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Dental Management of a Complex Patient > Endocrine Disease > Flashcards

Endocrine Disease Flashcards

1
Q

Zone: Glomerulosa
Hormone:
Action (3)

A

Aldosterone (mineralcorticoid)

Kidneys – distal tubules
Intravascular volume and RAA system
Regulates Na and H20 balance – affects BP

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2
Q

Zone: Fasciculata
Hormone:
Action

A

Cortisol (glucocorticoid)

  • Increases contractility and vascular reactivity to vascoconstriction
    (results in increased BP)
  • Antagonizes insulin
  • Activates lipolysis – increased FFA
  • Stimulates gluconeogenesis - (results in increased sugar, insulin
    intolerance and cholesterol)
  • Muscle catabolism – increases glucose
  • Decreases calcium absorption and activates osteoclasts
  • (results decreased in osteoporosis)
  • *Inhibits PLA2
    and mobilization, migration, function of leukocytes -
  • (results in immune response)
  • Increases appetite, suppresses sleep, regulates emotion and
    memory
  • Increases intraocular pressure
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3
Q

Zone: Reticularis
Hormone:
Action

A

Androgens (sex hormones)

Gonads
Sexual maturation, growth and development

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4
Q

Hormone: Norepinephrine and epinephrine
Action

A

Fight or flight - stress response
Increases BP, peripheral resistance, cardiac output

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5
Q

Hyperadrenalism

A
  • ↑Aldosterone, cortisol, androgen, estrogen isolated or in
    combination
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6
Q

Hyperaldosteronism

A
  • Hypertension, hypokalemia, edema
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7
Q

Glucocorticoid excess
(2)

A
  • MOST COMMON
  • High levels of cortisol
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8
Q
  • High levels of cortisol (2)
A

➢ Cushing disease (pituitary or adrenal tumor)
➢ Cushing syndrome (exogenous corticosteroids)

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9
Q

➢ Cushing disease (pituitary or adrenal tumor)
➢ Cushing syndrome (exogenous corticosteroids)
➢ Complications

A

o Diabetes
o Hypertension
o Weight gain
o Moon facies
o Buffalo hump
o Hirsutism
o Acne
o Heart failure
Adrenal
o Osteoporosis
o Delayed wound healing
o Susceptibility to infection
o irregular menses Insomnia
o Psychiatric disorders
o Peptic ulcers
o Glaucoma and cataracts

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10
Q

Primary adrenal insufficiency

A
  • Addison Disease
    ➢ Destruction of adrenal cortex
    o ↓Cortisol and ↑ACTH (adrenocorticotropic
    hormone)
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11
Q
  • Addison Disease
    ➢ Etiology
    (3)
A

o Most commonly autoimmune
❑ What does this mean?
o Chronic infectious disease and sepsis
❑ HIV, CMV, fungal infection
o Drugs

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12
Q
  • Addison Disease
    Cannot tolerate
A

stress (emotional or physical)
o Adrenal crisis

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13
Q
  • Addison Disease
    Requires
A

cortisol replacement
o Surgery and stress may require
supplemental corticosteroids
o Pain control is important

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14
Q

Adrenal insufficiency
* Secondary adrenal insufficiency
(3)

A

➢ Impaired/destructive pituitary disease
➢ ↓Cortisol and ↓ACTH; aldosterone
unchanged
➢ Lower dose replacement therapy

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15
Q

Tertiary adrenal insufficiency
(3)

A

➢ Impaired function of hypothalamus
➢ Most commonly a result of chronic
exogenous steroid use
➢ Lower dose replacement therapy

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16
Q

Hyperpigmentation and adrenal crisis do not usually occur/less likely with

A

secondary and tertiary adrenal insufficiency

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17
Q

Undiagnosed patient with signs and symptoms of adrenal disease should be promptly be
referred to

A

their primary physician for comprehensive work-up

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18
Q

Determine type and severity of adrenal disease
* Hyperadrenalism
(3)

A

➢ BP and glucose levels
➢ Avoid NSAIDs and aspirin → peptic ulcers, GI bleed
➢ If osteoporosis and osteopenia

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19
Q

➢ If osteoporosis and osteopenia
o More prone to
o May have history of

A

periodontal bone loss - monitor
bisphosphonate use

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20
Q

Impaired wound healing may be a consequence of both (2)

A

hyperadrenalism and
adrenal insufficiency

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21
Q

Adrenal insufficiency
➢ Necessity for supplemental corticosteroids? Discuss dosage w/physician
o Depends on?
(3)

A

✓ Type
✓ Severity/ stability/ medical status
✓ Dental procedure being performed (long: >1hr or invasive) /type of
stress/dental infection

