal phalanges. • Thickening of the clavicles. • Spine – Kyphoscoliosis, Lordosis. • Periosteal Calcifications.
  29. 29. • Heart – Cardiac enlargement, hypertension and cardiac failure. • Lung – Enlargement. • Larynx – Enlargement Of Vocal Cords results in deep voice.
  30. 30. • Lantern jaw. • Class III malocclusion. • Flaring of dental arches with spacing. • Macroglossia
  31. 31. Skull Changes • Enlargement of sella turcica, enlargement of paranasal sinus and excessive pneumatization of temporal bone squames and petrous ridge. • Diffuse thickening of outer table of skull. • Enlargement and distortion of the pituitary fossa • Air sinus—the air sinuses are really prominent in acromegaly rather than in gigantism.
  32. 32. Teeth • Increased tooth size especially root due to secondary cemental hyperplasia. • Diastema between teeth due to lengthening of dental arch. Increase in thickness and height of alveolar process.
  33. 33. Jaw bone • In acromegaly the angle between the ramus and body of mandible may increase, which results in anterior tooth root push forward so they appear as fan out. • There is also lengthening of condylar process, The new bone laid down on the condyle results in an increase in the vertical length of the ramus as well as overall length of whole bone. • Enlargement of the mandible, the length of the horizontal and ascending rami are both increased.
  34. 34. • Growth hormone assay. • Radiographic changes. • Biochemical. • Detection of parasellar involvement.
  35. 35. • BROMOCRYPTINE (Parloder 2.5 and 10 mg tab)
  36. 36. • External gamma radiation.(4500 rads) • Accelerated proton beam.(10,000 rads) • Local implantation of radioactive isotopes of yttrium, gold, strontium etc.
  37. 37. • Ablation of the Pituitary Adenoma.
  38. 38. • These patients may have DM, HTN or cardiomyopathy. • Medical consultation is advised before surgical manipulation or potentially stressful dental appointments. • Sedation in the acromegalic patient can be complicated by the enlargement of the tongue and epiglottis. • Deep conscious sedation and narcotic analgesics are ill-advised.
  39. 39. • Total absence of all pituitary secretions is known as Panhypopituitarism or Simmond’s disease
  40. 40. • • • • • • Idiopathic. Craniopharyngioma. Metastatic carcinomas. Pituitary adenoma Sarcoidosis. Sheehan’s syndrome.
  41. 41. • Stature of individual—the underdevelopment is symmetrical, individual is very small and in some cases there may be a disproportional shortening of the long bones. • The hallmark of this condition is that the growth is retarded to a greater degree than is bone and dental development. • Hypocalcemia — it may occur because of growth hormone and cortisol deficiency. Lack of gonadotrophin delays the onset of puberty.
  42. 42. • Symptoms— growth hormone secretion is lost resulting in lethargy, muscle weakness and increase fat mass in adults. • Sexual characteristic— after luteinizing hormone (LH) secretion becomes impaired, in the male loss of libido and impotence and in female oligomenorrhea or amenorrhea. The male produces gynecomastia and skin becomes fair and wrinkled. • Skull— the skull and facial bone are small and there is delay in maturation of the skeleton and epiphysis may remain ununited throughout the life.
  43. 43. • Growth retardation noticed 2-3 years after birth.
  44. 44. • Teeth — complete absence of third molar bud. Roots of teeth are short and apices are wide open and pulp canal toward the apex. • Alveolar bone—there is loss of alveolar bone.
  45. 45. • GROWTH HORMONE prepared from human pituitary glands. • Hypopituitarism caused by tumors may require surgery or radiotherapy.
  46. 46. • Schour and Vandyke(1932)  Rate of eruption was reduced.  Excessive thickness of dentine.  Shorter roots of teeth and diminished growth of bone.
  47. 47. • Tooth eruption is delayed and incomplete. • Clinical crowns are small in gingivo-occlusal dimension, and root length is reduced. • A small dental arch contributes to crowding and malocclusion. • Salivary glands are prone to hypofunction, which contributes to decreased salivary flow and increased oral bacterial infections. • Early orthodontic evaluation is important to correct skeletal-dental malrelationships.
  48. 48. • Fluoride treatments should be initiated early in life, and frequent periodontal recall implemented to reduce oral bacterial accumulations. • In pts with hypopituitarism and hypoaldrenalism may require supplemental corticosteroids during dental treatment.
  49. 49. • ADRENAL MEDULLA Epinephrine and Nor epinephrine. • ADRENAL CORTEX Glucocorticoids, Mineralocorticoids and Sex hormones.
  50. 50. • Addison’s disease. • Cushing’s disease
  51. 51. It is also called as chronic adrenal insufficiency of the adrenal cortex. It was first described by Addison in 1855.
  52. 52. • Autoimmune. • Infections. • Metastatic tumors. • Drugs.
