endocrine Flashcards
products of the adrenal glands
zones of adrenal glands and their products
HPA axis
adrenal and kidney BP regulation
aldo actions
cortisol actions
BP?
insulin?
lipids?
gluconeogenesis?
mm
IS
Ca?
appatite? sleep? emotion? memory?
IOP?
roles
Hyperadrenalism
- ↑Aldosterone, cortisol, androgen, estrogen isolated or in combination
most common excess adrenal hormone
cortisol; cushing dx (pit or adrenal tumor) or cushing syndrome (exogenous steroids)
complcations of excess cortisol
o Diabetes
o Hypertension
o Weight gain
o Moon facies
o Buffalo hump
o Hirsutism
o Acne
o Heart failure
o Osteoporosis
o Delayed wound healing
o Susceptibility to infection
o irregular menses Insomnia
o Psychiatric disorders
o Peptic ulcers
o Glaucoma and cataracts
pnemonic for cushing signs and symptoms
cushingoid
common glucocorticoids
importance of Rx glucocorticoids
much more potent then endogenous glucocorticoids, must monitor HPA
forms of adrenal insuff
- Tertiary > Secondary > Primary
addison dx
➢ Destruction of adrenal cortex
o ↓Cortisol and ↑ACTH (adrenocorticotropic
hormone)
addison dx etiology
o Most commonly autoimmune
o Chronic infectious disease and sepsis
❑ HIV, CMV, fungal infection
o Drugs
adrenal crisis of addison dx
Cannot tolerate stress (emotional or physical), no cortisol
addison dx tx
o Surgery and stress may require?
o Pain control?
➢ Requires cortisol replacement
o Surgery and stress may require supplemental corticosteroids
o Pain control is important
cutaneous findigs of addisons
skin
mucus membranes
nails
hair
casrtilage
d
addisons features
pain?
electrolytes?
hypotension?
weight?
fatique?
if untx?
- Secondary adrenal insufficiency
➢ Impaired/destructive pituitary disease
➢ ↓Cortisol and ↓ACTH; aldosterone unchanged
➢ Lower dose replacement therapy
Tertiary adrenal insufficiency
➢ Impaired function of?
➢ Most commonly a result of?
➢ therapy?
➢ Impaired function of hypothalamus
➢ Most commonly a result of chronic exogenous steroid use
➢ Lower dose replacement therapy
Hyperpigmentation and adrenal crisis with secondary and tertiary adrenal insufficiency?
Hyperpigmentation and adrenal crisis do not usually occur/less likely with secondary and tertiary adrenal insufficiency
Undiagnosed patient with signs and symptoms of adrenal disease?
Undiagnosed patient with signs and symptoms of adrenal disease should be promptly be
referred to their primary physician for comprehensive work-up
Hyperadrenalism
➢ BP and glucose levels?
➢ drugs to avoid? why?
➢ bone complications?
➢ increased BP and glucose levels
➢ Avoid NSAIDs and aspirin → peptic ulcers, GI bleed
➢ If osteoporosis and osteopenia
o More prone to periodontal bone loss - monitor
o May have history of bisphosphonate use
what can be impaired in both hyper and hypoadrenalism
Impaired wound healing may be a consequence of both hyperadrenalism and adrenal insufficiency
Necessity for supplemental corticosteroids?
o Depends on?
Discuss dosage w/physician
o Depends on?
✓ Type
✓ Severity/ stability/ medical status
✓ Dental procedure being performed (long: >1hr or invasive) /type of stress/dental infectio
signs of adrenal crisis
what to do?
o Hypotension - Monitor BP – vasopressors, patient position, fluid replacement
o Abdominal pain
o Myalgia
o Fever
o Supplement with 100 mg of hydrocortisone and send to ED
Pain control with adrenal insuff
o Adequate anesthesia, long-acting agent at end of procedure
o Good post-up pain control
Thyroid function
- Involved in developmental and metabolic processes
- Depends on iodide
- Thyroid produces 3 hormones
➢ T3 and T4
o Controlled by TSH (pituitary)
➢ Calcitonin
o Regulates circulating calcium and phosphorus levels
o Also influenced by actions of PTH and Vit D
Thyroid hormone effects at heart, gut, fat, mm, NS, lipoproteins, other
- Thyroid enlargement
- May be?
- Most are?
- Hyperthryoidism goiter seen in?
- Hypothyroidism goiter seen in?