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22
Q

Adrenal insufficiency
Know signs of adrenal crisis
(5)

A

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

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23
Q

Adrenal insufficiency
Pain control
(2)

A

o Adequate anesthesia, long-acting agent at end of procedure
o Good post-up pain control

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24
Q

Thyroid function
* Involved in (2) processes
* Depends on —
* Thyroid produces – hormones

A

developmental and metabolic
iodide
3

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25
Q

T3 and T4
o Controlled by

A

TSH (pituitary)

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26
Q

Calcitonin
o Regulates
o Also influenced by actions of (2)

A

circulating calcium and phosphorus levels
PTH and Vit D

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27
Q

Thyroid disorders
* Thyroid enlargement = Goiter
* May be (2)
* Most are —
* Hyperthryoidism goiter –
* Hypothyroidism goiter –

A

functional or non-functional
non-functional (euthyroid)
Graves disease
Hashimoto thyroiditis

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28
Q
  • Thyroid nodules
    (3)
A
  • Hyperplasia
  • Adenoma
  • Carcinoma
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29
Q

Thyroid disorders
* Thyroiditis

A
  • Hashimoto (autoimmune)
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30
Q

Hyperthyroidism (thyrotoxicosis)
* Primary –
* Secondary –

A

Graves disease (auto-immune disease)
Pituitary adenoma

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31
Q

Hypothyroidism (congenital or acquired)
* Primary –
* Secondary
* Transient

A

Graves disease (end-stage)

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32
Q

Neoplasia
(2)

A
  • Adenoma
  • Carcinoma (papillary, follicular,
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33
Q

Hyperthyroidism – Free T4; – TSH

A

↑
↓

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34
Q

Hypothyroidism Free — T4; — TSH or — TSH

A

↓
↓
↑

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35
Q

Thyroid
Hyper –
(2)

A
  • Increased periodontal bone loss
  • Increased susceptibility to caries
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36
Q

Thyroid
Hypo –
(5)

A
  • Delayed tooth eruption and altered bone formation
  • Macroglossia
  • Dysgeusia and burning mouth
  • Salivary gland enlargement
  • Oral lichen planus
37
Q

Patients with both hyper and hypothyroidism may be more susceptible
to

A

infections- treat aggressively

38
Q

Patients with uncontrolled, poorly controlled, suspected hyperthyroidism or
hypothyroism SHOULD NOT receive

A

dental care until disease is under control

39
Q

Risk of
(3)

A
  • Agranulocytosis from medications used to treat hyperthyroidism
  • Thyrotoxic crisis/storm - hyperthyroidism
  • Myxedema coma - hypothyroidism
40
Q
  • Agranulocytosis from medications used to treat hyperthyroidism
A

➢ Fever, sore throat, oral ulcers are warning signs

41
Q
  • Thyrotoxic crisis/storm - hyperthyroidism
    ➢ (2)
    ➢(2)
    ➢ Administer –
    ➢ IV —
    ➢ Administer —
    ➢ Send to –
A

CPR and vital signs
Ice packs or wet packs
hydrocortisone 100-300 mg
glucose
propylthiouracil
ED

42
Q
  • Myxedema coma - hypothyroidism
    ➢ (2)
    ➢ Conserve –
    ➢ Administer –
    ➢ IV –
    ➢ Administer –
    ➢ Send to –
A

CPR and vital signs
body heat – blanket
hydrocortisone 100-300 mg
saline and glucose
thyroxine
ED

43
Q

Drug interactions/side effects
* In hyperthyroidism
* Caution with aspirin and NSAIDS- can
* Ciprofloxacin contraindicated –
* Avoid local anesthestics containing

A

increase T4
decreases absorption of thyroid hormone
epinephrine and ginigval retraction cord
with epinephrine in poorly controlled patients

44
Q

Drug interactions/side effects
* In hypothyroidism
* Avoid — if patient is poorly controlled
* — should
be avoided – increases metabolism of —

A

CNS depressants (narcotics, barbituates, sedatives)
Cytochrome p450 inducers (phenytoin, carbamazepine, and rifampin)
levothyroxine

45
Q

diabetes
2 Main types

A
  • Type 1
  • Type 2
  • Gestational Diabetes occurs in 2-10% of pregnancies
    Diabetes
46
Q

Type 1 diabetes (T1D)
(3)

A
  • Aka juvenile diabetes
  • Insulin dependent
  • ~10-20% of diabetics
47
Q

Diabetes
* TYPE 1
(3)

A
  • Autoimmune disease
  • Destruction of pancreatic β-cells → insulin deficiency
  • Non-obese children and adults <40 years old
48
Q

Diabetes
Microvascular
(3)

