Metabolic Medicine for Dentists

Prof. Denis O’Mahony,

Dept. of Medicine, UCC
Renal Disease & Renal Failure - Classification
• Acute
• Chronic
• End-stage
• Renal replacement (dialysis or transplant)
• Congenital/acquired
 Renal Disease & Renal Failure - Acute

Causes of acute renal disease:

• Infection (e.g. UTI, pyelonephritis)
• Inflammation (e.g. post-streptococcal, certain drugs,
systemic vasculitis e.g. ANCA-mediated disease)
• Autoimmune disease (e.g. SLE, Goodpasture’s
Syndrome)
• Ischaemia/hypovolaemic shock --> Acute tubular
necrosis
Renal Disease & Renal Failure - Chronic
Causes of chronic renal disease:
• Obstructive uropathy (e.g. prostatic enlargement)
• Chronic ischaemia (e.g. hypertension, renal artery
atherosclerosis)
• Chronic pyelonephritis
• Congenital polycystic disease
• Diabetes mellitus
• Inflammation (e.g. post-streptococcal, vasculitis)
• Autoimmune (e.g. SLE, Goodpasture’s Syndrome)
Renal Disease & Renal Failure - Symptoms

• Lethargy (anaemia common)

• Haematuria, oliguria or polyuria
• Oedema or dehydration
• Hypertension
• Bleeding, drowsiness, nausea/vomiting, tremor and
pericarditis if severe uraemia
• Malnutrition (anorexia, proteinuria common)
• Gout (hyperuricaemia common)
Renal Disease & Renal Failure – Metabolic
effects
• Hypocalcaemia (25 OH cholecalciferol --> 1,25
(OH)2 cholecalciferol) --> PTH --> metabolic bone
disease
• Acidosis --> hyperventilation, arrhythmias
• Hyperkalaemia --> arrhythmias, muscle weakness
• Hypercholesterolaemia (esp. if nephrotic i.e. heavy
persistent proteinuria) --> atherosclerosis
• Hyperuricaemia --> gout, accelerated renal
deterioration
• Impaired excretion of certain drugs
 Renal Disease & Renal Failure - Complications

• Anaemia (failure of erythropoietin production)

• Osteomalacia (lack of metabolically active Vitamin D)
• Hypertension (common cause and effect of CRF)
• Accelerated atherosclerosis --> M.I., stroke, peripheral
vascular disease
• Impaired clotting --> haemorrhage
• Impaired immune function --> sepsis
For creatinine in µmol/L:

Renal Disease & Renal Failure - Diagnosis

• Blood urea > 7.5 mmol/l, serum creatinine > 130

mol/l
• Creatinine clearance (~ = GFR) reduced for age
• MDRD formula

• Urinalysis may show blood, protein, leucocytes,

nitrites, glucose, pH > 8.0
• Urine microscopy may show erythrocytes,
leucocytes, cell casts, tubular cell debris, crystals
Renal Disease & Renal Failure - Imaging

• Ultrasound, CT, MRI --> structure of renal tracts

• CT, MR angiography --> vascular supply to kidneys
• Intravenous urography --> outline of renal pelvis,
ureters & bladder
• Isotope renography --> excretory function of
kidneys
Renal Disease & Renal Failure - Treatment
• Hypertension (ACE inhibitors, ARB’s, calcium channel blockers)
• Anaemia: Erythropoietin analogues e.g. darbopoietin
• Secondary hyperparathyroidism: 1- cholecalciferol
• Phosphate binders: sevelamer, lanthanum, colestilan
• Dialysis (peritoneal or haemdialysis)
• Renal transplant (with drugs to prevent immune-mediated rejection
by the host e.g. corticosteroids, cyclosporin-A, azathioprine,
tacrolimus)
 Diabetes Mellitus - 1
• Commonest endocrine disorder
• Affects increasing numbers of children and
adults in Ireland
• A major cause of morbidity and mortality,
particularly through cardiovascular disease
• Numerous serious complications
• Close monitoring of condition and treatment is
paramount in achieving good outcome
 Diabetes Mellitus - 2
• Classification: Type I (insulin deficiency)
Type II (insulin resistance)
• Diagnosis by blood glucose measurement i.e. random
glucose > 11.0 mmol/l or
2-hour glucose after 75g glucose (glucose tolerance test) >
11.0 mmol/l --> diabetic
• HbA1c: normal range 20 – 42 mmol/mol
 Diabetes Mellitus - 3
• Treatment of Type I diabetes --> Insulin
• Treatment of Type II diabetes --> Diet +/- drugs
• Insulin given by subcutaneous injection, usually
several times per day
• Various different types of insulin, with various
speeds of onset and duration of action
• All Type I diabetics should carry details of their
diabetic status, treatment and doctor
 Diabetes Mellitus - 4
• Diabetic emergencies are common
• Often present as drowsiness or coma
• Most common emergency is hypoglycaemic coma (over
treatment or insufficient food)
• Symptoms usually occur when glucose < 3.0 mmol/l
• Can occur in both Type I and Type II diabetes
• Other causes of diabetic coma/drowsiness are
(i) Diabetic ketoacidosis (‘DKA’)
(ii) Diabetic hyperosmolar, non-ketotic coma (‘HONK’)
 Dental relevance of diabetes
Diabetes predisposes to:
• Rapidly progressive periodontal disease
• Gingivitis
• Xerostomia
• Oral candidiasis
• Poor wound healing
• Chronic oral dysaesthesiae (burning sensation of tongue and/or
mouth)
Higher risk of infection (prophylactic antibiotics often used)
Dental procedures may disrupt normal food intake  risk of
hypoglycaemia
Any sedation may increase the risk of hypoglycaemia
 Thyroid Disorders - 1

Thyroid diseases:
• Hypothyroidism --> Autoimmune, surgical, radio-isotope ablation;
drug-induced suppression
• Hyperthyroidism --> Overactive thyroid (‘toxic’ adenoma or diffuse
enlargement i.e. Graves’ disease)
 Thyroid Disorders - 2

Symptoms of Hypothyroidism:
• Lethargy
• Slowing of cognition, intellectual function
• Weight gain
• Hair loss
• Reduced sexual function
• Constipation
• Diffuse swelling (‘myxoedema’)
Dental relevance of Hypothyroidism
• Children with hypothyroidism -> delayed tooth development, more
tooth decay, periodontal disease.

