Endocrine Disease and Diabetes

Aims & Learning Objectives

• Session aims to enable participants to confidently explain the endocrine system's roles.
• The session will define different endocrine diseases.
• Participants will learn the pathophysiology of diabetes.
• The session will cover management of diabetes-related medical emergencies.
• It will discuss how dental treatments could be affected by these conditions.
• The medications these patients could be on and their relevance to dentistry will be detailed.

Importance of Understanding Endocrine Diseases

• Endocrine disorders encompass a variety of diseases that affect overall and dental health.
• These disorders exhibit striking features and symptoms important for oral health.
• In 2011, 360 million people had diabetes, with type 2 accounting for 95% of cases.
• The diabetic population is increasing worldwide.
• Patients who have endocrine disorders are often on medications, often long-term.
• Dental professionals should manage emergencies of low or high blood sugar, as well as Addisonian crises.

Endocrine System

• Endocrine glands release hormones directly into the bloodstream, the thyroid gland, for example.
• Exocrine glands release hormones via a duct or opening, like salivary glands.
• The endocrine system regulates every cell and affects various processes.
• These processes include puberty, growth, sexual behavior, sleep, mood, metabolism, reproduction and stress response.
• Endocrine disorders arise when glands or hormones fail to function correctly.

Common Endocrine Disorders and How They Occur

• Common endocrine disorders include Acromegaly and Adrenal insufficiency.
• Cushing's disease, Hyperthyroidism/Hypothyroidism, and Hyperpituitarism/Hypopituitarism are also common.
• Additional disorders are Polycystic ovary syndrome, and Diabetes.
• Acromegaly involves an increase in growth hormone, while adrenal insufficiency involves a decrease in cortisol.
• Cushing's disease involves an increase in cortisol.
• Hyperthyroidism/Hypothyroidism involves an increase or decrease in thyroid hormone.
• Hyperpituitarism/Hypopituitarism involves an increase or decrease in hormones from adrenal and thyroid glands.
• Polycystic ovary syndrome (POS) typically involves an increase in testosterone.
• Diabetes can involve an increase or decrease in insulin levels.

Acromegaly

• A rare disorder where the pituitary gland produces too much growth hormone.
• Increased growth hormone causes the liver to produce more IGF-1, resulting in increased bone and tissue growth.
• This can cause bones, cartilage, body organs, and other tissues to have an increased size.
• Larger, swollen noses, ears, hands, and feet are symptoms of acromegaly.
• In 90% of cases, tumors on the pituitary gland cause Acromegaly.
• Craniofacial features of Acromegaly include prognathism and frontal bossing.
• Macroglossia, tooth separation, and thickening of lips can also occur.
• Overgrowth of the mandible (class 3), maxillary widening, and skeletal malocclusion are sometimes seen.
• Treatment includes surgical removal of the tumor via transsphenoidal surgery.
• Radiation therapy is used if surgery is contraindicated.
• Somatostatin analogues help reduce the production of growth hormones.
• Growth hormone-receptor antagonists prevent GH from activating the release of IGF-1.

Adrenal Insufficiency (Addison's Disease)

• Addison's Disease, or Adrenal Insufficiency, results from autoimmune destruction of the adrenal gland.
• In this autoimmune disease, the adrenal glands don't produce enough Cortisol, the stress hormone.
• It can also occur after long-term steroid treatment has stopped.
• Symptoms can include fatigue, muscle weakness, loss of appetite, weight loss, and abdominal pain.
• Adrenal crisis occurs where the body shows hypotension, hypoglycaemia, low blood sodium, and high blood potassium.
• Symptoms of adrenal crisis include dizziness, vomiting, diarrhea, abdominal cramps, seizures, and loss of consciousness.

Cushing's Disease

• Cushing's disease is caused by too much cortisol.
• It occurs in 1 in 200,000 people.
• The disease isn't genetic, and there isn't any evidence for environmental triggers.
• Long-term steroid medication use usually causes it.

