endocrine disorders & steroid therapy dental overview

Endocrine disordersEndocrine disorders& &

Steroid TherapySteroid Therapy

Dental OverviewDental Overview

Hormones of the Anterior Pituitary

Disorders of Pituitary FunctionDisorders of Pituitary Function

HypopituitarismHypopituitarism Central hypoadrenalism, hypogonadism, Central hypoadrenalism, hypogonadism,

hypothyroidism or GH deficiency hypothyroidism or GH deficiency PanhypopituitarismPanhypopituitarism

Hypersecretion of Pituitary HormonesHypersecretion of Pituitary Hormones HyperprolactinemiaHyperprolactinemia AcromegalyAcromegaly Cushing’s DiseaseCushing’s Disease

Primary Primary vsvs Secondary Secondary PrimaryPrimary = Problem with gland itself = Problem with gland itself SecondarySecondary = Problem further back in = Problem further back in

hypothal/pithypothal/pit

HYPERPITUITARISMHYPERPITUITARISM

ACROMEGALY

GIGANTICISM

AcromegalyAcromegaly

What is the abnormaility in this 32 year old woman

with amenorrhoea and bitemporal hemianopia?

HyperprolactinemiaHyperprolactinemia

PanhypopituitarismPanhypopituitarism Pallor, Yellowish Tinge to SkinPallor, Yellowish Tinge to Skin Fine Wrinkling of SkinFine Wrinkling of Skin Absent Axillary HairAbsent Axillary Hair Face Puffy & ExpressionlessFace Puffy & Expressionless Hypopituitarism:Hypopituitarism:

GH lost firstGH lost first LH, FSH nextLH, FSH next TSHTSH ACTHACTH ProlactinProlactin

HYPOPITUITARISMHYPOPITUITARISM

SHEEHAN’SHEEHAN’S POST-S POST-PARTUM PARTUM

PITUITARY PITUITARY NECROSISNECROSIS

Diabetes InsipidusDiabetes Insipidus Deficient ADH (vasopressin)Deficient ADH (vasopressin) ADH works on receptors in the distal ADH works on receptors in the distal

tubules of the kidney to conserve watertubules of the kidney to conserve water Clinical features:Clinical features:

PolyureaPolyurea PolydepsiaPolydepsia Excessive thirstExcessive thirst Sudden onsetSudden onset Pale urine in immense amounts (2-24L/day)Pale urine in immense amounts (2-24L/day)

Dental Aspects:Dental Aspects:

Langerhans cell histiocytosis is one of Langerhans cell histiocytosis is one of the common causesthe common causes Jaw lesions (osseous infiltrates)Jaw lesions (osseous infiltrates) Loosening of teethLoosening of teeth

Dental fluorosisDental fluorosis

HyperthyroidismHyperthyroidism

Increased levels of T3 and T4Increased levels of T3 and T4 Caused by:Caused by:

Graves disease (autoimmune)Graves disease (autoimmune) Multinodular goiterMultinodular goiter Thyroid adenomaThyroid adenoma Ectopic thyroid tissueEctopic thyroid tissue Anterior pituitary diseaseAnterior pituitary disease

Hypothalamus secretes TRH which induces Hypothalamus secretes TRH which induces the release of TSH from the pituitarythe release of TSH from the pituitary

TSH stimulates the release of T3 and T4TSH stimulates the release of T3 and T4

Clinical picture:Clinical picture: NervousnessNervousness Emotional instabilityEmotional instability Inability to sleepInability to sleep TremorsTremors Excessive sweatingExcessive sweating Weight loss and increased appetiteWeight loss and increased appetite Heat intoleranceHeat intolerance Exophthalmos Exophthalmos

Thyrotoxic FacesThyrotoxic Faces

Eyes - Graves’ DiseaseEyes - Graves’ Disease

•Due to retro-orbital Due to retro-orbital inflammation and lymphocyte inflammation and lymphocyte infiltration.infiltration.

