endocrine+disorders

=The Influence of Endocrine Disorders on the Periodontium =


 * Endocrine Disorders**

> When the diabetes is controlled whether by medications or lifestyle changes and the individual has good oral home care often these oral changes are not seen. However, when it is uncontrolled the infections can become more severe. The diabetic patient is also more likely to have chronic periodontitis. Diabetes does not cause gingivitis or periodontitis but alters the response of the periodontal tissue to local factors hastening bone loss and slowing down healing.
 * __Diabetes Mellitus__**
 * Diabetes Mellitus (DM) is an endocrine disease where there is an inability of glucose to be transported from the bloodstream to the tissues due to impaired insulin production or insufficient insulin production. Uncontrolled diabetes is associated with microvascular and macrovascular disease, impaired wound healing, and a susceptibility to infections.
 * **Type I**: This type is an autoimmune destruction of the beta cells in the pancreas, which often occurs in young children. Individuals with type I often go into ketosis and coma. This type of diabetes is not preceded by obesity.
 * **Type II:** This type has an impaired insulin secretion, increased glucose production, or a resistance to insulin. This traditionally develops in adulthood, however is becoming increasingly common in American children. This type is typically preceded by obesity and often can be controlled by lifestyle changes.
 * Gestational diabetes also known as pregnancy diabetes it is acquired during pregnancy and usually subsides after giving birth. This type of DM is caused by sufficient amounts of insulin being blocked by pregnancy hormones.
 * Risk factors for DM. Type 2 risk factors include: obesity, not exercising, high blood pressure, high cholesterol, pregnancy, giving birth to a baby weighing more than 9 pounds, being of African-American, American Indian, Asian, Hispanic, or Pacific Islander descent. Type 1 and 2 risk factors are losing weight without trying, dry itchy skin, headache, drowsiness, bed wetting, malaise, sores that heal slowly, losing feeling in extremities, blurry eyesight and the 3 Ps: polyphagia, polydipsia and polyuria.
 * Oral Manifestations: Mucosal drying, cracking and burning of mouth and tongue, diminished salivary flow, alterations in flora of oral cavity, and an increased incidence of caries, abscesses, loosened teeth, gingival bleeding, and periodontitis.
 * Diabetic individuals who are over 45 and smoke are 20 times more likely to develop periodontitis than a person who doesn’t.
 * The oral complications include salivary gland dysfunction which can lead to caries, tooth loss or infection, periodontal disease, tooth loss which can lead to inability to wear prosthetics, taste dysfunction, burning mouth syndrome and lichen planus all of which can lead to nutritional deficiencies and increase the patients risk for a diabetic crisis, such as diabetic shock, ketoacidosis, coma or death. Periodontal disease is often referred to as the 6th complication of DM. DM can increase the host response to local microbial factors such as endotoxins which results in unusually destructive periodontal tissue breakdown.
 * The pathogens that are present in diabetic patient because of the high glucose content in the gingival fluid patients have higher ratios of //Actinobacillus actinomycetemcomitans//, //Porphyromonas gingivalis//, and //Prevotella intermedia//.
 * Insulin resistance has been observed in active inflammatory connective tissue diseases such as DM. Patients with DM usually have an inflamed periodontium, that is very vascular and the ulcerated pocket epithelium can act as a portal to systemic circulation for bacteria and inflammation mediators. The inflammatory mediators produced in chronic periodontitis are interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha. These mediators have been proven to have an influence on glucose and lipid metabolism as well as insulin resistance. There is direct and indirect evidence that supports the fact that periodontal infection adversely affects glycemic control in patients with DM.
 * DM is currently not a curable disease. After being diagnosed with DM therapy must be individualized and customized for each patient for remainder of the patients’ life. The patient will have continuous reevaluations and adjustments made to their therapy.
 * The therapeutic goals are: maintenance of blood glucose levels with out hyperglycemic episodes, attain and control normal body weight, control of hypertension and hyperlipidemia, and to attain a therapy regime that will not dominate the patients life any more than is necessary.
 * A goal of treating a patient with DM that is administering insulin as part of their treatment is to prevent diabetic shock during the dental appointment. Diabetic shock is caused by an excess of insulin, either the patient did not eat or administered too much insulin. There are 3 stages of insulin shock, mild, moderate and severe. The signs and symptoms for mild: hunger, weakness, tachycardia, pallor, sweating and paresthesia, for moderate: incoherence, uncooperativeness, belligerence, lack of judgment, and poor orientation, for severe: unconsciousness, tonic/clonic movements, hypotension, hypothermia and a rapid, thready pulse. This reaction can be corrected by having the patient drink fruit juice or anything with sugar in it.
 * Scheduling: short morning appointments are best for diabetics, also schedule frequent recall visits to monitor, maintain and treat oral complications. When seeing a patient that is taking insulin observe their physical movements and their responses to questions. Important questions for diabetic patient are, Have you eaten? What did you eat? What time did you eat? Did you take your medications? What did you take? When did you take it? Do you monitor your blood glucose levels? When and what was the last reading? After questioning the patient and recording responses the clinician should take the patients blood glucose level before starting treatment. It is also important to instruct the patient to tell you if at anytime during the procedure they feel symptoms of an insulin reaction.). Patients who have not seen their physician for a long time, have renal disease, cardiovascular disease, type 1 DM and are taking large doses of insulin, frequent episodes of diabetic shock or other signs and symptoms of DM should be referred to their physician for a medical consultation and consent prior to treatment due to the fact that a poorly controlled diabetic may require modifications to their existing treatment medications, such as increasing the amount of insulin to prevent hyperglycemia due to the stress or pain involved with dental procedures. Any patient that is going to receive extensive periodontal surgery needs to be given postoperative dietary instructions, the dental clinician should contact the patient’s physician or nutritionist to develop a plan.
 * Local anesthetics may be used on diabetic patients; however, it is important to consider that epinephrine has the opposite reaction of insulin: epinephrine could cause a rise in the patient’s blood glucose level. If a diabetic patient has hypertension, post myocardial infarction or cardiac arrhythmia epinephrine should be administered with caution (Little et al., 2008). Corticosteroids that are usually prescribed for erosive lichen planus should be used with caution as well because corticosteroids can antagonize the action of insulin and also lead to hyperglycemia.


