Endocrine Disorders Intro Lecture Notes PDF

1 2 Learning Objectives After completing this module, you should be able to Graves’ ophthalmopathy College of Medicine and Dentistry • outline the key signs and symptoms of the endocrine disorders introduced in the lectures and practical. Endocrine disorders Intro lecture • identify the under...

1 2 Learning Objectives After completing this module, you should be able to Graves’ ophthalmopathy College of Medicine and Dentistry • outline the key signs and symptoms of the endocrine disorders introduced in the lectures and practical. Endocrine disorders Intro lecture • identify the underlying hormonal imbalance(s) and their potential origins. • evaluate the consequences of these disorders on dental health. Dr Doris Pierce • identify considerations for the dental practice. https://en.wikipedia.org/wiki/Graves%27_dis ease. Text is available under the Creative Commons Attribution-ShareAlike License 4.0; 3 4 Causes of endocrine dysfunction Primary causes - Originate in the gland responsible for producing the hormone Secondary causes - Caused by defective levels of stimulating hormones or releasing factors but normal endocrine gland function Pituitary disorders All forms of endocrine disturbances can impact oral health and the safe management of dental patients. Tertiary causes - Result from hypothalamic dysfunction, affecting pituitary function https://commons.wikimedia.org/w/index.php?search=scales&titl e=Special:MediaSearch&go=Go&type=image Created by Korfi2Go with CC0 1.0 Universal (CC0 1.0) Public Domain Dedication 5 Pituitary disorders – Growth hormone deficiency • In children – short stature and immature facial features due to lack of growth • Particularly impacts linear bone growth before epiphyseal fusion • Delay in attaining puberty and hampered sexual development but normal intelligence • In adults - primarily affects metabolism • Destruction of bone cells in adults – fractures and osteoporosis and decline in productivity • Can be due to a lack of GHRH, a lack of GH-secreting cells (e. g. non-functional tumours) etc. Impacts on oral cavity in children • • • • Impacts mandibular and maxillary growth Malocclusion associated with smaller dental arches Retarded tooth root and supporting structures development Delays in normal eruption and shedding 6 Pituitary disorders – Growth hormone excess Pituitary gigantism • Serious condition that is nearly always caused by an adenoma, a tumour of the pituitary gland – secretes GH • Abnormally large height (GH targets growth epiphyseal plates) and weight but normal body proportions • Abnormal enlargement of the hands and fee (similar to acromegaly) • Changes in facial features, which can be quite prominent: enlarged forehead and jaw, pronounced underbite, spreading teeth, enlarged tongue, nose and lips • Hyperglycaemia and overactive β cells in pancreas – type 2 diabetes • Death in early adulthood http://www.zeno.org - Contumax GmbH & Co. KG. https://commons.wikimedia.org/wiki/File:Der_lange_Josef_(2,39_Meter),_Soldat.jpg. This file is made available under the Creative Commons CC0 1.0 Universal Public Domain Dedication. 7 Pituitary disorders – Growth hormone excess 8 Pituitary disorders – Growth hormone excess Acromegaly – “enlarged extremities” Characteristic craniofacial changes in acromegaly • Mandibular prognathism and thickening • Person cannot grow taller, but bones become thicker or deformed. • Increased thickness and height of alveolar process • Especially marked in bones of hands and feet and in membranous bones • Spacing and flaring of anterior teeth, with associated malocclusion, enlargement of tongue • Lower jaw protrusion, slanting forehead, hunchback • Dentists are well-placed to detect the insidious onset of these craniofacial changes. • Enlarged soft tissue organs including tongue, liver, heart and kidneys • Increased risk of bronchitis, diabetes, and heart failure Mary Ann Bevan born 1874, unknown author, https://commons.wikimedia.org/wiki/File:Mary_Ann_Bevan.jpg Public domain 9 (Gharnizadeh et al., 2013) licensed under a Creative Commons Attribution 4.0 International License Pituitary disorders – Growth hormone excess Pituitary disorders – Antidiuretic hormone deficiency Spiky exostosis-like growths in the alveolar bone as an early sign of acromegaly Diabetes insipidus • ADH stimulates water reabsorption in kidneys in response to increased plasma osmolarity. • ADH deficiency causes diabetes insipidus – excessive water loss. • Xerostomia is the leading oral issue (Gamal-AbdelNaser, 2021) licensed under Creative Commons Attribution 4.0 International https://pxhere.com/en/photo/488474. CC0 Public Domain 11 12 Thyroid disorders – Hyperthyroidism Graves’ ophthalmopathy Thyroid disorders Causes • Graves’ disease – autoimmune disorder associated with thyroid-stimulating antibodies • Overactive thyroid nodules or thyroiditis • Too much iodine • Non-cancerous tumour of the pituitary Common signs and symptoms • • • • • • • Increased skin temperature and excessive sweating Tachycardia or irregular heart rate Tiredness and muscle weakness but difficulty sleeping Twitching or trembling Nervousness, anxiety, irritability Exophthalmos (protruding eyes with lid retraction) Increased sensitivity to catecholamines https://en.wikipedia.org/wiki/Graves%27_disease. Text is available under the Creative Commons Attribution-ShareAlike License 4.0; 13 14 Thyroid disorders – Hyperthyroidism Thyroid disorders – Hypothyroidism (acquired) Concerns for dental practice • Caused by surgery, drugs such as lithium, excessive amounts, or lack, of iodine) • Patients more prone to caries and periodontal disease, as well as other oral problems, such as burning mouth syndrome • Hashimoto’s thyroiditis most common cause – autoimmune disease where an autoimmune reaction may completely destroy the thyroid gland – more common in women • Patients very sensitive to adrenaline-containing products – hypertensive crisis • Increased levels of anxiety - stressful dental procedures can elicit life-threatening thyrotoxic crisis (syndrome caused by high levels of thyroid hormone) • Impact related to hypometabolism (fatigue, weight gain despite loss of appetite, cold intolerance etc. ) affects almost all organ systems • Particularly for invasive dental therapy, best to liaise with physician to see how well controlled condition is • Severely advanced form - myxedema (“puffy” appearance) can lead to myxoedema crisis 15 Thyroid disorders – Hypothyroidism signs and symptoms Severe myxoedema before and after treatment 16 William Seaman Bainbridge, https://commons.wikimedia.org/wiki/File:Severe_myxedema_front_5.jpg, Public Domain Thyroid disorders – Hypothyroidism (congenital) • Previously known as cretinism Cretin male, age 12, mental capacity of a 5-year old • Partial or complete loss of thyroid gland function in infants • Most common cause is shortage of iodine in mother’s diet; 15-20% genetic causes • If untreated, can lead to impaired neurological function, stunted growth, and physical deformities • Thickening of lips and macroglossia due to increased accumulation of subcutaneous mucopolysaccharides • In older children and adults: slowing of metabolic processes and myxedema – ranges from being mild to life-threatening Robert Howland Chase, https://commons.wikimedia.org/wiki/File:Cretin_male_age_12.j pg, Public Domain Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.. https://commons.wikimedia.org/wiki/File:Signs_and_symptoms_of_hypothyroidism.png 17 Thyroid disorders – Hypothyroidism in dental practice 18 Thyroid disorders – Oral manifestations Oral signs • Enlarged gingiva and salivary glands • Enlarged tongue (macroglossia) with glossitis • Dysgeusia (taste disorder) • Delayed dental eruption • Poor periodontal health Hypothyroidism. Enlarged gingiva associated with edema from hypothyroidism, https://www.rdhmag.com/patientcare/article/16406511/hashimotos-disease-hypothyroidism-isautoimmune-disease. Considerations for dental practice • Generally, tolerate dental treatment well. • Poor cardiovascular health may be primary consideration • Delayed wound healing due to decreased fibroblast activity - susceptibility to infections • Sedatives (benzodiazepines) and opioids to be used with caution – increased sensitivity to their action (Chandna & Bathla, 2011). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169868/ 19 20 Parathyroid glands Parathyroid glands – Oral manifestaions Hyperparathyroidism - Usually caused by a tumour or hyperplasia of the gland • Key sign is bone lesions associated with excessive osteoclast activity • Malocclusion due to drifting with definite spacing of teeth may be one of the first signs • Higher risk of bone fracture Hypoparathyroidism • Mainly affects nerve and muscle activity • Enamel hypoplasia, delayed eruption, and there may be multiple unerupted teeth • More prone to dental caries thyroid/parathyroid in color against skeleton and various organs; BodyParts3D is made by DBCLS; https://commons.wikimedia.org/wiki/File:Parathyroid_med_ ani.gif; Licensed under Creative Commons Attribution-Share Alike 2.1 jp (Mittal et al., 2014). https://www.jdas.in/article.asp?issn=2277-4696;year=2014;volume=3;issue=1;spage=34;epage=38;aulast=Mittal#google_vignette 21 22 Adrenal cortical insufficiency Primary adrenal cortical insufficiency Adrenal disorders High ACTH levels in