A
  • Neuropathy – extremities, impotence, bladder dysfunction, gastroparesis
  • Retinopathy – cataracts, blindness
  • Nephropathy
49
Q

Diabetes
Macrovascular
(3)

A
  • Peripheral vascular disease, congestive heart failure – hypertension
  • Myocardial infarction – diabetes accelerates atherosclerosis
  • Stroke
50
Q

Diabetes
Impaired wound healing and susceptibility to infection
* — dysfunction, — M1:M2 ratio
* Increased — and increased —
* Impaired (2)

A

Neutrophilic, increased
pro-inflammatory cytokines, MMPs
angiogenesis and endothelial dysfunction

51
Q

Type 2 Diabetes
(3)

A
  • 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
52
Q

Higher prevalence of severe periodontal disease in poorly
controlled diabetics - HbA1c>9% [Tsai et al. Community Dent Oral
Epidemiol (2002)]
Controversial effect of periodontal therapy on glycemic control in
patients with Type 2 DM
(4)

A
  • 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)]
  • Severity of periodontitis and severity of retinopathy correlation
  • Periodontitis + Diabetes → more renal complications and
    cardiovascular complications
  • Severe periodontitis - association with neuropathic foot ulceration
53
Q

Decrease in gluconeogenesis
(2)

A
  • Biguanide – metformin
  • Insulin – rapid (lispro), short (regular -Novolin), long-acting (glargine)
54
Q

Increase in insulin secretion
(2)

A
  • Sulfonylureas –glipizide
  • Glucagon-like peptide 1 (GLP1) receptor agonist – exenatide, liraglutide
55
Q

Sensitization to insulin
(1)

A
  • Thiazolidinediones – pioglitazone
56
Q

Decrease in glucagon secretion
(2)

A
  • Dipeptidyl peptidase 4 (DPP4) – sitagliptin
  • GLP1 receptor agonist – exenatide, liraglutide
57
Q

Intestinal and renal absorption of glucose
(2)

A
  • Sodium-glucose cotransporter-2 inhibitors – canagliflozin
  • 𝛼-glucosidase inhibitor – acarbose
58
Q

diabetes synotons (6)

A
  • 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
59
Q

Diabetes
Concerns
Poor wound healing and infection
* If 2hr after meal glucose or fasting glucose reading – or –
mg/dl or HbA1c –
* Defer elective treatment
* If emergency/active infection, consider referral to
hospital/specialized setting
* Send medical consultation
* If patient not being closely followed by physician (> 6 months),
refer
* Prophylactic antibiotics? CONTEXT-DEPENDENT

A

< 70
> 200
> 8.0%

60
Q

Diabetes
Concerns
Control of comorbidities and drug interactions
(4)

A
  • HTN (refer back to previous lectures for drug interactions)
  • HLD
  • Other cardiovascular disease (angina, MI, CHF, stroke)
  • Renal impairment
61
Q

Diabetes
Considerations
Avoid

A
  • 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
62
Q

Diabetes
Considerations
Early morning appointments
(3)

A
  • 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)
63
Q

diabetes
Oral sedation not recommended as — is necessary

A

fasting

64
Q

Gestational Diabetes
* occurs in —% of pregnancies
* Fetus can have excess —
* Affects — development
* Delivery may require —
* Treated similar to —

A

2-10
weight gain
lung
cesarean section
Type 2 diabetes

65
Q

Pregnancy can be a — to oral health.
Pregnancy = — weeks: From the 1st day of last menstrual cycle.
➢ First trimester:
➢ Second trimester:
➢ Third trimester:

A

stressor
40

0-12 weeks (12 wks)
13-28 weeks (16 wks)
29-40 weeks (12 wks)

66
Q

Dental procedures could harm the developing fetus through
the effects of:
(3)

A

➢Ionizing Radiation
➢Drugs
- continues post-partum from transmission of drugs via
breast milk
➢Stress

67
Q

Common Pregnancy Discomforts
(7)

A

➢Nausea and vomiting
➢Indigestion
➢Headaches
➢Polyuria
➢Lumbar pain
➢Perspiration
➢Breast tenderness

68
Q

➢Nausea and vomiting

A
  • hormonal imbalances, stress (physical and emotional)
    and hyperacidity
69
Q

➢Indigestion

A
  • difficulties digesting foods rich in fats, sugars, acids
    can lead to nausea and vomiting
70
Q

For pregnant women:
* Maintain optimal — health
* Avoid elective dental care during the — trimester
* Avoid — known to be harmful to the fetus
* Lack of proper oral health care during pregnancy could
(2)

A

oral
first
drugs
harm the developing fetus and affect the time of delivery

71
Q

Avoid elective dental care during the first
trimester
(3)

