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true or false. Pt instruction may be provided by the dental hygienist for application of some topical agents?
If endocrine-related drugs are reported on health history, what are 2 things to consider?
- drug effects
- assessment of disease control
What are 2 dental hygiene functions in regards to drugs of the endocrine system?
- providing info related to the effects of DH treatment
- Specific drugs and implications for potential ADEs
What secretes humoral substances internally into systemic circulation?
What is the primary function of the endocrine system?
to regulate cellular metabolism and maintain homeostasis
Do endocrine glands act in isolation? How do they act?
- they have a series of complex interactions; abnormality in a gland produces compensatory reactions in others
These things are released into the bloodstream and are delivered indiscriminately to target and nontarget tissues, target cells contain specialized molecules or receptors that bind the thing and cause cellular activity. Is the mechanism of action for what? (thing)
What are the 9 endocrine glands?
- adrenal glands
Which adrenal hormone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes, and suppresses the immune system by reducing the activity of lymphoid cells?
What is a negative effect of blucocorticoids (steriods)?
they are perfecgt agents to suppress inflammation, but may delay would healing and cause infections
Which endocrine gland is known as the "Master Gland"?
Which type of drugs mimic the effect of hormones produced by the pituitary?
Where is the pituitary gland located in the body?
Sella turcica: cavity of sphenoid bone
There are 2 parts of the pituitary gland; anterior and posterior, how is each portion nourished?
- anterior: superior hypophysial arteries derived from the internal carotid
- posterior: branches of inferior hypophysial arteries
List the 6 hormones secreted by the anterior pituitary and which organs they effect.
- Prolactin: breast
- Luteinizing hormone (LH): ovary
- Follicle-stimulating hormone (FSH): testes
- Thyroid-stimulating hormone (TSH): thyroid
- Adrenocorticotropic hormone (ACTH): adrenals
- Growth hormone (GH): bone muscles
List the 2 hormones secreted by the posterior pituitary gland and the organs they effect.
- oxytocin: uterus and breast
- Antidiuretic hormone: kidney
What type of drugs are used therapeutically to control the function of the thyroid and adrenal glands and the ovaries and testes?
anterior pituitary drugs
Why are anterior pituitary drugs administered by injection?
because they are destroyed by the GI tract
What are substances that originate in the hypothalmus and are transported to the anterior pituitary gland via portal vessels of pituitary stalk through the bloodstream?
Which gland stores and releases vasopressin and oxytocin?
posterior pituitary gland
Which hormone regulates reabsorption of water by the kidneys?
What is the major physiologic action of vasopressin?
antidiuresis: antidiuretic hormone (ADH)
The absence of ADH, a failure to concentrate the urine despite an increased solute concentration of the plasma; this endocrine deficiency state is what?
The following are clinical manifestations of what condition?
Polyuria: excessive amounts of pale diluet urine
polydipsia: excessive thirst
What drug is used as synthetic vasopressin? And what is it used to treat?
- desmopressin acetate (Octostem, DDAVP)
- Diabetes insipidus and certain clotting disorders
How is synthetic vasopressin, or desmopressin acetate (Octostem, DDAVP) administered?
What hormone induces contractions in the uterus and promotes lactation, and it can be supplied by injection or intranasally?
Which endocrine glands are located on the kidney and are composed of a cortex and medulla?
What endocrine hormones secrete glucocorticoids and mineralocorticoids?
Synthesis and secretion of glucocorticoids is under the control of what hormone?
adrenocorticotropic hormone (ACTH)
What is the main glucocorticoid steroid?
What hormone does the renin-angiotensin pathway control?
What is the main mineralocorticoid hormone? And what does it do?
- regulates salt and water balance
What hormone does the following:
regulates cell metabolism
induces anti-inflammatory and immunomodulatory effets
allows other hormones to modulate cardiac contractility, vascular tone, and blood pressure
provides negative feedback to hypothalamus and anterior pituitary: which regulates CRH and ACTH
What is often used for the treatment of oral inflammatory lesions?
TOPICAL formulations of glucocorticosteroids
true or false. corticosteroids should never be used for tx of mucocutaneous viral infections because of their anti-inflammatory and immunomodulatory effects
What is an exception of a viral infection that it is ok to use corticosteroids for?
coadministration of prednisone: antiviral agent to treat severe herpes (varicella) zoster infections
Which hormone's mechanism of action is to
decrease inflammation: by suppressing migration of polymorphonuclear leukocytes
suppress the immune system: by reducing the activity of lymphoid cells
possibly resulting in delayed wound healing and infection
Name 7 glucocorticosteroids in the Top 200.
- prednisone (Deltasone)
- methylprednisolone (methylprednisolone)
- triamcinolone (Triamcinolone acetonide, Nasacort AQ)
- Mometasone (nasonex)
- Fluticasone (flonase)
- Fluticasone propionate (flovent)
- budesonide (Rhinocort Aqua)
What drugs are prescribed when endogenous cortosol hyposecretion develops, also called adrenocortical insufficiency or Addison disease?
In pt's with what condition do pts have very low to undetectable levels of aldosterone and cortisol in the blood? And cortisol levels do not increase in response to stress and ACTH?
The following are clinical manifestation's of what condition?
lethargy, anorexia, weight loss, nausea, possible brown patches on skin, buccal mucosa and tongue
What is the treatment for Addison's disease?
