Oral Diagnosis and Dental Radiology-II: Disorders of the Endocrine System and Metabolism PDF

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Disorders of the Endocrine System and of Metabolism Assoc. Prof. Büşra YILMAZ School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] Disorders of the Endocrine System and of Metabolism DIABETES MELLITUS DIABETES M...

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Disorders of the Endocrine System and of Metabolism Assoc. Prof. Büşra YILMAZ School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] Disorders of the Endocrine System and of Metabolism DIABETES MELLITUS DIABETES MELLITUS is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Diabetes mellitus produces multiple systemic complications, including;  nephropathy,  retinopathy,  neuropathy,  accelerated atherosclerosis,  delayed wound healing,  increased susceptibility to infections. The responsibility falls to the dental practitioner to; (1) recognize signs and symptoms of diabetes, to facilitate early diagnosis and management; (2) manage oral conditions, to maximize oral function, comfort, and esthetics for the life of the patient; and (3) work in conjunction with the patient, the patient’s physician, and diabetes management team, to facilitate long-term disease control Classification of Diabetes • Type 1 diabetes • Type 2 diabetes • Gestational diabetes Type 1 Diabetes Mellitus Results from the pancreas's failure to produce enough insulin. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". Type 2 Diabetes Mellitus Begins with insulin resistance, a condition in which cells fail to respond to insulin properly. This form was previously referred to as "non insulin-dependent diabetes mellitus" or "adult-onset diabetes". The primary cause is excessive body weight and not enough exercise. Gestational Diabetes Is the third main form and occurs in pregnant women without a previous history of diabetes The main symptoms are diabetes are described as; Polyuria or the need to urinate frequently helps the body remove excess glucose Polydipsia or increased thirst and fluid intake compensates for the loss of fluid Polyphagia or increased food intake compensates for the loss of glucose and fluids from the body Diagnostic tests • A normal fasting blood glucose level ranges from 60 mg/dL to 100 mg/dL. • A fasting blood glucose greater than 126 mg/dL on two occasions is generally considered diagnostic for diabetes • Blood glucose levels taken 2 hours after glucose ingestion that are greater than 200 mg/dL on two occasions are diagnostic of diabetes Diagnostic tests Glycosylated Hemoglobin Assay (HbA1c) measures the average blood glucose levels over the past 3 months The American Diabetes Association recommends that individuals with DM attempt to achieve a target HbA1c value of less than 7%. An HbA1c value of more than 8% suggests that a change in patient management may be needed to improve glycemic control. ORAL MANIFESTATIONS AND COMPLICATIONS Periodontal disease Increased risk of infection Delayed healing of wounds Xerostomia Tenderness, pain and burning sensation of tongue Sialosis Dental caries Dental Management Dental management of the diabetic patient should include four primary areas: 1. Screening and diagnosis of previously undiagnosed patients (based upon a health history review and oral examination), 2. Proper dental management of oral manifestations, 3. Prevention of complications during procedures related to hypoglycemic shock, hyperglycemic shock, and acute cardiovascular episodes, 4. Proper management of medical emergencies HYPERPITUITARISM GIGANTISM AND ACROMEGALY  Gigantism and acromegaly are both caused by excess growth hormone (GH).  Gigantism if it occurs before fusion of the epiphyseal plate (growth).  Acromegaly if it occurs after the bony growth plates have fused.  Gigantism develops during childhood and acromegaly appears in adulthood ACROMEGALY • Typically enlargement of the lips, nose, tongue and square shaped mandibular angulus formation is seen. Frontal bossing is a descriptive term in medical physical examination indicating a protuberance of the skull, most often in the frontal bones of the forehead CUSHING SYNDROME  Cushing's syndrome; It is a complex of symptoms that occurs as a result of continuous and excessive secretion of glucocorticoids (cortisol).  Cushing's disease is the picture that occurs due to an adenoma originating from the pituitary, while the picture that occurs with high doses and long-term administration of adrenal or exogenous ACTH or glucocorticoids (iatrogenic cushing) is called Cushing's syndrome.  