  53. 53. • Age and sex— it is more common in males Frequently seen in the 3rd and 4th decades. • Symptoms— feeble heart action, general debility, vomiting, and diarrhea and severe anemia. Patient complains of postural hypotension. • Sign— the disease is characterized by bronzing of skin, a pigmentation of the mucous membrane
  54. 54. • Metabolic function—decrease cortisol level interferes with the manufacture of carbohydrates from protein, causing hypoglycemia and diminished glycogen storage in the liver. • Neuromuscular function—neuromuscular function is inhibited, producing muscle weakness. • There is also reduced resistance to infection, trauma, and stress.
  55. 55. • The pale brown or deep chocolate pigmentation of the oral mucosa, spreading over the buccal mucosa from the angle of the mouth and/or developing on the gingiva, tongue, lips may be first evidence of disease.
  56. 56. • Plasma ACTH and Cortisol levels Low diurnal plasma Cortisol and ACTH levels.
  57. 57. • Blood sodium and chloride levels • Elevated serum potassium • Elevated blood urea nitrogen
  58. 58. • Oral lesions shows acanthosis with silver positive granules in the cells of stratum germinativum.
  59. 59. • Glucocorticoid replacement. • Mineralocorticoid supplement.
  60. 60. • Increased susceptibility to infections. • Possibility of adrenal crisis.
  61. 61. • Patients at a significant risk of adrenal suppression include those who are currently taking oral steroids daily and those who have taken an equivalent daily dosage of cortisol for more than 2 weeks during the previous 12 months. • Moderate risk- those receiving alternate day therapy or those who take less than half the daily dose of cortisol equivalent for less than 1 month. • No risk- topical steroids
  62. 62. Cushing's syndrome arises from excess secretion of glucocorticoids by the adrenal glands. It is described by Harvey Cushing in 1932.
  63. 63. • Age and sex—female to male ratio is 3:5, seen in 3rd and 4th decades. • Moon face—rapidly acquired obesity about upper portion of the body and rounded moon face. • Buffalo hump—there is truncal obesity with prominent supraclavicular and dorsal cervical fat pads giving rise to the 'buffalo hump' appearance at the base of neck.
  64. 64. • Other features—the distal extremities are usually thin. Weakness, hypertension, or concurrent diabetes is usually present. • Hair—alternation in hair distribution. • Abdomen—dusky plethoric appearances with formation of purple striae appear on abdomen. • There is also weight loss, menstrual irregularity, hirsutism, backache, obesity, hypertension can also occur.
  65. 65. • • • • Face is round, swollen, reddish Eyes- conjunctival edema Gingiva- enlarged, swollen and bleeds easily Despite the tendency for osteoporosis, no bony abnormalities of the jaws are usually noted. • Patients are prone to bacterial and fungal infections- periodontitis and candidiasis.
  66. 66. • • May show areas of loss of lamina dura. Skull—it may show diffuse thinning and have mottled appearance.
  67. 67. • Pituitary Gland Lesion – Surgery + Radiotherapy. • Adrenocortical HyperplasiaRadiotherapy. • Adrenal Cortical Tumors – Surgery. • Drugs – Metyropone, Ketoconazole or Aminogluthemide inhibit cortisol synthesis.
  68. 68. • • • • • • Hypertension. Heart failure. Diabetes mellitus. Osteoporosis. Impaired healing. Emotional depression or psychosis.
  69. 69. Acute adrenal insufficiency with acute septicemia. Characterized by rapidly fulminating septic course, a pronounced purpura and death within 48 to 72 hours.
  70. 70. It refers to any situation in which there is overproduction of androgens.
  71. 71. • Causes—it results when hyperplasia or tumors of the adrenal cortex occur. • Age and clinical features—-it may appear at 3 different times of life. i.e. at birth, in childhood and in adult. Clinical features vary according to appearance of lesion.
  72. 72. • At birth—in female child it produces pseudo- hermaphroditism, while in male child it produces macrogenitosornia praecox. • In childhood —In the females it produces masculinization and in males it produces sexual precocity.
  73. 73. • In adults—in females it produces virilism and in males it produces feminization.  Oral finding—if the disease begins premature eruption of the teeth may occur.
  74. 74. HORMONE ORIGIN Thyroid Hormones Tri Iodo Thyronine Tetraiodo Thyronine Calcitonin Follicular cells Parafollicular cells TARGET TISSUE Most cells of the body Bone
  75. 75. Thyrotrophic Releasing Hormone. Thyrotropin (TSH). T3 AND T4
  76. 76. • Hyperthyroidism. • Hypothyroidism
  77. 77. • • • • • Exopthalmic goitre. Toxic adenoma. Ectopic thyroid tissue. Grave’s disease. Pituitary disease.
  78. 78. • • • • • • • • Increased metabolic rate. High body temperature. Heat intolerance. Tachycardia. Weight loss. Increased appetite. Exopthalmos. Warm extremities.
  79. 79. • Age and sex—it has predilection for females between 20 and 40 years of age. • Thyroid is diffusely enlarged, smooth, possible asymmetrical and nodular, a thrill may be present, may be tender. Abdomen, liver and spleen may be enlarged.
  80. 80. Neuromuscular • Nervousness • Fine tremors • Muscle weakness • Mood swings from depression to extreme euphoria • Emotional liability, hyper-reflaxia, ill sustained clonus, proximal myopathy, bulbar myopathy and periodic paralysis.
