Endocrine disease

• This presentation covers endocrine diseases and diabetes, aimed at dental professionals, presented January 24th 2025, by Hannah Barrow, Khadeeja Saeed and Georgina Prosser

Learning Objectives

• Understand the role of the endocrine system
• Be able to define different endocrine diseases
• Explain diabetes pathophysiology
• Learn to manage diabetes-related medical emergencies
• Consider the impact of endocrine conditions on dental treatments
• Understand relevant medications and their implications for dentistry

Why Learn About Endocrine Diseases?

• Endocrine disorders encompass diverse diseases
• These diseases manifest unique symptoms impacting oral health
• In 2011, 360 million people had diabetes, with 95% having type 2
• Worldwide diabetes prevalence is increasing
• Patients often use medications, including long-term ones, for endocrine disorders
• Dental teams need to know about Addisonian crises and blood sugar management for emergencies

GDC and Dental Practice

• Dental professionals should understand physiology for patient management
• Understand medicines and agents and their relevance to patient care
• Comprehend medical and psychological conditions' impacts
• Be able to handle medical emergencies

Lecture Structure Outline

• Part 1: Endocrine system revision
• Part 2: How endocrine diseases develop including pathophysiology and symptoms
• Part 3: Diabetes- covering aetiology, pathophysiology, symptoms, treatments, and dental relevance
• Part 4: Managing dental patients with endocrine diseases including clinical considerations, risk management, prevention, and emergency protocols

The Endocrine System

• Endocrine glands secrete hormones straight into the bloodstream
• Eg Thyroid gland
• Exocrine glands like salivary glands release hormones through ducts or openings

Hormones

• Hormones regulate cells and affect puberty, growth, behavior, sleep, mood, metabolism, reproduction, and stress response

Endocrine Disorders

• They occur when glands or hormones fail to function correctly

Common Endocrine Disorders

• Acromegaly: Too much growth hormone
• Adrenal Insufficiency: Insufficient cortisol
• Cushing's Disease: Excess cortisol
• Hyper/Hypothyroidism: Over/underactive thyroid hormones
• Hyper/Hypopituitarism: Over/underactive pituitary hormones
• Polycystic Ovary Syndrome (PCOS): Increased testosterone
• Diabetes: Dysregulated insulin

Acromegaly

• Rare where the pituitary gland makes too much growth hormone
• This leads to excess IGF-1 production
• Causes increases in bones, cartilage, organs, and tissues
• Patients exhibit enlarged features like nose, ears, hands, and feet
• Tumors on the pituitary gland cause 9/10 cases of acromegaly

Craniofacial Features of Acromegaly

• Prognathism, frontal bossing, macroglossia, thickened lips
• Overgrowth of the mandible (class III), maxillary widening, teeth separation, skeletal malocclusion

Acromegaly Treatment

• Surgery to remove pituitary tumour, called transsphenoidal surgery
• Radiation therapy to kill tumour cells is used when surgery cannot be perfomed
• Medications help control excessive hormone production
• Somatostatin analogues help reduce the production of hormones, which reduces growth hormone
• Growth hormone-receptor antagonists stop growth hormone activating release of IGF-1

Adrenal Insufficiency (Addison's Disease)

• Rare, autoimmune; adrenals don't produce enough cortisol
• Can result from long-term steroid use stopping
• Symptoms include fatigue, muscle weakness, appetite and weight loss, and abdominal pain

Adrenal Crisis: Complications

• Occurs in high-stress situations where body requires more cortisol, which they cant produce
• Can cause hypotension, hypoglycaemia, low blood sodium, and high blood potassium
• Symptoms include dizziness, vomiting, diarrhoea, cramps, seizures, and unconsciousness

Cushing's Disease

• Caused by excessive cortisol
• Affects 1 in 200,000 individuals, is not genetic, nor has any environmental triggers been identified
• Usually a result of long-term steroid usage

