Oral manifestations

of Endocrine disorders
 Endocrine system
• the body’s second great controlling system
which influences metabolic activities of cells
by means of hormones together with the
nervous system

• it is composed of various endocrine glands

and endocrine cells
.
 Hormones
substances which are secreted by specialized cells that affect
distant organs.

The main physiologic function of hormones are growth,

maintenance of homeostasis and reproduction
Chemistry of hormones Hormones
are classified into three types depending on their chemical
nature
1.Steroid derivative e.g corticosteroid and sex hormones
2.Protein derivative e.g insulin ,leptin
.3.Derivative of amino acid e.g thyroid hormones, prostaglandins
 .
• General characteristic of hormones
1. they have specific rates and patterns of
secretion
2. 2. they operate within feedback systems, either
positive or negative, to maintain an optimal
internal environment (homeostasis)
3. 3. they affect only cells with appropriate
receptors
4. 4. they are excreted by the kidney, deactivated
by the liver or by other mechanisms.
PITOTIRY GLAND
 .
• The pituitary gland is divided into 2 functional units.

Anterior pituitary or adeno hypophysis

Growth hormone
Adrenocorticotrophic hormone
Thyroid stimulating hormone
Follicle stimulating hormone

Posterior pituitary or neuro hypophysis

Vasopressin (Antidiuretic hormone)
Oxytocin
 Associated diseas
• HYPERPITUITARISM
It results from hyperfunction of anterior lobe of
pituitary gland, most significantly with
increased production of growth horm
Types
Gigantism — If the increase occurs before the
epiphysis of the long bone are closed
Acromegaly — if the increase occurs later in
life after epiphysis closure
 Gigantism
overgrowth of most tissue in childhood.

• TALL SKELETON

• MUSCLES AND VISCERA –

LARGE.
 ORAL CHANGES
 Clinically
• Teeth
 Teeth in gigantism are proportional to the size of jaw and root may be
longer than norma
 The teeth become spaced
• Jaw bone
 Overgrowth of mandible leading to prognathism.
 Class III malocclusion.
• Palate
 usually flattened and the tongue increase in size
• Lips
 the lips become thick and Negroid
 Radiographically
• condyles appear large in diameter
• Hypercementosis
• Enlargement of the major salivary glands is possible.
Acromegaly

