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
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
3
Q
Zone: Reticularis
Hormone:
Action
A
Androgens (sex hormones)
Gonads
Sexual maturation, growth and development
4
Q
Hormone: Norepinephrine and epinephrine
Action
A
Fight or flight - stress response
Increases BP, peripheral resistance, cardiac output
5
Q
Hyperadrenalism
A
- ↑Aldosterone, cortisol, androgen, estrogen isolated or in
combination
6
Q
Hyperaldosteronism
A
- Hypertension, hypokalemia, edema
7
Q
Glucocorticoid excess
(2)
A
- MOST COMMON
- High levels of cortisol
8
Q
- High levels of cortisol (2)
A
➢ Cushing disease (pituitary or adrenal tumor)
➢ Cushing syndrome (exogenous corticosteroids)
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
10
Q
Primary adrenal insufficiency
A
- Addison Disease
➢ Destruction of adrenal cortex
o ↓Cortisol and ↑ACTH (adrenocorticotropic
hormone)
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
12
Q
- Addison Disease
Cannot tolerate
A
stress (emotional or physical)
o Adrenal crisis
13
Q
- Addison Disease
Requires
A
cortisol replacement
o Surgery and stress may require
supplemental corticosteroids
o Pain control is important
14
Q
Adrenal insufficiency
* Secondary adrenal insufficiency
(3)
A
➢ Impaired/destructive pituitary disease
➢ ↓Cortisol and ↓ACTH; aldosterone
unchanged
➢ Lower dose replacement therapy
15
Q
Tertiary adrenal insufficiency
(3)
A
➢ Impaired function of hypothalamus
➢ Most commonly a result of chronic
exogenous steroid use
➢ Lower dose replacement therapy
16
Q
Hyperpigmentation and adrenal crisis do not usually occur/less likely with
A
secondary and tertiary adrenal insufficiency
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
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
19
Q
➢ If osteoporosis and osteopenia
o More prone to
o May have history of
A
periodontal bone loss - monitor
bisphosphonate use
20
Q
Impaired wound healing may be a consequence of both (2)
A
hyperadrenalism and
adrenal insufficiency
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
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
23
Q
Adrenal insufficiency
Pain control
(2)
A
o Adequate anesthesia, long-acting agent at end of procedure
o Good post-up pain control
24
Q
Thyroid function
* Involved in (2) processes
* Depends on —
* Thyroid produces – hormones
A
developmental and metabolic
iodide
3
25
T3 and T4
o Controlled by
TSH (pituitary)
26
Calcitonin
o Regulates
o Also influenced by actions of (2)
circulating calcium and phosphorus levels
PTH and Vit D
27
Thyroid disorders
* Thyroid enlargement = Goiter
* May be (2)
* Most are ---
* Hyperthryoidism goiter –
* Hypothyroidism goiter –
functional or non-functional
non-functional (euthyroid)
Graves disease
Hashimoto thyroiditis
28
* Thyroid nodules
(3)
* Hyperplasia
* Adenoma
* Carcinoma
29
Thyroid disorders
* Thyroiditis
* Hashimoto (autoimmune)
30
Hyperthyroidism (thyrotoxicosis)
* Primary –
* Secondary –
Graves disease (auto-immune disease)
Pituitary adenoma
31
Hypothyroidism (congenital or acquired)
* Primary –
* Secondary
* Transient
Graves disease (end-stage)
32
Neoplasia
(2)
* Adenoma
* Carcinoma (papillary, follicular,
33
Hyperthyroidism -- Free T4; -- TSH
↑
↓
34
Hypothyroidism Free --- T4; --- TSH or --- TSH
↓
↓
↑
35
Thyroid
Hyper –
(2)
* Increased periodontal bone loss
* Increased susceptibility to caries
36
Thyroid
Hypo –
(5)
* Delayed tooth eruption and altered bone formation
* Macroglossia
* Dysgeusia and burning mouth
* Salivary gland enlargement
* Oral lichen planus
37
Patients with both hyper and hypothyroidism may be more susceptible
to
infections- treat aggressively
38
Patients with uncontrolled, poorly controlled, suspected hyperthyroidism or
hypothyroism SHOULD NOT receive
dental care until disease is under control
39
Risk of
(3)
* Agranulocytosis from medications used to treat hyperthyroidism
* Thyrotoxic crisis/storm - hyperthyroidism
* Myxedema coma - hypothyroidism
40
* Agranulocytosis from medications used to treat hyperthyroidism
➢ Fever, sore throat, oral ulcers are warning signs
41
* Thyrotoxic crisis/storm - hyperthyroidism
➢ (2)
➢(2)
➢ Administer --
➢ IV ---
➢ Administer ---
➢ Send to --
CPR and vital signs
Ice packs or wet packs
hydrocortisone 100-300 mg
glucose
propylthiouracil
ED
42
* Myxedema coma - hypothyroidism
➢ (2)
➢ Conserve --
➢ Administer --
➢ IV --
➢ Administer --
➢ Send to --
CPR and vital signs
body heat – blanket
hydrocortisone 100-300 mg
saline and glucose
thyroxine
ED
43
Drug interactions/side effects
* In hyperthyroidism
* Caution with aspirin and NSAIDS- can
* Ciprofloxacin contraindicated –
* Avoid local anesthestics containing
increase T4
decreases absorption of thyroid hormone
epinephrine and ginigval retraction cord
with epinephrine in poorly controlled patients
44
Drug interactions/side effects
* In hypothyroidism
* Avoid --- if patient is poorly controlled
* --- should
be avoided – increases metabolism of ---
CNS depressants (narcotics, barbituates, sedatives)
Cytochrome p450 inducers (phenytoin, carbamazepine, and rifampin)
levothyroxine
45
diabetes
2 Main types
* Type 1
* Type 2
* Gestational Diabetes occurs in 2-10% of pregnancies
Diabetes
46
Type 1 diabetes (T1D)
(3)
* Aka juvenile diabetes
* Insulin dependent
* ~10-20% of diabetics
47
Diabetes
* TYPE 1
(3)
* Autoimmune disease
* Destruction of pancreatic β-cells → insulin deficiency
