Wednesday, November 20, 2013

Classic Articles: Risk factors for drug-induced gingival overgrowth



Title: Risk factors for drug-induced gingival overgrowth
Authors: RA Seymour, JS Ellis, JM Thomason
Journal: Journal of Clinical Periodontology 2000
Resident: Margaret Cannon

Main Purpose:
Due to the high frequency of clinical signs and expressions of drug-induced gingival overgrowth still seen by periodontists, this article works to identify and quantify the various risk factors associated with both the development and expression of the drug-induced gingival changes.

Methods:
Risk factors evaluated included: age, sex, drug variables, concomitant medication, periodontal variables, and genetic factors.

Results:
- Age has been reported as risk factor for phenytoin- particularly in teenagers-  and cyclosporine- children more than adults.
- Age was not found to be a factor but for calcium channel blockers – slight confusion with this because Ca Channel blockers are usually only rx-ed to 40+ year old patient.
- Gender and race are not important risk factors for gingival hyperplasia.
- Drug dosage is a poor predictor of gingival changes, but drug concentration in saliva is a positive predictor
- The combination of some drugs produces more gingival overgrowth than if either drug was used singularly
- Plaque scores and gingival inflammation appear to exacerbate the expression of drug-induced gingival overgrowth
- Fibroblast heterogeneity remains one of the key factors used to explain the variables response of the gingival tissues to various gingival over-growth-inducing drugs.

Assessment:
We will at some point have patients taking drugs that are linked to gingival overgrowth. It is important that we as providers not only know enough about the drugs to manage their symptoms, but also how to educate the patient and their families on how to manages their signs and symptoms.  Especially since OH is such and important risk factor, we will have more of a hand in helping to prevent unnecessary side-effects.



Natal and Neonatal Teeth

Resident: Jeff Higbee
Article:  Natal and Neonatal Teeth
Journal: Journal of Dentistry for Children 1995
Authors: J. Zhu DDS, MS, DSc, et al

Background:
- Normal eruption of primary incisors starts at about 6 months of age.
- There are some instances reported in the literature of infants being born with teeth.
- Various terms have been used to describe these teeth, congenital teeth, fetal teeth, predeciduous teeth, and dentitia praecox.
- The terms to describe these teeth most widely used today are, teeth present at birth: natal teeth, teeth that erupt within 30 days: neonatal teeth.

Prevalence:
- Ranges from 1 in every 11.25 to 30,000 births.

Teeth Affected:
- Teeth most often affected are the mandibular central incisors.
- One study of neonatal teeth among 53,678 patients showed that all natal or neonatal teeth were mandibular incisors.
- Another study showed that 85% are mandibular incisors, 11% maxillary incisors, 3% mandibular canines or molars, 1% maxillary canines or molars.

Etiology:
- No cause and effect relationship has been established.
- These teeth are attributed to the superficial position of the developing tooth germ which predisposes it to erupt early.
- There may be some genetic predisposition to natal teeth from 8 to 62%.
- May be in association with a multisystem syndrome.

Clinical Appearance:
- Most appear like normal primary teeth but can be broken into categories.
                Shell-like crown loosely attached to the alveolas, no root attachment.
                A solid crown loosely attached to the alveolas, little or no root
                Incisal edge of the crown just erupted through the oral mucosa
                Mucosal swelling with tooth unerupted but palpable
If the mobility is more than 2mm (aspiration risk) the teeth should be extracted.

Management:
- If no problems noted to mother or baby with no significant mobility the tooth should be left alone.
- Natal and neonatal teeth that survive more than 4 months have a good prognosis.
- Riga-Fede disease may be relieved by grinding any sharp or jagged edges on the tooth.  This condition is not an absolute indication for extraction.
- Ext of these teeth are usually very simple because of the underdeveloped root.
- Ext should be followed by curettage to ensure that remnants of the Hertwig root sheath are not left behind in the socket possibly causing an alveolar abscess from the toothlike structure that can develop.

Assessment:
Good article discussing a topic that is potentially very concerning to parents.  It is important to understand the topics discussed in this paper to be able to discuss why their child has these “newborn” teeth and the prognosis and treatments.