• PRIMARY.
Pituitary tumor.
Pituitary hyperplasia.
• SECONDARY.
Ectopic GH/GRH secreting tumor.
MEN syndromes (association).
 ORAL CHANGES
 Clinically
 Lantern jaw.
 Class III malocclusion.
 Flaring of dental arches with spacing.
 Macroglossia
 Radiographically
 Skull Changes
 Enlargement of sella turcica and paranasal sinus
 Teeth
 Increased tooth size especially root
 Diastema between teeth
 Increase in thickness and height of alveolar process.
 MANEGMENT
• Medication
• Radiotherapy
• Surgically
DENTAL MANEGMENT
• These patients may have DM, HTN or cardiomyopathy.
• Medical consultation is advised before surgical
manipulation or potentially stressful dental
appointments.
• Sedation in the acromegalic patient can be complicated
by the enlargement of the tongue and epiglottis.
• Deep conscious sedation and narcotic analgesics are ill-
advised.
 HYPOPITUITRSM
Total absence of all pituitary secretions is known
as Panhypopituitarism or Simmond’s disease
 Etiology
 Idiopathic.
 Craniopharyngioma.
 Metastatic carcinomas
 . Pituitary adenoma Sarcoidosis.
 Sheehan’s syndrome.
 CLINICAL FEATURES
• Stature of individual —the underdevelopment is symmetrical,
individual is very small and in some cases there may be a
disproportional shortening of the long bones
• The hallmark of this condition is that the growth is retarded to a
greater degree than is bone and dental development.
• Hypocalcemia — it may occur because of growth hormone and
cortisol deficiency.
• Symptoms— growth hormone secretion is lost resulting in lethargy,
muscle weakness and increase fat mass in adults.
• Sexual characteristic— after luteinizing hormone (LH) secretion
becomes impaired,
• Skull— the skull and facial bone are small
 Radiographically
 Teeth — complete absence of third molar bud. Roots of teeth are short
and apices are wide open and pulp canal toward the apex.
 Alveolar bone —there is loss of alveolar bone.
 ORAL CHANGES & CONSIDERATIONS
• Tooth
eruption is delayed and incomplete.
• Clinical crowns
are small in gingivo-occlusal dimension, and root length is
reduced.
• A small dental arch
contributes to crowding and malocclusion.
• Salivary glands
are prone to hypofunction, which contributes to decreased
salivary flow and increased oral bacterial infections.
• Early orthodontic evaluation
is important to correct skeletal-dental malrelationships.
 .
• Fluoride treatments
should be initiated early in life, and frequent
periodontal recall implemented to reduce oral
bacterial accumulations
• In pts with hypopituitarism and
hypoaldrenalism may require supplemental
corticosteroids during dental treatment.
ADRENAL GLANDS
 .
• • ADRENAL MEDULLA
Epinephrine and
 Nor epinephrine.
• ADRENAL CORTEX
Glucocorticoids,
 Mineralocorticoids and
 Sex hormones.
 ASSOCIATED DISEASES
 Addison’s disease.
 Cushing’s disease
Addison’s disease.
It is also called as chronic adrenal insufficiency of the
adrenal cortex.
CAUSES
• Autoimmune.
• Infections.
