Endocrine Diseases & Diabetes GN PDF

Endocrine diseases & Diabetes 24th January 2025 Hannah Barrow Georgina Prosser Academic Clinical Fellow in Specialty Registrar in Special Special Care Dentistry Care Dentistry...

Endocrine diseases & Diabetes 24th January 2025 Hannah Barrow Georgina Prosser Academic Clinical Fellow in Specialty Registrar in Special Special Care Dentistry Care Dentistry Khadeeja Saeed Academic Clinical Fellow in Special Care Dentistry Aims & Learning objectives By the end of the session you should be able to: o Confidently explain the role of the endocrine system o Define different endocrine diseases o Explain the pathophysiology of diabetes o Describe how to manage medical emergencies involving diabetes o Discuss how dental treatments could be affected by these conditions o Describe what medications these patients could be on and their relevance to dentistry Why do I need to know about endocrine disease? o Endocrine disorders include many different diseases o They all show different striking features and symptoms affecting dental health o In 2011, 360 million people had diabetes (95% type 2) o The numbers of people with diabetes is increasing worldwide o Patients with endocrine disorders will be on different medications o Some are long term medications o Dental professionals need to know what Addison crisis is and how to manage patients with low or high blood sugars (medical emergencies) GDC preparing for practice: Dental hygienists and therapists The registrant will be able to… o Describe relevant and appropriate physiology and its application to patient management o Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management o Explain the impact of medical and psychological conditions in the patient o Recognise and manage medical emergencies Structure of lecture 1. The endocrine system Revision 2. How do endocrine diseases occur? Define different endocrine diseases, explain their pathophysiology, state what symptoms can occur 3. Diabetes Aetiology, pathophysiology, symptoms, treatments, relevance to dentistry 4. Management of dental patients with an endocrine disease discuss patient management, clinical considerations, discuss risk factors and prevention, understand medical emergencies involved with the endocrine system Group discussion – reflective learning MCQs Part 1: The Endocrine System What is an endocrine gland? Endocrine glands / Exocrine glands o Endocrine glands release hormones directly into the blood stream ▪ Example: Thyroid gland o Exocrine glands release hormones via a duct or opening ▪ Example: Salivary glands Hypothalamus and pituitary gland linked together Pineal gland - melatonin Hormones = chemical messengers Hormones in the endocrine system o Regulate what every cell does o Affects puberty, growth, sexual behaviour, sleep, mood, metabolism, reproduction, cope with stress and more! o Endocrine disorders occur when these glands/ hormones don’t carry out their normal role correctly Part 2: How do endocrine diseases occur? Common endocrine disorders – how do they occur? o Acromegaly o Adrenal insufficiency o Cushing's disease o Hyperthyroidism/Hypothyroidism o Hyperpituitarism/Hypopituitarism o Polycystic ovary syndrome o Diabetes Common endocrine disorders – how do they occur? o Acromegaly growth hormone o Adrenal insufficiency cortisol o Cushing's disease cortisol o Hyperthyroidism/Hypothyroidism or thyroid hormone o Hyperpituitarism/Hypopituitarism or hormones from adrenal and thyroid glands o Polycystic ovary syndrome (POS) testosterone o Diabetes or insulin Acromegaly o A rare disorder where the pituitary gland produces too much growth hormone o Growth hormone in the blood causes liver to produce IGF-1 = bone and tissues to grow o This causes bones, cartilage, body organs, and other tissues to increase in size o Patients may have larger/swollen nose, larger ears, hands and feet 9 out of 10 cases are caused by a tumour on the pituitary gland Craniofacial features: What can you notice? Craniofacial features Prognathism Overgrowth of the mandible (class 3) Frontal bossing Maxillary widening Macroglossia Tooth separation Thickening of lips Skeletal malocclusion Treatments 1. Surgery to remove tumour (transsphenoidal surgery) 2. Radiation therapy – to kill tumour cells (if surgery contraindicated) 3. Medicines (not a cure) to target excessive hormone in the body; o Somatostatin analogues (somatostatin is a hormone that reduces the production of other hormones, therefore reducing GH release) o Growth hormone-receptor antagonists (these stop GH from activating release of IGF-1) Adrenal insufficiency (Addison's disease) o Rare autoimmune disease where adrenal glands do not produce enough cortisol (stress hormone) o Can also occur after long term steroid treatment has stopped Symptoms: o Fatigue, muscle weakness, loss of appetite, weight loss, and abdominal pain.  