Endocrine system - together with
the nervous system, acts as
the body´s communication
- it is composed of various endocrine
glands and endocrine cells
- the glands are capable of synthesizing and
releasing special chemical messengers –
Hormones - substances which are
secreted by specialised cells in very low
concentrations and they are able to
• secreted cell itself (autocrine influence),
• adjacent cells (paracrine influence) or
• remote cells (hormonal influence)
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
3. polypeptidic and protein hormones (e.g. insulin,
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
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.
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
The pituitary gland is divided into 2
Anterior pituitary or adeno
Posterior pituitary or neuro
Adeno hypophysis include Pars
Anterior, Pars Intermedia & Pars
Neuro hypophysis includes Pars
Posterior, Infundibular Stem and
Growth hormone (GH,Somatotropin)- Accelerate
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
ovulation & leutinization of ovarian
follicle, testosterone secretion.
Prolactin(leutotrophic hormone)Stimulates secretion of milk and
maternal behavior and maintains
• Alpha & beta melanocyte stimulating hormone Stimulates melanin synthesis in melanocytes in
Four characteristic elements in the
regulation of pituitary hormone
levels have been identified1) Specific hypothalamic neurons
release small peptides into the
2) Secretory cells in the pituitary
coordinate the release of larger
peptides into the systemic
3) Resultant changes in specific
endocrine organs, which act as a
target tissue for the pituitary
hormones, have been linked to
specific pituitary hormones.
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
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
• It results from hyperfunction of anterior
lobe of pituitary gland, most significantly
with increased production of growth
• Cause of this condition is a benign,
functioning tumor of the eosinophilic
cells in the anterior lobe of the pituitary
• 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.
• Gigantism — If the increase occurs
before the epiphysis of the long bone
• Acromegaly — if the increase occurs
later in life after epiphysis closure.
• TALL SKELETON
• MUSCLES AND
VISCERA – LARGE.
Generalized overgrowth of most tissue in
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
underdevelopment and excessive
Complain of headache, lassitude, fatigue,
muscle and joints pain and hot flashes.
• Skull — There is increase in size of
calvarium which may lead to change in the
• Pituitary tumors may also induce
deficiency of other pituitary hormones
causing signs of hypogonadism including
decreased libido and menstrual problems
• 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
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
Class III malocclusion.
• Palate — the palatal vault is usually
flattened and the tongue increase in size
and may cause crenation on its lateral
• Lips — the lips become thick and
• In edentulous patients' enlargement of the
alveolus may prevent the comfortable fit
of complete dentures.
• Radiographically, the cortical plate is
radiodense and the condyles appear large in
• 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
• Enlargement of the major salivary glands is
Cause is not known.
Clinical features include
Large elongated head.
Large ears and jaws.
Antimongoloid slant to the eyes.
Coarse facial features.
Subnormal intelligence and
Age and sex — it is more common in males
occurs most frequently in 3rd decade.
Facial features — bone overgrowth and
thickening of the soft tissue cause a
characteristic coarsening of facial features
Symptoms — there is temporal headache,
phobia and reduction in vision.
• Increased Intrasellar tension.
• Compression of
• Enlarged hands and feet with clubbing
of the toes and fingers due to
enlargement of the tufts of the terminal
• Thickening of the clavicles.
• Spine – Kyphoscoliosis, Lordosis.
• Periosteal Calcifications.
• Heart – Cardiac enlargement, hypertension and
• Lung – Enlargement.
• Larynx – Enlargement Of Vocal Cords results in
• Lantern jaw.
• Class III malocclusion.
• Flaring of dental arches
• Enlargement of sella turcica,
enlargement of paranasal sinus and
excessive pneumatization of temporal
bone squames and petrous ridge.
• Diffuse thickening of outer table of
• Enlargement and distortion of the
• Air sinus—the air sinuses are really
prominent in acromegaly rather than in
• 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.
• 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.
• These patients may have DM, HTN or
• Medical consultation is advised before
surgical manipulation or potentially stressful
• 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.
• Total absence of all pituitary secretions is
known as Panhypopituitarism or Simmond’s
• 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.
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.
• Growth retardation noticed 2-3 years after birth.
• 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.
• GROWTH HORMONE prepared from human
• Hypopituitarism caused by tumors may require
surgery or radiotherapy.
• Schour and Vandyke(1932)
Rate of eruption was reduced.
Excessive thickness of dentine.
Shorter roots of teeth and diminished
growth of bone.
• 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
• 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.