  81. 81. Gastrointestinal • Weight loss despite normal or increased appetite • Diarrhea • Bowel alterations • Anorexia, Vomiting • Hyperdefecation
  82. 82. Cardiorespiratory • Palpitation, excessive perspiration, • Increased metabolic activity • Tachycardia and increased pulse pressure • Congestive cardiac failure. • Exhertional dyspnoea • Ankle edema, • systolic hypertension may be present. • Angina and cardiomyopathy • Exacerbation of asthma.
  83. 83. • Ocular— In thyrotoxicosis patient may have bulging eye and partial paralysis of the ocular muscles, corneal ulceration, optic neuritis, ocular muscle weakness, papilloedema, loss of visual activity, exophthalmos . • Reproductive—amenorrhea, oligomenorrhea, infertility, spontaneous abortion and loss of libido, impotence.
  84. 84. Dermatological— • Increases sweating • Pruritus • Pigmentation • Vitiligo • Digital clubbing • Pretibial Myxedema (bilateral non-pitting edema).
  85. 85. • TEETH – Advance rate of development, early eruption with premature loss of primary teeth. • Increased incidence of caries. • Osteoporosis. • Ectopic thyroid tissue in the tongue
  86. 86. • Thyroid storm/ crisis. Propylthiouracil (60-100mg, iv) • Complete blood picture. • Local anaesthetic without epinephrine should be used. • Sedatives are safe • Anticholinergics should be avoided. • Iodine preparations found in radiographic contrast solutions should be avoided.
  87. 87. • RADIOGRAPHIC PICTURE. • LABORATORY INVESTIGATIONS T3 , T4 and TSH levels.
  88. 88. • Radioactive iodine ( I 131) • Drug therapy – Prophythiouracil and methimazole. • Sub total thyroidectomy.
  89. 89. • PRIMARY. • SECONDARY.
  90. 90. Cretinism — if failure of hormone occurs in infancy. Juvenile Myxedema — if it occurs in childhood. Myxedema — if it occurs after the puberty. In it there is subcutaneous deposition of hydrophilic muco-polysaccharides.
  91. 91. Cretinism and Juvenile Myxedema • Age — it may be present at birth or become evidence within the first few months after birth. • Symptoms — hoarse cry, constipation, feeding problems in neonates, retarded mental and physical growth. • Bones — delayed fusion of all body epiphysis and delayed ossification of paranasal sinus, partially pneumatization.
  92. 92. • Signs — There is protuberant abdomen with umbilical hernia. The hairs are sparse and brittle, the finger nails are brittle and the sweat glands are atrophic.
  93. 93. Myxedema Symptoms • Early symptoms—it may include weakness. fatigue, cold intolerance, lethargy, dryness of skin, headache, menorrhagia and anorexia. • Late symptoms—it includes slowing of intellectual and motor activity, absence of sweating, modest weight gain, constipation, peripheral edema, pallor, hoarseness, decreased sense of taste and smell, muscle cramps, aches and pains, dyspnea, anginal pain and deafness.
  94. 94. • • • • Signs Dull expressionless face, periorbital edema, sparse hair and skin that feels droughty to touch. Temperature normal and the patient may be disorientated which may indicate impending myxedematous coma, pulse decreased, blood pressure normal, diastolic hypertension may be present Facial pallor, puffiness of face and eyelids (myxedema), loss of lateral third of the eyebrows “Queen Anne’s sign” occasional purpura. thickened nose and lips in more advanced cases, note scars in neck from thyroidectomy.
  95. 95. • • • Thyroid gland may be enlarged, thin brittle nails, coarse thin hair, dry rough skin, displaced apical beat may be present. Delayed return of deep tendon reflexes, pleural effusion may be present. There are also watery eyes, brittle hair and patchy alopecia.
  96. 96. Teeth • Dental development delayed and primary teeth slow to exfoliate. • Enamel hypoplasia can also be seen. • Abnormalities of dentin formation lead to enlarge pulp chamber. Jaw bone • Maxilla is overdeveloped and mandible is underdeveloped. • Retarded condylar growth leads to characteristic micrognathia and open bite relationship
  97. 97. • Tongue — tongue is enlarged by edema fluid and due to its tongue may protruded continuously and such protrusion may lead to malocclusion of teeth. • Skull — the base of skull is shortened leading to a retraction of the bridge of the nose with flaring. • Face — It is wide and fails to develop in longitudinal direction. • Lips — they are puffy, thickened and protruding.
  98. 98. • Macroglossia and enlarged lips. • Facial swelling. • Periodontal disease. • Dry and brittle hair.
  99. 99. • Delayed closing of the fontanelles. • Teeth reveal thinning of the lamina dura. • Delayed dental eruption. • Short tooth roots.
  100. 100. • TSH levels are increased.. • T3 & T4 levels are decreased. • Classic sinus bradycardia in ECG.
  101. 101. • THYROID PREPERATION – LEVOTHYROXINE • Early detection in children and timely therapy results in a dramatic resolution of the condition.