• Metastatic tumors.
• Drugs.
 ORAL CHANGES
• The pale brown or deep chocolate
pigmentation of the oral mucosa, spreading
over the buccal mucosa from the angle of the
mouth and/or developing on the gingiva,
tongue, lips may be first evidence of disease.
 MANAGMENT
• Glucocorticoid replacement.
• Mineralocorticoid supplement.
DENTAL CONSIDERATION
• Increased susceptibility to infections.
• Possibility of adrenal crisis.
• . Patients at a significant risk of adrenal suppression
include those who are currently taking oral steroids daily
and those who have taken an equivalent daily dosage of
cortisol for more than 2 weeks during the previous 12
months.
• Moderate risk- those receiving alternate day therapy or
those who take less than half the daily dose of cortisol
equivalent for less than 1 month.
• No risk- topical steroids
 Cushing's syndrome
• arises from excess secretion of glucocorticoids by the
adrenal glands. It is described by Harvey Cushing in
1932.
• GENRAL FEUTUR
• Age and sex
female to male ratio is 3:5, seen in 3rd and 4th
decades.
• Moon face
rapidly acquired obesity about upper portion
of the body hump—there is truncal obesity
 ORAL CHANGES
 Clinically
• Face
is round, swollen, reddish
• Eyes
conjunctival edema
• Gingiva
enlarged, swollen and bleeds easily
• Bone
no bony abnormalities of the jaws are usually noted.
• Patients are prone to bacterial and fungal infections- periodontitis and
candidiasis.
 Radiographically
 loss of lamina dura.
 Skull—it may show diffuse thinning
 DENTAL MANGMENT
• Hypertension.
• Heart failure.
• Diabetes mellitus.
• Osteoporosis.
• Impaired healing.
• Emotional depression or psychosis.
Waterhouse-friderichsen syndrome
Acute adrenal insufficiency with acute
septicemia. Characterized by rapidly
fulminating septic course, a pronounced
purpura and death within 48 to 72 hours
ANDROGENITAL SYNDOME
It refers to any situation in which there is
overproduction of androgens.
THYROID GLAND
.
 ASSOCIATED DISEASES
 Hyperthyroidism.
 Hypothyroidism
Hyperthyroidism.
 CAUSES
 Exopthalmic goitre.
 Toxic adenoma.
 Ectopic thyroid tissue.
 Grave’s disease.
 Pituitary disease.
 CLINICAL FEAUTURE
• Increased metabolic rate
• . High body temperature.
• Heat intolerance.
• Tachycardia.
• Weight loss.
• Increased appetite.
• Exophthalmoses. Warm extremities.
• Age and sex—it has predilection for females
between 20 and 40 years of age.
• Thyroid is diffusely enlarged
 .
 Neuromuscular
• Nervousness
• Fine tremors
• Muscle weakness
 Gastrointestinal
• Weight loss
• Diarrhea
• Anorexia,
• Vomiting
• Hyperdefecation
 Cardiorespiratory
• Palpitation, excessive perspiration,
• Tachycardia and increased pulse pressure
• Congestive cardiac failure. • Ankle edema,
• Angina and cardiomyopathy.
 ORAL CHANGES
• TEETH Advance rate of development, early eruption with
premature loss of primary teeth.
• Increased incidence of caries.
• Osteoporosis.
• Ectopic thyroid tissue in the tongue

