special patient endocrine and metabolic disorders

diabetes mellitus considerations

• condition that affects all ages

• can lead to vascular disease and metabolic complications

• untreated DM leads to retinopathy and nephropathy

• there is a bidirectional relationship between DM and oral health as blood glucose levels rise, so do the glucose levels of saliva hence making the patient more susceptible to caries

normal blood glucose level

• below 125 mg/dL

• anything 200 mg or higher is considered diabetic while 140 is considered prediabetes

diabetes melltius

• group of metabolic diseases characterized by high blood glycose and the inability to produce and/or use insulin

diabetes relevance to dentistry

•Bidirectional relationship with oral health

•Hyperglycemia, ketoacidosis, vascular wall disease contribute to decreased ability to fight infection and poor wound healing

type I diabetes

•Onset during childhood or adolescence insulin deficiency caused by destruction of pancreatic beta cells; genetic condition and autoimmune mediated.

• sudden onset of signs and symptoms at any age, but usually before age 40

type II diabetes

•Adult onset; insulin resistance and insulin deficiency due to defects in insulin receptors. Obesity, unhealthy lifestyle, and poor diet care associated with Type _

gestational diabetes

•abnormal glucose tolerance first appearing or detected during pregnancy; obesity is a risk factor; causes increase in size of baby and increases risk for miscarriage.

other specific types of diabetes

•results from defects in beta cell function and other diseases and infections (cancer, thyroid disease, inflammation)

signs and symptoms of type I diabetes

• Polydipsia

• Polyuria

• Polyphagia

• Weight loss, Loss of strength, Malaise, Irritability, Drowsiness, Bed wetting

• Blurred vision

• Ketoacidosis, which presents as:

  • Vomiting

  • Abdominal pain

  • Nausea

  • Tachypnea

  • Paralysis

  • Loss of consciousness

signs and symptoms of type II diabetes

• Onset >age 40 and associated with obesity

• Polydipsia, polyuria, polyphagia, weight loss, loss of strength are less common

• Frequent signs include: Slight weight changes (loss or gain), GI upset, Nausea, Nighttime urination

• Blurred or decreased vision, Paresthesia, Dry flushed skin , Loss of sensation, impotence, Vulvar pruritus, postural hypotension

testing for diabetes mellitus

• Testing is recommended based on age and risk factors for the disease.  Age >45 should get tested every 3 years.

• Diagnosis is made based on level of blood glucose upon random sampling, after fasting, or after a glucose tolerance test.

• Another way to test is by using the glycosylated hemoglobin test-shows average level of control over 2-3 months (HbA_1c)

medical management of type I diabetes

• goal is to mimic physiologic insulin secretion

•Patients who have Type I diabetes primarily use insulin to medically manage the condition.

•May take Parmlintide which is a synthetic amino acid that has been found to control blood glucose levels

•Dosage is designed to closely replicate natural insulin secretion

•May be rapid acting, short acting, intermediate acting, long acting, or a combination based on patient need.

•Regimen may change based on patient’s diet, glucose intake, and insulin needs

•May be delivered through self- injection or by continuous subcutaneous infusion using a pump.

insulin shock

• not enough calories + normal insulin dose = excess insulin

• Patients who take insulin are at risk for insulin shock if they do not maintain their diets as the insulin is prescribed to support.

• Results in hypoglycemia referred to as insulin shock. Symptoms may include:

• Hunger, weakness, trembling, tachycardia, pallor and sweating

• As it gets worse, the patient may become incoherent, uncooperative, and belligerent and lack judgment and orientation- may cause injury to themselves or others in the area

• The severe stage results in unconsciousness and possible tonic or clonic muscle movements accompanied by sweating, pallor, rapid pulse, hypotension and hypothermia.

medical management of type II diabetes

• goal is to manage glycemic control, treat associated condition, and manage complications

• Begins with lifestyle modifications- diet, weight loss, reduction in risk factors for CVD

• Oral glucose lowering agents may be used alone or in conjunction with insulin therapy

• As condition progresses therapeutic needs change. 

glucose lowering agents

•Biguanides- reduce glucose production in the liver and causes a slight increase in the body’s ability to use glucose for energy.  Metformin is a common drug in this class.

•Insulin Secretagogues- Sulfonylureas; stimulate insulin production by interacting with a component of the beta cells. Should be taken before a meal. Glipizide and Glyburide are commonly prescribed drugs in this class.

•Glinides work similarly to sulfonylureas, but they work faster and for a shorter time.