  102. 102. • MYXEDEMA COMA. 300µg thyroxine I.V. • HYPERSENSITIVE TO DRUGS • CONSERVATIVE TREATMENT IS DESIRABLE IN THESE PATIENTS. • Mouth breathing and the resultant gingivitis and rampant caries may require frequent oral prophylaxis, fluoride supplementation, restorative treatment, and protective pastes applied to the teeth at night before retiring. • Orthodontic evaluation in early adolescent years can help prevent malocclusion.
  103. 103. • Chief cells secrete parathyroid hormone. • Oxyphil cells function is not known.
  104. 104. • BONE  Increases bone resorption by intensifying the osteoclastic activity • KIDNEY  Facilitates the conversion of vitamin D into its final active end product.  Acts on renal tubules to increase calcium reabsorption and phosphate excretion.
  105. 105. • GIT PTH produces indirect effect. Decreased serum phosphate increases the production of active vitamin D which increases calcium and phosphate absorption from GIT, both by active and passive transport.
  106. 106. • HYPERPARATHYROIDISM. • HYPOPARATHYROIDISM.
  107. 107. • PRIMARY. • SECONDARY. • TERTIARY
  108. 108. • Parathyroid adenoma. • Parathyroid carcinoma. • Multiple endocrine neoplasia.
  109. 109. • Develops when PTH is continuously produced in response to low levels of serum calcium ,a physiologic response to Renal failure, Rickets, Malabsorption syndrome.
  110. 110. • Occurs after secondary hyperparathyroidism when the external factor is corrected but parathyroid glands remain hyperplastic.
  111. 111. • JACKSON AND FRAME (1972) aptly described the features as a composite of “BONES, STONES, ABDOMINAL GROANS AND PSYCHIC MOANS WITH FATIGUE OVERTONES.”
  112. 112. • Osteoporosis. • Cystic bone lesions. • Bone pain / tenderness. • Spontaneous fractures.
  113. 113. • Polyuria. • Polydypsia • Renal stones.
  114. 114. • Constipation. • Anorexia. • Vomiting. • Vague abdominal pain • Pancreatitis. • Peptic ulceration.
  115. 115. • • • • • • Muscle weakness Fatigue Weight loss Insomnia Polyuria polydypsia
  116. 116. • Vague jaw bone pain • Teeth that sensitive to percussion and mastication • Drifting and loosening of teeth causing malocclusion • Pulp stones and root resorption • Sialolithiasis • Skeletal muscle weakness • Peculiar fasciculations of the tongue
  117. 117. • Most common cause of generalized bone rarefaction of jaws • Generalized loss of lamina dura and loss of medullary trabeculation • Brown tumors (resemble CGCG histologically)
  118. 118. • GROUND GLASS. • MOTH-EATEN. • SALT AND PEPPER APPEARANCE.
  119. 119. • SUB PERIOSTEAL EROSIONS OF BONE OF MIDDLE PHALANGES IS THE HALL MARK.
  120. 120. • LOSS OF LAMINA DURA. • LOSS OF MEDULLARY TRABECULATION (Ground glass appearance) • PULP STONES AND ROOT RESORPTION MAY ALSO OCCUR.
  121. 121. • BROWN TUMORS APPEARS AS WELL DEMARCATED UNILOCULAR OR MULTILOCULAR RADIOLUCENCIES.
  122. 122. • Medical consultation is necessary to ensure adequate calcium levels • Low Ca can ppt arrythmias, bronchospasm, laryngospasm, convulsions, and death due to tetany • High levels can lead to renal failure and cardiac irregularities
  123. 123. • Elevated PTH and Serum Calcium – primary. • Elevated PTH and low or normal Serum Calcium-secondary. • Decreased serum Phosphate Level(less than 2.5mg/dl). • Increase in serum alkaline phosphatase level. • Elevated serum chloride levels.
  124. 124. • CORTICOSTEROID THERAPEUTIC TEST. • OTHER TESTS. Barium swallow. • IMAGING scan. - CT, MRI, thallium technetium subtraction
  125. 125. Unilocular • Postextraction socket and surgical defect-— history of extraction and surgery respectively. • Primordial bone cyst, traumatic bone cyst and odontogenic cyst—they all occur in a younger age group than in hyperparathyroidism and have normal serum chemistry values.
  126. 126. • • • • • • • Paget's disease Ameloblastoma Central giant cell granuloma Cherubism Aneurysmal bone cyst and central hemangioma Fibrous dysplasia Multiple myeloma
  127. 127. • SURGERY – Excision of parathyroid tumors. • MEDICAL - Sodium or potassium phosphate, sodium chloride, mithramycin. • Oral Vitamin D can prevent skeletal demineralization
  128. 128. • DI GEORGE SYNDROME. • POST OPERATIVE HYPOPARATHYROIDISM. • IDIOPATHIC HYPOPARATHYROIDISM. • PSEUDOHYPOPARATHYROIDISM.
  129. 129. • ALBRIGHT hereditary osteodystrophy. • Genetic X-linked dominant trait. • Lack of effect of PTH at target cell. • C/F : Obesity, diminished intelligence, short metacarpals and metatarsals, exostoses, brachydactyly. • Blood tests – Normal/high PTH, low calcium high phosphate.