There are also some tumor types (such as small cell lung cancers, bronchial carcinomas, thymus carcinoids, pancreatic tumors) that secrete ectopic ACTH and cause Cushing's syndrome. CUSHING SYNDROME CUSHING SYNDROME Obesity is the most prominent and known finding of Cushing's syndrome. It is prominent on the face, neck, nape (tr: ense) and belly, and the extremities appear thinner than the trunk. There is atrophy of the epidermal tissue and thinning of the underlying connective tissue. It is easily damaged by a minor trauma. Other clinical signs are -hyperpigmentation, -hirsutism (due to androgen and cortisol excess in women), -hypertension, -muscle weakness, -osteoporosis. CUSHING SYNDROME DENTIST APPROACH • While there is a bronze discoloration of the skin in Cushing's syndrome, melanosis may occur in the oral mucosa as a patch. The reason for this is ACTH elevation. • If Cushing's syndrome occurs with excessive and long-term glucocorticosteroids taken from the outside, complications that may occur due to the presence of adrenal suppression developed in these patients should be considered during dentistry practices. CUSHING SYNDROME DENTIST APPROACH • In these patients, the vessel walls of small vessels are more fragile. Therefore, the tendency to bleeding has increased. • They are prone to infection and the rate of fungal infection in the oral mucosa is increased. • There is a delay in wound healing. For this reason, the operation area should be followed closely after the surgical operation. • The presence of hypertension should be considered in these patients. • In Cushing's disease, there may be loss of the lamina dura. ADDISON DISEASE Addison’s disease is a disorder that occurs when the adrenal glands do not produce enough hormones due to damage to the adrenal cortex. The clinical picture is a reflection of the deficiency of cortisol and aldosterone. ADDISON DISEASE  A lack of cortisol produces altered glucose, fat, and protein metabolism, resulting in weakness, fatigue, weight loss, inability to tolerate stress, and hypotension.  Aldosterone deficiency leads to sodium imbalance, hypovolemia, hyperkalemia, and acidosis.  A generalized hyperpigmentation of the skin occurs, classically described as “bronzing» ADDISON DISEASE DENTIST APPROACH  Pigmented lesions are brown, diffuse, and patchy in distribution, commonly found on the dorsum of the tongue and buccal mucosa  Oral mucosal changes may be the first manifestations of the disease, with skin hyperpigmentation following.  Medical management of a patient with Addison disease includes glucocorticoid replacement, usually with daily cortisone or prednisone. ADDISON DISEASE DENTIST APPROACH  IMPORTANT!! When a patient with Addison disease is suddenly stressed, for example by dental infection or surgery, an adrenal crisis can be precipitated.  Patients with secondary adrenal insufficiency undergoing routine dental care (including dental extractions) with local anesthesia do not require supplementation.  This recommendation assumes adequate postoperative pain management and blood pressure monitoring.  However, if the patients exhibits extreme dental anxiety supplementation or from special anxiety management may be needed. ADDISON DISEASE DENTIST APPROACH  IMPORTANT!! When extensive procedures are planned for these patients, doubling the normal amount on the day of the dental procedure is recommended.  If postoperative pain is expected, recommendation would be to double the dose on the first postoperative day  Patients with adrenal insufficiency for whom dental procedures require general anesthesia should be treated in a hospital setting. ADDISON DISEASE DENTIST APPROACH  Steroid augmentation may include 100 mg of hydrocortisone the morning of the procedure, 100 mg 1 hour before and/or after the procedure and doubled maintenance dose the first postoperative day.  Patients with adrenal insufficiency should be monitored for possible hypotension and observed for signs of hypoglycemia.  A medical consultation regarding steroid supplementation may be helpful. THYROID DISEASES  The function of the thyroid gland is to convert iodine into thyroid hormones: thyroxine (T4) and triiodothyronine (T3).  Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone "strength" as T4. THYROID DISEASES  The thyroid gland manufactures hormones that regulates body metabolism. Several different disorders can arise when thyroid produces too much hormone (hyperthyroidism) or not enough (hypothyroidism).  Four common disorders of the thyroid are Hashimoto's disease, Graves' disease, goiter, and thyroid nodules. GOITER Abnormal enlargement of the thyroid gland. A goitre commonly develops as a result of iodine deficiency or inflammation of the thyroid gland. Not all goitres cause symptoms. Symptoms that do occur might include swelling and coughing. Hypothyroidism Hypothyroidism is an underactive thyroid gland. Hypothyroidism means that the thyroid gland can’t make enough thyroid hormone to keep the body running normally. Symptoms • Trouble sleeping • Tiredness and fatigue • Difficulty concentrating • Dry skin and hair • Depression • Sensitivity to cold temperature • Frequent, heavy menstrual cycle • Joint and muscle pain Hypothyroidism HASHIMOTO’S THYROIDITIS (LYMPHOCYTIC THYROIDITIS) • Also known as chronic lymphocytic thyroiditis • It is an autoimmune disorder involving chronic inflammation of the thyroid. • Hereditary • The ability of the thyroid gland to produce thyroid hormones often becomes impaired and leads to a gradual decline in function and eventually an underactive thyroid (Hypothyroidism). Hypothyroidism Dental Management • Detection of hypothyroidism requires medical referral of the patient prior to dental treatment. • Hypothyroid patients who are receiving warfarin or other oral anticoagulants along with levothyroxine may have prolonged prothrombin times and could be at risk for hemorrhage. Hypothyroidism