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