Pituitary, thyroid and

parathyroid medical
conditions and their
dental management
By: Rawan AlDakheel
 Pituitary Gland
• Posterior pituitary hypofunction
• Anterior pituitary hypofunction
• Anterior pituitary hyperfunction

Thyroid Gland
Outlines
• Hypothyroidism
• Hyperthyroidism
• Thyroid cancer

Parathyroid Gland
• Hypoparathyroidism
• Hyperparathyroidism
Pituitary Gland
Medical Conditions
and their Dental
Management
 Hypothalamus and
Pituitary Gland
• The hypothalamus is the part of the brain that controls many other
endocrine glands, via pituitary function.

• The anterior pituitary gland hormones :

-Growth hormone
-Prolactin
-Luteinizing hormone
-Follicle stimulating hormone
-Thyroid stimulating hormone
-Adrenocorticotropic Hormone

• The posterior pituitary gland hormones are:

-Antidiuretic hormone
-Oxytocin
 Anterior Pituitary Hypofunction

- The usual causes are local hypothalamic or pituitary lesions, such as tumors or
irradiation

- Clinical features:
Hypofunction of the target glands
Adrenal cortex (hypoadrenalism)
Thyroid (hypothyroidism)

- General management:
Hormone substitution therapy (corticosteroids and thyroxine)
Surgery
 Anterior Pituitary Hypofunction

- Dental aspect:

 Patients are at risk from adrenal crisis

Hypopituitary coma should be treated by laying the patient flat and giving an
immediate intravenous injection of 100mg hydrocortisone sodium succinate.

Blood should be taken for assay of glucose, thyroid hormones and cortisol

25–50 g dextrose should be given intravenously if there is hypoglycaemia

 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- Overproduction of growth hormone by an anterior pituitary

adenoma
 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- In both gigantism and acromegaly, local pressure effects from

the pituitary tumour may cause hypopituitarism plus
compression of the optic chiasma, with visual field defects

- Growth hormone disorders may be complicated by diabetes

mellitus, hypertension, cardiomyopathy, sleep apnoea,
hypercalcaemia and osteoarthritis
 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- In gigantism: all the organs, soft tissues and skeleton enlarge,

leading to :

oExcessively tall stature

oThickening of the soft tissues
oProminence of the supraorbital ridge
oCoarse oily skin
oThick spade-like fingers
oDeepening of the voice
 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- In acromegaly:
oOnly those bones with growth potential, particularly the
mandible, can enlarge
oThickening of the soft tissues
oThe hands become large and spade-like
 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- Dental aspect:
o Mandibular enlargement leads to prognathism (class III
malocclusion) with spacing of the teeth
o Orthognathic surgery may be needed
 Anterior Pituitary Hyperfunction
• Growth hormone excess: gigantism and
acromegaly

- Dental aspect:
o Local analgesia is suitable.
o CS may be given, if necessary, provided the airway is clear.
o Dental management may be complicated by: blindness,
diabetes mellitus, hypertension, cardiomyopathy,
arrhythmias and hypopituitarism and other deformities
affecting respiration, which may make GA hazardous.
 Posterior Pituitary Hypofunction
• Diabetes insipidus

- Diabetes insipidus is a rare disease caused by lack of ADH effect

(Cranial diabetes insipidus)
Rarely because of renal insensitivity to ADH

- Clinical features:

Polyuria
Polydipsia
Cranial diabetes insipidus may also cause pressure on the
optic chiasm, leading to visual or cranial nerve defects
 Posterior Pituitary Hypofunction
• Diabetes insipidus

- Dental management:

Local anaesthesia is the most satisfactory means of pain control

Dentistry is usually uncomplicated by this disorder except for dryness
of the mouth.
Thyroid and
Parathyroid Medical
Conditions and their
Dental Management
Thyroid Gland

• The thyroid gland is located in the anterior

portion of the neck and consists of two lateral
lobes connected by an isthmus.