 * __Female Sex Hormones__**

//The Gingiva in Puberty// Puberty is often accompanied by an exaggerated response to plaque. Gingival changes during puberty can include pronounced inflammation, bluish red discoloration, edema, and gingival enlargement. As adulthood approaches, the severity of the gingival reaction decreases. Although the occurrence and severity of gingival disease are increased during puberty, gingivitis is not a universal occurrence during this period, and with good oral hygiene, it can be prevented.

Gingival Changes Associated with Menstrual Cycle As a general rule, __the menstrual cycle is not accompanied with notable gingival changes__; however, occasional problems do occur. Gingival changes during menstruation have been attributed to hormonal imbalances and in some patients may be accompanied by ovarian dysfunction. During the menstrual cycle, the prevalence of gingivitis increases. Some patients may complain of bleeding gums, or a tense feeling of the gums following the menstrual cycle. Exudate from inflamed gingiva and salivary bacterial count are also increased during menstruation.

Gingival Disease in Pregnancy __Pregnancy itself does not cause gingivitis__. Gingivitis is pregnancy is caused by bacterial plaque, just as in the nonpregnant woman. Pregnancy accentuates the gingival response to plaque. The severity of gingivitis is increased in the second or third month, in which the gingiva becomes enlarged, edematous, discolored (varies from bright red to bluish red) and increased bleeding is also present. In some cases, the inflamed gingiva forms “tumor-like” masses, referred to as //pregnancy tumors.// Gingivitis becomes more severe during the eighth month and decreases during the ninth month. The severity of gingivitis reduces two months postpartum, and after a year, the gingiva is comparable to patients who have not been pregnant. Tooth mobility, pocket depth, and gingival fluid are also increased during pregnancy. Periodontal disease can also cause low-birth weight infants, The gram negative bacteria initiate the onset of premature labor by stimulation of the secondary inflammatory mediators such as PGE2 and interleukin 1B.