* Non-obese children and adults <40 years old
48
Diabetes
Microvascular
(3)
* Neuropathy – extremities, impotence, bladder dysfunction, gastroparesis
* Retinopathy – cataracts, blindness
* Nephropathy
49
Diabetes
Macrovascular
(3)
* Peripheral vascular disease, congestive heart failure – hypertension
* Myocardial infarction – diabetes accelerates atherosclerosis
* Stroke
50
Diabetes
Impaired wound healing and susceptibility to infection
* --- dysfunction, --- M1:M2 ratio
* Increased --- and increased ---
* Impaired (2)
Neutrophilic, increased
pro-inflammatory cytokines, MMPs
angiogenesis and endothelial dysfunction
51
Type 2 Diabetes
(3)
* 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
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)
* 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
Decrease in gluconeogenesis
(2)
* Biguanide – metformin
* Insulin – rapid (lispro), short (regular -Novolin), long-acting (glargine)
54
Increase in insulin secretion
(2)
* Sulfonylureas –glipizide
* Glucagon-like peptide 1 (GLP1) receptor agonist – exenatide, liraglutide
55
Sensitization to insulin
(1)
* Thiazolidinediones – pioglitazone
56
Decrease in glucagon secretion
(2)
* Dipeptidyl peptidase 4 (DPP4) – sitagliptin
* GLP1 receptor agonist – exenatide, liraglutide
57
Intestinal and renal absorption of glucose
(2)
* Sodium-glucose cotransporter-2 inhibitors – canagliflozin
* 𝛼-glucosidase inhibitor – acarbose
58
diabetes synotons (6)
* 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
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
< 70
> 200
> 8.0%
60
Diabetes
Concerns
Control of comorbidities and drug interactions
(4)
* HTN (refer back to previous lectures for drug interactions)
* HLD
* Other cardiovascular disease (angina, MI, CHF, stroke)
* Renal impairment
61
Diabetes
Considerations
Avoid
* 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
Diabetes
Considerations
Early morning appointments
(3)
* 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
diabetes
Oral sedation not recommended as --- is necessary
fasting
64
Gestational Diabetes
* occurs in ---% of pregnancies
* Fetus can have excess ---
* Affects --- development
* Delivery may require ---
* Treated similar to ---
2-10
weight gain
lung
cesarean section
Type 2 diabetes
65
Pregnancy can be a --- to oral health.
Pregnancy = --- weeks: From the 1st day of last menstrual cycle.
➢ First trimester:
➢ Second trimester:
➢ Third trimester:
stressor
40
0-12 weeks (12 wks)
13-28 weeks (16 wks)
29-40 weeks (12 wks)
66
Dental procedures could harm the developing fetus through
the effects of:
(3)
➢Ionizing Radiation
➢Drugs
- continues post-partum from transmission of drugs via
breast milk
➢Stress
67
Common Pregnancy Discomforts
(7)
➢Nausea and vomiting
➢Indigestion
➢Headaches
➢Polyuria
➢Lumbar pain
➢Perspiration
➢Breast tenderness
68
➢Nausea and vomiting
- hormonal imbalances, stress (physical and emotional)
and hyperacidity
69
➢Indigestion
- difficulties digesting foods rich in fats, sugars, acids
can lead to nausea and vomiting
70
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)
oral
first
drugs
harm the developing fetus and affect the time of delivery
71
Avoid elective dental care during the first
trimester
(3)
* 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
Radiation
* Women of childbearing age
* Inquire if the patient could possibly be
pregnan
73
Radiographs and pregnancy:
* 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
I. New and recall pregnant dental patients:
* 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
II. Emergency pregnant dental patients:
* 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
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
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
In advanced stages of pregnancy (late
third trimester), avoid the supine
position for long periods;
* 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
* Supine hypotension syndrome
* Manifests as:
(4)
* Fall in blood pressure
* Bradycardia
* Sweating
* Nausea
79
Patient can rotate to their
side to
allow venous return
to recover. Studies indicated
80
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
< 30 min and
with at least 50% oxygen
diffusion hypoxia.
Benzos
81
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
3 hours/week
82
IMPORTANT: occupational exposure for women is also a concern.
X-radiation
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
Maximum Permissible Dose
Occupational limits:
Avg. dental occupational exposure is ---
---% of dental workers have readings below the threshold of
detection
1 mSv/yr
0.2 mSv/yr
68
84
Maximum Permissible Dose
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
For lactating mothers:
(3)
* 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
Pregnancy
* Can range from
* Tooth --- may be present
* (3) is important for your pregnant
patients or those considering becoming
pregnant
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
--- is the most common oral condition in pregnancy, 60-75% of
pregnant women
Gingivitis
88
Pregnancy Gingivitis and Exacerbated Periodontitis affected by:
(3)
- Lack of attention to Oral Hygiene
- Increased systemic fluid levels from increased progesterone and
estrogen exacerbate any existing gingival/periodontal condition
89
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
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 –
