Oral Manifestations Of Endocrine Disorders Short Notes

Question 1. Dental treatment for a pregnant woman.
(or)
Dental treatment for a gravid mother.
Answer: The physiological changes during pregnancy require special care during dental treatment.

• During the first trimester (conception to 14 weeks):
  • Elective dental procedures should be avoided.
  • In case of emergency, procedures should be carried out with minimum medications or should be avoided if possible.
  • Homecare oral hygiene instructions should be given.
  • Routine radiographs should be avoided.

Read And Learn More: Oral Medicine and Radiology Question And Answers

• During the second trimester (14-28 weeks):
  • The ideal period to carry out dental treatment.
  • The use of medications should be minimized.
• During the third trimester (29 weeks to childbirth):
  • Only emergency dental procedures should be provided.
  • During treatment, the patient should be asked to turn on her left side to avoid supine position hypotension.
  • Appointment should be of short duration.
  • Precautions to be considered:
    • During 2nd and 3rd trimesters, cardiac output decreases in the supine position because of the compressive effect of the gravid uterus on the inferior vena cava, which results in a reduced venous return to the heart.
    • The supine hypotension syndrome (which includes bradycardia, hypotension, and syncope) can be pre¬vented by a left lateral position in the dental chair.
    • Lab reports reveal an elevated count of RBC and WBC, increased ESR, and increased clotting factors 7, 8, 9, and 10 lead to an increased risk of hypercoagulation state and thromboembolism.
    • Many antibiotics and analgesics cross the placenta and cause adverse effects on the fetus. Macrolides antibiotics (erythromycin, azithromycin) and COX- 2 inhibitors (celecoxib and rofecoxib) do not cross the placenta and harm the fetus. The use of metronidazole is also accepted because of its negligible side effects.

Question 2. Oral manifestations of hypothyroidism.
Answer:

• Cretinism: Congenital hypothyroidism is called as cretinism.
  • Delayed eruption of teeth and retained deciduous teeth.
  • An enlarged tongue (macroglossia) and thickening of lips due to deposition of glycosaminoglycans in subcutaneous tissues.
  • The shortened base of the skull, broad face with retraction and flaring of nasal bridges.
  • Underdeveloped mandible and over-developed maxilla.
  • Protruding tongue leads to malocclusion.
  • Impaction of 2nd molar due to altered ramus growth characterized by less than average resorption of internal aspect ramus and thus failure to create space for eruption.

Hypothyroidism Radiographic Finding: Thinned out lamina dura.

Hypothyroidism Clinical Significance:

• Delayed wound healing.
• Severe periodontitis.
• Myxedema: Hypothyroidism in children and adults is known as myxedema. Orofacial findings are limited to soft tissues:
  • Lips, nose, eyelids, and suborbital tissues are swollen and edematous.
  • The tongue is large and edematous leading to speech interference.

Hypothyroidism Dental Consideration:

• Patients with hypothyroidism will manifest:
  • Increased mucopolysaccharides in the subcutaneous tissues will reduce the contractile properties of blood vessels and cause prolonged mucosal bleeding.
  • Delayed wound healing and associated risk for infection.

Question 3. Dental treatment for hypothyroidism patients.
Answer: A detailed thyroid function test and endocrinologist’s opinion should be obtained before starting the dental procedures.

• For patients in a controlled state: Routine dental treatment can be provided. A regular dental check-up is necessary to prevent foci of infection.
• For patients in the uncontrolled state:
  • Surgical procedures in these patients may cause the sudden onset of myxedematous coma characterized by the symptoms of hypotension, hypothermia, slow heart rate, and seizures. If this happens in the dental chair, medical supervision should be immediately provided.
  • There is a probability for these patients to take prophylactic anticoagulation drugs as they are prone to cardiac disorders. Therefore, bleeding time and clotting time should be assessed before procedures that may induce bleeding.
  • Antibiotic prophylaxis is necessary for patients with atrial fibrillation.
  • Local anesthetics with vasoconstrictors should be avoided.