primary adrenal insufficiency – skin hyperpigmentation (darkening) Addison disease Mineralocorticoid deficiency Dehydration, low blood pressure, fatigue 23 24 Addison disease Hyperpigmentation in the palate and depapillation of the tongue Hyperpigmentation on face (A) and palmar creases (B); after treatment (C) Caused by autoimmune disorder, infection (TB), trauma, cancer or haemorrhage Glucocorticoid deficiency Poor stress tolerance, hypoglycaemia, lethargy, weakness, nausea, vomiting Addison disease - Treatment • Relies on hormone replacement • BUT: long-term corticosteroid therapy (>14 days) can suppress adrenal function (secondary adrenal insufficiency – very common) • Limited ability of adrenal cortex to deal with stress - predisposing factor of acute adrenal insufficiency (Addisonian/adrenal crisis) • Stress reduction protocol, effective anaesthesia and postoperative analgesia are very important in these situations. • Supplemental doses of corticosteroids can be used to help the body cope with stress. (Sarkar et al., 2012). https://www.contempclindent.org/article.asp?issn=0976237X;year=2012;volume=3;issue=4;spage=484;epage=486;aulast=Sarkar# Licensed under Creative Commons Attribution-NonCommercial-ShareAlike License (CC BY-NC-SA),. https://ykhoa.org/d/image.htm?imageKey=ENDO/74922 25 Glucocorticoid excess – Cushing syndrome 26 Glucocorticoid excess – Cushing syndrome Disorder resulting from long-term excess cortisol ACTH-dependent hypercortisolism from • Hypersecretion of ACTH by the pituitary gland due to pituitary adenoma (Cushing disease) • Secretion of ACTH by a nonpituitary tumour, such as small cell lung carcinoma or a carcinoid tumour (ectopic ACTH syndrome) ACTH-independent hypercortisolism from • Therapeutic administration of exogenous corticosteroids (e. g. prednisone) for treatment of inflammatory diseases (most common) • Adrenocortical adenomas or carcinomas Exogenous corticosteroids 27 Glucocorticoid excess – Cushing’s syndrome 28 Signs are basically the exaggerated actions of cortisol. • • • • • • • • • • (Raff & Carroll, 2015) Glucocorticoid excess – Cushing’s syndrome • Dental concerns are immune suppression and increased risk of infection, as well as alveolar bone loss and impaired wound healing. Altered fat metabolism and abnormal fat distribution Rounding and puffiness of the face (moon face) Protein breakdown and muscle wasting Thin and easily bruising skin Osteoporosis due to calcium resorption Deranged glucose metabolism – hyperglycaemia and increased insulin requirement – may lead to diabetes Excessive renal loss of potassium – hypokalaemia Immune suppression – increased susceptibility to infection Increased gastric acid secretion – gastric ulceration Emotional and sleep disturbances • Comorbidities of Cushing's syndrome such as obesity, osteoporosis, and diabetes may influence periodontal attachment apparatus. Klausur 123. https://upload.wikimedia.org/wikipedia/commons/7/76/Pa t._mit_Cushing-Syndrom.jpg. licensed under the Creative Commons Attribution-Share Alike 4.0 International license. 29 30 Reproductive hormones Oestrogen: may increase vascularisation of oral mucosa Progesterone: may cause vasodilation and increased vascular permeability – possible oedema and infiltration of inflammatory cells Pregnancy and reproductive disorders Increased risk of gingival bleeding and periodontal disease Before treatment After treatment https://commons.wikimedia.org/wiki/File:Gingivitis-before-and-after-3.jpg. Licensed under the Creative Commons CC0 1.0 Universal Public Domain Dedication 31 32 Pregnancy – Oral health Pregnancy considerations • Pregnancy gingivitis most common – mainly due to oestrogen and progesterone enhancing the inflammatory response • Routine dental care is not only safe but likely to benefit both mother and child. • Possible painless tumour-like growths – pregnancy granulomas (epulis gravidarum) – normally regress following parturition • Drug use always a concern – exercise caution, particularly during first trimester • Weeks 14 to 20 most comfortable times for dental visits • Good safety records for lignocaine and mepivacaine have • A few antibiotics (e. g. Amoxycillin) and antifungals (e. g. Nystatin) may be used. • Increased risk of caries –mainly due to o Food cravings and snacking o Reduced oral hygiene (↑gag reflex, fatigue etc) o Morning sickness o Hormone-induced xerostomia Anatomy of late pregnancy. Jan van Riemsdyk. https://commons.wikimedia.org/wiki/File:Pregnancy_by_Jan _van_Riemsdyk_and_William_Hunter.jpg. Public domain • Paracetamol is preferred analgesic – best to avoid NSAIDs during first and third trimester. • Sedation should be avoided – if required nitrous oxide