ADRENAL AND THYROID DISORDERS

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ADRENAL AND THYROID DISORDERS

• Claire Nowlan MD
• Jan 9, 2004

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The Adrenal Glands

• Medulla - part of the sympathetic nervous system
  
• produces epinephrine and norepinephrine
• Cortex produces
• 1) Aldosterone (a mineralcorticoid) acts mainly
  on the cells of the kidney tubules
• Regulation of plasma salts Na and K
• Blood pressure
• Blood volume
• 2) Androgen and Estrogen

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The Adrenal Cortex

• 3) Cortisol (a glucocorticoid)
• Catabolizes proteins and converts the resultant
  amino acids to glucose
• Inhibits inflammation
• Maintains homeostasis
• Secreted secondary to stress (cold, fasting,
  starvation, hypotension, hemorrhage, surgery,
  infections, pain, severe exercise, emotional
  trauma)
• Diurnal variation highest in the AM
• Essential for life

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Regulation of Secretion
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Synthetic glucocorticoids

• Most common ones are prednisone,
  methylprednisone, dexamethasone.
• Used to decrease inflammation in
• Rheumatoid arthritis, SLE, asthma, inflammatory
  bowel disease, organ transplantation
• Long term side effects include
• Hypertension, osteoporosis, diabetes, glaucoma,
  delayed wound healing, peptic ulcers

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Hyperadrenalism

• Cushings syndrome
• Commonly caused by adrenal/pituitary neoplasm or
  iatrogenic
• Symptoms weight gain, weakness, easy
  bruisibility, depression, insomnia, impotence
• Clinical symptoms acne moon facies, abdominal
  stria

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Hypoadrenalism

• Primary (problems with adrenal gland)
• Addisons disease
• Etiology includes autoimmune, Tb or HIV
  infections, metastatic

• Secondary
• Etiology includes excess steroid administration
  or pituitary/ hypothalmus problems

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Hypoadrenalism

• Acute adrenal insufficiency is a medical crisis
• Chronic disease usually presents with vague
  complaints
• Postural dizziness
• Weakness
• Nausea
• Anorexia
• Weight loss
• Classic findings hypotension, hyperpigmentation
• If you identify a patient with adrenal
  insuffiency Bravo! Refer to physician, and defer
  dental treatment until stable

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Lab tests

• Difficult to do
• 24 hour urine cortisol
• ACTH suppression test

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Medical management

• Hyperadrenalism
• Surgery/radiotherapy to destroy pituitary/adrenal
  tumour
• Ketoconazole inhibits adrenal hormone
  biosynthesis
• Hypoadrenalism
• Supplement mineralcorticoids, glucocorticoids
• Avoid ketoconazole, P450 inducers (rifampin,
  phenytoin, barbituates
• In surgery tx same as patient on steroids

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Dental managementPatients on steroids
hyperadrenalism

• Select a non NSAID analgesic - re risk of peptic
  ulcers
• Osteoporosis is related to periodontal bone loss
• Monitor BP
• You dont want to provoke an adrenal crisis

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Oral Steroids and procedures

• Determine length of time steroid taken
• Determine dose of steroid
• For routine/minimally invasive procedures
• Ensure patient has taken regular steroid dose
  preferably within 2 hours of procedure

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For major procedures

• Using general anesthesia, 1 hours, significant
  blood loss, in sicker patients
• Consider stopping steroid 1 week before ? (not
  likely)
• ACTH test ?
• Surgery in the AM
• Consult with physician
• Consider doing procedure in hospital setting
• Treat pain aggressively
• Monitor blood pressure
• Evaluate post-op for signs of adrenal
  insufficiency (weak pulse, hypotension, dyspnea,
  myalgia, fever)
• Supplement steroid intraoperatively and Q8H for
  24-48 hours

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The Thyroid

• Produces T3 and T4 which regulate the bodys
  metabolic rate and increase protein synthesis
• The body is responsible for converting 80 of the
  T4 to T3 (more potent)
• Carried in the blood by TBG Thyroid Binding
  Globulins

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Regulation of Secretion
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Lab Tests

• sTSH the best test

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Goiter thyroid enlargement

• Euthyroid goiter is most common form
• Iodine deficiency is the most common form of
  goiter in the world
• Eating a lot of goitrogens (cabbages, turnips,
  rutabagas) coupled with low iodine
• Associated with also with hypo/hyperthyroidism

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Hyperthyroidism

• Autoimmune (Graves disease)
• Antibody against the thyroid TSH receptor which
  results in continuous stimulation
• Women more at risk
• Other causes
• Overdose on thyroid medication
• Early stage thyroididits
• Pituitary disease

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Symptoms of hyperthyroidism

• Nervousness, anxiety, heat intolerance, fatigue,
  weight loss, palpitations, rapid heart beat, warm
  moist skin, rosy complexion, diarrhea, tremor
• Myxedema puffy, raised red areas
• Opthalmopathy
• Edema and inflammation of the extraocular muscles
  does not resolve when patient treated
• Wide stare, lid lag

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Thyroid Storm - lethal

• More likely in patients with
• Goiter
• Eye pathology
• Long history of hyperthyroidism
• Poorly treated
• Early symptoms
• Restlessness, fever, tachycardia, nausea,
  abdominal pain,sweating, pulmonary edema
• Precipitants
• Infections, trauma, surgical emergencies,
  operations
• Treatment
• Medical help, hydrocortisone, IV glucose, ice
  packs

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Hypothyroidism

• Hashimotos thyroiditis
• Lymphocytic infiltration of the gland
• Decreased peripheral conversion of T4 to T3
• In ill or elderly
• Congenital
• Other causes
• Lithium
• Thyroiditis
• Iodine excess
• postablative

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Symptoms of hypothyroidism

• Increased sensitivity to cold, constipation,
  weight gain, weakness, dry coarse hair and skin,
  alopecia outer third of the eyebrows, puffy
  eyelids, hoarseness, moving/thinking slowly
• Myxedema

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Medical treatment - hypothyroidism

• T4 (L-thyroxin, Synthroid) is titrated until the
  patient has a normal TSH
• May change insulin, coumadin requirements
• If untreated, can progress to a myxedema coma
  progressive weakness, hypothermia, hypoglycemia,
  hypoventalation leading to death it is treated
  with IV T4

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Dental management - Hypothyroidism

• Recognize signs and symptoms
• Patients who are untreated or incompletely
  treated are more sensitive to CNS depressants
• Myxedematous coma can be precipitated by stress
  in severe, poorly treated elderly patients

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Dental management - Hyperthyroidism

• Recognize signs and symptoms
• Patient untreated or incompletely treated are
  very sensitive to epinephrine do not administer
• More likely to have osteoporosis
• Beware thyroid storm

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Medical treatment - hyperthyroidism

• Propylthiouracil blocks the extrathyroidal
  deiodination of T4 to T3
• Betablockers like propranalol can treat tremors,
  sweating tachycardia
• Subtotal thyroidectomy/radioactive iodine

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Thyroid nodules

• Risk factors for cancer
• Young age
• Male
• History of neck irradiation
• Dyspnea, dysphagia
• Hard consistency
• Single nodule
• Rapid growth
• Fine needle biopsy is best test