Goiter
* May be functional or non-functional
* Most are non-functional (euthyroid)
* Hyperthryoidism goiter – Graves disease
* Hypothyroidism goiter – Hashimoto thyroiditis
Thyroid nodules
- Hyperplasia
- Adenoma
- Carcinoma
- Thyroiditis
- Hashimoto (autoimmune)
Hyperthyroidism (thyrotoxicosis)
- Primary – Graves disease (auto-immune disease)
- Secondary – Pituitary adenoma
Hypothyroidism (congenital or acquired)
- hasimoto
- Secondary
- Transient
thyroid Neoplasias
- Adenoma
- Carcinoma (papillary, follicular
symptoms hyperthy
clinical findings of hyperthy
Hyperthyroidism serum levels
Hyperthyroidism ↑ Free T4; ↓ TSH
Management hyperthyroidism
consultation?
b-blocker?
propylthiouracil?
methimazole?
radioiodine?
w
Thyroid storm/crisis
Medical emergency
May be precipitated by oral infection or surgical procedure in a patient who is poorly controlled
hypothy symptoms
clinical findings and complication hypothy
Hypothyroidism serum
Free down T4; ↓ TSH or up TSH
related features of hypothy
tongue?
wounds?
nose?
lips?
eyelids?
congential?
coma?
e
management hypothy
Hyperthy dental implications (effects on tissues)
- Increased periodontal bone loss
- Increased susceptibility to caries
Hypothy dental implications
- Delayed tooth eruption and altered bone formation
- Macroglossia
- Dysgeusia and burning mouth
- Salivary gland enlargement
- Oral lichen planus
hyper and hypothy with infection
both can be more sus to infection, tx aggressively
Patients with uncontrolled, poorly controlled, suspected hyperthyroidism or hypothyroism
Patients with uncontrolled, poorly controlled, suspected hyperthyroidism or
hypothyroism SHOULD NOT receive dental care until disease is under control
risks of tx uncontrolled thyroid pts
* risk with meds for hyper?
* hyper/hypo severe events?
- Agranulocytosis from medications used to treat hyperthyroidism
- Thyrotoxic crisis/storm - hyperthyroidism
- Myxedema coma - hypothyroidism
procedure with thy strom
➢ CPR and vital signs
➢ Ice packs or wet packs
➢ Administer hydrocortisone 100-300 mg
➢ IV glucose
➢ Administer propylthiouracil
➢ Send to ED
procedure with myxedma coma
➢ CPR and vital signs
➢ Conserve body heat – blanket
➢ Administer hydrocortisone 100-300 mg
➢ IV saline and glucose
➢ Administer thyroxine
➢ Send to ED
Drug interactions/side effects in hyperthy
NSAIDS/ASA
cirprofloaxcin
epi
- Caution with aspirin and NSAIDS- can increase T4
- Ciprofloxacin contraindicated – decreases absorption of thyroid hormone
- Avoid local anesthestics containing epinephrine and ginigval retraction cord with epinephrine in poorly controlled patients
drug interactions in hypothy
narcotics, barbituates, sedatives?
phenytoin, carbamazepine, and rifampin?
- Avoid CNS depressants (narcotics, barbituates, sedatives) if patient is poorly controlled
- Cytochrome p450 inducers (phenytoin, carbamazepine, and rifampin) should be avoided – increases metabolism of levothyroxine
diabetes
* Proper terminology is?
* Related to lack of?
* def needed for?
* Results in?
- Proper terminology is “diabetes mellitus” aka
diabetes - Related to lack of beta cell pancreatic production of
insulin - Insulin needed for sugar absorption into cells; leads
to increased serum glucose aka hyperglycemia - Results in undernourished tissues which have
multiple effects on systemic health
types of DM
- Type 1
- Type 2
- Gestational Diabetes occurs in 2-10% of pregnancies
Type 1 diabetes (T1D)
- Aka juvenile diabetes
- Insulin dependent
- ~10-20% of diabetics
- Autoimmune disease
- Destruction of pancreatic β-cells → insulin deficiency
- Non-obese children and adults <40 years old
stages of type 1 DM onset
microvascular complications of DM
- Neuropathy – extremities, impotence, bladder dysfunction, gastroparesis
- Retinopathy – cataracts, blindness
- Nephropathy
macrovascular complications of DM
- Peripheral vascular disease, congestive heart failure – hypertension
- Myocardial infarction – diabetes accelerates atherosclerosis
- Strok
complications of imparied healing and infection with DM
- Neutrophilic dysfunction, increased M1:M2 ratio
- Increased pro-inflammatory cytokines and increased MMPs
- Impaired angiogenesis and endothelial dysfunction
Type 2 Diabetes
- Aka adult onset diabetes; non-insulin dependent
diabetes - Pancreas produces insulin but it is in low titers or it
does not work properly - ~80-90% of diabetics
do the dif DM types have different micro/macrovascular and wound healing effects
NO
tests for DM
WNL, pre-diabetic, diabetic
DM test goals
perio dx and diabetes
Higher prevalence of severe periodontal disease in poorly controlled diabetics - HbA1c>9%
Controversial effect of periodontal therapy on glycemic control in patients with Type 2 DM
Consensus report: short-term reduction in HbA1c levels at 3-4 months after periodontal intervention, no confirmation that this is sustained long-term. [Sanz et al. J Clin Periodontol (2018)]
perio dx correlations with DM affects
* retinopathy correlation
* renal complications/ cardiovascular complications
* neuropathic foot?