Hyperthyroidism

• Thyroid produces too much thyroxine
• Causing increased metabolism
• Causes include Graves' disease, thyroid nodules, and iodine medications

Symptoms of Hyperthyroidism

• Nervousness, anxiety, mood swings, fatigue
• Goitre/swollen thyroid, unexplained weight loss, thinning hair
• Fast/irregular heartbeat, increased bowel movements, tremors, menstrual changes, sleep issues

Hyperthyroidism Treatments

• Medicine: Thyroid hormone production can be stopped using carbimazole or propylthiouracil
• Radioactive iodine treatment: Destroys cells which produce hormones by swallowing radioactive iodine
• Surgery: Removes partial or total gland, usually as a last resort

Hypothyroidism

• Occurs when the thyroid produces too little thyroxine

Hyperpituitarism & Hypopituitarism

• Umbrella terms: Over- or underactive pituitary gland
• Which leads to too much or too little of certain hormones being released

Polycystic Ovary Syndrome (PCOS)

• Caused by imbalanced hormones (e.g., insulin, testosterone)
• Symptoms include extra facial hair, weight gain, and irregular periods along with fertility problems and anxiety/depression

Key points about Diabetes

• Diabetes occurs when the pancreas doesn't produce enough insulin or the body cannot use insulin effectively
• Insulin: A hormone regulating blood glucose levels
• Elevated blood glucose over time damages heart, vessels, eyes, kidneys, nerves

Three Main Types of Diabetes:

• Type 1: The body produces no insulin due to autoimmune issue
• Type 2: The body does not release enough insulin, or has insulin resistance
• Gestational: Occurs during pregnancy due to hormonal changes
• These all result in high blood sugar

Type 1 Diabetes

• Autoimmune disorder
• The immune system destroys pancreatic cells, so there is little to no insulin producion

Type 2 Diabetes Fast Facts

• 90-95% of people with diabetes have type 2
• More than 1 in 10 adults have diabetes
• Over 25% of adults over 65 have diabetes
• Exercise and weight loss can reduce the risk of prediabetes becoming type 2 by 58%

Diabetes Symptoms

• Increased thirst and urination, extreme hunger
• Presence of ketones in the urine, fatigue, irritability
• Blurred vision, slow-healing sores
• Frequent infections (gums, skin, vaginal)

Pancreas Functions

• Located behind the stomach, it produces enzymes to break down food
• Releases insulin that controls blood sugar
• Triggers sugar to be used for energy

Pancreas and Blood Sugar Regulation

• Islets of Langerhans in the pancreas release insulin and glucagon
• Insulin is released when glucose is too high
• Allows sugars to be taken up by cells and the liver from the bloodstream
• Glucagon is released when glucose levels are too low.
• Signals liver to convert glycogen to glucose

Aim Blood Sugar Levels

• Before meals: Under 100 mg/dl (5.5 mmol/L) for those without diabetes and 80-130 mg/dl (4.4-7.2 mmol/L) with the condition
• 1-2 hours post-meal: Under 140 mg/dl (7.8 mmol/L) for those without and up to 180 mg/dl (10 mmol/L) having the condition

Causes of Type 1 Diabetes

• Viruses can trigger it
• Genetic markers also play a role
• Autoantibodies destroy the beta cells

Hyperglycaemia

• Causes oxidative stress, inflammation and dysfunction at the cellular level
• Small blood vessels that supply the nerves in your body are damages, This stops essential nutrients reaching those nerves and stop them working

Complications from poorly controlled diabetes

• Microvascular Damage: Neuropathy, retinopathy, nephropathy
• Macrovascular Damage: Cardiovascular, cerebrovascular, and peripheral vascular disease

Managing Type 1 Diabetes

• Taking insulin, monitoring blood sugar regularly, eating healthy, exercising, maintaining healthy weight