DENTAL MANGMENT
Thyroid storm/ crisis. Propylthiouracil (60-100mg, iv)
• Complete blood picture.
• Local anaesthetic without epinephrine should be used.
• Sedatives are safe
• Anticholinergics should be avoided.
• Iodine preparations found in radiographic contrast solutions should
be avoided.
 Hypothyroidism
• • PRIMARY.
• • SECONDARY.
 TYPES
• Cretinism
if failure of hormone occurs in infancy.
• Juvenile Myxedema
if it occurs in childhood.
• Myxedema
if it occurs after the puberty. In it there is subcutaneous
deposition of hydrophilic muco-polysaccharides.
 CLINICAL FEATURES
 Cretinism and Juvenile Myxedema
• Age
it may be present at birth or become evidence within
the first few months after birth.
• Symptoms
hoarse cry, constipation, feeding problems in neonates,
retarded mental and physical growth
. • Bones
delayed fusion of all body epiphysis and delayed
ossification of paranasal sinus, partially
pneumatization.
 ORAL CHANGES
 Teeth
 Dental development delayed and primary teeth slow to exfoliate.
 • Enamel hypoplasia can also be seen. • Abnormalities of dentin formation lead to
enlarge pulp chamber.
 Jaw bone
• Maxilla is overdeveloped and mandible is underdeveloped.
• Retarded condylar growth leads to characteristic micrognathia and open bite
relationship
 • Tongue
— tongue is enlarged by edema fluid and due to its tongue may protruded
continuously and such protrusion may lead to malocclusion of teeth
 . • Skull
the base of skull is shortened leading to a retraction of the bridge of the nose with
flaring.
 • FaceI
It is wide and fails to develop in longitudinal direction.
 Lips
they are puffy, thickened and protruding.
 DENTAL MANGMENT
• • HYPERSENSITIVE TO DRUGS
• • CONSERVATIVE TREATMENT IS DESIRABLE IN
THESE PATIENTS.
• • Mouth breathing and the resultant gingivitis
and rampant caries may require frequent oral
prophylaxis, fluoride supplementation,
restorative treatment, and protective pastes
applied to the teeth at night before retiring.
• • Orthodontic evaluation in early adolescent
years can help prevent malocclusion.
PARATHYROID GLANDS
 FUNCTIONS
 BONE
 Increases bone resorption by intensifying the osteoclastic
activity
 KIDNEY
 Facilitates the conversion of vitamin D into its final active
end product.
 Acts on renal tubules to increase calcium reabsorption and
phosphate excretion.
 • GIT
PTH produces indirect effect. Decreased serum phosphate
increases the production of active vitamin D which
increases calcium and phosphate absorption from GIT, both
by active and passive transport.
 ASSOCIATED DISEASES
 HYPERPARATHYROIDISM.
 HYPOPARATHYROIDISM.
HYPERPARATHYROIDISM.
 TYPES
 PRIMARY
• Parathyroid adenoma
.• Parathyroid carcinoma.
• Multiple endocrine neoplasia.
 SECONDRAY
Develops when PTH is continuously produced in response to low levels of
serum calcium ,a physiologic response to Renal failure, Rickets,
Malabsorption syndrome
 TERTIARY
Occurs after secondary hyperparathyroidism when the external factor is
corrected but parathyroid glands remain hyperplastic
 CLINICAL FEATURES
 BONE
 Osteoporosis.
 • Cystic bone lesions.
 • Bone pain / tenderness.
 • Spontaneous fractures.
 RENAL
• • Polyuria.
• • Polydypsia
• • Renal stones.
 GIT
• Constipation.
• Anorexia.
• Vomiting.
• Vague abdominal pain
• Pancreatitis.
• Peptic ulceration.
 ORAL CHANGES
 CLINICALLY
• Vague jaw bone pain
• Teeth that sensitive to percussion and mastication
• Drifting and loosening of teeth causing malocclusion
• Pulp stones and root resorption
• Sialolithiasis
• Skeletal muscle weakness
• Peculiar fasciculations of the tongue
 RADIOGRAPHICALLY
• GROUND GLASS.
• MOTH-EATEN.
• SALT AND PEPPER APPEARANCE.
• SUB PERIOSTEAL EROSIONS OF BONE OF MIDDLE PHALANGES IS THE HALL
MARK.
• LOSS OF LAMINA DURA.
• LOSS OF MEDULLARY TRABECULATION (Ground glass appearance)
• PULP STONES AND ROOT RESORPTION MAY ALSO OCCUR.
 DENTAL MANGMENT
• Medical consultation is necessary to ensure
adequate calcium levels
• Low Ca can ppt arrythmias, bronchospasm,
laryngospasm, convulsions, and death due to
tetany
• High levels can lead to renal failure and
cardiac irregularities
 HYPOPARATHYROIDISM.
 TYPES
• DI GEORGE SYNDROME.
• POST OPERATIVE HYPOPARATHYROIDISM.
• IDIOPATHIC HYPOPARATHYROIDISM.
• PSEUDOHYPOPARATHYROIDISM.
CLINICAL FEATURES
• TETANY.
• CARPOPEDAL SPASM.
• BRONCHOSPASM AND LARYNGOSPASM.
• In children a characteristic triad of carpopedal spasm, stridor and
convulsions occur
• Stridor is caused by spasm of the glottis
• Adults complain of tingling in the hands feet and around the mouth
 ORAL CHANGES
 CLINCALLY
• Altered tooth eruption pattern, short, blunted roots, enamel
hypoplasia, dentin dysplasia, malformed or impacted teeth, and
partial anodontia.
• After puberty- does not affect teeth
• Circumoral paresthesia is often one of the first symptoms of
hypoparathyroidism
• Patients are predisposed to oral candidiasis
 RADIOGRAPHICALLY
• Calcification of basal ganglion which appears flocculent and paired
with the cerebral hemisphere on PA view.
• Radiograph of jaw may reveal enamel hypoplasia, external root
resorption, delayed eruption or root calcification.
 MANGMENT
• Supplemental calcium and vitamin D
• In severe cases intravenous administration of calcium
gluconate is the treatment of choice.

