Endocrinology &adrenal disease

Lecture8:

Endocrinology

• Thyroid disease
Thyroid gland is on of the endocrine gland situated in the lower anterior portion of the neck. It contains two lobes connected together by an isthmus. It secretes T3, T4 and calcitonin. These hormone affect metabolism process body and oxygen use.T3 more potent than T4 and it is either secreted by thyroid gland or by conservation of T4to T3 in the peripheral tissue.
• Hyperthyroidism
Hyperthyroidism is a condition that refers to an excessof thyroid hormones, due to hyperfunction of the thyroidgland.Thyrotoxic patients present with anxiety, irritability,
hyperactivity, profuse sweating, tremor of thehands, insomnia, weight loss because of increased metabolism,tachycardia, arrhythmia, increased bloodpressure, weakness, and exophthalmos (71%).In certain circumstances, thyrotoxic patients maydevelop thyrotoxic crisis, that is, acute worsening ofthe thyroid symptoms mentioned above. Patients withthis condition have fever, marked tachycardia, arrhythmia,
abdominal pain, profuse sweating, nausea,congestive heart failure, pulmonary edema and perhapscoma, which in a large number of patients resultsin death. Precipitating factors of a thyrotoxic crisis includesevere stress, various infections, surgical procedures,trauma, pregnancy, diabetic ketoacidosis, drugscontaining iodine, etc. Local anesthesia or surgicalprocedures may precipitate a thyrotoxic crisis, becauseof the stress they cause. Therefore, the administrationof a sedative is deemed necessary to decrease the stressand fear a patient may have.Consultation with a physician is important in thecase of hyperthyroidism, because these patients usuallysuffer from cardiovascular disease, which must betaken into consideration by the dentist so that thetreatment plan is altered accordingly. Surgical dentalmanagement should be postponed until function ofthe thyroid has been normalized by appropriate medicalmanagement. These patients also present adverse interactionswith catecholamines, therefore there is increased riskof having a severe reaction to vasoconstrictors, especiallyadrenaline and noradrenaline. Thus, if thesepatients, whose cardiovascular system is already stimulated by the hyperthyroidism, are given vasoconstrictors,e.g., adrenaline (which is a drug thatstimulates the heart), then acute arrhythmia, ventricularfibrillation or even thyrotoxic crisis may result.Vasoconstrictors must be administered in the lowestconcentration possible and definitely after preliminaryaspiration. Felypressin is considered the safest
vasoconstrictor.
Goiter:enlargement of thyroid gland it may be toxic or non toxic
Lecture9:
Adrenal disease
The adrenal gland (suprarenal gland) located at the superior lobe of each kidney, it contain two layers, the outer one called cortex which secrete glucocorticoids, aldosterone and androgen;the inner layer called medulla which secretes epinephrine mostly.
• Cushing’s Syndrome
Apart from the cases of insufficient corticosteroid secretion, the patient may present with a pathologic condition characterized by hypersecretion of hormones from the adrenal cortex. Cushing’s disease or hyperadrenalism causes this condition. The preventive measures that are recommended for patients of this category who are to have dental surgery are the following:
?? The surgical procedure should be performed in a hospital with the cooperation of the patient’s physician
?? Sedative medication must be administered
?? In the case of a tooth extraction, manipulations must be performed carefully, because there is risk of fracture due to severe osteoporosis of the jaw.

Patients Receiving Corticosteroids
Patients who are to have oral surgery and who take corticosteroids must be managed in such a way to avert the possibility of acute adrenocortical insufficiency due to stress because of the imminent surgical procedure. There are, however, various opinions as to the criteria that determine which patients are at risk of developing acute adrenocortical insufficiency and which are not. According to Glick’s recommendations:
a. Patients who have received glucocorticoids during the last 30 days should be considered immunocompromised, and, as such, should be administered supplementation.
b. Patients who have received glucocorticoids in the past, but not during the last 30 days, are considered able to respond to stress and therefore do not need supplementation.
c. Patients who receive glucocorticoids on a long-term basis, using an alternate-day regimen, should have the surgery performed on the day they are not having therapy. These patients do not require an increase of their dosage of glucocorticoids.
d. Patients who receive glucocorticoids on a regular basis (daily), in doses greater than 10 mg prednisone (10 mg of Prezolon or 8 mg of Medrol), should be considered immunocompromised and do need supplementation. Supplementation involves the administration of 100 mg hydrocortisone (Solu-Cortef) intramuscularly or intravenously, before surgery. If the surgical procedure proves to be particularly painful or prolonged, then the supplementary administration of 50–100 mg hydrocortisone is recommended 6 h later. It is recommended that the total dose administered does not exceed 250 mg.
Despite the aforementioned recommendations and adhering to the recommendations of the patient’s physician, the dentist must be prepared to face the possibility of a crisis of acute adrenal insufficiency. Common findings of this condition include weakness, nausea, vomiting, hypotension, confusion, sleepiness, headache, dehydration and hyperpyrexia, and, if it is not treated rapidly, it may lead to coma and death of the patient.

Written by:
Mushtag t. mohammed
4th stage