Biological Mechanisms of Early Childhood Caries


Resident: Todd Bushman
Article: Biological Mechanisms of Early Childhood Caries
Author: W. Kim Seow
Journal: Community Dentistry and Oral Epidemiology Volume 26 1998
Purpose: A professional review of the carious process, the individual traits of several of the contributing bacterial species.
Methods: Didactic review and discussion of the caries process

Findings: The salivary pellicle begins to adhere immediately after even thorough cleaning and acts as lubrication, acid buffer, prevention of crystal growth and help remineralization. It also has many other protective factors such as antimicrobial systems, bacteria agglutins and bicarbonate buffering capacity. Saliva also includes immunological factors such as IgA, sIgA, IgG and phagocytes. Once the pellicle is formed, Streptococcus species can begin adhering. As the biofilm develops the bacterial population sways toward Actinomyces. The biofilm produces both acid and alkaline products, the balance of which is essential in determining its cariogenicity. The mutans streptococci family creates water insoluble adhesion glucans, produces of intracellular polysaccharide which allow acidogenic activity during periods of limited exogenous carbohydrate consumption, and has high aciduric capabilities. Mutans species are not typically found in predentate children, since they typically need a non shedding surface to colonize. The infection rate increases as more teeth erupt into the mouth and the earlier colonization begins. Dental malformation is another contributing factor to ECC, since it often creates an environment with deep noncleansible fissures. Sucrose, which is the most common dietary sugar and the most closely linked to dental decay, is unique in that one of its byproducts is plaque dextrans which are essential in the adherence and thus the progression of dental decay. The review reports that bovine milk is not cariogenic since exposure to lactose did not sufficiently lower the pH to cause demineralization. The review does warn of human milk and on demand breast-feeding, milk formulas and acidic fruit drinks. Fluoride is noted to have a multivariable positive effect ton reducing cariogenic activity.

Key points/Summary : Dental caries is a complicated, multivariable disease which affects millions of children worldwide. The interpretation of universal and individual factors are essential in the prevention and elimination of this disease.

Assessment of article:  Good overview of the cariogenic process reaffirming what we have all known since dental school.

Tuesday, November 19, 2013

A multidisciplinary approach to the diagnosis and treatment of early-onset periodontitis: a case report.

Resident: Derek Nobrega
Title: A multidisciplinary approach to the diagnosis and treatment of early-onset periodontitis: a case report.
Authors: Worch KP, Listgarten MA, Korostoff JM.
Journal: J Periodontol. 2001 Jan; 72(1):96-106.

Main Purpose:
This article was a case report describing a multidisciplinary approach for the treatment of a patient with severe generalized juvenile periodontitis (GJP) incorporating clinical laboratory evaluation with conventional concepts of periodontal pathogenesis and therapeutics to diagnose and effectively treat EOP.

Methods:
The 17-year-old female patient presented with clinical and radiographic evidence of severe attachment loss. Microbiological testing showed the presence of known periodontal pathogens including Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Porphyromonas gingivalis. Routine immunological tests did not reveal any of the functional defects thought to play a role in the pathogenesis of EOP. After initiation of therapy, which consisted of scaling and root planing, supplemented with administration of systemic antibiotics, a reduction in probing depth and gain in clinical attachment could be demonstrated. Microbiological testing was used to monitor the composition of the periodontal microbiota and to adjust antimicrobial therapy accordingly.

Results:
- Conventional treatment of this patient would have begun with extractions of hopeless teeth, SCRP, and periodontal surgery to further reduce probing depths. However, due to the extent of periodontal breakdown, a large number of teeth were considered candidates for extraction. The authors felt conventional treatment was not the best choice. The primary goal was to control her periodontal infection, while secondarily maintaining arch integrity and not commit the patient to denture or more complex restorative dentistry.
- A significant reduction in probing depth was observed after 3 months of treatment. The attachment levels continued to improve from 3 months up to 1 year and were maintained at the 2-year re-evaluation.
- It has been shown that 80% of patients with EOP have a form of major neutrophil dysfunction, possibly caused by an underlying defect in host immunity that may predispose her to serious systemic infections. Therefore the patient was referred to an immunologist to rule out immune deficiency.
- A major limiting factor in treating such a severe case of periodontitis is compliance. It is important to educate the patient and his/her guardian concerning the potential consequences of non-compliance.

