Endocrine Disorders PDF

Endocrine Disorders The endocrine system consists of a group of integrated glands and cells that secrete hormones. – The secretion is controlled by feedback mechanisms. – The amount of hormone circulating in blood triggers factors that control production. Diseases may result from...

Endocrine Disorders The endocrine system consists of a group of integrated glands and cells that secrete hormones. – The secretion is controlled by feedback mechanisms. – The amount of hormone circulating in blood triggers factors that control production. Diseases may result from conditions where too much or too little hormone is produced.  Endocrine Disorders Hyperpituitarism Hyperthyroidism Hypothyroidism Hyperparathyroidism Diabetes Mellitus Addison Disease  Hyperpituitarism Excess hormone production by the anterior pituitary gland – Caused most often by a benign tumor (pituitary adenoma) that produces growth hormone – Gigantism results if it occurs before the closure of long bones. – Acromegaly results when hypersecretion occurs during adult life.  Clinical Features and Oral Manifestations of Hyperpituitarism Affects both men and women, most commonly during the fourth decade of life – Patients experience poor vision, light sensitivity, enlargement of hands and feet, and an increase in rib size. Facial changes – Enlargement of maxilla and mandible may cause separation of teeth and malocclusion. – Frontal bossing and an enlargement of nasal bones may lead to deepening of voice. Mucosal changes – May have thickened lips and macroglossia  Clinical Features and Oral Manifestations of Hyperpituitarism (cont.)  Diagnosis and Treatment of Hyperpituitarism Diagnosis involves measurement of growth hormone. Treatment often includes pituitary gland surgery. Hyperthyroidism (Thyrotoxicosis) Excess production of thyroid hormone – More common in women than men – The most common cause is Graves disease Graves disease – Appears to be due to an autoimmune disorder in which a substance is produced that abnormally stimulates the thyroid gland – Other causes include hyperplasia of the gland, benign and malignant tumors of the thyroid, pituitary gland disease, and metastatic tumors.  Clinical Features of Hyperthyroidism Rosy complexion, erythema of the palms, excessive sweating, fine hair, softened nails – The patient may have exophthalmos. – Anxiety, weakness, restlessness, and cardiac problems may also be associated.  Oral Manifestations of Hyperthyroidism May lead to premature exfoliation of deciduous teeth in children and premature eruption of permanent teeth – Osteoporosis may affect alveolar bone. – Caries and periodontal disease may appear and develop more rapidly in these patients. – Burning tongue also has been reported. – Development of connective-tissue diseases such as Sjergen’s syndrome or systemic lupus erythematosus.  Treatment of Hyperthyroidism May include surgery, medications to suppress thyroid activity, or administration of radioactive iodine  Hypothyroidism A decreased output of thyroid hormone – Causes include developmental disturbances, autoimmune disease, iodine deficiency, drugs, and pituitary disease – Cretinism When it occurs in infancy and childhood – Myxedema When it occurs in older children and adults  Hypothyroidism (cont.) Oral manifestations – In infants Thickened lips, enlarged tongue, and delayed eruption of teeth – In adults Enlarged tongue  Oral manifestations of patients with hypothyroidism -enamel hypoplasia in both dentitions, -anterior open bite, -macroglossia, -micrognathia, -thick lips, -dysgeusia, -mouth breathing.  DENTAL MANAGEMENT- HYPOTHYROIDISM Medical consultation required  Hyperparathyroidism Due to excessive secretion of parathyroid hormone from the parathyroid glands – The four parathyroid glands are located near the thyroid gland. Parathyroid hormone plays a role in calcium and phosphorous metabolism. – Hyperparathyroidism is characterized by elevated blood levels of calcium (hypercalcemia) and low levels of blood phosphorous (hypophosphatemia). Hyperparathyroidism (cont.) May be the result of hyperplasia of parathyroid glands, a benign tumor of one or more parathyroid glands, or a malignant parathyroid tumor – Found in middle-aged adults – Much more common in women than men Parathyroid hormone increases the uptake of dietary calcium from the gastrointestinal tract and is able to move calcium from bone to circulating blood when necessary.  Clinical Features of Hyperparathyroidism Mild cases may be asymptomatic, or may have joint pain or stiffness. – Lethargy and coma may occur with severe disease.  Oral Manifestations of Hyperparathyroidism Well-defined unilocular or multilocular radiolucencies – Microscopically, they appear to be CGCG (central giant cell granulomas). – Bone may have a mottled appearance.  