Endocrine Disorders & Dental Care Introduction Module PDF

Endocrine Disorders & Dental Care Introduction Module Fariba S. Younai, D.D.S. Professor of Clinical Dentistry and Chair Division of Diagnostic & Surgical Sciences 1 Outline ¡ Diabetes Epidemiology & Impact ¡ Diabetes Cla...

Endocrine Disorders & Dental Care Introduction Module Fariba S. Younai, D.D.S. Professor of Clinical Dentistry and Chair Division of Diagnostic & Surgical Sciences 1 Outline ¡ Diabetes Epidemiology & Impact ¡ Diabetes Classification & Medical Management ¡ Thyroid Hormones & Medical Management ¡ Glucocorticosteroids Effects 2 3  Diabetes Epidemiology ¡ 34.1 million adults in the US are diagnosed with diabetes* l 13% of adults older than 18 years of age l 21% of adults > age 65 l Prevalence rates: ¡ 14.7% American Indians/Alaska Natives ¡ 12.5% for people of Hispanic origin ¡ 11.7% for non-Hispanic blacks ¡ 9.2% for non-Hispanic Asians ¡ 7.5% for non-Hispanic whites ¡ 1.4 million new diabetes cases/yr ¡ 14% of US healthcare cost - $132 billion dollars/yr for medical & supportive services and $40 billion in loss of work & disability * CDC Report 2020 There will be 366 million cases by year 2030 worldwide 4 Percent of obese adults (Body Mass Index of 30+) 20 - 24.9% 25 - 29.9% 30 - 34.9% 35%+ Adult obesity rates now exceed 35% in nine US states, 30% in 31 states and 25% in 48 states Mississippi and West Virginia have the highest adult obesity rate at 39.5% and Colorado has the lowest at 23% 5 Adult Body Mass Index (BMI) is a person’s weight in kilograms divided by the square of height in meters. A high BMI can be an indicator of high body fatness. 6  Diabetes Impact ¡ Leading cause of: Lack of Insulin Effect l Mortality l Early disability l Blindness Impaired Glucose l ESRD Metabolism ¡ Clinical outcomes depend on early Hyperglycemia & recognition, treatment Metabolic Effects and maintenance 7  Diabetes Classification 1. Type 1: ß cell destruction & absolute insulin deficiency 2. Type 2: insulin resistance w/ relative insulin deficiency a) Obese – insulin insensitivity Seen in 60-80% of cases; associated with Metabolic Syndrome (Syndrome X) – HTN, hyperglycemia, hyperinsulinemia & dyslipidemia; predisposes to CHD & stroke b) Non-Obese – insulin insensitivity & deficiency 20-40% of cases 3. Gestational – type 2 diabetes during pregnancy, increases the risk of loss of the fetus, large size of the surviving fetus and DM within 5-10 yrs 4. Other Types a) Latent Autoimmune Diabetes (LADA) – type 1 developing in adults with a strong genetic component l Often mistaken for type 2 because of the age of onset l Progression to insulin dependence is within 6 yrs of Dx 8 Child born to a diabetic mother 9  Diabetes Classification c) Maturity-Onset Diabetes of the Young (MODY) l A monogenic disorder that starts in childhood or before age 25, behaves more like type 1 l Has 6 subtypes d) Pancreatic disease l Trauma, infection, cancer e) Endocrinopathies l Excess growth hormone, glucocorticoids, catecholamines, thyroid hormone f) Drugs or chemical exposure l Glucocorticosteroids, thiazides, phenytoin, oral contraceptives g) Infections Rubella, coxackievirus, CMV, adenovirus, mumps 75% of MODY Dx are due to HNF-4 alpha (MODY-1) and 15% are due to mutation in the glucokinase gene (MODY 2). The rest are the types 3-6 with slower clinical progression. 10 11  DM Medical Management Liver Glucose production Sulfonylureas Thiazolidinediones (insulin production) (Effect of insulin) Alpha-glucosidase inhibitors (food absorption) 12 Medical Management – Oral Agents Ø Often start with the biguanide metformin (Glucophage, Fortamet) Ø Sulfonylureas – glyburide (Diabeta, Micronase), glipizide (Glucotrol), glimepiride (Armaryl) Ø Thiazolidinediones (TZDs) – pioglitazone (Actos), rosiglitazone (Avendia), troglitazone (Rezulin) Ø Alpha glucosidase inhibitor – acarbose (Precose) 13  Medical Management - Insulin Ø Insulin injections Ø Ultrashort-acting: lispro (Humalog), aspart (Novolog) Ø Short-acting: Iletin II Regular, Humulin R, Novolin R Ø