may be used with medical consultation. Avoidance of dental visits mostly due to concerns about the baby’s health 33 34 Menopause Thinning of oral mucosa Declining levels of oestrogen and progesterone impact oral health. • Increased risk of burning mouth syndrome • Hyposalivation and xerostomia Osteoporosis • Oestrogens normally promote apoptosis (death) of osteoclasts. • Decrease in bone mass with diminishing hormone levels, particularly after menopause Periodontium more prone to inflammation • Increased prevalence and severity of periodontitis • Bone resorption by osteoclasts outpaces bone deposition by osteoblasts. • Demineralisation can begin at 30 in females, 60 in males. Use of hormone replacement therapy is controversial. Good oral hygiene practices essential Increased osteoclast activity • Other contributing factors o Poor diet o Lack of exercise o Smoking o Diabetes • Risk of osteoporosis and exacerbated alveolar bone reabsorption Effects of Osteoporosis. BruceBlaus https://commons.wikimedia.org/wiki/File:Osteoporosis_02.png. licensed under the Creative Commons Attribution-Share Alike 4.0 International license.. https://commons.wikimedia.org/wiki/File:Gingivitis-before-and-after-3.jpg. Licensed under the Creative Commons CC0 1.0 Universal Public Domain Dedication 35 36 Osteonecrosis • Osteoporosis medications, including bisphosphonates (e. g. alendronate) and RANK ligand inhibitors (e. g. denosumab) decrease osteoclast activity/ bone resorption. • Potential problem of medication-related osteonecrosis of the jaw (MRONJ) associated with the use of these medications Exposed, necrotic bone in the left anterior maxilla. Presence of many small, fluid-filled sacs or cysts inside the ovaries in case of PCOS. • Irregular or absent menstrual periods, infertility, and symptoms like acne and excess hair growth, and/or unintended weight gain • MRONJ pathophysiology not completely elucidated • Greater risk with IV antiresorptive medications as opposed to oral and with chronic use • PCOS is most common endocrine disorder among women of reproductive age – up to 26% in Western societies • Substantial negative effects on metabolic, psychologic, and cardiovascular health • Osteonecrosis: non-healing exposed bone in the maxillofacial region, which may occur following oral surgery • Tooth extraction a “common” factor but teeth commonly had existing periodontal or periapical disease Polycystic ovarian syndrome (PCOS) • Associated with other comorbidities (insulin resistance, obesity, cardiovascular disease, and periodontal disease) https://emedicine.medscape.com/article/1447355-overview • Mechanisms include altered secretion of GnRH, defect in androgen synthesis, and development of insulin resistance. Polycystic ovary. Scientific animations. https://commons.wikimedia.org/wiki/File:Polycystic_Ovaries.jpg. This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license. 37 Polycystic ovarian syndrome - Dental concerns References • Low-grade chronic systemic inflammation - possible link to periodontal disease • Gingivitis difficult to treat due to underlying inflammation → gum sensitivity, bleeding gums, halitosis (bad breath), receding gums, bone loss around teeth, tooth loss • Altered sex hormones may impair epithelial barrier to bacterial injury or compromise collagen maintenance and repair. • Decline of oestrogen with aging – risk of bone loss density • Suspect PCOS if patients struggle with receding gums, difficulty chewing and tooth loss despite good oral hygiene. • Good oral hygiene important in managing symptoms of PCOS • Prevention includes special care of teeth and gums – brushing, flossing, antiseptic mouthwash, and bi-annual dentist visits https://encryptedtbn0.gstatic.com/images?q=tbn:ANd9GcRig5xw4MUySLoLNCiu_g9t3o21TWPiVedCMAEnNaKEAbOSa9ItjV3A5RUulqBoVW5zRZ s&usqp=CAU • Chandna, S., & Bathla, M. (2011). Oral manifestations of thyroid disorders and its management. Indian Journal of Endocrinology and Metabolism, 15(Suppl 2), S113-116. https://doi.org/10.4103/2230-8210.83343 • Khalekar, Y., Zope, A., Brahmankar, U., & Chaudhari, L. (2016). Hyperparathyroidism in dentistry: Issues and challenges!! Indian Journal of Endocrinology and Metabolism, 20(4), 581-582. https://doi.org/10.4103/22308210.183452 • Mittal, S., Gupta, D., Sekhri, S., & Goyal, S. (2014). Oral manifestations of parathyroid disorders and its dental management [Review Article]. Journal of Dental and Allied Sciences, 3(1), 34-38. https://doi.org/10.4103/22774696.156527 • Raff, H., & Carroll, T. (2015). Cushing's syndrome: from physiological principles to diagnosis and clinical care. Journal of Physiology, 593(3), 493-506. https://doi.org/10.1113/jphysiol.2014.282871