ENDOCRANIAL DISORDERS
INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
Introduction ď Ž
Hypothalamus
is
in
overall
control
factors
(CRH)
of
adrenocortical function.
ď Ž
Hypothalamus
releases
stimulate pituitary to release ACTH.
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that
Physiology:
Adrenal cortex produces
Glucocorticoids Cortisol Corticosterone
Mineralocorticoids Aldosterone
Adrenal medulla produces – - Epinephrine - Nor epinephrine www.indiandentalacademy.com
Applied Aspects Corticoids: Essential part of the body’s response to – – – – – – – – –
Trauma Infection Pain Fever Burns GA Hypoglycaemia Stress Operation
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Hypothalamus – Pituitary – Adrenocortical axis
Angiotensinogen
Renin
Angiotensin 1 (inactive)
Angiotensin 2 (active)
Aldosterone
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Angiotensin converting enzyme (ACE)
Mineralocorticoids
Acts on kidney to promote – Sodium retention – Potassium excretion – Fluid retention – Vasoconstriction – Thirst www.indiandentalacademy.com
Diseases – Adrenal cortex
Hyperadrenocorticism (Cushing’s syndrome)
Hypoadrenocorticism (Addison’s disease)
– Adrenal medulla
Phaeochromocytoma
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Cushing’s syndrome
Etiology – Due to overproduction of cortisol. – Pituitary adenomas – Ectopic ACTH from adrenal, lung carcinoma etc.
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Cushing’s cont’d……
C/F – Central obesity affecting face (moon face) – Inter scapular region (buffalo hum) – Trunk – Hypertension – DM – Osteoporosis, muscle weakness, thinning of the skin, skin striae – Oligomenorrhoea – Infections – Psychosis
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Cushing’s cont’d……
Dental aspects – LA preferred – Conscious sedation – Patient is on corticosteroid therapy need for corticosteroid coverage – GA (corticosteroid coverage) www.indiandentalacademy.com
Hyperaldosteronism
Etiology – Primary hyperaldosteronism results from hyperplasia of adrenal cortex. Rare benign tumor – Secondary hyperaldesteronim results in activation of renin-angiotensin system www.indiandentalacademy.com
Hyperaldosteronism Cont’d……
C/F: – Potassium loss – Sodium retention – Hypokalaemia often causes muscle weakness, cramps, parasthesia, polyurea, polydypsia – Sodium retention leads to hypertension www.indiandentalacademy.com
Hyperaldosteronism Cont’d……
General management – –
Aldosterone angagonist Excision of the gland
Dental aspects – LA for pain control – Corticosteroid coverage, if the patient undergone bilateral gland excision. – If the patient is untreated hypertension and muscle weakness of the main complications. www.indiandentalacademy.com
Hypoadrenocorticism (Addison’s disease)
Etiology: – – – – – – – –
Autoantibodies to adrenal cortex. Adrenal tuberculosis HIV Malignancy Haemorrhage Sarcodosis Amylodosis Adrenalectomy www.indiandentalacademy.com
Hypoadrenocorticism Cont’d……
C/F: – Hypotension – Hypoglycaemia – Hyperpigmentation – Sodium depletion – Weakness – Anorexia, nausia, vomiting, diarrhoea
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Hypoadrenocorticism Cont’d……
General management – Most of the patients are treated with oral hydrocortisone and fludrocortisone
Dental aspects – – – – – – –
Risk of hypotensive collapse Give 200mg i.v. hydrocortisone Medical assistance Give glucose if there is hypoglycaemia (25g i.v. / Oral) Repeat 200mg i.v. hydrocortisone (4 to 6 hourly) Monitor blood pressure Steroid supplementation to be continue for 3 days after blood pressure returned to normal. www.indiandentalacademy.com
No steroids for previous 12 months Conservative No cover required dentistry or dentoalveolar surgery (e.g. single extraction) under local anaesthetic Intermediate surgery (e.g. multiple extractions, or surgery under GA)
Maxillofacial surgery or trauma
Steroids taken during previous 12 months Give usual oral steroid dose in morning or hydrocortisone 2550mg iv. Preoperatively
Steroids currently taken Double oral steroid dose in morning or hydrocortisone 25-50 mg i.v. preoperatively Continue normal steroid medication postoperatively
Consider cover if large Give usual oral doses of steroid were steroid dose in given. morning plus hydrocortisone 25Test adrenocortical 50mg i.v. function (ACTH preoperatively and simulation test) i.m. 6-hourly for 24 h
Double oral steroid dose in morning plus hydrocortisone 25-50 mg i.v. preoperatively and i.m. 6-hourly for 24 h
Consider cover if large Give usual oral doses of steroid were steroid dose in given morning plus hydrocortisone 25-50 Test adrenocortical mg i.v. preoperatively function (ACTH and i.m. 6-hourly for stimulation test) 72 h
Double oral steroid dose in morning plus hydrocortisone 25-50mg i.v. preoperatively and i.m. 6-hourly for 72 h
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Then continue normal medication
Then continue normal medication
Phaechromocytoma
C/F: – Headache – Palpitations – Tachycardia – Sweating – Hypertension – Glycosuria www.indiandentalacademy.com
Dental aspects – LA is generally safe, epinephrine is modest amounts has no adverse effects. – Defer the elective treatment until surgical treatment for phaechromocytoma done. – If emergency care required – do monitor the blood pressure and look for the cardiac arrhythmias.
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Thank you
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