Hyperthyroidism

• Hyperthyroidism occurs when the thyroid gland makes too much thyroxine.
• Thyroxine is important is metabolism.
• Causes can include Graves disease, thyroid nodules, and medications like iodine.
• Common symptoms include nervousness and anxiety.
• Additional signs are mood swings, fatigue, and a swollen thyroid.
• A person may have unexplained weight loss, increase bowel movements, and tremors.
• Changes in menstrual cycle and sleep problems occur.
• Treatments: medicines such as carbimazole and propylthiouracil stop the thyroid hormone production.
• A radioactive iodine drink destroys thyroid cells.
• Surgical removal of thyroid is typical after the other two options are ineffective.

Hypothyroidism

• Defined by diminished thyroxine production in the thyroid gland.
• Causes include autoimmune conditions, radiotherapy complications, certain medications, and iodine deficiency.

Hyperpituitarism/Hypopituitarism

• These terms describe an overactive or underactive Pituitary gland.
• The condition can result in increased or decreased release of hormones, leading to various endocrine conditions.

Polycystic Ovarian Syndrome (PCOS)

• Polycystic Ovarian Syndrome is due to a hormonal imbalance of insulin and testosterone.
• Symptoms include excessive facial hair and weight gain.
• Irregular periods, fertility problems and anxiety/depression can also signal PCOS.

Diabetes

• Diabetes is a chronic disease that occurs either when the pancreas doesn't produce enough insulin or when the body cannot effectively use the insulin it produces.
• Insulin is a hormone that regulates blood glucose.
• Elevated blood glucose levels over time can damage the heart, blood vessels, eyes, kidneys, and nerves if left untreated.
• High blood sugar (glucose) in the blood isn't being taken up by cells to be used.
• 90% of UK adults who have diabetes have Type 2 diabetes.

Key Points of Diabetes

• There are three types of Diabetes.
• Type 1 occurs when not enough insulin is produced due to autoimmune condition.
• Type 2 results from not enough insulin being released and or insulin resistance.
• Gestational diabetes occurs during pregnancy due to hormonal changes.

Type 1 Diabetes

• Type 1 diabetes is an autoimmune condition.

Type 2 Diabetes

• 90-95% of people who have diabetes have it, according to fast facts.
• 1 out of 10 adults have diabetes, according to the stats.
• Over 25% of adults who are over the age of 65 have diabetes, the facts reveal.
• In people who have prediabetes, exercise and weight lost can reduce the risk of it by 58%.

Symptoms of Diabetes

• Symptoms are increased thirst and frequent urination.
• Extreme hunger and presence of ketones in the urine are additional symptoms.
• Fatigue and irritability and blurred vision occur.
• As well as slow-healing sores and frequent infections such as vaginal infections.

Pancreas

• Located just behind the stomach.
• Main job is to produce and release enzymes to break down food.
• Also produces insulin to control sugar levels in the blood.
• Insulin triggers sugar to be taken into cells from the blood for energy.
• Islets of Langerhans in the pancreas release insulin and glucagon.
• Insulin is released to allow sugars to be taken up by cells and the liver from bloodstream.
• Glucagon signals the liver to carry out glycogenolysis (convert glycogen to glucose) and breakdown proteins into glucose.

Normal Blood Sugar Levels

• Target blood sugar levels without diabetes before meals should be less than 100 mg/dL (5.5 mmol/L).
• Target blood sugar levels without diabetes 1-2 hours after meals should be less than 140 mg/dL (7.8mmol/L).
• Target blood sugar levels with diabetes before meals are 80-130 mg/dL (4.4-7.2mmol/L).
• Target blood sugar levels with diabetes 1-2 hours after starting a meal should be less than 180 mg/dL (10mmol/L).

Causes of type 1 diabetes

• The cause isn't exact, although there is an autoimmune condition.
• Family history can increase chances, but isn't absolute.
• Environmental reasons can occur as well e.g. viruses.

Hyperglycaemia

• Defined as elevated blood sugar.
• It's where blood glucose in the blood isn't taken up by cells in the body.
• Causes oxidative stress, inflammation and dysfunction at a cellular level.
• Damaging to small blood vessels that supply nerves.
• Small blood vessel damage stops nutrients from reaching those nerves.
• Nerves become damaged and eventually cease to function.