STertiary adrenal insufficiency - Secondary adrenal insufficiency 1 Primary adrenal insufficiency (Addison's disease) Complications? o In stressful situations (e.g. surgery), our body needs more cortisol (fight or flight response) o In patients who can’t produce cortisol – this can be life threatening o Known as Adrenal crisis o Here the body shows hypotension, hypoglycaemia, low blood sodium, high blood potassium Symptoms Dizziness, vomiting, diarrhoea, abdominal cramps, seizures, loss of consciousness Treatment = Steroid treatment Cushing's disease o Too much cortisol o 1 in 200,000 o Not genetic o No current evidence for environmental triggers o Usually due to long term steroid medication  Hyperthyroidism o Thyroid gland produces too much thyroxine o Thyroxine is important in metabolism (e.g. speed) o Causes Graves disease (autoimmune condition) Thyroid nodules Medications (e.g. iodine) Hyperthyroidism Symptoms: ✓ Nervousness ✓ Anxiety ✓ Mood swings ✓ Fatigue ✓ A swollen thyroid (Goitre) ✓ Unexplained weight loss ✓ Hair loss / thinning hair ✓ Fast or irregular heartbeat ✓ Increased bowl movements ✓ Tremors ✓ Changes in your menstrual cycle ✓ Sleep problems Treatments Medicine o Stop thyroid from producing hormones carbimazole and propylthiouracil Radioactive iodine treatment o Given a drink containing iodine and a small amount of radiation. To destroy cells which produce hormones Surgery o Remove part or all of thyroid gland (usually considered after first two options have not treated the condition (severe cases)  Hypothyroidism o Thyroid gland produces too little thyroxine o Causes Autoimmune Radiotherapy complication Some medications (e.g. amiodarone) Iodine deficiency Hyperpituitarism/Hypopituitarism o Umbrella term for over-active or underactive pituitary gland. o This in turn will cause too much of a certain hormone to be released and lead to different endocrine conditions Polycystic Ovarian Syndrome (PCOS) PCOS Causes: o Imbalance of certain hormones e.g. insulin and testosterone Symptoms/signs: o Excessive facial hair o Weight gain o Irregular periods o Fertility problems o Anxiety/depression Part 3: Diabetes What is diabetes?  Insulin stimulates removal of glucose from blood Glucagon = hormones that increase blood sugar Diabetes levels o Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces o Insulin is a hormone that regulates blood glucose o Elevated levels of blood glucose (or blood sugar) over time can lead to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Insulin stimulates glucose uptake in blood Diabetes : Key points o There are three types: 1. Type 1 (autoimmune) not enough insulin is produced 2. Type 2 not enough insulin is released or insulin resistance present 3. Gestational diabetes occurs during pregnancy due to hormonal changes o In all - the blood sugar is too high (glucose in the blood is not being taken up by cells) o 90% of adults in the UK with diabetes have type 2 Type 1 diabetes Type 2 diabetes Things are getting worse… Symptoms: o Increased thirst o Frequent urination o Extreme hunger o Presence of ketones in the urine o Fatigue o Irritability o Blurred vision o Slow-healing sores o Frequent infections, such as gums or skin infections and vaginal infections Pancreas o Located just behind your stomach o Produces and releases enzymes that break down food o Also produces insulin that controls sugar levels in the blood o Can trigger sugar to be taken into cells from the blood stream to be used for energy Cells known as islets of Langerhans in the pancreas release insulin and glucagon Insulin – released when sugars are too high o Allows sugars to be taken up by cells and the liver from the bloodstream Glucagon – released when sugars are too low o Liver is signalled to carry out glycogenolysis (convert glycogen to glucose) and gluconeogenesis (breakdown proteins in to glucose) o Thus increasing glucose in the bloodstream Normal blood sugar levels Target blood sugar levels Target blood sugar levels Time of check for people without diabetes for people with diabetes less than 100 mg/dl 80–130 mg/dl (4.4- Before meals (5.5mmol/L) 7.2mmol/L) 1–2 hours after the start of a less than 140 mg/dl less than 180 mg/dl meal (7.8mmol/L) (10mmol/L) Causes of type 1 diabetes o Autoimmune condition o Exact cause not known o Family history can increase your risk, but don’t cause it alone o Environmental influences e.g. viruses, can trigger it  Hyperglycaemia o Causes oxidative stress, inflammation and dysfunction at the cellular level o Extremely dangerous for the cells and the body o Essentially damages the small blood vessels that supply the nerves in your body. This stops essential nutrients reaching those nerves. They become damaged and eventually stop working Complications Microvascular Macrovascular Neuropathy Cardiovascular disease Retinopathy Cerebrovascular disease Nephropathy Peripheral vascular disease This Photo by Unknown Author is licensed under CC BY-SA Treatments for type 1 diabetes o Taking insulin o Regular blood sugar monitoring o Eating healthy foods o Exercising regularly o Maintain a healthy weight Insulin o Delivered by injection or pump o Short-acting insulin: Humulin R and Novolin R o Rapid-acting insulin: insulin glulisine (Apidra), insulin lispro (Humalog) and insulin aspart (Novolog) o Intermediate-acting (NPH) insulin: (Novolin N, Humulin N) o Long-acting insulin: (Lantus, Toujeo Solostar), insulin detemir (Levemir) and insulin degludec (Tresiba) Causes of type 2 diabetes o Obesity/overweight ▪ Large waist measurement (distribution of weight) increases risk further o High blood pressure o Inactivity o Family history o Age Pathophysiology o Defective