Available types of Insulin

• Using injections or Insulin Pumps is a way to deliver insulin
• Short-acting insulin: Humulin R and Novolin R
• Rapid-acting insulin: insulin glulisine (Apidra), insulin lispro (Humalog) and insulin aspart (Novolog)
• Intermediate-acting (NPH) insulin: (Novolin N, Humulin N)
• Long-acting insulin: (Lantus, Toujeo Solostar), insulin detemir (Levemir) and insulin degludec (Tresiba)

Causes of Type 2 Diabetes

• Obesity/overweight, large waist with excess weight around the stomach increases risk further
• High blood pressure, inactivity, family history, and age are all contributing factors

Type 2 Diabetes Pathophysiology

• Defective insulin secretion from pancreatic beta cells.
• Insulin resistance where cells don't absorb the insulin
• 34-56% less chance of developing T2DM in participants who walk 2-3 hours a week

Treatments for Type 2 Diabetes

• Often starts with lifestyle changes (diet and exercise) before insulin
• Insulin is the last treatment option when other drugs aren't effective
• Metformin is commonly prescribed to increase insulin sensitivity, decrease appetite/calorie intake, and decrease glucose production

Diabetes and Periodontitis

• Those who have diabetes are 3x likely to develop periodontitis
• There is a strong link between poorly controlled diabetes and periodontitis
• IL-6 and TNF-α is found at higher concentrations in those with both diabetes and obesity,

Management of Diabetes and Periodontitis

• Periodontal treatments improves control of blood sugar levels
• Need to risk assess patients
• Early diagnosis of both conditions
• Treat periodontal disease and warn patients about risk of tissue damage

Gestational Diabetes

• Diagnosed during pregnancy
• Placental hormones cause insulin resistance
• Glucose can't be absorbed
• Causes complications for both mother and child

Risk Factors for Gestational Diabetes

• Advanced maternal age

• Overweight/obesity

• Lack of physical activity

• Previous gestational diabetes or pre-diabetes

• PCOS

• Family history of diabetes

• Delivering > 9 pound baby

• Race/ethnicity

Complications with Gestational Diabetes

• Baby: Excessive weight at birth, premature birth, breathing difficulties, hypoglycemia, and increased risk of obesity and type 2 diabetes

• Mother: high blood pressure, pre-eclampsia, and risk of developing type 2 later in life

Gestational Diabetes Treatments

• Reduce glucose and carbohydrates in foods, reduce portion sizes and monitor bloods after meals
• Close monitoring by midwife and monitoring growth of baby
• Implement lifestyle changes and monitor bloods of mother after birth

Dental Management for Patients with Diabetes: Consult Questions

• When were you diagnosed/for how long?

• Do you take any medication, how much and how often?

• Any episodes of hypoglycaemia or hyperglycaemia?

• Have you ever been hospitalised?

• What are you blood sugar levels like?

• How often do you see your doctor?

• Do you have a social history?

Managing a Diabetic Patient

• It is important to ask about these, update patient MH and check blood sugars before treatment

• Risks: Delayed healing, increased risk of decay

Medical emergencies and the GDC

• A patient could collapse at any time whether they are in treatment or not
• All registrants must be trained in dealing with medical emergencies, be able to resuscitate, and possess up to date evidence of capability

Managing emergencies

• Risk management; take history and accurate notes
• Planning ahead; two dental/healthcare professionals and trained in medical emergencies
• Ensure you are aware of protocol and have up-to-date CPD

Hypoglycaemia

• Signs and symptoms: Shaking, confusion, pallor, blurred vision, lethargy, loss of consiousness, slurred speech or moody
• Management: ABCDE; give glucose drink
• If unconcious, recovery position, call 999, 1mg glucagon, check sugar levels, 0.5mg Glucagon IM if under 8 years or under 25kg

Adrenal Crisis

• Occurs when cortisol levels are too low
• Can cause collapse, pallor, cold/clammy skin, hypotension, dizziness, vomiting, diarrhoea
• Management: ABCDE, Call 999, Administer oxygen, lie patient flat and give hydrocortisone IM