oral path 7B

the adrenal glands made up of 2 parts

are the adrenal cortex and adrenal medulla. The cortex produces corticosteroids while the medulla produces catecholamines.

medulla

inner part of the gland,

Used in  conjunction with the sympathetic nervous system

Secretes epinephrine (adrenaline) and norepinephrine which are involved in the body's fight-or-flight response.

adrenal cortex

outer part of the adrenal glands, responsible for producing corticosteroids such as cortisol and aldosterone, which regulate metabolism and blood pressure.

mineralcorticoids

Aldosterone

Regulates electrolyte balance by causing kidneys to reabsorb sodium and secrete potassium

glucocorticoids

cortisol, cortisione, corticosterone

act as a cardiac stimulant

induces the release of vasocontrictive substances

Glucocorticoids continued

Regulates carbohydrate, lipid, and protein metabolism

Inhibits the effects of insulin

Increases red blood cell and platelet levels

Acts as a strong anti-inflammatory agents

androgens

Dehydroepiandrosterone (DHEA), androstenedione (converted to testosterone in peripheral tissues)

• Maturation of sex organs

• Secondary sex characteristics

• Spermatogenesis

• Maintenance of various tissues including: nervous, skeletal, muscle, skin, and hair

Estrogen

Estradiol, estrone, estriol

Maturation of sex organs

Secondary sex characteristics

Maintenance of the menstrual cycle and pregnancy

Maintenance of bone density

Various metabolic effects on numerous systems

Disorders associated with either excess or deficient hormones

adrenocortical insufficiency

•Adrenal gland consists of cortex (??) and a medulla (??)

cortex produces; steroid hormone producer

medulla produces; adrenaline

Primary Adrenal Insufficiency (Addison's Disease)

•Insufficient cortical hormones, high levels of ACTH

•Autoimmune destruction (common in US),  TB infection (globally),  cancer, hemorrhage associated with anticoagulants, opportunistic infections, trauma

Secondary Adrenal Insufficiency

•Sudden withdrawal of ingested or injected steroids

•Pituitary or hypothalamus disorders

extraoral characteristics for addison’s

•Weakness, fatigue, weight loss

•Abdominal pain, diarrhea/constipation

•Syncope

•Bronzing of the skin, exposed areas, and areas affected by friction

•Elevated levels of ACTH

•Hypoglycemia (low blood glucose level)

EO for secondary adrenocortical insufficiency

•No bronzing, elevated ACTH not present

•Pituitary doesn’t need to produce ACTH

•Cells in adrenal cortex become atrophied

•Weaning off of steroids necessary

Adrenocortical Insufficiency perioral and intraoral characteristics

•Hyperpigmentation of gingival/mucosal tissues

•Brown, black, blue discolorations

•Bronzing of the facial skin

•Hyperpigmentation is a feature of Addison disease but not of secondary adrenal insufficiency

dental implications for ACI (Adrenocortical Insufficiency)

•Identification of characteristic features and related medical history findings

•Referral for evaluation

Acute Adrenal Insufficiency
or Adrenal Crisis

•Life threating

•Caused by a sudden physiologically stressful event (surgery/trauma) in an individual with chronic adrenal insufficiency

Symptoms of acute adrenal insufficiency or adrenal crisis

•Weakness

•Vomiting

•Abdominal pain

•Confusion

•Low BP

•Tachycardia

•Lethargy

•Vascular collapse

•Loss of consciousness

Coma- death

Hyperadrenalism (adrenal gland disorder) aka???

•Also called Cushing's Syndrome

•Usually related to use of steroids (topical, inhaled, or ingested) for treating other medical condition (Exogenous)

•Can be caused by tumors of pituitary or adrenal gland (Endogenous)

•No matter the cause, the clinical characteristics the same

hyperadrenalism EO characteristics

•Classic ‘cushingoid’ features

•Fat deposits in the abdomen, above the clavicles, upper back (buffalo hump)

•Thinning or atrophy of the skin, rapid weight gain, purple striae or stretch marks

•Osteoporosis, diabetes mellitus, stomach ulcers, depression, vision problems

Hyperadrenalism

perioral and intraoral characteristics

•Moon face’ or round, full face caused by edema

•Patients are at a higher risk of developing oral or pharyngeal fungal infections (candidiasis)

dental implications for hyperadrenalism

Dental implications

•Review medical/dental/drug histories for conditions commonly treated with steroid therapy, past and present.