//Hormonal Contraceptives and the Gingiva// Hormonal contraceptives aggravate the gingival response to local factors in a manner similar to that seen in pregnancy. When taken for more than 1 ½ years, there is an increase in periodontal destruction. Some brands of oral contraceptives produce more dramatic changes than others.

//Menopausal Gingivostomatitis (Senile Atrophic Gingivitis)// Females can develop a gingivostomatitis during menopause or postmenopause, however this condition is not common. The gingiva and remaining oral mucosa can be dry and shiny, the color can be abnormally pale or erythemic, and bleeding may occur. Some patients complain of a dry, burning sensation throughout the oral cavity, extreme sensitivity to thermal changes, abnormal taste sensations, and difficulty with removable partial prostheses. Signs and symptoms similar to those of menopausal gingivostomatitis occasionally occur after ovariectomy or radiation treatment of malignant neoplasms.

Systemic administration of cortisone and adrenocorticotropic hormone (ACTH) appears to have no effect on the incidence and severity of gingival and periodontal disease. However, renal transplant patients who are receiving immunosuppressive therapy have significantly less gingival inflammation. Systemic administration of cortisone in animals results in osteoporosis of alveolar bone, capillary dilation and engorgement, hemorrhage in the periodontal ligament and gingival connective tissue, and inflammation and increased destruction of periodontal tissues. Cortisol, which is released during stress, can diminish the immune response to periodontal bacteria.
 * __Corticosteroid Hormones__**

Addison’s disease, also known as primary adrenal cortical insufficiency, results from hypofunction of the adrenal cortex. It is prevalent in 4 per 100,000 persons. Addison’s disease occurs in all ages, but most commonly occurs in persons 30-50 years of age, and also affects females more than males.
 * __Addison’s Disease__**

//Etiology// Clinical manifestations do not appear until at least 90% of the adrenal cortex has been compromised. Etiology includes:
 * Autoimmune adrenalitis (production of antiadrenal antibodies) (70% of cases)
 * Granulomatous infection of the adrenal grand (tuberculosis, sarcoidosis, histoplasmosis) (25% of cases). This is most common in immunosuppressed patients with cancer or AIDS
 * Hereditary disease of progressive myelin degeneration in the brain (5% of cases)

//Clinical Features//
 * Hyperpigmentation of the skin and mucous membranes **(often precedes all other symptoms by months or years)**. Orofacial manifestations: pigmentation that spreads over the buccal mucosa from the commissures and/or developing on the gingival (typically the dentogingival margins) and lips
 * Fatigue
 * Weight loss
 * Nausea
 * Hypotension
 * Syncope
 * High susceptibility to infections
 * Inability to tolerate stress
 * Inability to work or maintain usual daily routines
 * Cold intolerance
 * Abdominal pain

//Dental Significance// Patients with Addison’s disease are at risk for developing acute adrenal insufficiency (Addisonian crisis), which is often induced by infection, trauma, surgery, general anesthesia, or other high stress situations. Dental patients taking corticosteroids are at increased risk of developing severe dental infection, since corticosteroids depress the host’s normal inflammatory response.

Dental Management The chance of postoperative infection resulting from surgical or procedures with significant tissue manipulation can be minimized by use of prophylactic premedication as prescribed by the patient’s doctor. The dental professional should also assess the need for preoperative corticosteroid supplementation (as prescribed by the patient’s doctor) prior to dental treatment.