  130. 130. • TETANY. • CARPOPEDAL SPASM. • BRONCHOSPASM AND LARYNGOSPASM.
  131. 131. • In children a characteristic triad of carpopedal spasm, stridor and convulsions occur • Stridor is caused by spasm of the glottis • Adults complain of tingling in the hands feet and around the mouth
  132. 132.  Chvostek sign — a sharp tap over the facial nerve in front of ear causes muscle twitching of facial muscle around the mouth which is called as Chvostek sign.  Trousseau’s sign-it is elicited by occluding blood flow to the forearm for 3 minutes with sphygmomanometer cuff applied to the arm and raising the pressure above systolic level. This will induce carpopedal spasm.
  133. 133. • • • • Altered tooth eruption pattern, short, blunted roots, enamel hypoplasia, dentin dysplasia, malformed or impacted teeth, and partial anodontia. After puberty- does not affect teeth Circumoral paresthesia is often one of the first symptoms of hypoparathyroidism Patients are predisposed to oral candidiasis.
  134. 134. • Calcification of basal ganglion which appears flocculent and paired with the cerebral hemisphere on PA view. • Radiograph of jaw may reveal enamel hypoplasia, external root resorption, delayed eruption or root calcification.
  135. 135. • The serum calcium level is decreased usually below 7 mg/dl. • Serum phosphate level correspondingly elevated. • Urinary calcium is low or absent.
  136. 136. • Supplemental calcium and vitamin D depending on severity of the hypocalcaemia and the nature of the associated signs and symptoms. • In severe cases intravenous administration of calcium gluconate is the treatment of choice.
  137. 137. • Appropriate medical referral should be made after recognition of S/S • After medical evaluation and treatment, routine dental care can be provided • If oral candidiasis is present, antifungal agents such as nystatin should be provided.
  138. 138. • Hypercalcemia may be a presenting sign of multiple endocrine neoplasia (MEN). • Autosomal dominant • May account for 5% cases if hypoparathyroidism • MEN is divided into three categories: 1. MEN I 2. MEN IIa 3. MEN IIb
  139. 139. • Formerly called “Wermer’s syndrome” • 3 P’s 1. Parathyroid 2. Pituitary 3. Pancreas
  140. 140. • Formerly called “Sipple’s syndrome” • Dominated by: 1. Hyperparathyroidism 2. Medullary carcinoma of thyroid 3. Pheochromocytomas
  141. 141. • Formerly known as “Schimke’s syndrome” • Characterized by medullary carcinoma of thyroid and pheochromocytomas, but seldom shows hyperparathyroidism. • Other features: 1. Marfanoid habitus 2. Mucosal neuromas 3. Skeletal and alimentary tract abnormalities 4. Abnormal cutaneous nerves and mucosal neuromas occur within the mouth in more than 90% of these patients.
  142. 142. • Local anesthesia with vasoconstrictor should not be used in patients with pheochromocytoma. • Avoid all catecholamines in retraction cord because epinephrine present in these materials can precipitate severe hypertension.
  143. 143.  Clinical features – Polydipsia – Polyuria – Polyphagia – Breath – Visual activity-ranges from color blindness to total blindness disease more than 20yrs – Atherosclerosis-coronary heart disease & stroke – Diabetic neuropathy
  144. 144. • Infection recurrent vaginal infection, skin infection, UTI infection, paresthesia in toe or finger • Other symptoms -Nocturia, weight loss, fatigue, obesity, nausea, vomiting -Temp, BP may be elevated & peripheral pulses may be reduced
  145. 145. Oral manifestation • Gingival & Periodontal disease -More prone to periodontal disease & greater tendency for bleeding on probing -fulminating periodontitis with periodontal abscess, hemorrhagic gingival papillae & gives rise to mobility -severe & rapid alveolar bone loss & resorption -Gingival fluid in the diabetes has more glucose level which favors the growth of micro flora
  146. 146. • Oral candidiasis-due to multiplication of candida albicans due to impaired glucose level & immune mechanism • Localized osteititis-dry socket develops & show delayed healing • Burning mouth • Other feature -Increased caries activity -Atrophy of lingual papillae with fissuring & dry tongue -delay in wound healing due to decreased polymorphonuclear chemotaxsis
  147. 147. • Angular cheilosis • altered taste sensation Radiographic Features -Discontinuity or blurring of the cortex of alveolar crest -Destruction of lamina dura -Horizontal & vertical bone loss
  148. 148. Diagnosis • Often made by clinical symptoms • Plasma glucose concentration elevated & it is greater than 140mg/dl • The glucose tolerance test-200mg/dl • Taste paper strip-strips for direct estimation of blood glucose level • Blood-random glucose elevated, fasting glucose elevated 2h postprandial
  149. 149. Management • Diet control-who are obese dietary control towards a balanced calorie intake, exercise • Oral hypoglycemic drugs • Sulfonylurea-Tolbutamide 25-500mg 8-12hr-used in inducing hypoglycemia gliclazide & glipizide Biguanides less widely used. Metformin 500mg 12hrly(contraindicated in hepatic & renal impairment & excess of alcohol intake)
  150. 150. • Alfaglucoside inhibitors-acrobase 50-100mg with each meal • Insulin therapy-inj sc in sites of anterior wall, upper arm, outer thighs & buttocks is given 30 min before meal to allow adequate time for absorption