• Macroglossia, increased risk of periodontal disease, delayed wound

healing.

• Myxoedema coma may occur with opioid analgesia, surgical

procedures, infections
 Thyroid Disorders - 3

Symptoms & signs of hyperthyroidism

• Tiredness
• Heat intolerance
• Sweating, tremor
• Insomnia
• Weight loss
• Diarrhoea
• Rapid pulse rate
• Goitre (diffuse in Graves’ disease; nodular in others
• Exophthalmos (in Graves’ thyrotoxicosis)
 Thyroid Disorders - 4

Diagnosis of hypothyroidism:
• T4, T3
• TSH
• Thyroid autoantibodies detected in autoimmune hypothyroidism

Treatment of hypothyroidism:
• L-thyroxine until TSH is in normal range
 Thyroid Disorders - 5

Diagnosis of thyrotoxicosis:
• T4, T3
• TSH
• Thyroid ultrasound (--> nodule(s))

Treatment of thyrotoxicosis:
• Carbimazole, propylthiouracil --> T4 synthesis
• I131 ablation + later L-thyroxine replacement
 Dental relevance of thyrotoxicosis
• May accelerate periodontal disease
• Dental treatment may be dangerous in severe,
untreated thyrotoxicosis
• Patients with thyrotoxicosis are more sensitive to
adrenaline (may be constituent of local anaesthetic
injections): may cause arrhythmias
• Antithyroid drugs may predispose to infection, poor
wound healing
 Parathyroid disease - 1

• Hypoparathyroidism may result from:

(i) congenital disorder e.g. DiGeorge Syndrome
(ii) autoimmune disease
(iii) ablation (accidental) with thyroidectomy

• Hypoparathyroidism may be part of a polyglandular autoimmune

syndrome associated with chronic oral candidiasis
 Parathyroid disease - 2

• Hyperparathyroidism may result from

(i) parathyroid adenoma (most common)
(ii) parathyroid hyperplasia
(iii) parathyroid carcinoma (rare)

• May cause ‘brown tumours’ (cysts) of the mandible or maxilla

• May cause loss of lamina dura around teeth (diagnostic)

 Pituitary Disorders

Name Hormone Symptoms &

disorder signs
Acromegaly Growth hormone excess Expansion of face, hands,
feet, viscera
Cushing’s disease ACTH excess Moon facies, striae,
dermal atrophy, obesity,
diabetes, osteoporosis
Prolactinoma Prolactin excess Galactorrhoea,
amenorrhoea, impotence

Panhypopituitarism Lack of TSH, ACTH, LH, Loss of sexual

FSH, Prolactin characteristics,
hypogonadism,
hypothyroidism,
hypoadrenalism
Acromegaly may affect dentures,
Bridges and orthodontic work
(including restorations). Dental
Extractions may be difficult due
to bony ankylosis

Dental treatment may be

complicated by:
• Multiple endocrine problems
• Hypertension
• Cardiac disease
• Arthritis
 Adrenal Disorders

• Hypoadrenalism (‘Addison’s disease); usually due to autoimmune

destruction of adenal cortex --> deficiency of cortisol and
aldosterone

• Hyperadrenalism (‘Cushing’s syndrome); usually due to ACTH-

secreting adenoma of anterior pituitary --> excess secretion of
cortisol
 Adrenal Disorders - 2

Treatment of Addison’s disease (hypoadrenalism):

• Hydrocortisone (metabolised to cortisol)
• Fludrocortisone (aldosterone analogue)

Treatment of Cushing’s syndrome (hyperadrenalism):

• Removal of pituitary adenoma (source of ACTH)
• Inhibition of cortisol synthesis e.g. ketoconazole, metyrapone
 Adrenal Disorders - 3

Iatrogenic Cushing’s syndrome (common)

• Long-term use of steroids (mostly prednisolone) for
immuno-suppression e.g. immune-mediated
vasculitis, chronic severe asthma, kidney transplant
• Suppression of endogenous ACTH and cortisol
• Risk of severe hypoadrenalism (‘Addisonian crisis’) if
steroids suddenly stopped
• Patients usually need i.v. hydrocortisone before
moderate-major surgery or acutely & severely ill
 Practical Steroid Therapy - 1

• ALERT: any patient on daily steroid tablets (usually prednisolone) or

regular injections (usually methylprednisolone)
• ALERT: most steroid-dependent patients wear a pendant or bracelet
stating this fact
• ALERT: any patient who looks ‘Cushingoid’
• ALERT: any condition that requires steroids
Always enquire from patient or their doctor re. specific details of their
steroid treatment
 Practical Steroid Therapy - 2

Patients on maintenance oral steroids for more than 3 months

• For minor dental procedures --> no extra Rx
• For moderate - major procedures --> i.v. bolus of
hydrocortisone 100 - 200 mg at least 30 min. before
(adults)
• Never undertake elective or less urgent dental
procedures until underlying condition requiring
steroid therapy is stable (e.g. chronic severe
asthma, requiring long-term steroids)
• Never abruptly discontinue long-term oral steroids
prior to dental procedures or oral surgery