•Incretins- amplify the amount of insulin created when glucose is present. Victoza is popular because there are a lot of ads for it on tv. Ozempic is popular because physicians prescribe it for weight loss for individuals who do not have diabetes

•Sodium-Glucose Co-Transporter 2 inhibitors- Inhibit glucose reabsorption, lowers renal threshold for glucose and increases glucose excreted in the urine. Farxiga and Jardiance are popular due to tv ads.

dental management of patients with diabetes

• Evaluate for cardinal signs and symptoms- if no diagnosis and symptoms are present, dismiss and refer to MD

• Suspect DM if patient presents with headache, dry mouth, irritability, repeated skin infections, blurred vision, paresthesia, progressive periodontal disease, abscesses, loss of sensation- dismiss and refer to MD for testing

• Well controlled patients can receive treatment as indicated

• If DM has been diagnosed, fasting blood glucose level 126+ or HbA1c is >7 should not be treated- refer to MD

if patient reports a diagnosis of DM, follow up questions may include

• Type and when diagnosed

• Type of treatment- name, dosage, when taken, compliance

• Insulin dependent- ask how much they use and how often they inject themselves

• Current or previous complications or insulin/medication reactions- dismiss if frequent

• Do you monitor your blood glucose level? How? How often? Dismiss if no regular monitoring

• Latest blood glucose level and latest HbA1c levels Dismiss if patient cannot provide

• How often do you see your physician for this and how often do you have your HbA1c checked? Dismiss if last appt. >6 months

• Have you eaten today, what time, what did you eat?

• Advise patient to let you know during appointment if they experience insulin reaction

diabetes mellitus and drug interactions

• NSAIDs can enhance the effects of sulfonylureas- consult with physician prior to recommending

• Insulin dependent/uncontrolled may require antibiotic premedication- consult with physician

• Anesthesia- epinephrine is ok but could raise blood glucose level; use caution if patient has other conditions such as CVD

oral manifestations of diabetes mellitus

• Xerostomia

• Infections- bacterial, viral, fungal

• Poor wound healing

• Increased caries

• Gingivitis

• Periodontal disease

• Cheilosis

• Enlarged salivary glands

• Increased glucose in saliva

• Abscesses

• Burning mouth

thyroid gland function

• Secretes T₄, T₃, & calcitonin (thyroid hormones)

• Affects growth and maturation of tissues, cell respiration, & energy expenditure

Goiter

generalized enlargement of the thyroid gland

thyrotoxicosis

Excess of T_{4 and} T₃  in the blood; aka hyperthyroidism

Graves disease

•autoimmune disease associated with excess thyroid hormones and enlarged thyroid

hypothyroidism

low T_{4 and} T₃ blood plasma levels

Myxedema

severe hypothyroidism; dermatologic changes that occur with hypothyroidism

Hashimoto thyroiditis-

autoimmune disorder that causes hypothyroidism

thyroiditis

inflammation of the thyroid

•Most often caused by an autoimmune disorder manifesting as an asymptomatic goiter knowns as Hashimoto disease

•Affects young and middle-aged women most often

•Progresses to hypothyroidism

•Goiter is the main symptom

•The thyroid may become enlarged and firm with a nodular consistency

•Small goiters do not require treatment; larger goiters are treated with thyroid hormone replacement and may be surgically removed.

hyperthyroidism

•Commonly associated with Graves disease, toxic nodular goiter, or acute thyroiditis

•May be caused by eating large quantities of certain ground beef or functional ectopic thyroid tissue

•May be continuous or cyclic

•Causes nervousness, fatigue, heart palpitations, heat intolerance and weight loss, sweating, soft fingernails, thin hair

•Skin is warm, complexion is rosy, patient easily blushes

•Graves ophthalmopathy- edema and inflammation in extraocular muscles leading to eyelid retraction, proptosis, periorbital edema, chemosis, and bilateral exophthalmos.

•Other symptoms involving the eye include staring, infrequent blinking, jerky eyelid movements, failure to wrinkle the brow when gazing upward

•May result in loss of vision

thyroid storm

•potential emergency if condition is not controlled; results in restlessness, fever, tachycardia, pulmonary edema, tremor, sweating, stupor, coma and death

patient considerations hyperthyroidism

•Patients may be nervous and easily lose their temper or cry

•Have difficulty sitting still- constant movement

•Hand and tongue tremor may be present

•Radiographs may show increased bone loss due to excretion of calcium in urine

•Maybe be intolerant to glucose

medical management of hyperthyroidism

• Anti-thyroid agents- Propylthiouracil and Methimazole

• Radioactive iodine (RAI)

• Thyroidectomy (after antithyroid drug treatment)

• Management of thyrotoxic crisis as indicated- serious complication of hyperthyroid treatment.

dental management of hyperthyroid patients

• Risk for infection is no greater; consult with physician if the patient is not controlled before treating an infection

• Bleeding is not a concern unless taking Coumadin

• Able to provide care if controlled; risk of thyroid storm medical emergency is not controlled

• Epinephrine is ok if the condition is controlled- consult with physician if not controlled