Assessment:

This case was unusually severe, but it is still important to understand that a more conservative approach may be beneficial for EOP. It is also critical for us to know that a multidisciplinary approach to treatment is essential for successful treatment.

Oral Health Care for the Cancer Patient


Scully, C. and Epstein, JB. Oral Oncol, Eur J Cancer, Vol. 32B, No. 5, 281-292
“Classic 100 Articles: #70"
Resident: Anna Abrahamian

Background
Of the early early orofacial complications to both radiotherapy and chemotherapy, mucositis is the most common. Up to 40% of chemotherapy patients can be affected by mucositis. Other long-term complications ot RT to H/N include xerostomia, loss of taste, trismus, and ORN.  In children, cancer therapy may also cause enamel hypoplasia, microdontia, failure of tooth development and eruption, and problems with craniofacial development. Prevention and treatment planning before cancer therapy is key: oral infection should be controlled, good OH should be established, and preventive regimens such as custom fluoride  gel trays should be fabricated for patients.

Management of Oral health and Disease During Cancer Therapy

Complications of cancer therapy depend mainly on the treatment modality. For example, mucositis severity depends on the type of ionizing radiation used, the rate delivered, the total dose, and the individual’s response. Complications can be earlier post-treatment or later post-treatment.

Mucositis: (earlier) Appears 3-15 days after treatment (earlier with chemotherapy than with radiotherapy). Frank oral ulcerations can become portals for infection and septicemia.  Management includes: avoidance of mucosal irritation (plaque control/good OH with soft toothbrush and aqueous chlorohexidine; soft, bland diet, avoid irritants like tobacco, alcohol, spices), topical sucralfate (adheres to ulcer bases, has antibacterial activity, and binds EGFs that might accelerate healing), topical pain control (diphenhydramine, benzydamine), prophylactic antibiotics, antifungals, and antivirals to prevent superinfection.

Xerostomia: (later) As little as 20 Gy can cause permanent cessation of salivary flow. Severity depends on volume and type of gland irradiated. Whenever possible, unilateral radiotherapy and a reduced field size are recommended to reduce the severity of xerostoma.   Management includes: pretreatment salivary gland stimulation with pilocarpine (because high initial salivary flow rate is associated with higher flow rates post-RT), avoid tobacco and alcohol. If salivary glands are beyond repair, saliva substitutes can be helpful to some patients.

TMD and trismus: (later) may develop due to anxiety, depression, or stress; may also arise from fibrosis around the TM joint(s) following surgery or RT. Management: oral appliances, physical therapy to limit further deterioration in function.

ORN: (later) uncommon, but the most serious orofacial complication. An individual bone cell may not divide for months or years after radiation, or it may divide only when stimulated by trauma, therefore a slow protracted loss of bone after RT exists along with the risk of bone necrosis. Mandible is at greater risk than maxilla because of poorer blood supply and compact bone that absorbs more radiation.  Management: Prevention through minimizing radiation dose (<60 Gy), minimizing infection and trauma (extraction of NRT or those with advanced periodontal involvement); treatment for ORN should include local wound care, meticulous OH; systemic tetracycline, HBO, and minor surgery have all been shown to have success in certain cases.

Assessment:
This article is a concise, but very helpful reference of management techniques and tools to utilize if and when we see patients who are about to undergo cancer treatment, those who are presently undergoing treatment, and those who have previously received treatment.   

Latex Allergy

Review Article: Latex Allergy
Article #75

Resident: Hofelich
Authors: Spina et al
Journal:Oral Surgery, Oral Medicine, Oral Pathology
Year: January 1999

Key Points:
  • Prevalence of latex allergy in the general population is not accurately documented. Only 16 fatalities secondary to latex anaphylaxis have been reported, none of which were secondary to dental treatment. 
  • Latex is a natural rubber. It is a complex mixture of 1,4-polyisoprene particles in a phospholipoprotein envelope and a serum containing sugars, nucleic acids, lipids, minerals, and proteins. The proteins are responsible for the anaphylactic reactions that constitute type 1 hypersensitivity. 
  • Immediate type 1 reactions are IgE mediated secondary to the proteins in the latex
  • IgE antibodies form and bind to mast cells with the initial contact
  • Secondary exposure causes cross-linking of the IgE molecules on the surface of mast cells resulting in degranulation and histamine release
  • contact dermatitis- nonimmunologic inflammation of the skin 
  • allergic contact dermatitis- delayed type IV hypersensitivity mediated by T cells
  • Exposure can occur through the skin, mucous membranes, respiratory system, and vascular system