Intermediate-acting: Humulin N, Humulin L, Novolin L, Novolin N, NPH, Lente Iletin Ø Long-acting: glargine (Aventis), Humulin U, Ultralente Ø Insulin mixtures (short/intermediate and rapid/intermediate in multiple combinations) ¡ i.e., Humulin 70/30, Humulin 50/50, Novolin 70/30 ¡ Human insulin inhalation powder (Afrezza) l Approved June 2014 as meal time insulin Ø Continuous subcutaneous insulin infusion (CSII) Ø Pancreatic transplantation 14 15 16 Thyroid Hormones ¡ T3 and T4 circulate in plasma largely bound to proteins (thyroid binding proteins) but in equilibrium with the free hormone l It is the free form of these hormone, that are transported inside the cells ¡ Once in the cell, T4 is converted to T3, the active form ¡ T3 binds a specific receptor in the cell nucleus and promotes activation of genes and their protein products responsible for the biological activities of the hormone 17 Thyroid Hormone Function Mechanism & Disease State Increase in oxygen consumption Disease state: increased metabolic rate and heat intolerance in and heat production hyperthyroidism & the reverse in hypothyroidism Maintaining hypoxic & hypercapnic Disease state: hypoventilation in hypothyroidism drive in respiratory system Positive inotropic & chronotropic Disease state: increased cardiac output and heart rate in effect on myocardium hyperthyroidism and the reverse in hypothyroidism Amplification of catecholamine Disease state: increased adrenergic effect in hyperthyroidism action in post-receptor sites Stimulating gut motility Disease state: diarrhea in hyperthyroidism and constipation in hypothyroidism Disease state: hyperthyroidism leads to significant osteopenia Stimulating bone turn over and in severe cases causes hypercalcemia Increase in protein turn over in Disease state: myopathy in hyperthyroidism muscles Increase in hepatic Disease state: exacerbation of diabetes in hyperthyroidism gluconeogenesis, glycogenolysis Maintaining mental alertness Disease state: nervousness in hypothyroidism and inability to concentrate in hypothyroidism 18 Hyperthyroidism Treatment Treatment involves: ¡ Drugs - to decrease hormone production - usually by inhibiting thyroid peroxidase enzyme ¡ Propylthiouracil or methimazole – tx may take 6 months to 20 years with high relapse (may need maintenance tx) ¡ Beta-blockers - to counteract peripheral effect use ¡ Radioactive iodine – to help shrink the gland ¡ Surgery – partial or total thyroidectomy 19 Hypothyroidism Treatment Treatment: thyroid hormone replacement therapy l Levothyroxine (synthetic T4); levels monitored by free T4 & TSH ¡ It can exacerbate angina & heart failure; long term use, esp in women, may cause osteoporosis ¡ Today, hypothyroidism mostly occurs in pts who receive radioactive iodine treatment in Grave’s disease 20 21 Glucocorticoids General Effects ¡ Inhibition of DNA, RNA & protein synthesis in most tissues - Growth retardation ¡ Increased protein catabolism in muscle, bone, connective and lymphatic tissue l Reduced bone density & muscle mass l Immunosuppression ¡ Reduced bone deposition l Growth retardation & reduced bone density ¡ Promoting gluconeogenesis & reduced peripheral glucose utilization by muscle & fat tissues l Hyperglycemia l Insulin resistance ¡ Increased lypolysis and release of fatty acids; also lead to fat deposition -Central obesity, peripheral wasting 22  Cushing’s Syndrome Signs and Symptoms ¡ Typical habitus l Moon faces, buffalo hump, truncal obesity ¡ Increased body weight, edema ¡ Hypertension ¡ Hypokalemia ¡ Heart failure ¡ Hyperglycemia, polyuria, polydipsia ¡ Osteoporosis and pathological fractures ¡ Fatigability, weakness ¡ Hirsutism ¡ Cutaneous striae, ecchymosis ¡ Personality changes l Sleep disturbances, depression & psychosis 23 Addison’s Disease Symptoms & Signs Due to mineralocorticosteroid deficiency that leads to: ¡ Hyponatremia, hyperkalemia ¡ Salt craving ¡ Hypotension, hypovolemia ¡ Weight loss, anorexia, nausea, vomiting ¡ Hypoglycemia ¡ Weakness ¡ Pigmentation of skin and mucous membranes 24 Thank You 25