Dental Management • Stressful situations, such as cold, surgery, or trauma, may precipitate a hypothyroid (myxedema) coma in the undiagnosed severely hypothyroid patient. • In general, patients with mild symptoms of untreated hypothyroidism are not in danger when receiving dental therapy. • However, depressants, sedatives, or narcotic analgesics may produce an exaggerated response in patients with mild to severe hypothyroidism. • When the hypothyroid patient is under effective medical care, regular dental care can be provided. Hyperthyroidism Hyperthyroidism is a condition in which the thyroid gland is overactive and makes excessive amounts of thyroid hormone. Symptoms: • Fatigue or muscle weakness • Hand tremors • Mood swings or irritability • Nervousness or anxiety • Rapid heartbeat • Heart palpitations or irregular heartbeat • Skin dryness • Trouble sleeping • Weight loss • Increased frequency of bowel movements • Light periods or skipping periods Hyperthyroidism GRAVES’ DISEASE • Graves’ disease is an autoimmune disease that leads to a generalized overactivity of the entire thyroid gland. • Most common cause of hyperthyroidism in the United States. Symptoms: Hyperthyroidism symptoms including racing heartbeat, hand tremors, trouble sleeping, weight loss, muscle weakness, neuropsychiatric symptoms and heat intolerance. Hyperthyroidism GRAVES’ DISEASE Symptoms: Eye disease: associated with inflammation of the eyes, swelling of the tissues around the eyes and bulging of the eyes (called Graves’ ophthalmopathy or orbitopathy). Skin disease: pretibial myxedema (called Graves’ dermopathy), usually painless and relatively mild. Hyperthyroidism Dental Management • Patients with uncontrolled hyperthyroidism require special dental management. • They are sensitive to epinephrine and pressor amines in local anesthetics and gingival retraction cords. • These agents should not be administered until hyperthyroidism is controlled. Hyperthyroidism Dental Management • The most important complication is thyrotoxic crises. • Precipitating factors are infections, trauma, surgical emergencies, and surgery. • Symptoms are extreme restlessness, nausea, vomiting, and abdominal pain. • Coma and severe hypotension may develop. • Immediate treatment consists of anti-hyperthyroid therapies to include propylthiouracil, potassium iodide, propranolol, hydrocortisone, and ice packs or cooling blankets; CPR may be needed until medical help arrives. HYPERPARATHYROIDISM Hyperparathyroidism is chronic excessive secretion of the PTH by the parathyroid glands. It results in uncontrolled chronic high serum calcium (hypercalcemia). PARATHYROID HORMONE(PTH) Primary function is to maintain the extracellular fluid calcium concentration with in normal range. Acts directly on bone(calcium resorption) kidney (calcium reabsorption) Stimulates 1 alpha hydroxylase activity, increases production of 1,25(OH)2D, which increases the efficiency of calcium absorption. 1,25(OH)2D: Calcitriol is the active form of vitamin D, normally made in the kidney. It is also known as 1,25-dihydroxycholecalciferol HYPERPARATHYROIDISM Primary hyperparathyroidism is the term that refers to excessive PTH secretion arising from one or more of the parathyroid glands. Commonly it is caused by a solitary adenoma, parathyroid hyperplasia and due to carcinoma of the parathyroid glands. Secondary hyperparathyroidism occurs with compensatory parathyroid gland enlargement in response to persistent hypocalcemia induced by renal failure, or metabolic disorders of deficiency of calcitriol (1,25(OH)2D), or malabsorption of calcium found in rickets and some forms of osteomalacia. Chronic Renal Failure, Impaired production of 1,25(OH)2D by the diseased kidneys is thought to be the principal factor that causes calcium deficiency, secondary hyperparathyroidism, and bone disease. Calcitriol is the active form of vitamin D, normally made in the kidney . It is a hormone which binds to and activates the vitamin D receptor in the nucleus of the cell, which then increases the expression of many genes.[11] Calcitriol increases blood calcium (Ca2+) mainly by increasing the uptake of calcium from the intestines HYPERPARATHYROIDISM The dental findings of hyperparathyroid disease are usually found as abnormalities on dental radiographs Bone changes almost always reflect late-stage disease. The changes include one or more of the following: (1) complete or partial loss of lamina dura; (2) alveolar bone demineralization (ground-glass appearance) (3) fibrous giant-cell bone lesions (brown tumor, osteitis fibrosa cystica) HYPOPARATHYROIDISM  Hypoparathyroidism is relatively rare and may be congenital or induced by parathyroid or thyroid surgery, or radiation to that area.  These events can lead to a low serum calcium level which can lead to muscular spasms and tetany.  The dental manifestations only occur in the congenital form, which affects the teeth at the developmental stage, causing mottling (hypoplastia) and discoloration  There are no dental findings in acquired hypoparathyroidism. References • Michael Glick (ed.); Martin S. Greenberg (ed.); Peter B. Lockhart (ed.); Stephen J. Challacombe (ed.). Burket's Oral Medicine. 13th edition. Wiley-Blackwell. June 2021. ISBN: 9781119597780