Cushing’s syndrome, also known as hypercortisolism, is caused by adrenal hyperplasia or neoplasia, in which hypersecretion of corticosteroids results. In 70% of cases, Cushing’s syndrome results from hypersecretion of ACTH from pituitary adenomas. In clinical practice, Cushing’s syndrome is often found in patients taking synthetic steroids for rheumatoid arthritis, systemic lupus erythematosus, asthma, and other autoimmune diseases.
 * __Cushing’s Syndrome__**

//Clinical Features//
 * Periodontal bone loss
 * Osteoporosis affecting the alveolar bone
 * Weight gain that is prominent in the face and trunk
 * Moon-shaped face
 * “buffalo hump” on the upper back
 * Acne
 * Redness in the face
 * Glucose intolerance
 * Overt diabetes
 * Fatigue
 * Weakness
 * Mentally unstable
 * Abdominal striae
 * Hypertension

//Dental Management// Patients with Cushing’s syndrome require a medical consultation from the patient’s doctor prior to dental treatment. Treatment planning should address the risk for periodontal bone loss and measures should be taken to promote bone mineralization, and avoid extensive neck manipulation if osteoporosis is present. Post operative analgesics should not include aspirin or NSAIDs for long-term steroid users.

Hyperthyroidism is characterized by excessive production of thyroid hormone. It is more common in women than men. Hyperthyroidism has several different causes, including Graves disease (most common), hyperplasia of the gland, benign and malignant tumors of the thyroid, pituitary gland disease, and metastatic tumors.
 * __Hyperthyroidism__**

//Clinical Features// //Oral Manifestations// //Dental Management// Medical consultation with the patient’s physician is required to evaluate thyroid function tests (i.e.: TSH) within the past 6-12 months. Dental treatment should be deferred if the patient presents with undiagnosed or untreated hyperthyroidism, an unreliable or vague history of thyroid disease, and failure to follow physician-initiated control of thyroid disease for more than 6 to 12 months. Since emotional stress can induce a thyrotoxic crisis, appropriate stress reduction measures should be taken, such as keeping the appointments as short as possible, morning appointments, Nitrous-oxide-oxygen sedation, and/or premedication with oral antianxiety medications 1 hour before the appointment as prescribed by the patient’s physician.
 * Rosy complexion
 * Erythema of the palms
 * Excessive sweating
 * Fine hair
 * Softened nails
 * Tremor
 * Heat intolerance
 * Protrusion of the eyeballs (exophthalmos)
 * Anxiety
 * Weakness
 * Restlessness
 * Cardiac problems
 * In children, premature exfoliation of primary teeth and premature eruption of permanent teeth
 * Osteoporosis, affecting alveolar bone
 * Dental caries
 * Periodontal disease
 * Burning discomfort of the tongue

Hypothyroidism results from a deficiency of thyroid hormone production or resistance to thyroid hormone action.
 * __Hypothyroidism__**

//Clinical Features// //Dental Management// The dental professional should conduct a physical evaluation and assess thyroid function tests (i.e.: TSH) within the last 6-12 months. The dental professional should also asses for the presence of cardiovascular disease. Dental treatment should be deferred if the patient presents with undiagnosed or untreated hypothyroidism, an unreliable or vague history of thyroid disease, and failure to follow physician-initiated control of thyroid disease for more than 6 to 12 months. Patients with well-controlled hypothyroidism require no special precautions.
 * Weakness
 * Fatigue
 * Cold intolerance
 * Dry skin
 * Decreased sweating
 * Macroglossia
 * Dysgeusia
 * In children and adolescents, delayed eruption of teeth
 * Poor periodontal health
 * Delayed wound healing

Parathyroid hypersecretion produces several oral changes. These changes include: Bone cysts become filled with fibrous tissue containing macrophages and giant cells. These cysts are called //brown tumors//, although they are really giant cell granulomas. These lesions sometimes appear periapically on the teeth, which can lead to misdiagnosis of an endodontic lesion. Loss of lamina dura and giant cell granulomas in the jaws are late signs of hyperparathyroid bone disease, which is uncommon. Complete loss of the lamina dura does not occur often in hyperparathyroid bone disease, but it can occur in Paget’s disease, fibrous dysplasia, and osteomalacia. Thus, clinicians must be careful not to confirm hyperparathyroid bone disease on a patient until tests are conducted by the patient’s physician confirming the condition.  
 * __Hyperparathyroidism__**
 * malocclusion and tooth mobility
 * alveolar osteoporosis with closely meshed trabeculae
 * widening of the periodontal ligament space
 * absence of the lamina dura
 * radiolucent cystlike spaces within the osseous