• Fluoride treatments should be initiated early
in life, and frequent periodontal recall
implemented to reduce oral bacterial
• In pts with hypopituitarism and
hypoaldrenalism may require supplemental
corticosteroids during dental treatment.
• ADRENAL MEDULLA
Epinephrine and Nor epinephrine.
• ADRENAL CORTEX
and Sex hormones.
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
Metabolic function—decrease cortisol level
interferes with the manufacture of
carbohydrates from protein, causing
hypoglycemia and diminished glycogen
storage in the liver.
function is inhibited, producing muscle
There is also reduced resistance to infection,
trauma, and stress.
• 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.
• Plasma ACTH and Cortisol levels
Low diurnal plasma Cortisol and ACTH levels.
• Increased susceptibility to infections.
• Possibility of adrenal crisis.
• 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
• Moderate risk- those receiving alternate day
therapy or those who take less than half the
daily dose of cortisol equivalent for less than 1
• No risk- topical steroids
Cushing's syndrome arises from
excess secretion of glucocorticoids
by the adrenal glands. It is described
by Harvey Cushing in 1932.
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
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
There is also weight loss, menstrual
irregularity, hirsutism, backache, obesity,
hypertension can also occur.
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.
May show areas of loss of lamina dura.
Skull—it may show diffuse thinning and have
Acute adrenal insufficiency with acute
Characterized by rapidly fulminating septic
course, a pronounced purpura and death within
48 to 72 hours.
It refers to any situation in
which there is
overproduction of androgens.
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.
At birth—in female child it produces
pseudo- hermaphroditism, while in male
child it produces macrogenitosornia
In childhood —In the females it produces
masculinization and in males it produces
In adults—in females it produces
virilism and in males it produces
Oral finding—if the disease begins
premature eruption of the teeth may
Most cells of
Thyrotrophic Releasing Hormone.
T3 AND T4
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.
• Fine tremors
• Muscle weakness
• Mood swings from depression to
• Emotional liability, hyper-reflaxia,
ill sustained clonus, proximal
myopathy, bulbar myopathy and
• Weight loss despite normal or
• Bowel alterations
• Anorexia, Vomiting
• 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.
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,
infertility, spontaneous abortion and loss
of libido, impotence.
• TEETH – Advance rate of development, early
eruption with premature loss of primary teeth.
• Increased incidence of caries.
• Ectopic thyroid tissue in the tongue
• Thyroid storm/ crisis.
Propylthiouracil (60-100mg, iv)
• Complete blood picture.
• Local anaesthetic without epinephrine should be
• Sedatives are safe
• Anticholinergics should be avoided.
• Iodine preparations found in radiographic
contrast solutions should be avoided.
• RADIOGRAPHIC PICTURE.
• LABORATORY INVESTIGATIONS
T3 , T4 and TSH levels.
• Radioactive iodine ( I 131)
• Drug therapy – Prophythiouracil and
• Sub total thyroidectomy.
Cretinism — if failure of hormone occurs in
Juvenile Myxedema — if it occurs in childhood.
Myxedema — if it occurs after the puberty. In it
there is subcutaneous deposition of hydrophilic
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
• Bones — delayed fusion of all body epiphysis
and delayed ossification of paranasal sinus,
Signs — There is protuberant abdomen
with umbilical hernia. The hairs are
sparse and brittle, the finger nails are
brittle and the sweat glands are
• Early symptoms—it may include
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.
Dull expressionless face, periorbital edema,
sparse hair and skin that feels droughty to
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.
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
effusion may be present.
There are also watery eyes, brittle
• Dental development delayed and primary teeth
slow to exfoliate.
• Enamel hypoplasia can also be seen.
• Abnormalities of dentin formation lead to enlarge
• Maxilla is overdeveloped and mandible is
• Retarded condylar growth leads to characteristic
micrognathia and open bite relationship
Tongue — tongue is enlarged by
edema fluid and due to its tongue may
protruded continuously and such
protrusion may lead to malocclusion of
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
• Macroglossia and
• Facial swelling.
• Periodontal disease.
• Dry and brittle hair.
• Delayed closing of the fontanelles.
• Teeth reveal thinning of the lamina dura.
• Delayed dental eruption.
• Short tooth roots.
• TSH levels are increased..
• T3 & T4 levels are decreased.
• Classic sinus bradycardia in ECG.
• THYROID PREPERATION –
• Early detection in children and timely therapy
results in a dramatic resolution of the condition.
• 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.