insulin secretion by pancreatic β-cells o Inability of insulin-sensitive tissues to respond to insulin o An increase in insulin resistance (impaired response of insulin release to circulating blood sugar levels) o Hyperglycaemia as a result 34% - 56% reduction of developing T2DM in participants walking 2–3 h a week or at least 40 min a week – (Weinstein et al 2004) Macrovascular complication of type 2 diabetes Treatments for type 2 diabetes o Different to Type 1 diabetes o Insulin only given as a last treatment option when other drugs have not helped to control diabetes Alternatives o Lifestyle advice (eating well and moving more) o Weight loss o Metformin (commonly used medication) - increases insulin sensitivity of body tissues, reducing appetite and calorific intake and decreasing glucose production in the liver Periodontitis and diabetes Periodontitis and diabetes 3 x more likely to develop periodontitis if you have diabetes o Strong two-way relationship between uncontrolled diabetes increasing severity of periodontitis/ increasing complications from diabetes o Importance of glycaemic control (HbA1c) o Mechanisms involved – neutrophil function and cytokine biology o Periodontitis = a chronic inflammatory condition due to plaque present on the gingivae o In T1DM and T2DM there is a systemic increase of inflammatory markers; ▪ IL-6 and TNF-α (also increased levels seen in people with obesity), serum levels of IL-6 and C-reactive protein (CRP) Patient management: diabetes and periodontitis o Periodontal treatment improves glycaemic control o Important to risk assess patients o Early diagnosis of diabetes and periodontal disease o Treat periodontal disease and make patients aware of the risks of irreversible tissue destruction caused by poorly controlled periodontitis and diabetes Gestational diabetes Gestational diabetes o Diagnosed in pregnancy o Hormones produced by placenta cause insulin resistance o Cells aren’t able to take up glucose in the blood o Can cause complications for the baby and mother Gestational diabetes Risk factors: o Older age. o Overweight and obesity. o A lack of physical activity. o Previous gestational diabetes or prediabetes. o Polycystic ovary syndrome. o Diabetes in an immediate family member. o Previously delivering a baby weighing more than 9 pounds (4.1 kilograms). o Race Complications If not controlled: Baby: Mother: o Excessive birth weight o High blood pressure o Premature birth and pre-eclampsia o Breathing difficulties o Type 2 diabetes o Hypoglycaemia later in life o Obesity and type 2 diabetes o Stillbirth o C section Treatments o Reducing sugars and carbohydrates in foods o Small plate sizes o Checking bloods before and after meals o Close monitoring by midwife o Close monitoring of babies o Further lifestyle changes (if risk factors present) o Further monitoring (increased chances of getting diabetes later in life) Part 4: Dental management of patients with endocrine disease Dental management of patients with diabetes: Questions to ask at consultation ✓ When were you diagnosed? / how long have you had it? ✓ Do you take any medications – which ones and how often? ✓ Any episodes of hypo/hyper glycaemia? ✓ Have you ever been to hospital? How many times? What happened? ✓ How often do you check your blood sugars? ✓ Are they well controlled? ✓ How often do you see your doctor? ✓ Get a detailed social history These questions allow you understand how well controlled a patient's diabetes is Management of a diabetic patient ✓ Update MH ✓ Taken medication? ✓ Eaten? ✓ Check blood sugars before treatment ✓ Timing of appointment ✓ Emphasis on prevention and warn regarding increased periodontitis risk Risks from dental surgery: o Delayed healing after extraction o Increased risk of dental decay Medical emergencies The General Dental Council (GDC) states: 'a patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that all registrants must be trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability’ Medical emergencies o Risk management – how can we avoid one? ▪ Take a full accurate detailed patient history o Planning ahead – two dental/ health care professionals in the clinical environment trained in medical emergencies o Ensure you are aware of the management of medical emergencies ▪ CPD up to date with regular revision and training within your team  Hypoglycaemia Low blood sugar Management Signs and symptoms: ✓ ABCDE o Shaking/trembling Conscious and safe to swallow: give glucose (drink) or gel (fast acting) o Slurred speech ✓ Oral glucose o Confusion o Sweating and pallor; blurred vision Unconscious: ✓ Call 999 o Tiredness/lethargy ✓ Recovery position o Moody/anger ✓ Glucagon 1mg IM ✓ Once conscious – give oral glucose o Loss of consciousness ✓ Take blood sugar reading ✓ Under 8 years of age (under 25kg) = 0.5mg IM Glucagon  Adrenal crisis Lack of cortisol Signs and symptoms: Management ✓ ABCDE o Collapse, pallor, cold and clammy skin ✓ Call 999 o Hypotension and dizziness ✓ Lie flat, administer oxygen (15L/min) o Vomiting and diarrhea ✓ Hydrocortisone IM 100mg  Further reading o https://www.diabetes.org.uk/ o https://www.osmosis.org/learn/Diabetes_mellitus o https://www.nature.com/articles/bdjteam20157 o https://www.bsperio.org.uk/patients/gum-disease-and-diabetes