Presented by:

Barba, Veronica
Flores, Cristine Joy
Gawat, Rona Niquechole
Moises, Josyl Angelique
Paredes, Francheska
Santocildes, Ma. Angelika

GROUP 3
PRIMARY ADRENAL INSUFFICIENCY

It also called Addison’s disease

Addison’s disease is a chronic condition that results from
the partial or complete destruction of the adrenal
cortex. It manifests as a clinical syndrome in which the
symptoms are associated with deficient production of
the adrenocortical hormones, cortisol, aldosterone, and
androgen.
PRIMARY ADRENAL INSUFFICIENCY

Addison’s disease involves in all zones of the cortex,

causing deficiencies of the adrenocortical secretions,
glucocorticoids, androgens, and mineralocorticoids.
Addison’s disease is a decrease in the biosynthesis,
storage, or release of adrenocortical hormones.
 Etiology
Autoimmune diseases Malignancy
HIV infection Drugs
Cytomegalovirus infection Genetic mutation
Fungal infection
 Signs and Symptoms
Weakness Anorexia
Fatigue Salt craving
Abdominal pain Myalgia
Hyperpigmentation of the Hypoglycemia
skin and mucous Weight loss
membrane
Hypotension
 Oral Manifestation

Pigmentation of oral
mucous membrane
Delayed healing
Possible oral infection
 Adrenal Crisis
Sunken eyes Weakness
Profuse sweating Headache
Hypotension Dehydration
Weak pulse Fever
Cyanosis Dyspnea
Nausea Myalgia
Vomiting Arthralgia
 Treatment
Hypothermia
Severe hypotension
Hypoglycemia
Confusion
Circulatory collapse
Death
 Dental Management
Investigate type and degree of adrenal dysfunction,
and the type of dental procedure to be done.
Blood pressure should be taken before the dental
procedure, and repeated every 5 minutes during dental
procedure.
Blood glucose should be taken, and dental procedure
performed under good glycemic control.
 Dental Management
Aspirin and NSAIDs should be avoided for patient on
long term corticosteroid therapy.
Patient with primary adrenal deficiency require
corticosteroids supplementation.
Dental surgery should be scheduled in the morning
when cortisol level is highest.
 Dental Management
Nitrous Oxide and Benzodiazepine are helpful in
reducing stress therefore reducing cortisol demands by
body.
Barbiturates should be used with caution.
Blood loss should be reduced because it increases
probability of hypertension.
 Dental Management
It is recommended to use long acting local anesthetic
(Bupivacaine) at the end of the procedure.
Use supine position for patient to reduce hypotension.
Drugs like ketoconazole and aminoglutethimide should
be discontinued by the patent 24 hours before dental
surgery in consultation with patient’s physician
 DIABETES

According to the American Dental Association, Diabetes

Mellitus is a group of metabolic diseases that leads to high
levels of blood glucose and is caused when the body does
not make any or enough insulin, or does not use insulin well.
It is a disease that occurs when your blood glucose / blood
sugar, is too high.
Insulin is a hormone made by the pancreas, helps glucose
from food get into your cells to be used for energy.
 Types
TYPE 1 DIABETES
Formerly known as juvenile diabetes
A chronic autoimmune disease in which the beta cells in
the pancreas create little to no insulin.
Exogenous insulin is needed to regulate blood glucose
levels in people with type 1 diabetes
 Types
TYPE 2 DIABETES
Type 2 diabetes is a common condition that causes the
level of sugar (glucose) in the blood to become too
high.
It can cause symptoms like excessive thirst, needing to
pee a lot and tiredness. It can also increase your risk of
getting serious problems with your eyes, heart and
nerves.
 Types
It's a lifelong condition that can affect your everyday
life. You may need to change your diet, take medicines
and have regular check-ups.
It's caused by problems with a chemical in the body
(hormone) called insulin. It's often linked to being
overweight or inactive, or having a family history of type
2 diabetes.
 Patients with cardinal signs of diabetes:
POLYDIPSIA
POLYURIA
POLYPHAGIA
Poor wound healing
Severe infections
Obesity
Weakness
 Oral Comlications of Poorly Controlled
Diabetes:

Xerostomia
Burning sensation
Gingivitis and periodontitis
Dental Caries
Bacterial viral and fungal infection
Periapical abscesses
 Dental Management

PRE-OPERATIVELY:
Morning appointments should be given
Patient should come with normal breakfast taken and
normal regular dose of insulin taken
 Dental Management
AT CLINIC:
Immediate treatment should be provided
A source of glucose such as orange juice should be present
in the dental office to avoid hypoglycemic attack
Maintain verbal contact with the patient during surgery
Atraumatic extraction
Advise patient to inform dentist or staff if symptoms of insulin
reaction occur during dental visit.
 MANAGEMENT OF INSULIN SHOCK WHEN
OCCUR:
Most common diabetic emergency which dentist
encounter is hypoglycemia
As soon as such signs or symptoms are present, the dentist
should check the glucose by glucometer
Establish airway, breathing, and circulation
Turn on fans, conditioner
Place the patient in a supine position
 MANAGEMENT OF INSULIN SHOCK WHEN
OCCUR:
If the patient is conscious and is able to take her food by
mouth, give 15 g of the carbohydrate in the following form:
Orange juice
3-4 tablespoon of sugar
small amount of honey/sweet can be placed in the buccal
fold
if unconscious, patient take 50ml of the dextrose in 50% of the
concentration or 1 mg of the glucagon IV or 1mg of the
glucagon IM.
 MANAGEMENT OF INSULIN SHOCK WHEN
OCCUR:

