Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 20 Other Hormones

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hyperthyroidism  Due to an excessive secretion of thyroid hormone  Can affect multiple body systems  Commonly reported symptoms include diarrhea, flushing, increased appetite, tachycardia, fatigue, irritability, sleep disorders, and heat intolerance.  Oral manifestations include accelerated tooth eruption, marked loss of alveolar process, diffuse demineralization of the jaw bone, and rapidly progressing periodontal destruction. 2

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hyperthyroidism  Hyperthyroidism can be treated with medication.  Methimazole and propylthiouracil (PTU) are antithyroid drugs.  Methimazole inhibits the incorporation of iodine molecules into the amino acid tyrosine.  PTU inhibits the conversion of T 4 to T 3 in the peripheral circulation.  Both drugs cause a loss of taste, drowsiness, headache, lymphadenopathy, and enlarged thyroid. 3

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hyperthyroidism  Saturated solution of potassium iodide (SSKI) and Lugol’s solution (potassium iodide) are two more options used to treat hyperthyroidism.  SSKI inhibits thyroid hormone synthesis.  Lugol’s solution prevents the release of thyroid hormones from the thyroid gland.  Adverse effects include skin rash, conjunctivitis, metallic taste, burning in the mouth, sore throat, and head cold symptoms. 4

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hyperthyroidism  Most patients usually receive either one of these drugs prior to thyroidectomy.  Many patients also under radiation therapy.  Patients receive radioactive iodine ( 131 I) orally.  The drug is sequestered in the thyroid gland and its use results in the localized destruction of thyroid tissue. 5

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hyperthyroidism  Patients with uncontrolled hyperthyroidism should not receive a vasoconstrictor because of the increased risk for a cardiotoxic event.  Patients may have an increased tolerance to opioid analgesics and other CNS depressant drugs.  Larger doses of these drugs may be required until the patient is considered euthyroid. 6

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hypothyroidism  Hypothyroidism is due to either primary thyroid gland failure or a decrease in thyroid hormone synthesis.  Signs and symptoms include mental and physical retardation in children, dry skin, coarse skin and hair, cold intolerance, bradycardia, weight gain, periorbital puffiness, constipation, weakness, lethargy, and fatigue.  Oral findings include delayed tooth eruption, malocclusion, periodontal disease, poorly shaped and carious teeth, and inflamed, pale or enlarged gingiva. 7

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Thyroid Hormones  Hypothyroidism is treated with thyroid supplementation.  This is a life-long treatment.  Thyroid supplements can be either synthetic or natural.  Thyroid supplements work by giving the body an exogenous supply of thyroid.  Common adverse effects of thyroid supplements include tachycardia, palpitations, hypertension, insomnia, tremors, headache, anxiety, and weight loss.  The adverse effects mimic hyperthyroidism.  Patients who are hypothyroid may require lower doses of CNS depressant drugs because their livers are metabolizing drugs at a much slower speed than someone who is euthyroid. 8

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Diabetes mellitus is a group of metabolic disorders characterized by persistent hyperglycemia.  Type I diabetes usually develops in people <30 years of age and results from an autoimmune destruction of pancreatic β cells.  These people need exogenous insulin to survive.  Type II diabetes usually develops in people over the age of 40.  Type II diabetes is a result of impaired insulin action, insulin resistance, and defective pancreatic β cells. 9

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Oral Complications of Diabetes  Uncontrolled diabetes can cause many oral complications.  Tight control of plasma glucose levels can help minimize oral complications.  Patients with diabetes are at higher risk for xerostomia.  These patients are also at a higher risk for caries.  Patients with uncontrolled diabetes are at a higher risk for periodontal disease.  Patients with diabetes have fragile blood vessels, delayed wound healing, and a tendency to develop infections.  Epinephrine, steroids, and opioid analgesics should be used with caution in diabetic patients because they can decrease insulin release or increase insulin requirements. 10