- Severity of periodontitis and severity of retinopathy correlation
- Periodontitis + Diabetes → more renal complications and cardiovascular complications
- Severe periodontitis - association with neuropathic foot ulceration
DM tx targets
Decrease in gluconeogenesis
Increase in insulin secretion
Sensitization to insulin
Decrease in glucagon secretion
Intestinal and renal absorption of glucose
drugs to decrease gluconeagenesis
Biguanide – metformin
Insulin – rapid (lispro), short (regular -Novolin), long-acting (glargine)
drugs to increase insulin secretion
- Sulfonylureas –glipizide
- Glucagon-like peptide 1 (GLP1) receptor agonist – exenatide, liraglutide
drugs to sensitize to insuiln
- Thiazolidinediones – pioglitazone
drugs to Decrease in glucagon secretion
- Dipeptidyl peptidase 4 (DPP4) – sitagliptin
- GLP1 receptor agonist – exenatide, liraglutide
drugs to inhibit Intestinal and renal absorption of glucose
- Sodium-glucose cotransporter-2 inhibitors – canagliflozin
- 𝛼-glucosidase inhibitor – acarbose
Diabetes oral s/s
- Xerostomia/dry mouth
- Oral burning (different from burning mouth, secondary)
- Infections (bacterial, fungal, viral)
- Poor wound healing
- Increased caries
- Increased severity risk of periodontal disease
concerns with DM oral signs
Poor wound healing and infection
Control of comorbidities and drug interaction
when is elective tx defered with DM pts (glucose levels)
what if there is an emergency?
- If 2hr after meal glucose or fasting glucose reading < 70 or > 200mg/dl or HbA1c > 8.0%
- Defer elective treatment
- If emergency/active infection, consider referral to
hospital/specialized setting - Send medical consultation
- If DM patient not being closely followed by physician (> 6 months),
refer
DM antibiotic prophylaxis
CONTEXT-DEPENDENT
what drugs should be avoided with diabetes? interactions with insulin?
- Tetracyclines (including doxycycline) with insulin– hypoglycemia
- fluoroquinolones ciprofloxacin (Cipro), levofloxacin (Levaquin), etc. with insulin– hypoglycemia
- Aspirin with sulfonylureas– hypoglycemia
Be aware that sulfonylureas may cause thrombocytopenia
time of day appt for DM
Early morning appointments
* Eat normal meal and take medication(s) prior to appointment
* Be aware of and have patient communicate symptoms of hypoglycemia
* Have high-concentration sugar products readily available (orange juice, cake icing, soft drinks (non-diet, non-zero)
oral sedation with DM
Oral sedation not recommended as fasting is necessary
Gestational Diabetes
* occurs in % of pregnancies
* Fetus can have?
* Affects development of?
* Delivery may require what delivery method?
* Treated similar to?
- occurs in 2-10% of pregnancies
- Fetus can have excess weight gain
- Affects lung development
- Delivery may require cesarean section
- Treated similar to Type 2 diabete
preg time cycle
Pregnancy = 40 weeks: From the 1st day of last menstrual cycle.
➢ First trimester: 0-12 weeks (12 wks)
➢ Second trimester: 13-28 weeks (16 wks)
➢ Third trimester: 29-40 weeks (12 wks)
how can dental tx affect the fetus
- Dental procedures could harm the developing fetus through the effects of:
➢Ionizing Radiation
➢Drugs- continues post-partum from transmission of drugs via breast milk
➢Stress
- Common Pregnancy Discomforts
➢Nausea and vomiting- hormonal imbalances, stress (physical and emotional) and hyperacidity
➢Indigestion- difficulties digesting foods rich in fats, sugars, acids can lead to nausea and vomiting
➢Headaches
➢Polyuria
➢Lumbar pain
➢Perspiration
➢Breast tenderness
when to provide dental care to preg pts
- Avoid elective dental care during the first
trimester - Second trimester is the best time to perform dental
treatment on a pregnant patient - After the middle of the third trimester, elective dental
care is best post-poned - Dental treatment can be safely performed in all
trimesters
- Lack of proper oral health care during pregnancy could:
- Lack of proper oral health care during pregnancy could harm the developing fetus and affect the time of delivery
radio with women of childbearing age
ask if possibly preg
- Radiographs and pregnancy: dose to fetus w Pb apron and 2 PAs
- The gonadal/fetal dose incurred with 2 periapical images when a Pb apron is used is 700 times less than that for 1 day exposure to natural background radiations in the US
when should preg pts recieve radiographs
only in emergencies that are for standard of care to prevent harm to mother/child
Emergency Dental Treatment during Pregnancy
* Maybe provided when?
