Management

of Medically
compromised pa3ents: Endocrine
System
 Endocrine System
•  The endocrine system is an informa3on signal
system like the nervous system, yet its effects
and mechanism are classifiably different.
•  The endocrine system's effects are slow to
ini3ate, and prolonged in their response,
las3ng from a few hours up to weeks.
•  The nervous system sends informa3on very
quickly, and responses are generally short
lived.
 Endocrine System
•  Special features of endocrine glands are, in
general,
–  their ductless nature,
–  their vascularity, and
–  commonly the presence of intracellular vacuoles
or granules that store their hormones.
•  This is opposite to exocrine glands (salivary,
sweats, GIT glands)
 Endocrine System
•  Specialized endocrine organs –
–  thalamus, pineal, pituitary, thyroid, pancrease,
adrenal, testes/ovary
•  Secondary endocrine Organs –
–  bone, kidney (renin, erythropoie3n), liver, heart,
gonads

 Endocrine System
•  Major endocrine systems:
–  TRH-TSH-T3/T4
–  GnRH-LH/FSH-Sex hormones
–  CRH-ACTH-Cor3sol
–  Renin-angiotensin-aldosterone
–  Lep3n-Insulin
Diabetes Mellitus
 Diabetes Mellitus
•  Defini3on
–  Syndrome of chronic hyperglycaemia due to
rela3ve insulin deficiency, resistance or both.
•  Causes
–  Increase insulin resistance (Problem in the
peripheral 3ssue in responding to insulin)
–  Insulin deficiency (Problems in the pancreas to
secrete insulin)
 Diabetes Mellitus
•  Pathophysiology
–  Beta-cells of the pancrea3c islets secretes insulin
which then go the target organs with the prime
target organ being liver. It has glucose receptor
thus responds based on glucose levels.
–  Alpha-cells meanwhile secretes glucagon which
ac3on opposites of the insulin. It has no glucose
receptor thus responds based on the insulin level
 Diabetes Mellitus
–  Liver being the principle target organ for glucose
homeostasis absorbs and stores glucose (as glycogen).
It also does gluconeogenesis from fat and protein.
90% of glucose is from liver glycogen and hepa3c
gluconeogenesis. Remaining 10% from kidney
gluconeogenesis.
–  Brain is the major consumer of glucose and are not
dependent on insulin (obligatory uptake). Other
organs such as fat and muscle needs insulin to
consume glucose (faculta3ve uptake). When glucose
in not available (starva3on), brain consumes ketones
body as a subs3tute.
 Diabetes Mellitus
•  Thus Low/resistance in insulin causes
–  Increase hepa3c glucose output
–  Reduce u3lisa3on by various organs
–  Reduce storage of excess energy (glucose via
glycogen, fat and protein)
–  Increase renal reabsorp3on of glucose
–  Reduce incre3n hormones
Diabetes Mellitus
 Diabetes Mellitus
•  Screening has 2 pathways
–  Symptoma3c pa3ents
•  Tiredness, lethargy, polyuria, polydipsia, polyphagia, weight
loss, pruritus vulvae, balani3s
–  Asymptoma3c pa3ents (annually)
•  BMI 23 kg/m2 or have a waist circumference 80 cm for
women and 90 cm for men AND
•  First-degree rela3ve with diabetes, History of cardiovascular
disease (CVD), Hypertension, Impaired glucose tolerance
(IGT) or impaired fas3ng glucose (IFG), High density
lipoprotein (HDL) cholesterol <0.9 mmol/L or triglycerides
(TG) >2.8 mmol/L, Women who delivered a baby weighing 4
kg or were diagnosed with gesta3onal diabetes mellitus,
Women with polycys3c ovarian syndrome (PCOS)
Diabetes Mellitus
 Diabetes Mellitus
•  History
–  When diagnosed
–  How diagnosed
–  Why check for DM
–  Medica3on used
–  Any recent change in medica3on
–  Any complica3ons
•  Acute
•  Chronic
–  Ask control level (Home monitoring / HbA1c)
 Diabetes Mellitus
•  Common medica3on
•  Biguanides– weight neutral and no risk of hypoglycemia but
risk for lac3c acidosis in CKD cases, long term Vit B12
deficiency
–  Meformin (Glucophage)
•  Sulphonylurea – risk for hypoglycaemia (should be taken 30
minutes before meal) and weight gain
–  Glibenclamide – worst risk for hypoglycemia
–  Glicazide (Diamicrone)
•  Insulin
–  Actrapid (Meal / short ac3ng),
–  Insulitard (Basal / intermidiete ac3ng),
–  Mixtard (Premixed / biphasic ac3ng)
 Diabetes Mellitus
•  Monitoring
–  HbA1c - Perform A1c approximately every 3–6
months (intervals depend on whether A1c targets
are achieved): 3 monthly, if A1c is above target
and to allow assessment of effect of therapeu3c
adjustment. 6 monthly, if A1c target is achieved
and stable. Target < 6.5% in young newly
diagnosed, not so 3ght in elderly
 Dental Management
•  History
–  Detailed history on DM and other associated
diseases
–  Medica3on type, dosage and changes
–  Follow-up, compliance and control(HbA1c value)
–  Medica3on and food intake on day of treatment
•  Examina3on
–  Any signs sugges3ng poor control – periodon33s,
dry mouth, candidiosis, amputated leg, poor
eyesight
 Dental Management
•  Inves3ga3on
–  Random blood sugar pretreatment
•  Treatment
–  Early morning appointment of possible
–  Postponed if poor control – and refer to medical
doctor to op3mize
–  Ensure con3nua3on of normal food / medica3on
intake post treatment
–  An3bio3cs?
–  Avoid DM emergencies –
•  Hypoglycemia
•  Diabe3c Ketoacidosis and hyperosmolar hyperglycemic state
 Dental Management
•  Hypoglycemia
•  Low plasma glucose level (<4.0 mmol/L) OR
Development of autonomic or neuroglycopenic
symptoms