•Obtain medical consultation if in doubt as to the need for supplemental steroids prior to dental treatment

•Treat fungal infections aggressively

Air polishing contraindicated (sodium bicarbonate based

the pancreas functions as an?

endocrine and exocrine gland

pancreas endocrine function?

islets of langerhans produces insulin

hormones reg the metabolism of carbs, fats, and protein

pancreas exocrine function?

pancreas produces digestive enzymes

Reduces acidity of food substances in the duodenum = proper digestive enzyme function

Pancreatic Disorder

Diabetes mellitus

•Most common disorder of the endocrine pancreas

•Metabolic disorders

•Characterized by hyperglycemia

•Failure of β (beta) cells to produce insulin

•Inability of the body to use insulin (insulin resistance)

•Leads to chronic disorders:

•Microangiopathy (small vessels and capillaries)

•Neuropathy

•Macrovascular disease (large vessels)

classes of diabetes mellitus (4 major ones)

type 1, type 2, gestational, and prediabetes

•Other genetic syndromes sometimes associated with diabetes

down syndrome

turner syndrome

Large portion of population has diabetes

aprox 9.3% of population in canada

•Incidence of different diabetes

•Type I approx.  5-10%

•Type II approx. 90-95%

•All other except gestational 1-5%

how to test Diabetes mellitus (3 ways)

1.Fasting plasma glucose (FPG)

2.Oral glucose tolerance test (OGTT)

3.Glycated hemoglobin test (A1C)

glucose tests

A1C (hemoglobin A1C): measures how much glucose binds to HbA1c (a specific type of hemoglobin) during life of red blood cell.  7% and below are targets for an individual with diabetes

FPG: you fast for 8 hours then have blood sample taken to test for plasma glucose levels (normal 80 to 100 mg/dl)

OGTT (Oral glucose tolerance test): usually used to test gestational diabetes.  Fasting blood taken, then you will drink syrupy substance and wait two hours.  Blood samples taken at 1 and 2 hours to check blood glucose levels

Glycosylation and AGE

•process where glucose normally binds to substances (i.e. proteins, lipids and nucleic acids)

usually in reversible way

•Chronic hyperglycemia leads to irreversible binding of glucose to proteins, lipids, nucleic acids

•Substances that are permanently changed by this process are collectively called AGE’s

•Play an important role in the destructive nature of diabetes

Diabetes Mellitus Type 1

•Autoimmune destruction of β-cells in islets of Langerhans, strong genetic predisposition

90% of the Islets are destroyed before the disease is clinically apparent

Presents mostly as a medical emergency- diabetic ketoacidosis

Classic Symptoms: DM type 1

•Polydipsia- excessive thirst

•Polyuria- excessive urination

•Polyphagia - excessive hunger/eating

Persistent hyperglycemia affects all organ systems, especially the

eyes and vascular system

EO of type 1

Extra oral characteristics

•Three classic signs of hyperglycemia (previous slide)

•Thin or normal weight

•Flu-like symptoms

•Weakness, fatigue

•Frequent infections

•Slow wound healing

•Ketoacidosis (DKA)

Acute Complications of DM type 1: Hypoglycemia

•Also called insulin reaction or insulin shock

•Results from having or taking too much insulin, not eating enough food, strenuous exercise, extreme stress

•Most common in Type 1 diabetes

•Altered consciousness, coma, death

•Hypoglycemic unawareness often seen in children, diabetics on various BP & heart meds

Acute Complications DM type 1: Diabetic Ketoacidosis (DKA)

•Excessive hyperglycemia

•Body can’t metabolize sugars for energy, it breaks down fat

•Increases the fatty acids in the blood, causing liver to make ketones to build up in blood causing acidosis

•Symptoms include acetone or fruity breath odor, dry mouth, fatigue, hypotension, increased rate and depth of respiration, nausea, vomiting, coma and eventual death

Long Term Complications

neuropathy DM type 1

Neuropathy

•Peripheral neuropathy

•Autonomic neuropathy

long term complication of DM type 1 microvascular changes

Microvascular changes

•Retinopathy, blindness

•Nephropathy (kidney failure)

•Foot problems (ulcerations, bone deformities)

•PERIODONTAL DISEASE

DM type 1

long term complication

macrovascular disease

•Atherosclerosis

•Coronary artery disease

•Thrombus formation

•Peripheral vascular disease (amputation of lower extremities)