Complications of Diabetes

• Over time, hyperglycaemia, or high blood sugar, can cause complications to cardiovascular, cerebrovascular, and peripheral vascular systems.
• Neuropathy, retinopathy, and nephropathy are among the microvascular complications.
• Kidney and eye problems are common microvascular issues.
• Neuropathy has been found to trigger foot ulcers and potentially the need for amputations.

Type 1 Diabetes Treatments Include

• The most widely known treatment is taking insulin.
• Routine blood sugar monitoring, eating healthy foods, and exercising round out the treatments.
• Maintaining a healthy weight is advantageous as well.
• Insulin can be delivered by injection or pump.
• There are short-acting/rapid-acting/intermediate-acting/long-acting insulin treatments. Carbimazole and propylthiouracil

Causes of Type 2 Diabetes

• Obesity/overweight are a cause.
• High blood pressure, inactivity, family history, and age are additional causes.
• A large waist measurement of distribution and weight increases risk.

Type 2 Diabetes Pathophysiology

• Pathophysiology includes defective insulin secretion by pancreatic beta-cells.
• Inability of insulin-sensitive tissues to respond to insulin causes it.
• Increased insulin resistance impairs response of insulin release to circulating blood sugar levels.
• Leads to hyperglycaemia due to these contributing factors.
• Developing type 2 diabetes can be reduced by 34%-56% for participants who walk for 2-3 hours a week or at least 40 min a week.

Macrovascular Complication of Type 2 Diabetes

• T2DM can cause hyperglycaemia and hyperinsulinemia.
• It can also cause insulin resistance.
• Endothelial dysfunction is another factor.
• These all lead to Atherosclerosis/CVD.

Treatments for Type 2 Diabetes

• Aims to control diabetes, different to Type 1
• Insulin is only a last treatment after failing other methods
• Lifestyle and diets are advised
• Recommended weight loss
• Can take Metformin - increases sensitivity in bodily tissues, reduces appetite, and calorific intake/glucose production
• In Type 1 and Type 2 diabetes, there is a systemic increase of inflammatory markers.

Diabetes and Periodontal Disease

• People with diabetes are 3x more likely to develop periodontitis.
• Uncontrolled diabetes and periodontitis are two-way relationship.
• Glycaemic control is important.
• Periodontitis is a chronic inflammatory condition due to plaque present on the gingivae.
• IL-6 and TNF-a (also increased levels seen in people with obesity), serum levels of IL-6 and C-reactive protein (CRP).
• Patients must be risk assessed.
• Diagnosing early and treating it is better.
• Should be aware of damage by controlled periodontitis of the tissues.

Gestational Diabetes

• Diagnosed in pregnancy and hormones produced by placenta cause resistance of it.
• Cells cant collect glucose in blood may cause complications to mother/baby.
• Risk factors include older age, obesity, lack of activity and diabetes in family.

Complications of Gestational Diabetes

• Babies can be born with high birth weight, premature and have breathing problems.
• Mothers have risk of high BP and pre-eclampsia.
• Both can trigger type 2 diabetes, and C section if not regulated.
• Treatments are reducing high sugars in diet and regulating with checking bloods.

Dental Management of Patients with Diabetes:

• Questions to ask in consultations are diagnosis history and medications taken, and whether there are episodes of hypo and hyperglycaemia.
• Check hospitals and blood sugar controls and doctor visits, and get social history
• These questions allow you understand how well controlled a patient's diabetes is

Management of Diabetic Patients

• Update history and medicines and whether they have eaten.
• Check blood sugars and timings of appointments, with emphasis on prevention of periodontis.
• Risks as dental surgery - delayed healing, and potential of infection.
• Dentists must provide detailed patient history and have two dental/ health staff.

Medical Emergencies and GDC

• The General Dental Council requires registrants get trained and keep up to date with resuscitations.
• One must take proper medical history as well as have two members of dental healthcare staff present.
• Hypoglycaemia is low blood sugar, presenting as shaking, slurred speech and pallor.
• Treatment involves giving glucose to conscious patients and calling for help if not.
• Adrenal Crisis sees collapse, pallor, and cold skin from lack of cortisol.
• Treatment is assistance, oxygen admission, and hypochloritism injection.