The signs and symptoms of hypoglycemia should be

resolved in 10-15 minutes
Patient should be observed for 30 – 60 minutes after the
recovery. Normal blood glucose level is confirmed by
the glucometer before the patient leaves.
 MANAGEMENT OF INSULIN SHOCK WHEN
OCCUR:
POST OPERATIVE:
If the patient is not able to eat after the dental
procedure, he is recommended to eat soft food and
liquids
Consult the patient’s physician for the post operative
diet plan
Antibiotics should be given after surgery.
 HYPOTHYROIDISM

Hypothyroidism is defined by a decrease in thyroid hormone

production and thyroid gland function. It is caused by, chronic
thyroiditis (Hashimoto's disease), radioactive iodine, surgery and
pharmacological agents such as lithium and amiodarone.
Insufficient levels of thyroid hormone cause symptoms such as
slower metabolic rate, weight gain, lethargy, intolerance to
cold, dry and cool skin, and puffiness of the face and eyelids, as
well as others. The blood pressure appears to be normal, but the
heart rate is slow.
 Medical conditions associated with
hypothyroidism include:
Anemia Myxedema
Cardiomegaly Reduced cardiac output
Dry hair Reduced respiratory rate
Goiter Seizure
Hyperlipidemia Tachycardia
Hypertelorism Weight gain and failure to
Lethargy grow
 Oral Manifestations
Macroglossia
Enlarged salivary gland
Delayed eruption of teeth
Compromised periodontal
health
Dysgeusia
 Dental Management
Hemostasis
Local pressure for an extended time will probably
control the bleeding from the small vessels
adequately.
Susceptibility to infection
Patient with hypothyroidism may have delayed
wound healing due to decreased metabolic activity
in fibroblasts.
 Dental Management
Patients who have hypothyroidism are susceptible to
cardiovascular disease from arteriosclerosis and
elevated LDL.
Drug actions and interactions
Patients who have hypothyroidism are sensitive to
central nervous system depressants and barbiturates,
so these medications should be used sparingly.
 PSORIASIS

Is a common skin condition that speeds up the life cycle

of skin cells. It causes cells to build up rapidly on the
surface of the skin. The extra skin cells form scales and
red patches that are itchy and sometimes painful.
The cause of psoriasis isn't fully understood, but it's
thought to be related to an immune system problem
with T cells and other white blood cells, called
neutrophils, in your body.
 Psoriasis Triggers:
Infections, such as strep Heavy alcohol
throat or skin infections consumption
Injury to the skin, such as a Vitamin D deficiency
cut or scrape, a bug bite, Certain medications
or a severe sunburn
Stress
Smoking
 Signs and Symptoms
Red patches of skin Itching, burning or soreness
covered with thick, silvery Thickened, pitted or ridged
scales nails
Small scaling spots Swollen and stiff joints
(commonly seen in
children)
Dry, cracked skin that may
bleed
Signs and Symptoms
 Oral Manifestation
Oral manifestations of psoriasis are less well recognized
than skin lesions, and treatment for oral lesions is not
standardized.
There are well-documented reports of intraoral psoriasis
appearing on the lips, tongue, palate, buccal mucosa
and gingiva. Showing no consistent lesion pattern.
 Oral Manifestation
Oral manifestations
suggestive of oral
psoriasis include small,
whitish papules that
yield bleeding points
when scraped; red and
white plaques that
follow skin lesions; and
bright red patches.
 Oral Manifestation

There is increased
frequency of geographic
tongue lesions and fissured
tongue seen in patients
with psoriasis.
 Oral Manifestation
Linking this particular disease to oral health beyond its
manifestation still requires more research, but in Norway,
a study found that 24% of participants with psoriasis had
moderate to severe periodontitis. In contrast, only 10% of
the control group without psoriasis suffered from
moderate to severe periodontal disease
 Complications
Psoriatic arthritis Metabolic syndrome
Eye conditions Other autoimmune
Obesity diseases

Type 2 diabetes Parkinson's disease

High blood pressure Kidney disease

Cardiovascular disease Emotional problems

Medical or Dental Management
Although there is no cure for psoriasis, there are multiple
effective treatment options:
Topical therapy
Topical therapy is the standard of care for treatment of
mild to moderate disease. A large proportion of patients
would benefit from topical therapy, which can be
initiated at the primary care level.
Medical or Dental Management
Corticosteroids: Considered the cornerstone of topical
treatment, corticosteroids are often well tolerated and
effective for patients with mild psoriasis.
Vitamin D3 analogues: Calcipotriol, a vitamin D3
analogue, is a first-line topical agent for treatment of
plaque psoriasis and moderately severe scalp psoriasis.
Medical or Dental Management