  151. 151. • Treatment should be in such way that it minimize disturbances of metabolic balance • Complaint of hypoglycemia glucose drink should be given • Use of LA with out epinephrine • Extraction socket should be sutured to prevent excessive hemorrhage • Physician advice should be taken before undergoing GA • Antibiotic prophylaxis before dental treatment to prevent infection
  152. 152. Complications • Ketoacidosis, coronary heart disease, peripheral vascular disease. • Recurrent skin & urinary infections, renal & retinal changes, cataracts • Peripheral neuropathy, • premature mortality, • hyperosmotic nonketotic coma
  153. 153. Diabetes insipidus • • • • Causes Insufficiency of posterior pituitary hormone Traumatic episodes like head trauma or surgical procedures carried near pituitary region Tumors like craniopharyngioma, syphilis & basal meningitis There is damage for production of vasopressin
  154. 154. Symptoms • Increased thirst • Passage of large quantities of urine. urine of low specific gravity • Dehydration, headache, irritability & fatigue
  155. 155. Management • Administration of vasopressin • Desmopressin intra nasal of 5-10mg once or twice daily
  156. 156. • Some gravid women are prone to develop a hypersensitive gag reflex. In combination with increased intra-abdominal pressure and nausea, regurgitation may occur. This can lead to halitosis and erosion of tooth enamel. The enamel of the lingual surface of the maxillary anterior teeth is most susceptible to erosion. Because erosion of enamel is an irreversible process, preventive or restorative dental procedures may become necessary.
  157. 157. • Hormonal gingivitis (pregnancy gingivitis) occurs in almost all pregnant women to some extent. • It is characterized by accentuated gingival inflammation and hyperplasia that develops during periods of increased secretion of estrogen and progesterone. • The gingivitis begins at the marginal and interdental gingiva usually in the second month of pregnancy and becomes most prominent interproximally. • Marginal gingivae appear fiery red, swollen, and tender, whereas the papillae become compressible, edematous and lumpy. • Poor oral hygiene can exacerbate the condition. • Spontaneous remission occurs after parturition.
  158. 158. • Pregnancy tumor or, as it is more commonly known, “pyogenic granuloma” is an exaggerated response to irritation that is seen in about 1% gravid women. • The polypoid or pedunculated mass is bright red, fleshy, soft and bleeds easily. • Usually arises from the labial aspect of the interdental papilla, but it may protrude from the lingual side. • Lesion is asymptomatic initially, but tooth brushing or some other oral trauma eventually precipitates bleeding. • Treatment consisting of surgical excision along with root scaling, should be delayed until after childbirth.
  159. 159. • Facial pigmentation (chloasma or melasma gravidarum) occurs in some pregnant women in response to increased hormone production. • Usually chloasma appears as a light brown, diffuse patch on the forehead and malar areas. • The hyperpigmented patch is accentuated by exposure to sunlight and fades after delivery.
  160. 160. • Main dental considerations of the pregnant patient are to: 1. Minimize radiographic exposure 2. Prevent supine hypotension syndrome 3. Avoid hypoxia 4. Withhold drugs that cross placenta that are potentially damaging to the fetus. Stage of fetal development (first, second or third trimester) is important to know because it dictates the modifications required in dental treatment.
  161. 161. FIRST TRIMESTER • Dentist should initiate a preventive oralhealth care program, but avoid all other elective care. • This recommendation is sound because the 1st trimester is the most critical phase of fetal organ development and over 75% of all spontaneous abortions occur during this trimester. • Avoidance of dental care in the 1st trimester minimizes the likelihood of miscarriage.
  162. 162. SECOND TRIMESTER • After organogenesis and before maternal circulatory expansion, is the safest time to provide dental care. • The dentist should attempt to eliminate potential problems and to control active disease during this trimester. • Extensive, stressful, hypoxic or surgical procedures should be postponed.
  163. 163. THIRD TRIMESTER • Preventive and emergency care can be provided • However, all routine care should be postponed until after delivery.
  164. 164. • Deleterious drugs and infections should be avoided. • Drugs to avoid: 1. Respiratory-depressants- barbiturates, sedative/hypnotics and narcotics 2. Analgesics- NSAIDs 3. Antibiotics- tetracyclins, streptomycin and gentamicin • Acetaminophen, codeine, penicillin, erythromycin, and cephalosporins can be prescribed to women throughout pregnancy, especially when the woman’s health would deteriorate without them.
  165. 165. • For oral infection, penicillin is the antibiotic of choice during pregnancy unless contraindicated by hypersensitivity. • Nitrous oxide-oxygen can also be administered in emergency situations after the 1st trimester, as long as 50% oxygenation is provided. • Acetaminophen should be used cautiously because it can cause methemoglobinemia, hemolytic anemia, and liver or kidney damage. • Codeine should be minimized except when absolutely needed.