 Dental Management
•  Diabe3c Ketoacidosis
–  Capillary blood glucose >11 mmol/L (200mg/dL) AND
–  Capillary ketones >3 mmol/L (31mg/dL) or urine ketones ≥2+ AND
–  Venous pH <7.3 and/or bicarbonate <15 mmol/L

•  Hyperosmolar hyperglycemic state

–  Hypovolemia
–  Severe hyperglicemia RBS > 30mmmol/L
–  Osmolality > 320 mosmol/kg
–  Calcula3on osmolality : 2(Na + K) + urea + glucose
–  Others: no significnat hyperketonaemia (<3.0mmol/L), no acidosis
(pH>7.3; HCO3 > 15mmol/L)
Thyroid
 Hyperthyroidism
•  Defini3on
–  Set of disorders that involve excess synthesis and
secre3on of thyroid hormones by the thyroid
gland, which leads to the hypermetabolic
condi3on of thyrotoxicosis
 Hyperthyroidism
•  Types
–  Grave’s Disease (most common)
–  Toxic solitary adenoma
–  Toxic mul3nodular goitre
–  Acute thyroidi3s (de Quervin’s [viral] and others)
–  Exogenous
–  Amiodarone
 Hyperthyroidism
•  Ae3ology
–  Autoimmune (graves disease)
–  Muta3ons (Toxic solitary adenoma / toxic
mul3nodular goitre)
–  Viral (de quervain’s thyroidi3s)
–  Radia3on
–  Drugs – amiodarone
–  Exogenous iodine
–  Hormonal (gesta3onal or puberty)
 Hyperthyroidism
•  Symptoms
–  Metabolic - Weight loss, Increase appe3te, Heat
intolerance, hyperdefeca3on (not diarrhea),
–  urinary frequency, oligomenorrhea or amenorrhea
(women) , gynecomas3a and erec3le dysfunc3on (men)
–  Cardiovascular - Palpita3ons (tachycardia or atrial
fibrilla3on in older adults)
–  Neuropsychiatric - Tremor Irritability, Restless, proximal
myopathy, imsomnia
–  Ocular - Eye complaints (mainly in Graves disease)
–  Cutaneous - pre3bial myxedema
 Hyperthyroidism
•  Signs
–  Neck – goitre, bruit
–  Eyes – lid lad, exopthalmus, periorbital and
conjunc3val edema, limita3on of eye movement,
(Graves)
–  Cardiovascular – tachycardia, atrial fibrilla3on,
irregularly irregular, full pulse, systolic hypertension
–  Hands - tremors
–  Legs - infiltra3ve dermopathy/ pre3bial myxedema
(graves)
 Hyperthyroidism
•  Disease complica3ons:
–  opthalmopathy
–  infiltra3ve dermopathy
–  Heart arack / arrythmia
–  Pregnancy related issue
–  Osteoporosis
–  Other outoimmune disease (in graves)
–  Thyroid storm
•  Treatment complica3ons:
–  Hypothyroidism
–  Agranulocytosis
 Hyperthyroidism
•  Thyroid storm – excessive thyrotoxicosis causes
increase metabolism (hyperpyrexia) and all the
other symptoms of hyperthyroidism in the most
severe form (fast and osen irregular heart beat,
vomi3ng, diarrhea and agita3on). Cause by
stress, infec3on or surgery. Occur commonly in
undiagnosed/untreated / non-compliance
thyrotoxicosis.
•  undiagnosed/untreated / non-compliance +
known hyperthyroid + stressor = THYROID
STORM
 Hyperthyroidism
•  Treatment
–  An3thyroid drugs – carbimazole or propylthiouracil to
inhibit forma3on of thyroid hormones
–  Radioac3ve iodine – destroy thyroid glands by local
irradia3on
–  Surgery thyroidectomy – on selec3ve cases (aesthe3c,
compression (large goitre), contraindicated with
radioiodine, drugs side effects, poor compliance to drugs,
suspected malignancy) – normalized thyroixine level
before op by carbimazole to prevent thyroid crisis due to
release of hormone during surgery
–  Eye – eye-drops, systemic steroids, eye tape, surgery,
irradiate the orbit
 Dental Management
•  Pain, anxiety, trauma, GA, infec3on may
precipitate thyrotoxicosis
•  Povidone iodine best avoided
 Hypothyroidism
•  Defini3on
–  Set of disorders that involve defeciency in
synthesis and secre3on of thyroid hormones by
the thyroid gland - myxedema
 Hypothyroidism