• The thyroid gland secretes three hormones:

thyroxine (T4), triiodothyronine (T3), and
calcitonin
Thyroid Gland

• Thyroid hormone influences the growth and

maturation of tissues, cell respiration, total
energy expenditure and the turnover of
essentially all substances, vitamins, and
hormones.

• It also increases the heart rate, mental alertness,

ventilatory drive, gastrointestinal motility, and
bone turnover.
Thyroid Gland

• Dentists should be aware that blood

levels of T4 and T3 are controlled
through a servo feedback mechanism
mediated by the hypothalamic–
pituitary–thyroid axis
 Hypothyroidism

• Hypothyroidism may be primary (due to

thyroid disease) or secondary (due to
hypothalamic or pituitary dysfunction).

• hypothyroidism can cause weight gain, dry

skin, myxoedema, loss of hair, cardiac failure,
ischaemic heart disease, bradycardia, anaemia,
neurological or psychiatric changes.
 Dental aspect:
• Untreated patients exposed to stressful situations may
develop hypothyroid (myxedema coma)
• Untreated hypothyroid patients may be highly sensitive
to actions of narcotics, barbiturates.
• May have comorbidities: hypercholesterolemia, or
Hypothyroidism bleeding issues

Oral manifestations:
• Increased tongue size
• Delayed eruption of teeth
• Malocclusion
• Gingival edema
 Prevention of problems:
• Detection and referral
• Avoidance of narcotics and barbiturates in untreated
hypothyroid patients
• Recognition of initial stage of hypothyroid (myxedema
coma):
• Hypothermia
Hypothyroidism • Bradycardia
• Hypotension
• Epileptic seizures
• Initiation of immediate treatment for myxedema coma:
• Seek immediate medical aid.
• Administer hydrocortisone (100–300 mg).
• Provide CPR as indicated
Hyperthyroidism
(THYROTOXICOSIS)
• Excess of T4 and T3 in the bloodstream.
This excess may be the result of:
oProduction by ectopic thyroid tissue
o Multinodular goiter
oThyroid adenoma
oSubacute thyroiditis
oPituitary disease involving the
anterior portion of the gland.
• Hyperthyroidism may cause:
o Exophthalmos.
oMimics the effects of adrenaline.
oAnorexia, vomiting or diarrhea.
o Weight loss, anxiety and tremor.
oSweating and heat intolerance.
oCardiac disturbances.
 • Thyrotoxic crisis may be precipitated in patients with untreated or incompletely
treated thyrotoxicosis by:

oInfection
oTrauma
oSurgical procedures

Hyperthyroidism oStress

• Patients may be very sensitive to actions of epinephrine and other pressor

amines; thus, these agents must not be used.

• Thyrotoxicosis increases the risk for hypertension, angina, myocardial

infarction (MI), congestive heart failure, and severe arrhythmias.
 • Oral manifestations:

o Early jaw development.

o Osteoporosis may occur. o Acute salivary gland swelling, pain, loss

o Periodontal disease may be more
progressive.
Hyperthyroidism o Dental caries may be more extensive.
of taste
o Radioactive drug-induced: Chronic
sialadenitis, xerostomia, pain, and dental
caries

o Premature loss of deciduous teeth and

early eruption of permanent teeth may
occur.
 • Dental aspect:

o Detection of patients with thyrotoxicosis by history and

examination findings

o Referral for medical evaluation and treatment

o Avoidance of any dental treatment for patient with

Hyperthyroidism thyrotoxicosis until good medical control is attained

o Any acute oral infection is dealt with by antibiotic therapy and

other conservative measures to prevent development of
thyrotoxic crisis

o Avoidance of epinephrine and other pressor amines in untreated

or incompletely treated patients
 • Dental aspect:
(thyrotoxic crisis)