Oral manifestations of patients with hyperparathyroidism 1. Dental abnormalities: -widened pulp chambers; -development defects; -alterations in dental eruption -weak teeth -maloclussions 2. Loss of bone density 3. Soft tissue calcifications  Diagnosis and Treatment of Hyperparathyroidism Measurement of parathyroid hormone blood levels – May include serum calcium and phosphorous measurements Treatment is directed at correcting the cause of increased hormone production. – Causes may include tumors, renal disease, and vitamin D deficiency.  The clinical management of these patients does not require any special consideration.  Diabetes Mellitus A chronic disorder of carbohydrate metabolism characterized by abnormally high blood glucose levels – These result from a lack of insulin, defective insulin that does not work to lower blood glucose levels, or increased insulin resistance due to obesity. Diabetes Mellitus (cont.) Glucose normally signals beta cells of the pancreas to make insulin. – The hormone is then secreted into the bloodstream to facilitate the uptake of glucose into fat and skeletal muscle. – In the presence of insulin, fat and skeletal muscle cells can use glucose as an energy source.  Diabetes Mellitus (cont.) Without insulin, tissue is broken down to provide energy and weight loss occurs. – A severe hyperglycemia can lead to diabetic coma. – Ketone can be produced by the breakdown of fatty acids. Ketoacidosis lowers the pH of blood. Collagen production is abnormal.  Types of Diabetes Insulin-dependent diabetes mellitus – Type 1 Non–insulin-dependent diabetes mellitus – Type 2  Insulin-Dependent Diabetes Mellitus Thought to be an autoimmune disease – Insulin-producing cells of the pancreas are destroyed. – 3% to 5% of all diabetic patients have this type. Can occur at any age, the peak is at age 20 Acute onset with polydipsia (excessive thirst and intake of fluid), polyuria (excessive urination), and polyphagia (excessive appetite) Insulin-Dependent Diabetes Mellitus (cont.) These patients will require insulin their entire lives. – The current approach to management of these patients involves multiple insulin injections and proper diet, exercise, and frequent determination of blood glucose levels. – But multiple injections of insulin can more readily lead to low blood sugar (hypoglycemia) and insulin shock (severe hypoglycemia). Insulin-Dependent Diabetes Mellitus (cont.) New methods of treatment – Nasal spray rather than injection – Insulin pump A backup may be necessary in case the pump fails Low insulin can lead to ketoacidosis, resulting in nausea, abdominal cramps, disorientation, and fatigue  Non–Insulin-Dependent Diabetes Mellitus Characterized by insulin resistance – 95% of all diabetic patients have this type of diabetes. – Usually occurs in patients 35 to 40 years of age or older Many of these individuals are obese – Obesity probably decreases the number of receptors for insulin binding in sensitive tissues like fat or muscle. – Diet and weight reduction may control it in some individuals; others require oral hypoglycemic agents.  Risk factors for diabetes There are many risk factors for type 2 diabetes, including: -Age over 45 years -A parent, brother, or sister with diabetes -Gestational diabetes or delivering a baby weighing more than 9 pounds -Heart disease -High blood cholesterol level -Obesity -Not getting enough exercise -Polycystic ovary disease (in women) -Previous impaired glucose tolerance  Clinical Features of Non–Insulin- Dependent Diabetes Mellitus Atherosclerosis, a thickening of the blood vessel wall from plaque, can lead to impaired circulation, causing impaired oxygenation and nutrition in tissue. – This increases the risk of ulceration and gangrene of the feet, high blood pressure, kidney failure, and stroke. Diabetic retinopathy in the eye can lead to blindness. The nervous system may be affected. The person may have decreased resistance to infection.  Oral Complications of Non–Insulin- Dependent Diabetes Mellitus Patients may have an increased prevalence of oral candidiasis. – Mucormycosis, a rare oral fungal infection that affects the palate and maxillary sinuses, may be seen in uncontrolled or poorly controlled diabetes. Bilateral asymptomatic parotid gland enlargement may occur. – Xerostomia may be associated with uncontrolled diabetes mellitus. – Patients may have an accentuated response to plaque. – Patients may have slow wound healing and increased susceptibility to infection.  Oral Complications of Non–Insulin- Dependent Diabetes Mellitus (cont.)  