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Evaluating Dental Patients with Diabetes Ask the patient what their most current plasma glucose levels have been. Ask the patient what their most current plasma glucose levels have been. Ask the patient when they last measured plasma glucose levels. Ask the patient when they last measured plasma glucose levels. Ask for the results of those levels. Ask for the results of those levels. Ask the patient when they last took their insulin or oral hypoglycemic medicine and when they last ate. Ask the patient when they last took their insulin or oral hypoglycemic medicine and when they last ate. If the patient has not eaten or taken medicine then the appointment should be rescheduled. If the patient has not eaten or taken medicine then the appointment should be rescheduled. If the patient becomes hypoglycemic then glucose should be given. If the patient becomes hypoglycemic then glucose should be given. Fruit juice, cake frosting, or icing are excellent sources of glucose. Fruit juice, cake frosting, or icing are excellent sources of glucose. 11

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Drugs Used to Manage Diabetes Insulin is the only drug used to manage type I diabetes. Insulin is the only drug used to manage type I diabetes. It is ultimately used to manage type II diabetes. It is ultimately used to manage type II diabetes. It must be injected several times a day, dependent upon the patient’s plasma glucose levels. It must be injected several times a day, dependent upon the patient’s plasma glucose levels. Hypoglycemia is its most common adverse effect. Hypoglycemia is its most common adverse effect. Oral antidiabetic drugs are initially used to manage type II diabetes. Oral antidiabetic drugs are initially used to manage type II diabetes. 12

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Drugs Used to Manage Diabetes There are several different classes of medication available to treat type II diabetes. There are several different classes of medication available to treat type II diabetes. Patients usually receive a combination of a second generation sulfonylurea and a biguanide to help them maintain tight control of their plasma glucose levels. Patients usually receive a combination of a second generation sulfonylurea and a biguanide to help them maintain tight control of their plasma glucose levels. α glucosidase inhibitors, thiazolidinediones, and newer agents are also available to help patients achieve and maintain tight control of their plasma glucose levels. α glucosidase inhibitors, thiazolidinediones, and newer agents are also available to help patients achieve and maintain tight control of their plasma glucose levels. 13

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Drugs Used to Manage Diabetes Most of these drugs can cause GI upset, nausea, vomiting and diarrhea. Most of these drugs can cause GI upset, nausea, vomiting and diarrhea. Sulfonylureas can cause hypoglycemia. Sulfonylureas can cause hypoglycemia. There have been reports of metformin causing a metallic taste. There have been reports of metformin causing a metallic taste. 14

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pancreatic Hormones  Diabetes  Managing Dental Patients that are Taking Insulin or Oral Hypoglycemic Drugs Hypoglycemia - Question patient about last meal ingested. Hypoglycemia - Question patient about last meal ingested. Infection more likely - Monitor closely and give antibiotics if needed (treat aggressively). Infection more likely - Monitor closely and give antibiotics if needed (treat aggressively). Healing prolonged - Follow patient with any surgical procedure. Healing prolonged - Follow patient with any surgical procedure. Drug interactions - Large doses of salicylates may produce hypoglycemia. Drug interactions - Large doses of salicylates may produce hypoglycemia. Appoint patient in morning after breakfast and insulin or oral hypoglycemic agent. Appoint patient in morning after breakfast and insulin or oral hypoglycemic agent. Provide quick glucose source for hypoglycemia (cake icing, orange juice). Provide quick glucose source for hypoglycemia (cake icing, orange juice). Check for oral complications related to diabetes. Check for oral complications related to diabetes. Ask patients what the results of their blood glucose monitoring have been (if checked). Ask patients what the results of their blood glucose monitoring have been (if checked). 15

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Both male and female sex hormones occur in both sexes in different proportions.  The 2 major female sex hormones are estrogen and progesterone.  They are largely responsible for female sexual characteristics, developing the reproductive system, and preparing the reproductive system for contraception.  Estrogen and progesterone levels vary on a daily basis. 16