• Chief cells secrete parathyroid hormone.
• Oxyphil cells function is not known.
Increases bone resorption by
intensifying the osteoclastic activity
Facilitates the conversion of vitamin
D into its final active end product.
Acts on renal tubules to increase
calcium reabsorption and phosphate
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.
• Vague jaw bone pain
• Teeth that sensitive to percussion and
• Drifting and loosening of teeth causing
• Pulp stones and root resorption
• Skeletal muscle weakness
• Peculiar fasciculations of the tongue
• Most common cause of generalized bone
rarefaction of jaws
• Generalized loss of lamina dura and loss of
• Brown tumors (resemble CGCG histologically)
• GROUND GLASS.
• SALT AND PEPPER
• SUB PERIOSTEAL EROSIONS OF BONE OF
MIDDLE PHALANGES IS THE HALL MARK.
• LOSS OF LAMINA
• LOSS OF
• PULP STONES AND
MAY ALSO OCCUR.
• BROWN TUMORS APPEARS AS WELL
DEMARCATED UNILOCULAR OR
• Medical consultation is necessary to ensure
adequate calcium levels
• Low Ca can ppt arrythmias, bronchospasm,
laryngospasm, convulsions, and death due to
• High levels can lead to renal failure and
• Elevated PTH and Serum Calcium –
• Elevated PTH and low or normal Serum
• Decreased serum Phosphate Level(less
• Increase in serum alkaline phosphatase
• Elevated serum chloride levels.
• 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.
Central giant cell granuloma
Aneurysmal bone cyst and central
• SURGERY – Excision of parathyroid
• MEDICAL - Sodium or potassium
phosphate, sodium chloride, mithramycin.
• Oral Vitamin D can prevent skeletal
• DI GEORGE SYNDROME.
• POST OPERATIVE
• IDIOPATHIC HYPOPARATHYROIDISM.
• ALBRIGHT hereditary
• 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.
• In children a characteristic triad
of carpopedal spasm, stridor and
• Stridor is caused by spasm of the
• Adults complain of tingling in the
hands feet and around the mouth
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
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.
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.
• 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.
• The serum calcium level is decreased usually
below 7 mg/dl.
• Serum phosphate level correspondingly
• Urinary calcium is low or absent.
• Supplemental calcium and vitamin D
depending on severity of the hypocalcaemia
and the nature of the associated signs and
• In severe cases intravenous administration of
calcium gluconate is the treatment of choice.
• 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.
• Hypercalcemia may be a presenting sign of
multiple endocrine neoplasia (MEN).
• Autosomal dominant
• May account for 5% cases if
• MEN is divided into three categories:
1. MEN I
2. MEN IIa
3. MEN IIb
• Formerly called “Sipple’s syndrome”
• Dominated by:
2. Medullary carcinoma of thyroid
• Formerly known as “Schimke’s syndrome”
• Characterized by medullary carcinoma of
thyroid and pheochromocytomas, but seldom
• 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.
• Local anesthesia with vasoconstrictor should
not be used in patients with
• Avoid all catecholamines in retraction cord
because epinephrine present in these
materials can precipitate severe
– Visual activity-ranges from color
blindness to total blindness disease
more than 20yrs
– Atherosclerosis-coronary heart
disease & stroke
– Diabetic neuropathy
• Infection recurrent vaginal infection,
skin infection, UTI infection,
paresthesia in toe or finger
• Other symptoms
-Nocturia, weight loss, fatigue, obesity,
-Temp, BP may be elevated & peripheral
pulses may be reduced
• Gingival & Periodontal disease
-More prone to periodontal disease
& greater tendency for bleeding on
-fulminating periodontitis with
periodontal abscess, hemorrhagic
gingival papillae & gives rise to
-severe & rapid alveolar bone loss &
-Gingival fluid in the diabetes has
more glucose level which favors
the growth of micro flora
• 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
• Angular cheilosis
• altered taste sensation
-Discontinuity or blurring of the
cortex of alveolar crest
-Destruction of lamina dura
-Horizontal & vertical bone loss
• Often made by clinical symptoms
• Plasma glucose concentration
elevated & it is greater than
• 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
• Diet control-who are obese dietary
control towards a balanced calorie
• 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)
• 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
• 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
• Antibiotic prophylaxis before dental
treatment to prevent infection
Insufficiency of posterior pituitary
Traumatic episodes like head trauma or
surgical procedures carried near
Tumors like craniopharyngioma, syphilis
& basal meningitis
There is damage for production of
• Increased thirst
• Passage of large quantities of urine.
urine of low specific gravity
• Dehydration, headache, irritability &
• Administration of vasopressin
• Desmopressin intra nasal of 5-10mg
once or twice daily
• 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.