Question 4. Oral manifestations of hyperthyroidism.
Answer:

• Hyperthyroidism: In children, the shedding of deciduous teeth occurs earlier than normal with the earlier eruption of permanent teeth.
• In adults:
  • Rapidly progressing periodontitis and dental caries.
  • Burning mouth syndrome
  • Dryness of mouth
  • Alveolar atrophy in the advanced state due to osteoporosis.
• Consideration of dental procedures: Hyper¬thyroidism
  patients may have:
  • Hypertension and tachycardia that require a longer duration of local pressure application following surgical procedures to stop bleeding.
  • Drug-induced leukocytosis requires the patients to be subject for differential blood count before any invasive procedures.
  • Patients taking the antithyroid drug propylthiouracil may have an increased tendency for bleeding because this drug has a vitamin K antagonistic effect.
  • The thyrotoxic crisis is also a potential complication in patients undergoing dental surgical procedures due to stress and anxiety.

Question 5. Dental treatment for hyperthyroidism patients.
Answer: Before starting the dental treatment, a detailed lab investigation should be carried out (T3, T4, and TSH).

• Patients in controlled situations: Dental treatment can be carried out routinely without any particular alterations.
• Care should be taken to avoid stressful situations for the patient. High priority is mandatory to circumvent the anchoretic spread of oral infections.

Patients in uncontrolled situations:

• A complete blood test should be advised to rule out agranulocytosis and prothrombin time to avoid bleeding problems, especially for patients taking propylthiouracil drugs.
• Local anesthetics without vasoconstrictors (epinephrine) should be used. Because in these patients, the myocardium is highly sensitive to the vasoconstrictor effect and leads to cardiac arrhythmias, tremors, and chest pain.
• Surgical procedures should be avoided due to the possibility for stress-induced thyroid crisis (sweating, tachycardia, hypertension, nausea, and vomiting). In emergency dental care, if thyroid crisis symptoms develop, treatment should be discontinued, and medical care should be provided by hospitalizing the patient.
• Adequate pain control is essential to prevent stress-induced complications; hence NSAIDs should be included in the preparatory phase.
• Oral foci of infection should be elimi¬nated.

Question 6. Describe the oral manifestation of hyperparathyroidism.
Answer: Hyperparathyroidism is an endocrine disorder characterized by a generalized disturbance in calcium, phosphate, and bone metabolism due to the increased amount of circulating parathyroid hormone (PTH).

Hyperparathyroidism Mechanism:

Hyperparathyroidism Oral Manifestations:

• Brown tumor (osteitis fibrosa cystic):
  • Brown tumors are non-neoplastic focal lesions of bone due to abnormal bone metabolism in hyper parathyroid conditions. There are localized areas of severe osteoclastic activity and bone resorption.
  • The resorbed bone is filled with fibrous tissues and intermingled with osteoclast-like multinucleated giant cells, hemorrhagic spots, and hemosiderin deposition. The name brown tumor derives from the color caused by areas of hemorrhage and hemosiderin.
  • The occurrence of brown tumors has a preference for women (3:1, female-male ratio) and elder age groups, usually above 50 years, but may involve hyperthyroidism patients of any age. In the oral cavity, brown tumors appear as asymptomatic or mildly painful, exophytic growth that is hard in consistency.
  • Radiologically, brown tumors in the jaw bones appear as well-defined unilocular patterns or as multilocular cyst-like lesions known as osteitis fibrosa cystic. Cortical bone expansion and thinning are common in the mandible.
  • Thin cortices and loss of trabeculae give the characteristic cystic appearance. Bony trabeculae are replaced by vascular connective tissue with the attempted formation of coarse woven bone. Resorbed roots and loss of lamina dura are the associated dental findings.
  • Treatment of brown tumors depends on the control of hyperparathyroidism. The tumor tends to disappear following the treatment of hyperparathyroidism condition. Surgical removal is indicated in resistant cases following endocrine management.

Hyperparathyroidism Alveolar Bone:

• Reduction in bone density is due to the replacement of mineralized bony contents by fibrous connective tissues.
• There is a loss of cortical bone and a compensatory expansion of the trabecular bone. The expansion of trabecular bone may lead to increased occurrence of tori in hyperthyroid patients.