Populations at risk:
  • anyone with a history of multiple latex exposures
  •  most common: patients with spina bifida (18-73%), patients undergoing multiple surgeries, and health care workers
  • atopy- type 1 hypersensitivity with a genetic predisposition, ~20% of the population, tendency to develop asthma, allergic rhinitis, dry skin, or eczema 
  • people with certain food allergies may have a latex allergy because the polypeptides found in natural rubber are also found in certain foods, especially fruit
    • banana, avocado, chestnut, apricot, kiwi, pineapple, peach, nectarine, plum, cherry, melon, fig, grape, papaya, passion fruit, potato, tomato, and celery are the most common
Management:
  • avoid latex products
  • premedication with antihistamines and corticosteroids has been suggested for patients with spina bifida  or a latex allergy, may reduce the allergic response in case of an allergic reaction
  • bronchodilators
  • anaphylactic reaction- administer epinephrine





Recurrent Aphthous Stomatitis: An update.

Resident: Mackenzie Craik

Article: Recurrent Aphthous Stomatitis: An update.

Journal: Oral Surgery, Oral Medicine, Oral Pathology, 1996

Author: Jonathan A. Ship, DMD, et al.

Key Points:  Recurrent aphthous ulceration or recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease known to human beings.  Despite much clinical and research attention, the causes remain poorly understood, the ulcers are not preventable, and treatment is symptomatic.

-The most common presentation is minor recurrent aphthous stomatitis: recurrent, round, clearly defined, small, painful ulcers that heal in 10 to 14 days without scarring.

-Major recurrent aphthous stomatitis lesions are larger (greater than 5 mm), can last for 6 weeks or longer, and frequently scar.

-The third variety of recurrent aphthous stomatitis is herpetiform ulcers, which present as multiple small clusters of pinpoint lesions that can coalesce to form large irregular ulcers and last 7 to 10 days.

Diagnosis of all varieties is usually made after clinical examination.  Many local and systemic factors have been associated with these conditions, and there is evidence that there may be a genetic and immunopathogenic basis for recurrent aphthous ulceration.  Management of immunomodulary drugs.  As dental clinicians and researchers become better trained in oral medicine and stomatology, it is anticipated that the pathophysiology, prevention, and treatment of recurrent aphthous ulceration will improve in the future.

Assessment: It is important to review this very common disease as it is something that we will see all the time.  This served as more of a review of the information, and not as much a clinical study. Excellent knowledge overall.

Monday, November 18, 2013

The dental patient with Asthma: an update and oral health considerations


The dental patient with Asthma: an update and oral health considerations
Derek M. Steinbacher, et al
Avani Khera

Overview: Asthma has steadily increased over the past 20 years, affecting more than 100 million people worldwide.  The mortality rate has almost tripled in the past 20 years, reaching a peak of more than 5,000 annual deaths.

Pathophysiology/Diagnosis/Treatment:
Asthma is a chronic inflammatory disorder involving many cell types, manifesting with episodes of chest tightness, coughing, labored breathing, and wheezing—all of which are related to bronchiole inflammation.  Demonstration of reversible airway obstruction is the clinical criterion for asthma.  For patients with mild, intermittent asthma, the occasional use of an inhaled short active beta 2-agonist is indicated. For patients with moderate asthma, a regular regimen of asthma medication is indicated.  When symptoms are more persistent and a short acting beta 2-agonist does not provide relief, inhaled/nebulized corticosteroids are indicated.  If patients are still not responding, systemic corticosteroids may be given to patients.

Oral health changes in patients with Asthma:
There is an increase in caries rate  and gingivitis due to reduced salivary flow attributed to prolonged use of beta-2 agonists.  Only 10-20 percent of the dose from an inhaler actually reaches the lungs, the rest remains in the oropharynx.  Rinsing the mouth with water after steroid inhalation can minimize the potential for candida growth. Children with asthma also have more calculus due to increased levels of calcium and phosphorus found in the submaxillary and parotid glands.  In addition, dentofacial abnormalities have been noted in asthmatic patients such as increased upper anterior and total anterior facial height, higher palatal vaults, greater overjets, and higher prevalence of posterior crossbites in children with chronic rhinitis and a tendency towards mouth breathing.