• Be prepared to manage thyroid storm by recognizing the signs; activate emergency medical treatment and call 911

oral manifestations hyperthyroidism

• Children- teeth and jaws develop fast

• Deciduous teeth are lost early, and permanent teeth erupt early

• Babies may have teeth at birth

• Lingual thyroid may be present

• May develop periodontal disease and caries more rapidly

• Possible change in taste and smell

oral manifestations of thyroiditis

• Salivary gland disfunction

• Dry mouth

• Pain radiating to the ear, jaw, or eyes

• Hoarseness

• Dysphagia

• Enlarged, firm, nodular, tender thyroid

hypothyroidism signs and symptoms in older children/adults

• Dull expression

• Puffy eyelids

• Alopecia of eyebrows

• Dry rough skin

• Dry, brittle hair

• Increased tongue size

• Slowing of activity

• Slurred hoarse speech

• Anemia

• Constipation

• Increased sensitivity to cold

• Weight gain

• Muscle weakness

• Deafness

hypothyroidism signs and symptoms in neonatal

• Dwarfism

• Overweight

• Facial features

• Poor muscle tone

• Pale skin

• Stubby hands

• Retarded bone age

• Delayed teeth eruption

• Malocclusion

• Hoarse cry

• Umbilical hernia

• Mental retardation

medical management of hypothyroidism

• synthetic thyroid hormone

• Sodium levothyroxine (LT4)

• sodium liothyronine (LT3)

• Results in need for lower insulin or glucose lowering medications for patients who have diabetes

• Myxedema may lead to CHF; Levothyroxine can help this subside.

• Hypothyroidism causes sensitivity to narcotics, barbiturates, and tranquilizers

• Smoking makes condition worse

• myxedema coma

myxedema coma

• brought on by stressful situations in untreated hypothyroid patients

• High mortality

• Treated by levothyroxine injection

dental management hypothyroid

• No antibiotics if uncontrolled- risk for myxedema coma

• Risk for bleeding- minimal

• Do not treat if not controlled or no medical management- may result in myxedematous coma

• If uncontrolled/untreated patient may experience exaggerated response to some drugs

• Be prepared to manage medical emergency- myxedema coma; know signs and symptoms

oral manifestations of hypothyroidism

• Thick lip-  infants

• Enlarged tongue- infants and adults

• Low salivary flow- adults

• Dysgeusia

• Delayed eruption

• Poor periodontal health

• Altered tooth morphology

• Delayed wound healing

thyroid cancer

•Caused by receiving cervical radiation in childhood including multiple dental x-rays before 1970 and mandibular imaging

•History of thyroiditis, very high or low iodine intake, and family history of thyroid cancer are risk factors

•Cancer from other areas may metastasize to the thyroid

•May present as firm irregularly shaped nodules in the thyroid that are fixed to the underlying tissue, hard painless max, attached to other local structures, enlarged lymph nodes

•Diagnosed after ultrasound and biopsy

•Treated surgically with lobectomy or complete thyroid removal

hyperadrenalism

•Cushing Syndrome- excessive cortisol production from any cause

•Cushing Disease- excessive cortisol production caused by pathology

adrenal insufficiency

•Primary- Addison disease is caused by adrenal gland removal or adrenal cortex destruction

•Secondary- Caused by problems with the pituitary gland

•Tertiary- caused by issues with the hypothalamus

cushings disease signs and symptoms

•Weight gain

•Broad/round face

•Buffalo hump on upper back

•Abdominal striae (stretch marks)

•Hypertension

•Hirsutism

•Acne

•Glucose intolerance and impaired healing

•Osteoporosis

•Psychiatric disorders

addisons disease signs and symptoms

•Impaired glucose metabolism

•Hypotension

•Impaired fluid excretion

•Hypovolemia

•Hyperkalemia

•Acidosis

medical management of addison’s disease

Hormone replacement is required for the rest of the patient’s life

•Dosage will correspond with amount body normally would produce

•Given in two doses so the levels are like they would be a certain times of the day

•Diet should include enough sodium and patients monitor BP

adrenal crisis

LIFE THREATENING EMERGENCY

• May occur when someone who has adrenal insufficiency (Addison Disease) is in a stressful situation, has had surgery, or has an infection.

• The lack of glucocorticoid prevents the body from dealing with the situation.

• Must immediately stop whatever is causing it and administer glucocorticoid

dental management and oral manifestations of adrenal conditions

•Patients can receive treatment, but highest risk is those with primary insufficiency (Addison)

•Recommendation for supplemental glucocorticoid comes from physician- not usually indicated for DH care

•Monitor BP during invasive procedures

•If patient is hypotensive adjust chair, give fluids, and activate medical emergency procedures

•Addison- Mucous membranes may have brown macules