ExopthalmosProptosis

Dental aspects:Dental aspects: In childhood may cause early exfoliation of In childhood may cause early exfoliation of

deciduous teeth and early eruption of permanent deciduous teeth and early eruption of permanent teethteeth

Tremor of the tongueTremor of the tongue A small reddish asymptomatic mass on the tongue A small reddish asymptomatic mass on the tongue

in some patients (lingual thyroid)in some patients (lingual thyroid) Iodides (used in the treatment) may cause altered Iodides (used in the treatment) may cause altered

taste sensation, excessive salivation, and taste sensation, excessive salivation, and enlargement of salivary glandsenlargement of salivary glands

Patients with uncontrolled hyperthyroidism Patients with uncontrolled hyperthyroidism are sensitive to epinephrine and pressor are sensitive to epinephrine and pressor amines in local anaesthesia and retraction amines in local anaesthesia and retraction cordscords

Thyrotoxic crisis:Thyrotoxic crisis: A serious complicationA serious complication May be precipitated by infections, May be precipitated by infections,

trauma, or surgerytrauma, or surgery Characterized by extreme restlessness, Characterized by extreme restlessness,

nausea, vomiting, and abdominal painnausea, vomiting, and abdominal pain Hypotension and coma may followHypotension and coma may follow

Thyroid StormThyroid Storm

Acute life threatening Acute life threatening exacerbation of exacerbation of ThyrotoxicosisThyrotoxicosis

Thyroid Storm

Fever

Delerium

Cardiovascular collapse

Gastrointestinal distress

Thyroid CancersThyroid CancersMALIGNANTMALIGNANT

1)1) PapillaryPapillary - 70%- 70% M:F= 1:3M:F= 1:3

2)2) FollicularFollicular - 15%- 15% M:F= 1:3M:F= 1:3

3)3) MedullaryMedullary - 5-10%- 5-10%

4)4) AnaplasticAnaplastic - Rare- Rare R.I.P.R.I.P.

BENIGNBENIGN

5)5) Follicular adenomaFollicular adenoma

Plus:Plus: Lymphoma, teratoma, squamous Lymphoma, teratoma, squamous and 2and 2erer

This lady complains of fatigue, increasing weight, memory loss and

constipation

HYPOTHYROIDISMHYPOTHYROIDISM

Prevalence 0.5-0.8% Prevalence 0.5-0.8% Increased TSH and decreased T4 and T3Increased TSH and decreased T4 and T3 Cause is primarily treatment of Cause is primarily treatment of

hyperthyroidism, medically or surgically or hyperthyroidism, medically or surgically or Hashimoto’s ThyroiditisHashimoto’s Thyroiditis

Signs and symptoms: lethargy, hypotension, Signs and symptoms: lethargy, hypotension, bradycardia, CHF, gastroparesis, bradycardia, CHF, gastroparesis, hypothermia, hypoventilation, hypothermia, hypoventilation, hyponatremia, and poor mentationhyponatremia, and poor mentation

Treatment with thyroxineTreatment with thyroxine

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Multi system effects - Hypothyroidism

General•Lethargy, Somnalence•Weight gain, Goitre•Cold IntolerenceCardiovascular•Bradycardia, Angina•CHF, Pericardial Effusion•HyperlipIdemia, XanthelsmaHaematologicalIron def. Anaemia, Normo cytic /chromic AnaemiaReproductive system•Infertility, Menorrhagia•Impotence, Inc. Prolactin

Neuromuscular•Aches and pains•Muscle stiffness•Carpel tunnel syndrome•Deafness, Hoarseness•Cerebellar ataxia•Delayed DTR, Myotonia•Depression, PsychosisGastro-intestinal•Constipation, Ileus, AscitesDermatological•Dry flaky skin and hair•Myxoedema, Malar flushes•Vitiligo, Carotenimia, Alopecia

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MyxedemaMyxedema

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MacroglossiaMacroglossia

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Recovery after L-Thyroxine

Myxedema Coma

Decompensated hypothyroidismAltered mental status (Comatose or semi comatose)Dry coarse skin &Thin dry hairHoarse voiceDelayed reflex relaxation timeHypothermiaPericardial, pleural effusions, ascitesAtaxiaHistory:

Previous thyroid surgeryRadioiodineDefault thyroid hormone therapy

Preciptating illness Infections Myocardial Infarction

Medical ManagementMedical Management

Thyroid hormone replacement once Thyroid hormone replacement once in the hypothyroid phasein the hypothyroid phase