Management in dental care:
Elective dentistry should be performed only on asthmatic patients who are asymptomatic and whose symptoms are well-controlled. They symptomatic person should not be treated, and the presence of asthmatic symptoms such as coughing and wheezing necessitate reappointment.  Sealants, tooth enamel dust, fluoride trays and cotton rolls have been implicated in promoting asthmatic events.  Appointments for asthmatic patients are best in late morning or late afternoon as his or her bronchodilators and oxygen should be available during treatment.  Nitrous is contraindicated in a patient with severe asthma, but may be used in patients with mild-to-moderate asthma.

Emergency protocol for handling an acute Asthmatic attack:
Establish and maintain a patent airway, administer beta 2 agonist via inhaler or nebulizer, and administer oxygen.  If there is no improvement, epinephrine (.01mg/kg) is given subcutaneously.  Emergency medical services should also be alerted. 

Wednesday, November 13, 2013

Efficacy of Antibiotic Prophylactic Regimens for the Prevention of Bacterial Endocarditis of Oral Origin


Efficacy of Antibiotic Prophylactic Regimens for the Prevention of Bacterial Endocarditis of Oral Origin
Authors: I.Tomas CarmonaI, P. Diz Dios, and C. Scully
Journal: Critical reviews in Oral Biology and Medicine

Purpose: Despite the controversy about the risk of individuals developing bacterial endocarditis of oral origin, numerous “Expert Committees” in different countries continue to publish prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures. This paper analyzes the efficacy of antibiotic prophylaxis in the prevention of bacteremia following dental tx and in the prevention of bacterial endocarditis.
Key Points:
- This paper covers both animal models and human studies. 
- In the last decades, prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures have been modified, but remain consensus- based.
- Studies on antibiotic prophylaxis and post-dental manipulation bacteremia are essential for investigation of the prevention of bacterial endocarditis of oral origin. There is scientific evidence of the efficacy of amoxicillin in the prevention of bacteremia following dental procedures. However, the results reported in the literature do not confirm the efficacy of other recommended antibiotics (PenVK).
- The majority of studies on animal models verified the efficacy of antibiotics administered after the induction of bacteremia to prevent experimental bacterial endocarditis, confirming a complementary action of antibiotic prophylaxis in later stages in the development of bacterial endocarditis.
- Currently, there is no scientific evidence that prophylaxis with penicillin is effective in reducing bacterial endocarditis secondary to dental procedures in patients considered to be "at risk".
- The literature reports very few cases of severe allergic reactions following prophylaxis with penicillin.
- It has been demonstrated that antibiotic prophylaxis could contribute to development of bacterial resistance, but only when several prophylactic doses are administered consecutively.
- Due to scarce scientific evidence on this topic, future research on bacterial endocarditis prophylactic protocols should be carried out in relation to the antibiotic of choice, and the time and route of administration of the antibiotic prophylaxis. Alternative prophylactic drugs, such as oral antiseptics and peptides, should also be explored.

Conclusion: I thought this paper was interesting because it challenged a lot of the ideas that I was taught in school. It also is pretty boldly opposing what the AHA, AAO, AAOS reports and suggests.  However it definitely leaves us needing more research in order to best treat our patients.

An updated concept of coagulation with clinical implications

Resident: Jeff Higbee
Article: An updated concept of coagulation with clinical implications
Author: Romney, G. and Glick, M
Journal: J Am Dent Assoc (2009)

Purpose/Background:
The coagulation cascade/waterfall model has gained the most widespread acceptance to explain coagulation. This model, however, has problems when it is used in different clinical scenarios. A more recently proposed cell-based model better describes the coagulation process in vivo and provides oral health care professionals with a better understanding of the clinical implications of providing dental care to patients with potentially increased bleeding tendencies.

Methods:
- The authors conducted a literature search using the PubMed database.
- They searched for key words including “coagulation,” “hemostasis,” “bleeding,” “coagulation factors,” “models,” “prothrombin time,” “activated partial thromboplastin time,” “international normalized ratio,” “anticoagulation therapy” and “hemophilia” separately and in combination.