* what actions should be performed?
* Emergency dental treatment may require a consult with? why?
* Untreated dental infections may pose a risk to?
* Dental radiographs as needed?
- Maybe provided as needed any time during pregnancy.
- Pain control and elimination of infections should be performed.
These can stress mother and endanger the fetus. - Emergency dental treatment may require a consult with the
obstetrician, if there is a concern about medications or effect of
emergency treatment on the fetus. - Untreated dental infections may pose a risk to the developing fetus
→ Fever and sepsis may precipitate a spontaneous abortion - Dental radiographs as needed to establish a diagnosis
why is the supine postion avoided in later stages of pregnancy
compression of IVC
- Supine hypotension syndrome manifests how
- Fall in blood pressure
- Bradycardia
- Sweating
- Nausea
dealing with supine hypotension in preg pts
Patient can rotate to their
side to allow venous return
to recover (roll left)
drugs and preg pts
All drugs should be avoided during pregnancy, if possible. Benefit should outweigh potential risks.
common dental drugs and preg
- Most common dental drugs can be safely used in pregnant patients
- Do not exceed maximum dose of LA – lido w/ or w/o epi is safe
Avoid aspirin and other NSAIDs with preg
- Closure of the ductus arteriosus
- Risk of post-partum hemorrhage and delayed labo
preffered analgesic of pregnancy
acetaminophin
opiods and preg
Opioids should be avoided
* Only when absolutely necessary and in consultation with the physician –codeine with acetaminophen (APAP) is usually the preferred agent
Antibiotics and preg pts which can and cannot be used?
- Amoxicillin, clindamycin, azithromycin, metronidazole and erythromycin are common antibiotics that may be used in pregnant patients
- Tetracycline and doxycycline are CONTRAINDICATED in pregnant patients → teratogenic
preg pts and sedation
* preferred?
* If absolutely necessary?
* Pt should with multiple appointments or extended appointment?
* Avoid when? what to do after sedation?
* Benzos?
* If plan is to proceed with any type of sedation, even nitrous, what is needed?
- No pharmacologic sedation is preferred
- If absolutely necessary, nitrous oxide may be used for < 30 min and with at least 50% oxygen
- Pt should not have multiple appointments or extended appointment with nitrous oxide sedation as cumulative effects are a point for concern.
- Avoid during first trimester. As always, appropriate oxygenation after nitrous is necessary to avoid diffusion hypoxia.
- Benzos should be avoided.
- If plan is to proceed with any type of sedation, even nitrous, consultation with the physician is necessary
female occupational exposure to
Nitrous oxide
why?
Women of child-bearing age should not be chronically exposed to nitrous in occupational capacity for more 3 hours/week without scavenging equipment.
* Risk for decreased fertility and greater rates of spontaneous abortion.
female x ray occupational exposure
Pregnant radiation workers should wear shall be given personal dosimeter monitoring devices to monitor occupational dose limits and assure that the annual effective dose is < 1mSv/yr
- For lactating mothers:
- Most drugs are?
- Do not prescribe drugs known to be?
- Medications should be taken?
- For lactating mothers:
- Most drugs are of little pharmacologic significance to
lactation - Do not prescribe drugs known to be harmful
- Medications should be taken just after breast feeding
pregnancy effect on gums
Can range from mild inflammation to severe overgrowth. The hormonal increase can exaggerate the gum tissue’s response to bacterial plaque.
tooth mobility and preg
- Tooth mobility may be present
importance of orla health in preg pts or those who want to be
- Prevention, good oral health, and periodontal
maintenance is important for your pregnant
patients or those considering becoming
pregna
preg and perio dx
most common oral condition in preg
gingivitis 60-75%
Pregnancy Gingivitis and Exacerbated Periodontitis affected by:
- Lack of attention to Oral Hygiene
- Increased systemic fluid levels from increased progesterone and estrogen exacerbate any existing gingival/periodontal condition
Pyogenic granuloma/ Epulis gravidarum/ Pregnancy Tumor
- not an actual granuloma as there is proliferation of vascular tissues as well proliferation of fibrous tissue
- forms submucosally and takes the shape a nodular growth
- in pregnancy, it is an exacerbated response to plaque and bacteria precipitated by the changes in progesterone and estrogen hormonal levels –
Pyogenic granuloma/ Epulis gravidarum/ Pregnancy Tumor
- not an actual granuloma as there is proliferation of vascular tissues as well proliferation of fibrous tissue
- forms submucosally and takes the shape a nodular growth
- in pregnancy, it is an exacerbated response to plaque and bacteria precipitated by the changes in progesterone and estrogen hormonal levels –