Symptoms of diabetes Patients with type 1 Type 2 diabetes develops diabetes usually develop slowly, some people with symptoms over a short high blood sugar period of time. The experience no symptoms condition is often diagnosed at all. in an emergency setting Symptoms of type 2 Symptoms of type 1 diabetes: diabetes: 1. Blurred vision 1. Fatigue 2. Fatigue 2. Increased thirst 3. Increased urination 3. Increased appetite 4. Nausea 4. Increased thirst 5. Vomiting 5. Increased urination 6. Weight loss in spite of increased appetite Main oral health problems People with diabetes are at higher risk for oral health problems, such as 1. gingivitis, 2. periodontitis. People with diabetes are at an increased risk for PDD disease because they are Gingivitis in a 19-year-old 1. generally more women with uncontrolled susceptible to bacterial diabetes mellitus infection 2. have a decreased ability to fight bacteria that invade the gums.  Other oral problems associated with diabetes include: thrush, dry mouth which can cause soreness, ulcers, infections and cavities. Inflamed, papulonodular hyperplasia of the gingiva in a diabetic patient  Oral Complications of Diabetes Oral changes associated with diabetes include cheilosis, mucosal drying, burning mouth and tongue, alterations in the flora of the oral cavity and increased rate of dental caries. Periodontal changes include enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferations, abscess formation, periodontitis, and loosened teeth. Periodontal disease in diabetics follows no consistent or distinct pattern. Increased rate of dental caries Xerostomia Salivary dysfunction (diminished salivary flow) Candidiasis Glossodynia Lichen Planus  Periodontal Disease Increased prevalence of PerioDisease Decreased healing in poorly controlled DM Management of periodontal disease may help improve glycemic control  Salivary Dysfunction & Xerostomia Salivary Hypofunction/ Dry mouth Dry mouth (xerostomia) occurs when the salivary glands are not functioning properly resulting in decreased saliva. Saliva not only aids in digestion, but is a necessary factor in oral health because it also helps to keep your mouth moist and prevent tooth decay. Diabetic neuropathy can also affect the salivary glands. Polyuria Topical treatments: 1. fluoride containing mouthrinses 2. salivary substitutes  Dental Caries Increased prevalence of dental caries Salivary hyperglycemia  Oral Candidiasis Opportunistic fungal infection commonly associated with hyperglycemia. Salivary dysfunction compromise immune function. Salivary hyperglycemia provide substrate for fungal growth  Burning Mouth Syndrome Burning mouth syndrome (BMS) is a condition with no determined cause and is characterized by a chronic burning pain in your mouth. This burning sensation can be severe, feeling much the same as scalding and can affect the overall areas of your mouth such as your tongue, gums, lips, inside of your cheeks, and the roof of your mouth. Although BMS has no known cause and finding treatment may by difficult, most people can bring it under control by working with an oral health specialist.  PATIENT MANAGEMENT:DIABETES MELLITUS Appointments: – Early morning – Regular dental visits Infection and wound healing – Post-op antimicrobial or antibiotic therapy – Avoidance of smoking  Addison's disease Addison's disease results from a chronic insufficiency of the adrenal cortex. The first signs of the disease may be: - pigmentation of the skin and mucous membranes due to excessive deposition of melanin in the connective tissue and epithelial cells. Pigmentation of the skin appears in the areas exposed to light (the face, the back surface of the hands). As the disease progresses the skin become light brown or bronze color.  Addison's disease small (one to several square millimeters) grey-black spots or stripes, dark brown or grey-blue color without signs of inflammation on the mucous membrane of the: mouth in the cheek area, tongue edges, palate, gums. The spots can be oval or take the form of strips or fine grit, above the level of the mucous membrane.  Addison's disease The most common symptoms are fatigue, lightheadedness upon standing or while upright, muscle weakness, fever, weight loss, difficulty in standing up, anxiety, nausea, vomiting, diarrhea, headache, sweating, changes in mood and personality, joint and muscle pains. Addison's disease is differentiated from: -multiple melanotic macules, -smoker’s melanosis, -Peutz-Jeghers syndrome, -heavy metal poisoning, -postinflammatory hyperpigmentation, -congenital pigmentation of the oral mucosa Fig. the band-like grayish blue pigmentation of the maxillary and mandibular anterior gingiva after using drugs that include antimalarial agents. *  Addison's disease Treatment: -replace the missing or low levels of cortisol (hydrocortisone ) Prognosis: -Prognosis for patients appropriately treated with hydrocortisone and aldosterone is excellent. These patients can expect to enjoy a normal lifespan. -Without treatment, or with substandard treatment, patients are always at risk of developing Addisonian crisis.