Results/Conclussions:
- The coagulation cascade/waterfall model is insufficient to explain coagulation in vivo, predict a patient’s bleeding tendency, or correlate clinical outcomes with specific laboratory screening tests such as prothrombin time, activated partial thromboplastin time and international normalized ratio.
-The cell-based model of coagulation that reflects the in vivo process of coagulation provides insight into the clinical ramifications of treating dental patients with specific coagulation factor deficiencies.

Assessment:
Understanding the in vivo coagulation process will help us better predict a patient’s bleeding tendency. 

Tuesday, November 12, 2013

AAPD Handbook Chapter 20 - Endocrine Disorders



Resident: Anna Abrahamian

Endocrine System: a collection of glands that secrete hormones into the bloodstream to regulate metabolism, growth and sexual development/reproduction.

I. PANCREAS
Produces enzymes to break down digestible foods (exocrine function)
Secretes hormones that affect carbohydrate metabolism (endocrine function)

Diabetes Mellitus
    Characterized by hyperglycemia from defects in insulin secretion, action or both; total prevalence of
7% and 0.22% under the age of 20
     Diagnosis: RBG >/= 200mg/dl, FBG >/= 126mg/dl, 2hr BG >/=200mg/dL during oral glucose
tolerance test
     Type I - destruction of insulin-producing beta cells, etiology involves genetics and environmental
factors, family history 3-5%, most common type of diabetes in children (1:400-600 children), classic
symptom triad includes polyuria, polydipsia, and weight loss, polyphagia may be absent in children,
ketoacidosis present in 15-40% of newly dx children, treated with insulin injections
     Type II - insulin resistance, frequently overweight, family history 74-
100%, treated with diet and exercise
     Type III - diabetes caused by other identifiable etiologies (genetic defects of beta cell function or
insulin action, syndromes, etc)
     Type IV- gestational diabetes (2-5% of all pregnancies)
      Long term complications: retinopathy, nephropathy, peripheral
neuropathy, atherosclerotic cardiovascular disease, hypertension, growth impairment, infection
      Dental/Oral findings: xerostomia, increased caries risk, candidiasis,
burning mouth/tongue, taste alteration, increased risk of periodontal disease, poor wound healing, acetone breath, odontalgia (diabetes-related microangiopathy), acetone breath
      Dental Considerations: good medical history (recent blood glucose, meds/dosages), morning
appointments, short appointments, eat a usual meal with usual medications/dosages, minimize stress (good local anesthesia), surgical procedures may require insulin dosage adjustment, aggressive periodontal care, salivary substitutes, defer orthodontic/surgical procedures in uncontrolled patients
      Hypoglycemic episode: stop treatment, high carbohydrate beverage or IM glucagon,
seek medical assistance for unconscious patient 

II. THYROID GLAND
Secretes thyroxine (T4), triiodothyronine (T3) and calcitonin

Hypothyroidism
      Insufficient production or diminished action of thyroid hormone, 10x more common in females
      Epidemiology: Primary - 95% of all cases, Congenital (thyroid agenesis/dysplasia),
Acquired (Hashimoto thyroiditis – automimmune), Drug-induced (lithium, amiodarone; transferred from mother to fetus), iodine deficiency, radiation therapy, secondary to surgical removal, secondary to pituitary necrosis (Sheehan syndrome)
     Symptoms: general reduction in metabolic function; fatigue, cold intolerance, decreased appetite, hair
loss, dry/scaly skin, generalized edema, slow wound healing, weight gain, constipation
    Treatment: replacement T4 (levothyroxine)
     Oral Findings: enlarged tongue, delayed dental development/tooth eruption, malocclusion, gingival
edema, delayed skeletal, protruding tongue
      Dental Management: good medical history, sensitivity to stress/infection/surgery/drugs

Hyperthyroidism
      Hypermetabolic state that results from excess synthesis and release of thyroid hormones, overall
incidence of 0.05-1%
       Graves disease – overactive thyroid gland, autoimmune, most common form, 5x more common in
women, associated with eye disease and skin lesions
      Other Causes: excessive intake of thyroid hormone or iodine, pituitary tumor, infection, cancer
      Treatment: antithyroid drugs, radioactive iodine, surgery
      Oral Findings: osteoporosis of alveolar bone, dental caries, periodontitis, early dental/skeletal
development, premature loss of primary teeth; euthyroid infants of hyperthyroid mothers have been
reported with erupted teeth at birth