Hyperparathyroidism Teeth:

• Gradual loosening and drifting of teeth.
• Radiographically:
  • In developing and erupting teeth—Loss of crypt wall pointed and tapered roots at the apical third are the associated findings.
  • In erupted teeth—Large pulp chambers with pulpal calcification and loss of lamina dura around one or more teeth are common. The cortical bone loss in the region adjacent to tooth leads to the discontinuity of lamina dura and the widening of periodontal space.
• Precaution during dental treatment: Bone fracture is a potential complication, and preventive measures should be taken before extensive dental procedures.

Question 7. Discuss dental considerations for patients on prolonged glucocorticoid therapy.
(or)
Factors to be considered for dental patients on chronic steroid therapy.
(or)
Dental consideration for Cushing’s syndrome patients.
Answer: Patients on long-term glucocorticoid therapy have:

Defective Hemostasis:

• Decreased subcutaneous collagen and fibroblasts derived extracellular proteins. This deficient amount of collagen fibrils and proteins leads to easy bruising and bleeding.
• Defective constriction of small blood vessels during bleeding results in prolonged bleeding.
• Poor wound healing and scar formation.

Risk Of Infection:

• Increased susceptibility to infection and are considered as immunocompromised.
• More likely to develop candidiasis and other fungal infections.
• Antibiotic prophylaxis should be considered based on immune status, dosage, and duration of steroid and related dental procedures.

Ability to Withstand Dental Treatment:

• Patients receiving low-dose glucocorticoids (< 30 mg hydrocortisone/day) can withstand dental treatment without additional doses because adrenal suppression will not occur at this dosage.
• Patients on higher doses of corticosteroids (>40 mg hydrocortisone per day) exhibit symptoms of Cushing’s syndrome and have minor difficulties with hemostasis, wound healing, and infections.
• Patients on prolonged glucocorticoid therapy are prone to adrenal insufficiency due to stressful events like invasive dental procedures or exacerbation of dental infections. In such conditions, the adrenal fails to produce adequate cortisol and experience hypotension, nausea, anorexia, dysphoria, wasting, stress-induced shock, and cardiovascular collapse (adrenal crisis).
• Hence patients with adrenal insufficiency require 100 mg of hydrocortisone acetate intramuscular injection 30 minutes before invasive dental procedures.
• For patients who stopped corticosteroid treatment within 2 weeks period: Mainte¬nance of steroid dose is necessary on the day of treatment for anxious patients and for extensive dental procedures.
• For patients who stopped corticosteroid treatment for more than 2 weeks period: No steroid supplement is necessary.
• For patients who are receiving alternate-day corticosteroid treatment: No supplement is necessary if a dental procedure is carried out on the non-corticosteroid day.

For patients taking 30-40 mg of daily corticosteroid:

• The dose should be doubled on the day of extensive dental treatment and if postoperative pain is suspected.
• General precautions:
  • Dental appointments should be given in the morning time to control anxiety.
  • Long-acting anesthetics should be used.
  • Adequate pain control measures should be followed.
  • Patients’ anxiety and stress should be relieved or minimized before the procedure.
  • Antacids may reduce the half-life of prednisone and should be used with care.
  • The risk of bone fracture should be assessed before doing dental surgery for patients on prolonged corticoste¬roid therapy.

Question 8. Discuss endocrine pigmentation.
Answer:

• Addison’s disease (primary adrenal cortical insufficiency) and Cushing’s syndrome (pituitary-based cortisol excess) are associated with cutaneous and oral, perioral pigmentations.
• Addison’s disease: Bronze skin and oral melanotic patches are the characteristic signs.
• Overproduction of adrenocorticotrophic hormone (ACTH has melanocyte exciting action) causes excess melanin deposits on skin and mucosa.

• The pigmentation often starts earlier than other manifestations by months to years. Usually generalized and more prominent in sun-exposed regions. In the oral cavity, pigmentation is noted in the buccal mucosa, lip, and gingival margins.
• Cushing’s syndrome: The skin appears tanned, and the gingiva, palate, and buccal mucosa are blotchy and pigmented.