•Stroke

•Hypertension

long term muscoskeletal DM type 1

•Osteoporosis/osteopenia

•Frozen shoulder

•Carpal tunnel syndrome

•Limited joint mobility (skin thickening, decreased connective tissue elasticity)

•Altered host response type 1 DM

•Infection (skin, urinary tract, PERIODONTAL DISEASE)

DM type 1 perioral and intraoral characteristics

•Often seen in those unable to maintain control of blood glucose

•Periodontal disease (2-3 X more likely)

•Other severe oral infections (perio abscess, fungal)

•Parotid enlargement

•Possible xerostomia

•Burning mouth syndrome

•Higher rates of caries (uncontrolled )

dental implications type 1 DM

•Medical referral for patients that present with signs/symptoms

•Glucose levels should be checked before treatment (ask patient)

•Sugar should be kept close by for hypoglycemic events

•Results of patients most recent A1C test should be noted as it indicates how well patient controlling blood glucose (A1C results greater than 9% are absolutely associated with gum disease)

•Individualized OHI and Tx plans based on patient need

•Patient education and reinforcement of sticking with recommended diet

•Finish scale in one area before moving on to next due to high risk of periodontal abscess

risk factors for type 2 DM

•Obesity

•Family history

•Prior gestational diabetes

•Impaired glucose metabolism

•Hypertension

Physical inactivity

Race/ethnicity

Older age (>45)

Polycystic ovary syndrome

Diabetes Mellitus Type 2
EO characteristics

•90% of type 2 diabetics are obese or overweight

•Vague symptoms progress slowly from mild to severe

•May go unnoticed by the patient/physician

•May be suffering from varying degrees of long-term complications at diagnosis

•Recurrent infections, non-healing sores, visible sores and numbness in the extremities are indicators

acute complications for type 2

1.Hypoglycemia (Same as in Type I, more subtle)

2.Hyperosmolar Hyperglycemic State (HHS)

•Manifest with high levels of blood glucose

•Severe dehydration

•Low blood volume, and low blood flow to organs

•Leads to coma and death if not reversed

•Often seen in older individuals with comorbidities

3.Long term complications same as Type I

DM type 2 perioral/intraoral

•Parotid gland enlargement

•Xerostomia

•Burning mouth syndrome

•Higher caries risk (poor control)

•2-3 times more likely to have periodontal infections and also more severe infections than someone without diabetes

•Increased risk for periodontal abscesses

•Increased risk of fungal infections (candidiasis)

type 2 dental implications

•Medical referral to evaluate a patient who presents with oral signs

•Glucose levels should be checked before treatment (ask patient)

•Sugar should be kept close by for hypoglycemic events

•Results of patients most recent A1C test should be noted as it indicates how well patient controlling blood glucose (A1C results greater than 9% associated with gum disease)

•Individualized OHI and Tx plans based on patient need

•Patient education & reinforcement of sticking with recommended diet

oral care for type 2

•DH treatment should stress thorough periodontal debridement with little trauma.

•High risk of developing periodontal abscesses, complete periodontal debridement  in one area before moving to next

•Tx of xerostomia, burning mouth syndrome, and fungal infections should be aggressive, with steps taken to prevent recurrence

•Uncontrolled blood sugar, uncontrolled infection cycle

prediabetes

•have an elevated glucose level but not to the point they are classed as a Type 2 diabetic (warning sign)

•Genetic and environmental factors influence the development of prediabetes

EO for prediabetes

Extra oral characteristics

•Acanthosis nigricans or hyperpigmentation of the skin of the neck, axillae, and groin area associated with:

•High levels of insulin

•Obesity

•Diabetes

•Other endocrine disorders

•May present prior to clinical signs, screening tool

•Refer for medical evaluation.

perio/intraoral for prediabetes and dental implications

Perioral/intraoral characteristics

All of the oral problems associated with type 1 or 2 diabetes may manifest in these patients

Dental implications

Recognition of an individual at risk of prediabetes and prompt referral may prevent chronic complications from developing

•Glucose intolerance detected during pregnancy (2-10% of all pregnancies)

•Seen in women who have

•A family history of diabetes

•Had previously unsuccessful pregnancies

•Delivered large babies or delivered 5 or more babies

•Older maternal age

•Ethnic origin associated with higher risk for type 2

•Obesity

gestational diabetes (GMD)