A
  • 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
72
Q

Radiation
* Women of childbearing age

A
  • Inquire if the patient could possibly be
    pregnan
73
Q

Radiographs and pregnancy:

A
  • 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
74
Q

I. New and recall pregnant dental patients:

A
  • Radiographs should be postponed until post-partum
  • long term benefit to the health of the mother from new patient or recall exam radiographs
  • BUT no benefit to the health of developing child
  • unborn child faces greater risks from the radiation exposure than the mother, without any
    benefit to their health
  • National Council on Radiation Protection and Measurements (NCRP Report 177, 2019)
    2
    recommends different radiation exposure thresholds for pregnant radiation workers than
    non-pregnant radiation workers
  • radiation exposure thresholds for pregnant radiation workers is lowered to the same
    thresholds as the general population
  • SoD Dental Radiography recommendation guidelines for Pregnant Patients mirrors these
    NCRP recommendations
75
Q

II. Emergency pregnant dental patients:

A
  • necessary radiographs are part of the standard of care to treat and diagnose a condition that
    threatens the health of the mother and the unborn child
  • lack of radiographs compromises the emergency care diagnosis and treatment,
  • this will directly impact the health of the unborn child.
  • primary beam is not directed toward the child-bearing area.
76
Q

Emergency Dental Treatment during Pregnancy
* Maybe provided as
* — control and elimination of infections should be performed. These can stress mother and endanger the fetus.
* Emergency dental treatment may require a
* Untreated dental infections may pose a risk to t
* Dental radiographs as needed to establish a diagnosis

A

needed any time during pregnancy.
Pain
consult with the
obstetrician, if there is a concern about medications or effect of
emergency treatment on the fetus.
he developing fetus
→ Fever and sepsis may precipitate a spontaneous abortion

77
Q

In advanced stages of pregnancy (late
third trimester), avoid the supine
position for long periods;

A
  • Supine hypotension syndrome in late
    (3rd trimester) pregnancy
  • Due to compression of
    the inferior vena cava
    that results in impaired
    venous return to the
    heart.
78
Q
  • Supine hypotension syndrome
  • Manifests as:
    (4)
A
  • Fall in blood pressure
  • Bradycardia
  • Sweating
  • Nausea
79
Q

Patient can rotate to their
side to

A

allow venous return
to recover. Studies indicated

80
Q

Sedation
* No pharmacologic sedation is preferred
* If absolutely necessary, nitrous oxide may be used for
* 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
* — should be avoided.
* If plan is to proceed with any type of sedation, even nitrous,
consultation with the physician is necessary

A

< 30 min and
with at least 50% oxygen
diffusion hypoxia.
Benzos

81
Q

IMPORTANT: occupational exposure for women is also a concern.
Nitrous oxide
Women of child-bearing age should not be chronically exposed to
nitrous in occupational capacity for more — without
scavenging equipment.
* Risk for decreased fertility and greater rates of spontaneous
abortion

A

3 hours/week

82
Q

IMPORTANT: occupational exposure for women is also a concern.
X-radiation

A

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.

83
Q

Maximum Permissible Dose
Occupational limits:
Avg. dental occupational exposure is —
—% of dental workers have readings below the threshold of
detection

A

1 mSv/yr
0.2 mSv/yr
68

84
Q

Maximum Permissible Dose

A

That amount of ionizing radiation which in the light of
present knowledge will not produce any serious, harmful, or
deleterious effects on the individual receiving it.

85
Q

For lactating mothers:
(3)

A
  • 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
86
Q

Pregnancy
* Can range from
* Tooth — may be present
* (3) is important for your pregnant
patients or those considering becoming
pregnant

A

mild inflammation to severe
overgrowth. The hormonal increase can
exaggerate the gum tissue’s response to
bacterial plaque.
mobility
Prevention, good oral health, and periodontal
maintenance

87
Q

— is the most common oral condition in pregnancy, 60-75% of
pregnant women

A

Gingivitis

88
Q

Pregnancy Gingivitis and Exacerbated Periodontitis affected by:
(3)

A
  • Lack of attention to Oral Hygiene
  • Increased systemic fluid levels from increased progesterone and
    estrogen exacerbate any existing gingival/periodontal condition
89
Q

Pyogenic granuloma
Epulis gravidarum
Pregnancy Tumor
* not an actual granuloma as there is
* forms — and takes the shape a — growth
* in pregnancy, it is an exacerbated response to

A

proliferation of vascular tissues as well proliferation
of fibrous tissue
submucosally, nodular
plaque and bacteria precipitated by the
changes in progesterone and estrogen hormonal levels –

Dental Management of a Complex Patient (13 decks)

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