Dental ManagementDental Management Aggressively treat infectionsAggressively treat infections Avoid thyrotoxic crisisAvoid thyrotoxic crisis Closely monitor vitalsClosely monitor vitals Stress managementStress management

ParathyroidParathyroid

HypoparathyroidismHypoparathyroidism

PresentationPresentation No symptoms to severe symptomsNo symptoms to severe symptoms Muscle pain and crampsMuscle pain and cramps Numbness, stiffness, and tinglingNumbness, stiffness, and tingling Candidiasis infectionsCandidiasis infections SeizuresSeizures Eventual mental and physical Eventual mental and physical

deteriorationdeterioration

HYPOCALCEMIAHYPOCALCEMIA

Perioral numbness Perioral numbness TinglingTingling Carpal pedal spasmCarpal pedal spasm TetanyTetany LaryngospasmLaryngospasm

HyperparathyroidismHyperparathyroidism Primary defect (adenoma, hyperplasia)Primary defect (adenoma, hyperplasia) Increased PTH productionIncreased PTH production

Usually from secondary compensation effect from low Usually from secondary compensation effect from low calciumcalcium

Ricketts , osteomalaciaRicketts , osteomalacia Malabsorption syndromesMalabsorption syndromes PseudohypoparathyroidPseudohypoparathyroid Chronic renal diseaseChronic renal disease

Presentation = hypercalcemiaPresentation = hypercalcemia Muscular weaknessMuscular weakness Nausea/vomitingNausea/vomiting ConstipationConstipation FeverFever

HYPERCALCEMIAHYPERCALCEMIA

Mental confusionMental confusion DehydrationDehydration AnorexiaAnorexia Abdominal painAbdominal pain ConstipationConstipation Renal stonesRenal stones UlcersUlcers Bony painBony pain

The Metabolic The Metabolic SyndromeSyndrome

Constellation of major risk Constellation of major risk factors, life-habit risk factors, life-habit risk factors and emerging risk factors and emerging risk factorsfactors

Over-represented among Over-represented among populations with CHDpopulations with CHD

Clue is distinctive body-type Clue is distinctive body-type with increased abdominal with increased abdominal circumference (although circumference (although some leaner men and some leaner men and women with abdominal women with abdominal obesity without increased obesity without increased waist)waist)

Metabolic SyndromeMetabolic Syndrome Any three of five of the followingAny three of five of the following

Glucose intolerance/insulin resistance: FBS Glucose intolerance/insulin resistance: FBS ≥ 110 mg/dL≥ 110 mg/dL (≥ 100 mg/dL, or on drug Rx) (≥ 100 mg/dL, or on drug Rx)

Hypertension:Hypertension: BP ≥ 130/85 BP ≥ 130/85 (or on drug Rx)(or on drug Rx) DyslipidemiaDyslipidemia

TG ≥ 150 mg/dL TG ≥ 150 mg/dL (or on drug Rx)(or on drug Rx) HDL < 40 mg/dL in men, < 50 mg/dL in women HDL < 40 mg/dL in men, < 50 mg/dL in women

(or on drug Rx)(or on drug Rx) Central adiposity: waist circ > 102 cm /M, > Central adiposity: waist circ > 102 cm /M, >

88 / F88 / F

Adult ObesityAdult ObesityDefinitionDefinition Excess fat accumulation in the body (mainly subcutaneous). Clinically BMI Excess fat accumulation in the body (mainly subcutaneous). Clinically BMI

>30kg/m>30kg/m22

CausesCauses Usually diet related, calorie intake > energy usage. Several diseases can Usually diet related, calorie intake > energy usage. Several diseases can predispose to gain weight. These are Cushing’s syndrome, hypothyroidism, predispose to gain weight. These are Cushing’s syndrome, hypothyroidism, polycystic ovarian syndrome and hypothalamic disease. Diet is responsible for polycystic ovarian syndrome and hypothalamic disease. Diet is responsible for over 99% of obese patients. Also drugs cause (e.g. corticosteroids)over 99% of obese patients. Also drugs cause (e.g. corticosteroids)