III. ADRENAL GLAND
Cortex: produces three steroid hormones: 1) glucocorticoids (cortisol), 2) mineralocorticoids (aldosterone), 3) androgens
Medulla: secretes noradrenaline and adrenaline

Adrenal Insufficiency (AI)
      Deficiency of one or more adrenal hormones
      Primary - Addison disease (destruction or mafunction of >90% of adrenal cortex)
      Secondary and Tertiary AI - problem lies at the pituitary gland and hypothalamus
      Symptoms: fatigue, weakness, darkening of the skin, GI problems, hypotension, salt cravings
      Adrenal Crisis: life-threatening adrenal insufficiency that can lead to shock; characterized by
dehydration, hypotension, and imbalances of sodium and potassium
      Treatment: replacement hormones (depending on type)
      Oral Findings: hyper-pigmented mucosa, delayed healing, infection
      Dental Considerations: early warning signs of adrenal crisis, take usual steroid dose, morning
appointment, reduce stress, dental extractions and surgery require increased steroid dosage prior to
procedure; page 249 has table of stress dosing of hydrocortisone for pediatric patients

Hyperadrenalism (Cushing syndrome)
      Excess glucocorticoid typically from excess corticotropin (ACTH) secretion from tumors of the
pituitary (Cushing's disease)
      Symptoms: moon facies, buffalo hump (fat between shoulders), central obesity with thin extremities,
hypertension, purple striations of the skin 
      Treatment: surgical resection of tumor, radiotherapy
      Dental Findings: osteoporosis, delayed wound healing
       Dental Management: susceptibility to fractures, implants contraindicated

IV. PARATHYROID GLAND
Produces parathyroid hormone (PTH) which regulates serum calcium

Hyperparathyroidism
     Excess secretion of PTH
     Primary: caused by adenomas, hypercalcemia
     Secondary: chronic renal failure, hypocalcemia
     Symptoms: osteoporosis, renal stones, gastric distress, CV problems
     Oral Findings: loss of lamina dura, decreased density of bony trabeculae "ground glass" appearance,
osteitis fibrosa cystica "brown tumors" or central giant cell granulomas, pulp stones

Hypoparathyroidism
       Reduced secretion of PTH
       Primary: surgical removal of parathyroid gland, radiation
       Secondary: DiGeorge syndrome, idiopathic atrophy
       Symptoms: tetany/neuromuscular irritability, paresthesia of distal extremities, laryngospasm,
       Oral Findings: circumoral paresthesia, enamel hypoplasia, delayed eruption, enamel attrition

V. PITUITARY GLAND
Major role in endocrine and links to CNS.  Multiple hormones: thyrotropin, gonadotropins, growth hormone, corticotropin, prolactin.

Hypopituitarism
      Primary: genetic defect, tumors, infection, inadequate blood flow to gland, sarcoidosis, amlyoidosis,
radiation, surgical removal, autoimmune
       Secondary: hypothalamus tumors, inflammatory disease, head injuries, surgical damage
       Symptoms: fatigue, decreased appetite, weight loss, cold sensitivity, abdominal pain, visual
disturbances, loss of body hair, short stature, infertility
       Dental and Facial Findings of Hypopituitary Dwarfism: decreased linear facial measurements,
delayed tooth eruption, smaller mandible
       Dental Considerations: good medical history, dental caries and periodontal disease prevention

Hyperpituitarism
     GH excess: acromegaly and gigantism
     Causes: tumor, hypersecretion of GH, increased levels of IGF-I
     Symptoms: prognathism, soft tissue hypertrophy, diplopia, barrel chest, sleep apnea, hypertension,
cardiovascular abnormalities, insulin resistance
      Oral/Facial Finding: Frontal bossing, enlarged nose and lips, prognathism, malocclusion, increased
spacing, macroglossia, macrodontia, temporomandibular arthritis
      Dental Considerations: SBE consideration, management of craniofacial abnormalities, sedation
consideration

*All endocrine disorders require a thorough medical history and consult with physicians before any treatment is initiated