Question 9. Adrenal crisis.
Answer:

Acute adrenal insufficiency is known as Addi-son’s crisis or adrenal crisis. Acute stress is the cause of the adrenal crisis and is due to:

• Acute physiological stress—This increases the metabolic demand for corticoids. Cortex cannot produce this increased amount and the corticosteroid dose (exogenous) should be increased.
• Infection—Alters the host’s inflammatory response and hence leads to critical conditions.
• Acute withdrawal of long-term steroid therapy.
• Adrenal crisis is manifested as nausea, vomiting, dehydration, hypotension, and circulatory collapse.
• In patients taking 30 mg or above cortisol equivalent for more than 2 weeks duration, the hypothalamic—pituitary—adrenal axis may become suppressed. A functional ability to respond to stress may return within 2 weeks to 1 month, but for complete recovery, it may take up to 12 months.

Adrenal Crisis Dental Consideration:

• When treating dental patients under steroid therapy, the procedures that involve soft tissue manipulation and the chances of developing postoperative wound infection should be minimized by following atrau¬matic and aseptic protocols.
• Presurgical antibiotic prophylaxis should be considered.
• Penicillin V potassium 2 g 1 hour before the procedure and then 500 mg every 8 hours for 7 days.

Adrenal Crisis Medical Management:

• Blood pressure monitoring before, during, and after dental procedure.
• Fluid replacement for hypotension.
• Dexamethasone 4 mg 4 or IM.

Question 10. Tetany.
Answer:

• Tetany represents low-level blood calcium (hypocalcemia) and is characterized by mild symptoms like perioral numbness, muscular spasm, or paresthesias of extremities and severe symptoms like laryngospasm, generalized muscle cramps, seizures, or even myocardial dysfunction.
• It can also occur in case of severe alkalosis (When the blood is highly alkaline). Magnesium deficiency is also is a contributory factor and hypokalemia in the absence of alkalosis may also cause tetany.
• Trousseau’s sign and Chvostek’s sign are clinical tests to diagnose latent tetany.

Tetany Trousseau’s Sign:

• A blood pressure cuff is placed on the arm and inflated to a pressure higher than the systolic pressure and held in place for 3 minutes. This will occlude the brachial artery and stops blood flow.
• In hypocalcemic patients, the subsequent neuromuscular irritability will induce spasms of the hand and forearm muscles. This sign is also known as “main accoucheur” — (French for the hand of the obstetrician).

Tetany Chvostek Sign:

• It is an abnormal reaction to a stimulus on the 7th cranial nerve.
• The simple tapping at the angle of the mandible, causes the facial nerves to become hyperexcitable and twitching of the same side facial muscles, especially of the nose and lips.
• The underlying mechanism for this is hypocalcemia due to either hypoparathyroidism, pseudo-hypoparathyroidism, or hypovitaminosis D.

Tetany Management: One or two 10 mL ampoules of 10% calcium gluconate diluted in 50-100 mL of 5% dex¬trose and infused slowly over 10 minutes as an initial treatment followed by repeated administrations to prevent the recurrence of hypocalcemia.

Question 11. Discuss multiple endocrine neoplasia syndrome.
Answer: Multiple endocrine neoplasias (MEN) syndrome is a group of familial syndromes and is characterized by the occurrence of neoplastic changes in many endocrine glands of the affected person.

It has four types:

1. MEN type 1:
   • Neoplasia of pancreatic islets, adrenal cortex, parathyroid and pituitary glands.
   • In addition, it comprises Zollinger-Ellison syndrome (multiple primary gastrin-secreting adenomas or adenosarcomas in the pancreas, duodenum, and extra-abdominal sites).
2. MEN type 2 A: It is characterized by the occurrence of medullary carcinoma of the thyroid, pheochromocytoma, adenoma or hyperplasia of the parathyroid gland.
3. MEN type 2 B or MEN type 3:
   • Multiple neuromas of commissural lip mucosa, tongue, buccal, nasal, conjunctival, and pharyngeal mucosa in association with endocrine neoplasia are hence known as multiple mucosal neuroma syndrome.
   • Thickening of lip giving rise to characteristic bumpy or blubbery lip appearance, cafe-au-lait spots, and marfanoid habitus is other characteristic findings.
4. MEN type 4: Rare condition and is characterized by tumors occurring in two or more endocrine glands and sometimes cause tumor occurrence in the nonendocrine organs like renal and reproductive organs.

• Oral inference: The presence of oral mucosal neuromas and familial history of carcinoma of the thyroid or pheochromocytoma gives a diagnostic clue for MEN 3 and guidance for early management.