  166. 166. • LA can cross placenta however no adverse effects have been reported following use of lidocaine and mepivacaine. • High doses of prilocaine can cause methemoglobinemia and should be avoided. • Minimum amount of drug should be used and aspiration done before injecting. • Dental radiographs can be taken in case of an emergency to confirm diagnosis but only when lead apron is fully draped across the patient.
  167. 167. • Proper dental chair position is important to prevent supine-hypotension syndrome and hypoxia so chair should be placed more upright. • Syncope can be triggered by anxiety, incorrect chair position and poor oxygenation. • Dentist should provide a more comfortable chair position and a continuous flow of oxygen and reduce the patient’s anxiety with relaxation techniques and reassurance.
  168. 168. American Society if Anesthesiologists (ASA) Physical Risk Status Classification: A Guide for Endocrine Disorders DISEASE RISK CATEOGORY Hyperpituitarism Gigantism Acromegaly with cardiomyopathy, dysrrhythmia II II/III III/IV Hypopituitarism II Hyperadrenocorticism II Hypoadrenocorticism III Hyperthyroidism III uncontrolled Hypothyroidism Pseudohyperthyroidism Hyperthyroidism (HP) IV II/III II II/III Secondary HP with renal osteodystrophy IV Pseudohyperthyroidism II
  169. 169. American Society if Anesthesiologists (ASA) Physical Risk Status Classification: A Guide for Endocrine Disorders DISEASE RISK CATEOGORY Diabetes mellitus Diet-controlled II Oral hypoglycemic controlled II Insulin-controlled II/III Poorly controlled III/IV with renal complications Pregnancy IV II Preeclampsia III eclampsia IV
  170. 170. 1. Treatment should be avoided if the condition is poorly controlled or is evident by frank edema, hypertension, mental irritability, and/or abnormal glucose levels. 2. ASA class II requires some modifications in dental treatment. 3. ASA class III or higher mandates medical consultation and several modifications in dental treatment. 4. ASA IV status mandates hospital therapy.
  171. 171. Medical Consultation Guidelines A medical consult should be obtained when: 1. P/o S/S suggestive of endocrine ds eg: tissue swelling, nausea, vomiting, fatigue, dullness, lethargy, somnolence, irritability, neuropathy, pruritus, polydipsia, polyuria, hypertension, weight loss/gain, bone pain or fractures exist. 2. There is uncertainity about the patient’s medical status, the severity of the disease, or level of control.
  172. 172. 3. The systemic condition is poorly controlled and the patient has not seen the physician within the last year. 4. The patient is ASA class III or higher. 5. Corticosteroids have been taken within the last 12 months. 6. Anti-infectives may be needed, and to determine the infectious nature of the disease. 7. The medications and dosage used are uncertain. 8. The need for additional medications, a change in medication to protect the patient’s health during dental treatment, or any other special precautions needs to be determined.
  173. 173. 1. Consultation with the physician is needed to determine the need for additional steroids. 2. The patient should be advised to obtain proper rest the night before treatment and to reduce work and social obligations the day of treatment. 3. Morning appointment. Eg: diabetes have peak insulin effects in the morning. 4. Appointments should be kept short.
  174. 174. 5. Sedative agents such as benzodiazepines, narcotics, and barbiturates are safe and reliable relaxation drugs that can be used in patients with endocrine disease, except pregnant women, because of hypoxemia, and patients with hypothyroidism, because those drugs over, stressful situations such as cold, infections, and surgery can also precipitate myxedema coma in the hypothyroid patient.
  175. 175. 6. Nitrous oxide-oxygen therapy is an excellent anxiolytic well accepted by patients with endocrine disease. Its use should be deferred in pregnant women until second trimester. 7. The trauma of dental surgery should be delayed until the endocrine disorder is resolved. If the disease is chronic, consultation with the physician is mandatory to determine the need for supplemental drugs such as corticosteroids or insulin.
  176. 176. 8. Diabetes patients should always be instructed to take their insulin and eat a normal breakfast before routine dental appointments. If the procedure is extensive or stressful, the diabetes may require more insulin, because stress elevates blood glucose concentrations by increasing epinephrine and corticosteroid release, while decreasing insulin secretion.
  177. 177. 1. On completion of dental treatment, the patient with adrenal insufficiency requires the chair to be slowly raised because of postural dizziness and hypotension. 2. Patients with hyperadrenocorticism (Cushing’s disease) may have severe osteoporosis because of excess cortisol production and are prone to vertebral body collapse. The patient’s neck should not be unduly extended or stressed during positioning.
  178. 178. 3. Patients with hyperadrenocorticism or hyperthyroidism often have muscle weakness that makes rising from the chair difficult. Therefore, sit the patient in the semireclined position or in the position that is most comfortable and also assist the patient following completion of treatment.
  179. 179. 4. The pregnant dental patient requires a more upright chair position than non-pregnant patients for two reasons : (1) respiratory function is decreased because of increased demand for oxygen by the developing fetus; and (2) supine hypotension syndrome may occur because of pressure of the fetus on the inferior vena cava.