•  Primary Type (from thyroid) –
–  Autoimmune – Hashimoto’s thyroidi.s, atrophic
thyroidi3s, postpartum thyroidi3s (transient)
–  Synthesis problems – Iodine deficiency, an3-thyroid or
other drugs
–  Congenital – Agenesis
–  Infec3ve – post subacute thyroidi3s
–  Iatrogenic – thyroidectomy, radioac3ve iodine, neck
irradia3on
–  Neoplasia - tumour infiltra3on
•  Secondary type
–  Hypopituitarism – TSH deficiency
 Hypothyroidism
•  Symptoms
–  Asymtoma3c
–  Tiredness
–  cold intolerance,
–  goitre
–  Wieght gain
–  puffiness,
–  decreased swea3ng, and coarse skin
–  cons3pa3on
–  oligomenorrhea or menorhagia (women)
–  depression
 Hypothyroidism
•  Signs
–  Dry skin and dry thin hair
–  Goitre
–  Bradycardia, pericardial effusion
–  Slow relaxing reflex or hypo-reflexia or both
–  Mental slowness
–  Nonpixng edema (myxedema)
–  Pixng edema of lower extremi3es
 Hypothyroidism
•  Myxoedema coma –
•  severe hypothyroidism leading to decreased mental status,
hypothermia, and other symptoms related to slowing of
func3on in mul3ple organs. Important clues to the possible
presence of myxedema coma in a poorly responsive pa3ent
are the presence of a thyroidectomy scar or a history of
radioiodine therapy or hypothyroidism. can occur as the
culmina3on of severe, long-standing hypothyroidism or be
precipitated by an acute event such as infec3on,
myocardial infarc3on, cold exposure, or the administra3on
of seda3ve drugs, especially opioids. hallmarks of
myxedema coma are decreased mental status and
hypothermia, but hypotension, bradycardia, hyponatremia,
hypoglycemia, and hypoven3la3on are osen present as
well.
 Hypothyroidism
•  Treatment
–  Levothyroxine
 Dental Management
•  Avoid sedaton, opiods and GA – risk for
mtxoedema
Cushing’s Syndrome/Disease
 Cushing’s Syndrome/Disease
•  Defini3on
–  an endocrine disorder that occurs when there is
excess glucocor3coid
 Cushing’s Syndrome/Disease
•  Types
–  ACTH dependent / Cushing’s disease: Elevated
ACTH from pituitary or ectopic
–  Non-ACTH dependent: Excess cor3sol from
adrenal gland or exogenous
 Cushing’s Syndrome/Disease
•  Pathophysiology
–  In Cushing’s disease it is due to pituitary adenoma
–  In Non-ACTH dependent due to adrenal adenoma
or glucocor3coid inges3on
 Cushing’s Syndrome/Disease
•  General symptoms
–  Sudden weight gain
–  Dermatologic symptoms -Reccurent infec3ons. Easily bruised, skin
atrophy, striae, pigmenta3on (ACTH dependent)
–  Androgen excess symptoms: Low libido, Menstrua3on disorder,
hirsu3sm, oily skin (acne), viriliza3on (balding, deep voice, clitoral
hypertrophy)
–  Diabetes mellitus symptoms – polyuria, polydispsia
–  Osteoporosis – pathologic fracture, low back pain
•  ACTH dependent symptoms
–  Pigmenta3on (high ACTH)
–  Bitemporal hemianopsia (pituitary tumor)
•  Non-ACTH dependent symptoms
–  Hyperpigmenta3on is not present because ACTH secre3on is not
increased.
 Cushing’s Syndrome/Disease
•  Signs
–  Pigmenta3on (in ACTH dependent)
–  Hypertension
–  Cushinoid – central obesity, buffalo hump, moon
face, thin skin, purple striae, hirsu3sm, and female
frontal balding
–  Others - osteoporosis, proximal myopathy,
bruising, acne, , facial plethora
 Cushing’s Syndrome/Disease
•  Func3on of the hypothalamic-pituitary-
adrenal cortex axis distrupted
•  Nega3ve feedback reduce ACTH
•  Adrenocor3cal atrophy
 Dental Managment
•  Look for history of prolonged systema3c
steroid (<30days)
•  Steroid cover
–  100mg hydrocor3sone / 20mg prednisolone / 4mg
Dexamethasone / double the dose
•  An3bio3cs
–  Higher risk of infec3on
•  Look for DM