DENTAL MANGMENT
• Appropriate medical referral should be made after
recognition of S/S
• After medical evaluation and treatment, routine dental
care can be provided
• If oral candidiasis is present, antifungal agents such as
nystatin should be provided.
 DIABETES MELLITS
is a chronic disorder of carbohydrate, protein, and fat metabolism
resulting from insulin deficiencyor abnormality in the use of insulin
 Types
Type I formerly known as Insulin Dependent
Type II formerly known as Non Insulin–Dependent Diabetes Mellitus

 Clinical features
• Polydipsia
• Polyuria – Polyphagia
• Atherosclerosis-coronary heart disease & stroke
• Diabetic neuropathy
• Infection recurrent skin infection, UTI infection, paresthesia in toe
or finger
 ORAL CHANGES
 CLINCALLY
• Gingival & Periodontal disease
• Oral candidiasis-due to multiplication of candida albicans
• Localized osteititis-dry socket develops
• Burning mouth
• Increased caries activity
• Atrophy of lingual papillae with fissuring
• Angular cheilosis
• altered taste sensation
 RADIOGRAPHICALLY
• Discontinuity or blurring of the cortex of alveolar crest
• -Destruction of lamina dura
• -Horizontal & vertical bone loss
 DENTAL MANGMENT
Treatment should be in such way that it minimize
disturbances of metabolic balance
• Complaint of hypoglycemia glucose drink should be
given
• Use of LA with out epinephrine
• Extraction socket should be sutured to prevent
excessive hemorrhage
• Physician advice should be taken before undergoing GA
• Antibiotic prophylaxis before dental treatment to
prevent infection
ENDOCRAIN ALTRITION IN
PREGNANCY
 ORAL CHANGES
• Some gravid women are prone to develop a hypersensitive gag reflex. In
combination with increased intra-abdominal pressure and nausea,
regurgitation may occur. This can lead to halitosis and erosion of tooth enamel
.
• Hormonal gingivitis (pregnancy gingivitis)

• Pregnancy tumor or, as it is more

commonly known, “pyogenic granuloma”
Is an exaggerated response to irritation that is seen
in about 1% gravid women.

Facial pigmentation (chloasma or

melasma gravidarum) occurs in some pregnant
women in response to increased hormone production..
 DENTAL MANGMENT.
• Main dental considerations of the pregnant patient are to:

1. Minimize radiographic exposure

2. Prevent supine hypotension syndrome
3. Avoid hypoxia
4. Withhold drugs that cross placenta that are potentially damaging to the
fetus.
• Stage of fetal development (first, second or third trimester) is important
to know because it dictates the modifications required in dental
treatment.
 .
• FIRST TRIMESTER
• Dentist should initiate a preventive oralhealth care program, but avoid all other
elective care.
• This recommendation is sound because the 1st trimester is the most critical phase of
fetal organ development and over 75% of all spontaneous abortions occur during this
trimester.
• Avoidance of dental care in the 1st trimester minimizes the likelihood of miscarriage.
• SECOND TRIMESTER
• After organogenesis and before maternal circulatory expansion, is the safest time to
provide dental care.
• The dentist should attempt to eliminate potential problems and to control active
disease during this trimester.
• Extensive, stressful, hypoxic or surgical procedures should be postponed.
• THIRD TRIMESTER
• Preventive and emergency care can be provided • However, all routine care should be
postponed until after delivery
•
• Drugs to avoid:
.
Deleterious drugs and infections should be avoided.

1. Respiratory-depressants- barbiturates, sedative/hypnotics and narcotics

2. Analgesics- NSAIDs
3. Antibiotics- tetracyclins, streptomycin and gentamicin
• Acetaminophen, codeine, penicillin, erythromycin, and cephalosporins
can be prescribed to women throughout pregnancy, especially when the
woman’s health would deteriorate without them.
• For oral infection, penicillin is the antibiotic of choice during pregnancy
unless contraindicated by hypersensitivity.
• Nitrous oxide-oxygen can also be administered in emergency situations
after the 1st trimester, as long as 50% oxygenation is provided.
• Acetaminophen should be used cautiously because it can cause
methemoglobinemia, hemolytic anemia, and liver or kidney damage.
• Codeine should be minimized except when absolutely needed.
 .
• LA can cross placenta however no adverse effects have been
reported following use of lidocaine and mepivacaine.
• High doses of prilocaine can cause methemoglobinemia and should
be avoided.
• Minimum amount of drug should be used and aspiration done
before injecting.
• Dental radiographs can be taken in case of an emergency to
confirm diagnosis but only when lead apron is fully draped across
the patient.
• Proper dental chair position is important to prevent supine-
hypotension syndrome and hypoxia so chair should be placed more
upright.
• Syncope can be triggered by anxiety, incorrect chair position and
poor oxygenation.
• Dentist should provide a more comfortable chair position and a
continuous flow of oxygen and reduce the patient’s anxiety with
relaxation techniques and reassurance.
.