Combination products: Combination of calcipotriol and

betamethasone dipropionate was shown to be more
effective for psoriasis than either monotherapy alone.
Medical or Dental Management
Systemic therapy

Phototherapy: Phototherapy is a mainstay treatment of

moderate to severe psoriasis, especially in psoriasis that
is unresponsive to topical agents.
Medical or Dental Management
Biologic therapy: Biologics have emerged as highly
potent treatment options in patients for whom
traditional systemic therapies fail to achieve an
adequate response, are not tolerated owing to adverse
effects, or are unsuitable owing to comorbidities.
Medical or Dental Management
For patients who present with an oral condition, palliative
treatment is indicated.
Topical anesthetic (Benadryl)
Emollient toothpaste (Orábase) or Maalox,
Alkaline rinses are appropriate
Topical corticosteroids (Lidex)
 RHEUMATOID ARTHRITIS

A systemic, chronic, inflammatory autoimmune disease

affecting many tissues but principally attacking the joints
of older patients.
It causes a non-suppurative proliferative synovitis that
frequently progresses to destroy articular cartilage and
the underlying bone.
The process of abnormal proliferation of synovial tissue is
known as pannus formation.
 RHEUMATOID ARTHRITIS

Most common systemic arthritic condition to affect or

involve the Tempomandibular Joint (TMJ).
 Etiology
Idiopathic causes
Genetics
Lifestyle (may include
nocturnal bruxism)
Infectious Agents
Autoimmunity
 Signs and Symptoms
Morning stiffness
Arthritis of three or more
joint areas
Extreme Pain
Rheumatoid Nodules
Symmetric Arthritis*
Radiographic Changes*
 RHEUMATOID ARTHRITIS

Rheumatoid Arthritis Affecting Tempomandibular Joint

(TMJ)
TMJ symptoms the result from rheumatoid arthritis may
occur at an early age than those associated with
Degenerative Joint Disease (DJD). As opposed to DJD
which is usually unilateral, rheumatoid arthritis usually
affects the TMJs bilaterally.
 RHEUMATOID ARTHRITIS

 Radiographic findings of the TMJ shows erosive

changes in the anterior and posterior aspects of the
condylar heads that may progress to large eroded
areas that leave the appearance of a small, pointed
condyle in a large fossa.
 RHEUMATOID ARTHRITIS

Tempomandibular Joint Dysfunction (TMD)

Rheumatoid arthritis patients with TMD may present
pain, difficulty with opening the mouth, “locking” of the
jaw, tenderness of the masticatory muscles and joint
sounds.
The most frequent joint sound is clicking, followed by
crepitus indicating TMJ degeneration but maybe seen
less often due to improved RA medication.
 RHEUMATOID ARTHRITIS

Patients may also experience ear pain, tinnitus, dizziness,

headache and neck pain.
Clinical signs of TMJ involvement include swelling,
reduced range of motion and/or deviation of mandible
to the affected side
Medical or Dental Management
Pharmacological therapy is an important aspect of
nonsurgical management of TMD. Medications typically
used includes:
NSAIDs (does not only reduce inflammation but also have
an excellent analgesic reaction; eg. Ibuprofen, Aspirin
and Indomethacin)
These drugs are not associated with severe addiction
problems and their use of analgesic are strongly
preferred over narcotic medications.
Medical or Dental Management

Cyclo-oxygenase-2 (COX-2) inhibitors (gained

popularity as prostaglandins produced mediate pain
and inflammation; eg. Celecoxib)
May be associated with potential significant side
effects including cardiac complications
Medical or Dental Management
Analgesics (may range from acetaminophen to
potent narcotics)
With sedative and depressive effects potential for
addiction, these medications are restricted for short-
term use only not longer than 10 days to 2 weeks, if
possible
Medical or Dental Management

Muscle relaxants (may provide significant

improvement in jaw function and relief of masticatory
pain; eg. Diazepam and tizanidine)
Tricylic Antidepressants (useful in the management of
patients with chronic pain; eg. Elavil)
Medical or Dental Management
Physical Therapy can be useful in the management of
patients with TMD. The most common modalities used
include range of motion exercises, relaxation training,
ultrasound, spray and stretch and pressure massage.
Motion exercises include gentle stretching exercises
done within pain tolerance through passive opening
or active exercise routines.
Medical or Dental Management
Passive stretching is done by exerting a scissor effect
with the thumb and forefinger placed between upper
and lower teeth. Force is exerted until resistance is
encountered and maintained for several seconds.
Therabite appliance may also be used to provide
easy an efficient methods of improving jaw mobility.
Medical or Dental Management
Splint Therapy specifically, occlusal splints are generally
considered part of the reversible or conservative
treatment phase in the management of patients with
TMD
Surgical Interventions are given to patients whose
conditions improved slightly through reversible
nonsurgical treatment. Surgery is needed to improve
masticatory function and decreased pain.