Endocrine & Metabolic Disease

Dental Management

Refer to physician for diagnosis & treatment if they are undiagnosed, but show signs of diabetes.

Chart the disease, if known, and all complications involved

Take vitals to control and manage disease

patients with controlled diabetes need little to no special attention during dental treatment

Consult with physician if not under control

patients should take their usual insulin dosage and eat normal meals before their dental appt, which is best to schedule in the morning

Keep a source of sugar close by during treatment

follow up: inspect for oral lesions as a way to monitor for disease progression. Poor periodontal health is associated with poor glycemic control.

Medical Management

strict glycemic control established through regular monitoring reduces vascular and ocular complications

no cure

modified nutrient intake

weight reduction

oral hypoglycemic medications

insulin injections and pumps

medications for vascular, kidney and ocular complications, including antihypertensive drugs.

Signs & Symptoms

type 1:

5-10% of cases

onset before age 15

polydipsia, polyphagia, polyuria

weight loss

loss of strength

irritability

bed wetting

drowsiness

skin infections

dry mouth

type 2:

90-95% of cases

onset over 40 years old

obese

rate of onset: slow

slight weight loss or gain

Gastrointestinal upset

nausea

blurred vision

dry flushed skin

loss of sensation

postural hypotension

Classifications of Diabetes

Type 1:
-Beta cell destruction, usually leading to absolute insulin deficiency.
-immune-mediated: presence of islet cell or insulin antibodies that identify the autoimmune process, leading to beta cell destruction
-Idiopathic: no evidence of autoimmunity

Type 2:
-Insulin resistance with relative insulin deficiency/insulin secretory defect with insulin resistance

Gestational:
-any degree of abnormal glucose tolerance during pregnancy diabetes.

Dental management

Avoid epinephrine in patients with poorly controlled disease

look for signs of allergic reaction in patients treated with antithyroid meds

excessive bleeding may occur

may be subject to arrhythmias

thorough EO/IO, especially in thyroid area

avoid CNS depressants and sedatives in patients with poorly controlled disease

treat acute infection aggressively using appropriate antibiotics and incision and drainage when indicated

Use drugs with care because some drugs can increase the metabolism of thyroid replacement drugs

myxedema coma-med emergency: vital signs monitored and seek medical aid

Medical Management

Thyrotoxicosis

antithyroid agents that block hormone synthesis, iodides, radioactive iodine, or subtotal thyroidectomy

large dose of antithyroid drugs for people who have thyrotoxic crisis

hypothyroidism

synthetic preparations that contain sodium levothyroxine or sodium liothyronine

thyroid cancer

surgery to remove thyroid

radioiodine ablation and lifelong thyrotropin suppression achieved through levothyroxine replacement therapy

cervical lymph node dissection

external beam radiotherapy and chemotherapy

Signs & Symptoms

hyperthyroidism

skeletal- osteoporosis

cardiovascular- palpitations, tachycardia, arrhythmias, hypertension, cardiomegaly, congestive heart failure, angina, MI

GI- weight loss, increased appetite, pernicious anemia

CNS- anxiety, restlessness, sleep disturbances, emotional lability, impaired concentration, weakness, tremors

skin- erythema, thin fine hair, areas of alopecia, soft nails

eyes- retraction of upper lid, exophthalmos, corneal ulceration, ocular muscle weakness

other- increased risk for diabetes, decreased serum cholesterol level, increased risk for thrombocytopenia, sweating

hypothyroidism

musculoskeletal- arthritis, muscle cramps

cardiovascular- shortness of breath, hypotension, slow pulse

GI- constipation, anorexia, nausea and vomiting

CNS- mental and physical slowness, sleepiness, headache

general- dry, thick skin/dry hair; fatigue; edema; cold intolerance; hoarseness; weight gain

thyroiditis

Hashimoto's- rubbery firm goiter, hypothyroidism develops later

subacute painful- enlarged, firm, tender gland, pain that may radiate to ear or jaw

acute suppurative- pain, tenderness in gland, fever, malaise

chronic fibrosing- hard, fixed, enlarged gland

subacute painless- firm, nontender, enlarged gland

Dental Management

anxiety and stress increase risk of adrenal crisis, if adrenal insufficiency present--use stress/anxiety reduction techniques

monitor blood pressure throughout stressful procedures. Post-op monitoring for at least 8 hours is recommended after moderate surgery.

hypotension possible- may need to use supine chair position

steroid supplementation for primary adrenal insufficiency during surgical procedures or infection

have emergency medical kit ready

postsurgery patients should be monitored for good fluid balance and adequate blood pressure during the first 24 hours. Tell patient to watch for signs of adrenal crisis.

Medical Management

primary adrenal insufficiency

management of the adrenal disease (elimination of the infectious agent or malignant disease)

hormonal replacement therapy

secondary adrenal insufficiency

correcting the ACTH-dependent disorder and replacing the missing glucocorticoid

steroids are prescribed in the management of nonendocrine, inflammatory, and autoimmune disorders

adrenal crisis

timely diagnosis

immediate treatment

IV injection of a glucocorticoid

fluid and electrolyte replacement

resolution of precipitating event/condition

Signs & symptoms

Hypoadrenalism

Addison's Disease

weakness

fatigue

abdominal pain

hyperpigmentation of the skin and mucous membranes

hypotension

anorexia

salt craving

myalgia

hypoglycemia

weight loss

Hyperadrenalism

Cushing's syndrome

"moon facies"

"buffalo hump"

abdominal striae

hypertension

hirsutism

Subtopic

acne

4 syndromes that are dependent on the adrenal product that is in excess

androgen

Rare, but most commonly affect reproductive organs

estrogen

mineralcorticoid

primary aldosteronism is associated with hypertension, hypokalemia, and dependent edema

cortisol

Dental Management

consult with physician before prescribing antibiotics

acetaminophen is drug of choice for analgesics

avoid most anxiolytics. short-term use of nitrous oxide is permissible if needed. 50% oxygen used.

may have difficulty breathing in supine position

watch for supine hypotension if patient is in supine position; most likely in late 3rd trimester. May need to change chair position

avoid all drugs if possible. If needed, use FDA category A or B, if possible.

make only necessary X-ray exposures; use lead apron and thyroid collar

follow-up evaluation after delivery is recommended to ensure resumption of needed dental care, with radiographic assessment.

oral complications/manifestations

pregnancy gingivitis

fiery red and edematous interdental papillae

gestational diabetes

may be associated with increased risk for periodontal disease

periodontal disease

preeclampsia

preterm birth

low birth weight

hypersensitive gag reflex

halitosis

enamel erosion