Endocrine Diseases and its Dental Management

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SPECIAL NEEDS:�Endocrine Diseases

Tan Li Ting, Melissa Lee Lay See, Nurul ‘Adilah Jumati, Syahirah Malek

OVERVIEW •  Endocrine System

•  Common Endocrine Diseases

•  Risk factors

•  Signs and symptoms

•  Dental Management & Considerations

ENDOCRINE SYSTEM

- Responsible for hormonal secretion

- Diversify it's function through hypothalamus and pituitary

- Controls physiological process and homeostasis

MAJOR ENDOCRINE GLANDS

1.  Pineal gland

2.  Pituitary gland

3.  Thyroid gland

4.  Thymus

5.  Adrenal gland

6.  Pancreas

7.  Ovaries

8.  Testes

TOP 4 COMMON ENDOCRINE DISEASES (NOT IN ORDER)

  Osteoporosis

  Diabetes mellitus

  Hyper/Hypothyroidism

  Hyper/Hypoparathyroidism

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ENDOCRINE DISEASES: OSTEOPOROSIS

•  Define Osteoporosis (U.S. National Library of Medicine):

o  A disease in which bones become fragile and more likely to fracture.

o  Usually the bone loses density, which measures the amount of calcium and minerals in the bone

ENDOCRINE DISEASE:

Osteoporosis


•  Commonly found amongst women

•  Causes:

o  Lack of intake of Calcium/Vit. D

o  Menopause: decreased estrogen level

ENDOCRINE DISEASE:

Osteoporosis

RISK FACTORS: OSTEOPOROSIS

Low Body Weight

Family History

Smoking & High Alcohol Consumption

RISK FACTORS

ENDOCRINE DISEASE:

Osteoporosis

SYMPTOMS: OSTEOPOROSIS

Early Stages:

•  Almost no symptoms

More than often, many will have experienced a fracture before finding out.

Later Stages:

•  Pain (Due to compression fractures)

•  Loss of height

ENDOCRINE DISEASE:

Osteoporosis

•  Assoc. with alveolar bone loss & increased risk of periodontal disease o  Weakened bone structure

o  Increased risk of alveolar bone resorption, attachment loss, tooth loss and edentulism

•  Bisphosphonate therapy o  Increased risk of Osteonecrosis after dental extraction

ENDOCRINE DISEASE:

Osteoporosis

DENTAL CONSIDERATIONS: OSTEOPOROSIS

DENTAL CONSIDERATIONS:

OSTEOPOROSIS

•  Frequent dental visits o  Scaling and Root Planing to prevent progression of

periodontal disease resulting in bone loss

•  Denture fit o  Ill-fitting dentures

•  Susceptible to periodontal bacteria o  Increase risk for periodontal diseases and tooth loss

ENDOCRINE DISEASE:

Osteoporosis

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•  High blood sugar, because pancreas does not produce enough insulin or cells do not respond to the insulin.

•  Most common endocrine disease in Singapore

•  Prevalence: 11.3% in 2010

•  M>F

•  Indian 17.2%, Malay 16.6% and Chinese 9.7%

ENDOCRINE DISEASE:

Diabetes Mellitus

ENDOCRINE DISEASES: DIABETES MELLITUS

TYPES:

•  Type I Diabetes Mellitus o  Juvenile diabetes o  Insulin dependent

•  Type II Diabetes Mellitus o  Adult onset o  Non-insulin dependent

•  Third type o  Gestational diabetes o  pregnant women

ENDOCRINE DISEASE:

Diabetes Mellitus

TYPES: DIABETES MELLITUS

SYMPTOMS

•  Excessive thirst, urination and hunger

•  Sudden weight loss

•  Increased fatigue

•  Increased susceptibility to infections due to lowered immunity

ENDOCRINE DISEASE:

Diabetes Mellitus

SYMPTOMS: DIABETES MELLITUS

!  Hemoglobin joins with glucose " HbA1C

!  Glycosylated hemoglobin

!  Measured 3-6 monthly to check if DM is under control

!  Blood sample from vein or finder prick is needed to measure

!  6.5% is good for DM patient

!  > 7% is not well controlled

ENDOCRINE DISEASE:

Diabetes Mellitus

HB1AC: DIABETES MELLITUS

TYPE 1 TYPE 2 Genes Age > 45 years old

Environment Pre-diabetes (DM during prev. pregnancy)

Diet Given birth to a baby > 9 pounds

Chemicals and Drugs

Impaired glucose tolerance

Distribution of fats: Excess body weight(esp. around waist)

Family history of DM

Inactivity: Low activity level (exercising < 3 times a week)

ENDOCRINE DISEASE:

Diabetes Mellitus

RISK FACTORS: DIABETES MELLITUS

•  Gestational diabetes o  Greater than 25 years old

o  Family or personal health history

o  Excess weight

o  Nonwhite race

ENDOCRINE DISEASE:

Diabetes Mellitus

RISK FACTORS: DIABETES MELLITUS

•  Oral manifestations o  compromised periodontal health/worsen due to DM o  candidosis (denture wearers) o  dry mouth and sialosis-> increased caries o  glossitis o  burning mouth syndrome o  oral, facial dysasthesia

•  Poor response/healing to periodontal therapy

•  Priority given to dental infections

ENDOCRINE DISEASE:

Diabetes Mellitus

DENTAL CONSIDERATIONS: DIABETES MELLITUS

•  Enlarged salivary glands and xerostomia

•  Increase susceptibility to periodontal disease

•  More severe case of periodontal disease

•  Poorer wound healing

ENDOCRINE DISEASE:

Diabetes Mellitus

DENTAL CONSIDERATIONS: DIABETES MELLITUS

Diabetes Mellitus: Patient Management

ENDOCRINE DISEASE:

Diabetes Mellitus

PATIENT MANAGEMENT: DIABETES MELLITUS

•  Scheduling dental visits: o  Early morning, since their blood sugar level is higher at this

time.

o  Regular dental visits

•  Infection and wound healing: o  Post-op antimicrobial or antibiotic therapy

o  Avoidance of smoking

ENDOCRINE DISEASE:

Diabetes Mellitus


Diabetes Mellitus: Patient Management

•  Diet: o  Ensure patient has eaten normally and

taken medicines as usual.

•  Advice: o  Eat healthily

o  Exercise regularly

o  Take medication on time

o  Frequent medical check up (HbA1c)

ENDOCRINE DISEASE:

Diabetes Mellitus


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ENDOCRINE DISEASE:

Thyroid gland disorders

ABOUT THE THYROID

Secretes 3 hormones:   Thyroxine (T4)   Triiodothyronine (T3)   Calcitonin- Regulate Ca and phosporus

levels, skeletal remodeling

Thyroid hormones influence the growth and maturation of tissues, energy metabolism and turnover of both cells and nutrients.

Metabolic processes Oxygen use

ENDOCRINE DISEASE:


Hypothyroidism and hyperthyroidism are the two most common thyroid disorders in women between the age of 20 and 50, who are also five times more

likely than men to develop thyroid disorders. #

Hyperthyroidism is the condition caused by unregulated production of thyroid hormones. (decrease TSH, increase T3 and T4)

Hypothyroidism is defined by a decrease in thyroid hormone production and thyroid gland function. (increase TSH, decrease T3 and T4)

-singhealth

CAUSES: HYPERTHYROIDISM

Other risk factors:

Gender History

Age Smoking

Trauma to the thyroid

Major stress

ENDOCRINE DISEASE:


CAUSES

Thyroid nodules

Thyroiditis

Excessive iodine intake

Graves’ disease

Medications

TYPES AND CAUSES:

HYPOTHYROIDISM

1) CRETINISM (CONGENITAL)

•  Iodine deficiency •  Defective or absent thyroid gland

2) MYXEDEMA (ACQUIRED)

•  Hashimoto’s thyroiditis •  Treatment of overactive thyroid •  Severe iodine deficiency •  Pituitary gland disorder •  Long -term lithium intake

ENDOCRINE DISEASE:


HYPERTHYROIDISM HYPOTHYROIDISM

1.  Nervousness

2.  Anxiety

3.  Hand tremors

4.  Goiter

5.  Weight loss, despite increased appetite

6.  Heart palpitations

7.  Heat intolerance

8.  Increased perspiration

1.  Fatigue

2.  Cold intolerance

3.  Thin brittle hair or fingernails

4.  Weight gain, easily with normal diet

5.  Weakness

6.  Goiter

Thyroid Gland Disorders: SYMPTOMS

Oral manifestations:

•  Enlargement of extraglandular thyroid tissue (mainly in the lateral posterior tongue)

•  Accelerated dental eruption •  Burning mouth syndrome •  Increased susceptibility to caries •  Periodontal disease •  Maxillary or mandibular osteoporosis •  Sjogren's syndrome •  Thyroid may be enlarged or noticeably palpable (Graves’ disease)

Medications:

o  anti-thyroid drugs- methimazole, propylthiouracil

o  radioactive iodine

o  beta-blocker and iodides

DENTAL CONSIDERATIONS: HYPERTHYROIDISM

ENDOCRINE DISEASE:


ENDOCRINE DISEASE:


Our role: Look out for signs and symptoms to aid in early diagnosis. If a suspicion of thyroid disease arises for an undiagnosed patient, all elective dental treatment to put on hold until full medical evaluation.

1.  Brief and stress-free appointments

2.  NO local anaesthetic with epinephrine and epinephrine impregnated cord for uncontrolled hyperthyroidism

3.  Side effects: Propylthiouracil !  agranulocytosis !  Sialolith !  prolonged bleeding due to warfarin

4.  Susceptible to infections due to drug side effects

5.  Dietary advice: Avoid iodized salt, seafood

PATIENT MANAGEMENT: HYPERTHYROIDISM

Oral manifestations: •  Delayed dental eruption •  Salivary gland enlargement •  Macroglossia •  Glossitis (swollen tongue) •  Compromised periodontal health- delayed bone formation •  Dysgeusia (distortion of taste) •  Delayed wound healing

Medications: Synthroid. levothyroxine, armour thyroid

DENTAL CONSIDERATIONS: HYPOTHYROIDISM

ENDOCRINE DISEASE:


1.  Susceptible to cardiovascular disease (e.g atrial fibrillation) !  Consult primary care provider to seek whether antibiotics

prophylaxis is required

2.  Focus on lethargy, may indicate uncontrolled state and a risk for patients and respiratory rate

!  possibility of an iatrogenic hyperthyroid state caused by hormone replacement therapy used to treat hypothyroidism

3.  Avoid giving depressants, sedatives or narcotic analgesics !  may cause exaggerated response in patients with mild to severe

hypothyroidism

PATIENT MANAGEMENT: HYPOTHYROIDISM

ENDOCRINE DISEASE:


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ENDOCRINE DISEASE:

Parathyroid gland disorders Parathyroid glands

•  small endocrine glands that produce parathyroid hormone (PTH)

•  there are four parathyroid glands usually located behind the thyroid gland

•  controls the amount of calcium in the blood and within the bones so that nervous & muscular systems can function properly

•  PTH increases blood calcium levels by stimulationg osteoclasts to break down bone, increasing resorption

•  PTH increases gastrointestinal calcium absorption by activating Vitamin D

•  PTH increases renal absorption of calcium by the kidneys ENDOCRINE DISEASE:

Parathyroid Disorders

Hyperparathyroidism

•  Overactivity of the parathroid glands

•  Excess production of PTH

•  Raised PTH levels are harmful to bone

•  Primary hyperparathyroidism / Secondary hyperparathyroidism

ENDOCRINE DISEASE:


ENDOCRINE DIS: DIABETES MELLITUS ENDOCRINE DISEASES: HYPERPARATHYROIDISM

Symptoms

•  Fragile bones that easily fracture

•  Kidney stones

•  Excessive urination

•  Abdominal pain

•  Tiring easily or weakness

•  Depression or forgetfulness

•  Bone and joint pain

•  Frequent complain of illness with no apparent cause

•  Nausea, vomiting or loss of appetite

ENDOCRINE DISEASE:


SYMPTOMS: HYPERPARATHYROIDISM

Complications of Hyperparathyroidism

1.  Dental abnormalities •  widened pulp chambers

•  development defects

•  alterations in dental eruption

•  weak teeth

•  malocclusions

•  loss of lamina dura on radiographs

•  giant cell lesions

ENDOCRINE DISEASE:



DENTAL CONSIDERATIONS: HYPERPARATHYROIDISM


2. Brown tumor

3.Loss of bone density (bone resorption)

4.Soft tissue calcifications

ENDOCRINE DISEASE:


DENTAL CONSIDERATIONS: HYPERPARATHYROIDISM

Patient management

•  No special consideration

•  higher risk of bone fracture •  Take precaution in surgical tx

•  Recognize presence of brown tumor

•  Perform correct differential diagnosis so as not to conduct an inadequate tx

ENDOCRINE DISEASE:


PATIENT MANAGEMENT: HYPERPARATHYROIDISM

Hypoparathyroidism

•  Decreased function of the parathyroid glands

•  Underproduction of PTH

•  Leads to low levels of calcium in the blood

•  Can be inherited but is also encountered after thyroid or parathyroid surgery

ENDOCRINE DISEASE:


ENDOCRINE DISEASES: HYPOPARATHYROIDISM

Symptoms

•  Tingling or burning (paresthesia) on fingertips, toes and lips •  Muscle aches or cramps affecting legs, feet, abdomen or face •  Twitching or spasms of muscles, particularly around mouth, hands, arms

or throat •  Fatigue or weakness •  Dry, coarse skin •  Brittle nails •  Anxiety or nervousness •  Headaches •  Depression, mood swings •  Memory problems

ENDOCRINE DISEASE:


SYMPTOMS: HYPOPARATHYROIDISM

Complications of Hypoparathyroidism

1.  Dental abnormalities •  Enamel hypoplasia in horizontal lines

•  poorly calcified dentine

•  widened pulp chambers

•  dental pulp calcifications

•  shortened roots

•  hypodontia

•  delay or cessation of dental development

ENDOCRINE DISEASE:


DENTAL CONSIDERATIONS: HYPOPARATHYROIDISM


2. Mandibular tori

3. Chronic candidiasis

4.Parasthesia of the tongue or lips

5.Alteration in facial muscles

ENDOCRINE DISEASE:


DENTAL CONSIDERATIONS: HYPOPARATHYROIDISM

Patient management

!  More susceptible to caries !  Due to dental anomalies

!  Dental management: !  Prevention of caries with periodic reviews, advice regarding diet,

OHI

!  Before performing dental tx, find out serum calcium level (must be 8mg/100ml) !  Prevents cardiac arrythmias, seizures

ENDOCRINE DISEASE:


PATIENT MANAGEMENT: HYPOPARATHYROIDISM

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The end. Thank you for your attention.

References •  http://jada.ada.org/content/137/suppl_2/26S.full •  http://www.ugr.es/~jagil/lalla_diabetes.pdf •  http://jada.ada.org/content/137/8/1144.full.pdf+html •  http://www.niams.nih.gov/Health_Info/Bone/Bone_Health/Oral_Health/default.asp •  http://www.medicinaoral.com/odo/volumenes/v2i4/jcedv2i4p196.pdf •  http://www.fourthmolar.com/blogs/entry/The-Dental-Management-of-Patients-with-Endocrine-Disease •  http://webcache.googleusercontent.com/search?q=cache:e-dTttBHpwQJ:web.squ.edu.om/med-Lib/

MED_CD/E_CDs/Essential%2520of%2520Oral%2520Medicine/docs/ch09.pdf+endocrine+and+dental&cd=9&hl=en&ct=clnk&client=safari •  http://www.singhealth.com.sg/PatientCare/ConditionsAndTreatments/Pages/Thyroid-Disorders-Hyperthyroidism.aspx •  http://www.singhealth.com.sg/PatientCare/ConditionsAndTreatments/Pages/Diabetes-Mellitus.aspx#section3 •  http://www.cgh.com.sg/Medical_Specialities/Medical_Services/Pages/endocrinology.aspx •  http://www.singhealth.com.sg/PatientCare/ConditionsAndTreatments/Pages/Thyroid-Disorders.aspx •  http://thyroid.about.com/od/hyperthyroidismgraves/a/risks-symptoms.htm •  http://www.webmd.com/drugs/condition-584-Hypothyroidism.aspx?d.. •  http://www.medicinenet.com/hyperthyroidism/index.htm

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Endocrine Diseases and its Dental Management