• Hormonal gingivitis (pregnancy gingivitis)
occurs in almost all pregnant women to some
• 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
• Marginal gingivae appear fiery red, swollen,
and tender, whereas the papillae become
compressible, edematous and lumpy.
• Poor oral hygiene can exacerbate the
• Spontaneous remission occurs after
• 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.
• Facial pigmentation (chloasma or melasma
gravidarum) occurs in some pregnant women
in response to increased hormone
• Usually chloasma appears as a light brown,
diffuse patch on the forehead and malar
• The hyperpigmented patch is accentuated by
exposure to sunlight and fades after delivery.
• 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
• Dentist should initiate a preventive oralhealth care program, but avoid all other
• 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
• Avoidance of dental care in the 1st trimester
minimizes the likelihood of miscarriage.
• 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.
• Preventive and emergency care can be
• However, all routine care should be
postponed until after delivery.
• Deleterious drugs and infections should be
• Drugs to avoid:
1. Respiratory-depressants- barbiturates,
sedative/hypnotics and narcotics
2. Analgesics- NSAIDs
3. Antibiotics- tetracyclins, streptomycin and
• Acetaminophen, codeine, penicillin,
erythromycin, and cephalosporins can be
prescribed to women throughout pregnancy,
especially when the woman’s health would
deteriorate without them.
• For oral infection, penicillin is the
antibiotic of choice during pregnancy
unless contraindicated by
• 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
anemia, and liver or kidney damage.
• Codeine should be minimized except
when absolutely needed.
• LA can cross placenta however no
adverse effects have been reported
following use of lidocaine and
• High doses of prilocaine can cause
methemoglobinemia and should be
• Minimum amount of drug should be
used and aspiration done before
• Dental radiographs can be taken in case
of an emergency to confirm diagnosis
but only when lead apron is fully draped
across the patient.
• Proper dental chair position is important to
prevent supine-hypotension syndrome and
hypoxia so chair should be placed more
• Syncope can be triggered by anxiety,
incorrect chair position and poor
• 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.
American Society if Anesthesiologists (ASA) Physical Risk
Status Classification: A Guide for Endocrine Disorders
with cardiomyopathy, dysrrhythmia
Secondary HP with renal osteodystrophy
American Society if Anesthesiologists (ASA) Physical Risk
Status Classification: A Guide for Endocrine Disorders
Oral hypoglycemic controlled
with renal complications
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
Medical Consultation Guidelines
A medical consult should be obtained
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.
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
7. The medications and dosage used are
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.
1. Consultation with the physician is
needed to determine the need for
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
4. Appointments should be kept short.
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.
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
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.
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.
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
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
3. Patients with
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
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.
LA can be used safely in majority of
patients with endocrine diseases.
1. Administer intraoral LA slowly,
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
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
Endocrine diseases have important
implications in the management of
1. Narcotic or barbiturate-containing
analgesics can depress respiration;
therefore, their use should be
avoided in hypothyroid patients,
acromegalics, and pregnant
2. Aspirin, aspirin-containing
analgesics, and other nonsteroidal
anti-inflammatory drugs (NSAID)
are generally to be avoided in
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
4. Tetracyclines should not be
prescribed to pregnant women
because of the intrinsic staining
effects of these drugs on the
5. Aminoglycosides are oto and
nephrotoxic and should not be
prescribed to patient with
diabetes, hyper parathyroidism
and pregnancy complicated with
6. Cephalosporins and massive salts
of penicillin should be avoided in
p/o renal failure.
Respiratory depressant drugs should be
avoided in hypothyroidism and pregnancy
because of ventilatory complications.
2. Epinephrine should be avoided in
hypothyroidism because of cardiac
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.
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.
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.
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.
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.
1. Antibiotic prophylaxis and oral
antimicrobial rinses should be considered
in case of severely immunocompromised
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
4. Aseptic protocol must be
5. Contact with blood, saliva and
aerosols should be minimized
by using rubber dam and high
velocity evacuation. Use of
rotary handpieces should be
6. Cross-contamination is
reduced by wrapping objects
subject to touch.
should be cleaned before
disposables should be properly
8. Surfaces should be cleaned and
disinfected with appropriate
9. Water lines and evacuation
systems should be flushed with
disinfectants when the patients