  180. 180. LA can be used safely in majority of patients with endocrine diseases. 1. Administer intraoral LA slowly, with aspiration. 2. Avoid LA with vasoconstrictor in patients with pheochromocytoma or hyperthyroidism, because epinephrine stimulates cardiac activity and elevates blood pressure. An LA that contains no vasoconstrictor should be administered.
  181. 181. 3. Local anesthetics are highly lipid soluble and readily cross the placental barrier, but no adverse effects have been reported following the use of lidocaine and mepivacaine in pregnant women. Of course, the minimum amount of drug should be used and aspiration performed prior to injection. Avoid high doses of prilocaine. 4. LA containing vasoconstrictor should be used prudently in the patient with diabetes mellitus. Epinephrine antagonizes the action of insulin and in large doses can elevate blood glucose levels.
  182. 182. Endocrine diseases have important implications in the management of dental pain. 1. Narcotic or barbiturate-containing analgesics can depress respiration; therefore, their use should be avoided in hypothyroid patients, acromegalics, and pregnant women. 2. Aspirin, aspirin-containing analgesics, and other nonsteroidal anti-inflammatory drugs (NSAID) are generally to be avoided in pregnant women.
  183. 183. 1. Culture and sensitivity testing is recommended whenever oral infection is present. 2. Oral penicillin is the DOC for oral infection in patients with endocrine diseases long as they are not hypersensitive to the drug. 3. Diabetics whose disease is well controlled and who are free of infection do not require antibiotics. In poorly controlled diabetics, prophylactic antibiotics are recommended to prevent infections. The total antibiotic dosage should be reduced in diabetic patients who also have renal failure and consultation with physician is advised.
  184. 184. 4. Tetracyclines should not be prescribed to pregnant women because of the intrinsic staining effects of these drugs on the teeth. 5. Aminoglycosides are oto and nephrotoxic and should not be prescribed to patient with diabetes, hyper parathyroidism and pregnancy complicated with renal failure. 6. Cephalosporins and massive salts of penicillin should be avoided in p/o renal failure.
  185. 185. 1. Respiratory depressant drugs should be avoided in hypothyroidism and pregnancy because of ventilatory complications. 2. Epinephrine should be avoided in hypothyroidism because of cardiac overstimulation. 3. Drugs that cross the placenta and are teratogenic or alter hemodynamics should be avoided in pregnancy to prevent the damage to fetus. These include: respiratory depressants like- barbiturates, sedatives, hypnotics and narcotics which induce hypoxia; analgesics like: aspirin and other NSAIDs which are teratogenic and induce neonatal bleeding and fetal abnormalities; antibiotics- like tetracycline that results in intrinsic staining & aminoglycosides.
  186. 186. 4. Patient with diabetes mellitus or gestational diabetes should have their glucose level adjusted before extensive or surgical treatment. Beta-adrenergic blocking agents such as propranolol can mask the hypoglycemic effects of insulin. Corticosteroids increase blood glucose level whereas sulfonamides can increase the hypoglycemic effect of sulfonylurea agents.
  187. 187. 5. Patients who are taking steroids or have taken steroids during the last 12 months are likely to have adrenal suppression and reduced ability to withstand the stress of dental treatment. The dosage of steroid should be ascertained by the dentist and physician consultation is required to determine the need for additional steroids. The steroid dose should be increased whenever patients are undergoing surgery or any stressful or long dental procedure. If the postop course of patient is complicated by infection or other superimposed stress, then the dose should not be tapered until complication resolves.
  188. 188. 6. Anti-cholinergic drugs should be avoided in hyperthyroidism because these drugs interfere with the body’s heat regulating mechanism and contribute to increased cardiac activity. Vasoconstrictors are contraindicated in hyperthyroidism. Iodine preparations found in radiographic contrast solutions should be avoided in hyperthyroidism.
  189. 189. Infection control precautions are mandatory for all the patients particularly pregnant women, diabetic patients and diabetic patients receiving dialysis who are at an increased risk of hepatitis.
  190. 190. 1. Antibiotic prophylaxis and oral antimicrobial rinses should be considered in case of severely immunocompromised patients. 2. Oral infections should be treated prior to the treatment to minimize complications. Diabetics may require a prolonged course of antibiotics and pregnant women should not receive tetracyclines. 3. Normal barrier equipment such as gloves, mask and eye protection is mandatory while dealing with infectious patients to reduce airborne dissemination of oropharyngeal secretions.
  191. 191. 4. Aseptic protocol must be followed. 5. Contact with blood, saliva and aerosols should be minimized by using rubber dam and high velocity evacuation. Use of rotary handpieces should be avoided. 6. Cross-contamination is reduced by wrapping objects subject to touch.
  192. 192. 7. Contaminated instruments should be cleaned before sterilization. Contaminated disposables should be properly discarded. 8. Surfaces should be cleaned and disinfected with appropriate disinfectants. 9. Water lines and evacuation systems should be flushed with disinfectants when the patients is dismissed.
  193. 193. THANK YOU

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