Signs & Signs & SymptomSymptom

ss

CushingsCushings – hair growth, acne, muscle weakness, amenorrhoea, thin skin, – hair growth, acne, muscle weakness, amenorrhoea, thin skin, depression, bruising & abdo striae. depression, bruising & abdo striae. Hypothyroidism Hypothyroidism – lethargy, anorexia, cold – lethargy, anorexia, cold intol, goitre, dry skin/hair, constipation & menorrhagia. intol, goitre, dry skin/hair, constipation & menorrhagia. POSPOS – hirsutism, – hirsutism, menstrual irregs menstrual irregs HypothalamicHypothalamic – Hx neurosurgery, tumours affecting – Hx neurosurgery, tumours affecting hypothalamus, unctrl’d excessive eatinghypothalamus, unctrl’d excessive eating

DiagnosisDiagnosis

BMI (kg/mBMI (kg/m22)) Risk of Co-morbiditiesRisk of Co-morbidities

OverweightOverweight 25-3025-30 Mildly IncreasedMildly Increased

ObeseObese >30>30

Class IClass I 30-3530-35 ModerateModerate

Class IIClass II 35-4035-40 SevereSevere

Class IIIClass III >40>40 Very SevereVery Severe

InvestigatioInvestigationsns

Waist/hip circumference ratio and skinfold tests. Over middle of triceps (20mm Waist/hip circumference ratio and skinfold tests. Over middle of triceps (20mm in men and 30mm in women). in men and 30mm in women). TFTs TFTs – hypothyroid screen; – hypothyroid screen; U&EU&E – ↓ K – ↓ K+ + in in Cushings; Cushings; ↑ urine gluc↑ urine gluc in Cushings diabetes; in Cushings diabetes; US US for POS, for POS, MRIMRI - hypothalamic - hypothalamic disease; low dose dexamthasone – fails to suppress cortisol in Cushings; disease; low dose dexamthasone – fails to suppress cortisol in Cushings; ↑ 24hr ↑ 24hr urine free cortisolurine free cortisol (Cushings) (Cushings)

TreatmentsTreatmentsControl diet. Treat underlying cause if present. Drugs used (<3 mths) w/ diet. Control diet. Treat underlying cause if present. Drugs used (<3 mths) w/ diet. Peripheral acting drugs i.e Orlistat - inhibs pancreatic/gastric lipases. Central Peripheral acting drugs i.e Orlistat - inhibs pancreatic/gastric lipases. Central acting i.e. sibutramine acts on serotoninergic & noradrenergic pathways. acting i.e. sibutramine acts on serotoninergic & noradrenergic pathways. Surgery involves gastric bypass/banding, jaw wiring or gastroplasty.Surgery involves gastric bypass/banding, jaw wiring or gastroplasty.

ComplicatioComplicationsns

↑ ↑ BP, blood cholesterol; DM (Type II); hyperinsulinaemia; Ischaemic heart BP, blood cholesterol; DM (Type II); hyperinsulinaemia; Ischaemic heart disease; Angina; CCF; CVA; gallstones; cholecystitis/cholelithiasis; gout; OA; disease; Angina; CCF; CVA; gallstones; cholecystitis/cholelithiasis; gout; OA; hiatus hernia; Ca (breast, prostate, colon); preg complications; bladder ctrl hiatus hernia; Ca (breast, prostate, colon); preg complications; bladder ctrl probs; psychological disorders (depression, eating disorders).probs; psychological disorders (depression, eating disorders).

HyperlipidaemiaHyperlipidaemia

PubertyPuberty Which hormone is responsible for the onset Which hormone is responsible for the onset

of puberty?of puberty? Gonadotropin releasing releasing hormone Gonadotropin releasing releasing hormone

(GnRH)(GnRH) First signs of puberty in girls and in boys?First signs of puberty in girls and in boys?

Girls: breast bud (10-11 years)Girls: breast bud (10-11 years) Boys: testes growth and thinning of scrotumBoys: testes growth and thinning of scrotum

Precocious PubertyPrecocious Puberty Puberty onset < age 8 for girls, and < 9 in boysPuberty onset < age 8 for girls, and < 9 in boys

Laboratory testsLaboratory tests LH is undetectable in prepubertal kidsLH is undetectable in prepubertal kids GnRH as a stimulation testGnRH as a stimulation test

TreatmentTreatment GnRH analogsGnRH analogs