 Recognition of early stages of thyrotoxic

crisis:

oFever
oAbdominal pain
oDelirious, obtunded, or psychotic
Hyperthyroidism
 Initiation of immediate emergency treatment
procedures:

oSeek immediate medical aid.

oCool with cold towels, ice packs.
oHydrocortisone (100–300 mg)
oMonitor vital signs.
oStart cardiopulmonary resuscitation
(CPR) if needed.
oManage pain and xerostomia
Thyroid Cancer

• Three main histologic types of

thyroid cancer have been
identified: differentiated,
medullary, and anaplastic.
Thyroid Cancer
• Dental aspect:

 Examine for signs and symptoms of thyroid cancer:

o Hard, painless lump in thyroid
o Hoarseness,
o dysphagia,
o dyspnea
o Cervical lymphadenopathy
o Nodule that is affixed to underlying tissues

 Patients found to have thyroid nodule should be referred

for fine-needle aspiration biopsy.

 Consult with patient’s physician regarding permissible

degree of hyperthyroidism in patients treated with
thyroid hormone
 Thyroid Cancer
• Treatment plan
modifications:

 The dental treatment plan is not affected unless

the cancer treatment includes external
irradiation or chemotherapy.
 Care with the use of epinephrine is indicated in
patients made to be hyperthyroid as part of
their cancer treatment
 Patients with anaplastic carcinoma have a poor
prognosis, and complex dental procedures
usually are not indicated.
 Parathyroid
Glands

• The parathyroids are four pea-sized glands

located on the back of the thyroid gland in
the neck, which produce parathyroid
hormone (PTH).

• PTH and vitamin D both act to control

plasma calcium levels.
 Parathyroid
Glands

• PTH secretion is stimulated by a fall in the

level of the plasma ionized calcium. It acts
on the kidneys to increase renal reabsorption
of calcium and impair phosphate
reabsorption

• PTH enhances gastrointestinal absorption of

calcium and promotes osteoclastic bone
resorption, causing a rise in the plasma level
of calcium
 The most frequent
cause is Clinical features:
thyroidectomy

Low plasma
Hypoparathyroidism calcium leads to Facial twitching
muscle irritability (Chvostek’s sign)
and tetany

Carpopedal spasms Numbness and

(Trousseau’s sign) tingling of arms
 Hypoparathyroidism

- General management:

 Replacement therapy includes vitamin D and calcium

supplements

- Dental aspect:
 Chronic mucocutaneous candidiasis
 Facial paraesthesia and facial twitching caused by tetany
(Chvostek’s sign).  LA is satisfactory

 Enamel hypoplasia  CS can be given.

 Shortened roots with osteodentine formation  Dental management may be complicated by tetany and seizures

 Delayed eruption
 Primary hyperparathyroidism: caused by a
parathyroid adenoma and is seen in
postmenopausal women.

Secondary hyperparathyroidism: a response to low

Hyperparathyroidism
plasma calcium caused by chronic renal failure or
prolonged dialysis, or by severe malabsorption.

Tertiary hyperparathyroidism: follows prolonged

secondary hyperparathyroidism, which has become
autonomous.
 Hyperparathyroidism

- The main features include:

 Hypercalcaemia

Renal disease (renal calcifications)

Skeletal disease (bone pain, pathological fractures, giant cell tumours,

bone rarefaction)

Peptic ulceration

Pancreatitis

Hypertension and arrhythmias

 Hyperparathyroidism
- Dental aspect:
Loss of the lamina dura and generalized bone rarefaction
Giant cell lesions of hyperparathyroidism (brown
tumours) are rare but histologically indistinguishable from
central giant cell granulomas of the jaws.
LA is the main means of pain control, especially if
hypertension and arrhythmias are present.
CS is preferably carried out with nitrous oxide and
oxygen.
 GA may be challenging because of cardiovascular
complications and sensitivity to muscle relaxants.
 Dental treatment in hyperparathyroidism may be
complicated by renal disease, peptic ulceration and bone
fragility.
Thank you