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Estrogen  Estrogens are primarily responsible for the changes that take place in girls during puberty.  Synthetic estrogens are used in combination with progesterone to prevent therapy.  Estrogen is used to treat dysmenorrhea, dysfunctional uterine bleeding, osteoporosis, atrophic vaginitis, cancer, acne, and symptoms of menopause. 17

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Estrogens  Adverse effects include nausea, vomiting, uterine bleeding, vaginal discharge, edema, thrombophlebitis, weight gain, and hypertension.  Oral adverse effects include gingivitis, gingival inflammation, dry socket after extraction, and increased gingival fluid.  Meticulous, home oral health care can help minimize oral adverse effects. 18

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Progestins  Progesterone promotes secretory changes in the endometrium and prepares the uterus for implantation of the fertilized egg.  Progestins are used alone or in combination with estrogen for contraception.  Progestins are used in combination with estrogen to treat the symptoms of menopause.  Progestins are available as an intramuscular injection administered every 3 months, as a progestin-only pill, in the form of an intrauterine device, or as an implant under the skin on the arm, all as contraception.  Adverse effects include abnormal menstrual bleeding, breakthrough bleeding, and amenorrhea. 19

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Oral Contraceptives  Oral contraceptives are made up of estrogens and progestins in varying combinations.  Combination oral contraceptives are taken for 21 days each month.  The last 4-7 days of each packet contain no active ingredients.  The newest oral contraceptive available is designed to be given daily for three months. As a result, women only bleed every 3 months, or 4 times a year. 20

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Oral Contraceptives  Oral contraceptives interfere with fertility by inhibiting the release of FSH and LH, which prevents ovulation.  There are many adverse effects associated with oral contraceptive therapy.  Adverse effects include thrombophlebitis and the risk for thromboembolism.  Minor adverse effects include nausea, dizziness, headache, weight gain, and breast discomfort. These side effects are usually noted during the first six months of therapy. 21

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Oral Contraceptives  Oral contraceptives increase gingival fluid, stimulate gingivitis, and are associated with gingival inflammation.  Oral contraceptives are associated with a significant increase in the frequency of dry socket after tooth extractions.  This risk can be minimized by performing extractions during days of a tablet cycle or the end of the extended-cycle tablet dispenser.  Use caution if antibiotics are necessary. The patient should use an additional method of birth control during antibiotic therapy through the end of the oral contraceptive cycle. 22

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Female Sex Hormones  Managing Dental Patients Taking Oral Contraceptives  Because of the increased risk for thrombophlebitis have patients stretch or move their legs.  Give the patient the chance to walk around if the appointment is long.  Check the patient’s blood pressure at each visit because oral contraceptives can cause hypertension.  More frequent recall appointments may be necessary because of oral contraceptive effects on oral tissue.  Meticulous, home oral health care is necessary to minimize oral adverse effects. 23

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Male Sex Hormones  The main male sex hormone is testosterone.  Testosterone has both androgenic and anabolic effects.  Androgens are responsible for the development of secondary male sex characteristics.  Anabolic effects include increases in tissue protein and nitrogen retention in the body.  Other effects include increased osteoblastic activity and increased sebaceous gland activity (acne).  Androgenic steroids are used to treat breast cancer or as hormonal replacement therapy.  Its use as an athletic performance enhancer is illegal.  Androgenic steroids are Scheduled III drugs because of their abuse by athletes. 24

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Male Sex Hormones  Androgens  The adverse effects of androgens include nausea, cholestatic jaundice, types of liver cancer, increased serum cholesterol levels, habituation, depression, psychosis, and aggressive behavior.  In women, these drugs can cause virilization.  Women experience acne, hirsutism, deepening voice, clitoral enlargement, and male-pattern baldness. 25

Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Other Agents that Affect Sex Hormone Systems  Other drugs are used to affect sex hormone systems for a variety of reasons.  They can either mimic hormonal activity or inhibit the action of naturally occurring sex hormones.  Hormones of the opposite sex are used to treat prostate, breast, or uterine cancer when the cancer is stimulated by the patient’s own hormones.  Other drugs are used to treat endometriosis and fertility. 26