- Daily use of oral glucocorticoid and mineralocorticoid
- Stressful events may require additional doses
Are adrenal crisis's common in dentistry? (from Addison's disease)
What are 4 conditions besides Addision
s disease that indicate the use of glucocorticoids?
- Anti-inflammatory effect: allergic rhinitis, asthma, autoimmune diseases
- Immunosuppressive therapy: prevent rejection of organ transplants
- Spinal cord injury
- Lynphocytic leukemia chemotherapy
What is the most common corticosteroid used for oral administration?
What condition may occur when supraphysiologic dosease of corticosteroids are used for prolonged periods of time?
How are the target doses of corticosteroids generally determined?
equal to or greater than the normal daily output of cortisol
What is the physiologic cortisol secretion per day?
3 agents used as medicine to administer cortisol to the body include:
prednisone and prednisolone
What is the proper daily dose in mg for each of them?
- hydrocortisone: 20 mg
- prednisone and prednisolone: 5 mg
- dexamethasone: 0.75 mg
true or false. When an oral glucocorticoid such as methyleprednisolone (Medrol) is prescreibed, the administration includes a step-down approach
Describe 3 dental uses of glucocorticoids.
- Topical: mucosal injury, aphthous ulcers, ulcerations from lichen planus, erythema multiforme, pemphigus, pemphigoid
- Injection: TMJ pain and swelling
- Oral: Perioperative and postoperative vascular congestion, edema
What type of glucocorticoids are most often used in dentistry? Why?
- topical agents or short-term therapy
- there is no risk of cortisol and aldosterone suppression
Name 3 topical glucocorticoids used in dentistry.
- triamcinolone (Kenalog)
- clobetasol (Temovate)
- fluocinonide (Lidex)
Describe how topical agents of glucocorticoids are applied.
3-4 times a day after meals, and at bedtime with a cotton tip applicator
Why are topical glucocorticoid agents often formulated with non-water-soluble products with adsorptive qualities?
to keep the active ingredient localized to the area of concern
Which of the following doseforms of glucocorticoids has a greater potential to produce ADEs?
The following Adverse drug effects may affect dental hygiene treatment and are caused by what agent?
masked symptoms of infection, candidiasis, nervousness, hyperglycemia, vision disturbances, edema, hypertension, peptic ulceration, osteoperosis, and Cushing's syndrome
The following are signs and symptoms of what condition? (caused by glucocorticoids)
round face (moon face)
fat distrubution around shoulders (buffalo hump)
If a pt reports using a steroid spray for respiratory disease, what precautions should be made? (3)
- monitor oral tissues for yeast infection
- report findings of yeast infection to dentist
- recommend that pt rinse mouth out after using spray to reduce candidiasis
true or false. Topical gels of steroids are unlikely to result in a yeast infection
Why is periodontal health assessed using probing depth info with pts using steroids?
because the clinical appearance is not reliable due to the possibility of masked infection
What are 3 potential drug-drug interactions in the dental setting that may occur with the use of steroids?
- methylprednisolone toxicity: when macrolides are taken as an antibiotic (avoid concurrent use)
- decreased metronidazole effect: when corticosteroids are taken concurrently
- increased risk of peptic ulcers: with COX-1 inhibitors
What are 3 potential medical emergencies to be aware of in pts taking steroids?
- Addisonian crisis (acute adrenal insufficiency): most likely after stressful surgical procedures when Addison's disease is reported
- Hypertensive syndrome: question pt about ability to respond to stressful situations, history of blood pressure fluctuations, monitor BP
- Stressful dental tx: (oral surgery) in pts with dental phobia
The following are clinical considerations for systemic cortocosteroid administration; What is the clinical procedure in which these will be identified?
chronic, high dose of steroid
- extraoral exam
- comprehensive periodontal assessment
- intraoral exam for oral candidiasis
- monitor BP
- assess vision capabilities; acetaminophen for postop analgesia; if oral steroid spray is used, recommend rinsing after use
What hormone is the releasing factor that stimulates the release of lutenizing hormone (LH) and follicle-stimulating hormone (FSH)? (a hormone of reproduction)
Hypothalamic lutenizing hormone
What regulates the activities of LH and FSH?
When estrogens and progesterone drugs are taken, how are they?
when needed, for supplementaion
true or false. Oral contraceptives contain a variety of hormones.
Which oral contraceptives are most likely to be reported on the health history?
- those containine estrogen, progesterone, or both
Where are estrogens mainly synthesized? (3 places)
- adrenal glands
During menopause, what is the main source of estrogen in women?
What hormone dramatically influences the growth and development of female reproductive organs by inducing the synthesis of specific proteins via intracellular receptors?
What drug is supplied as menopause approaches, to relieve hot flashes or other symptoms?
name 3 estrogen drugs used for relief of menopausal symptoms that are in the TOP 200.
- conjugated estrogens: premarin, menest, cenestin, enjuvia
- Estradiol: climara, estrace, vivelle, evamist, and others
- Conjugated estrogesn/medroxyprogesterone: prempro
Name 5 estrogen drugs used for oral contraception combination products in the TOP 200.
- estradiol/medrowyprogesterone: Lunelle
- Norethindrone/ethynyl estradiol: ortho-novum, midrogestin Fe, Necon
- Norgestimate/ethinyl estradiol: Ortho tri-cyclen, ortho cyclen
- Levonorgestrel/ethinyl estradiol: trivora-28, aviana
- Desogestrel/ethinyl estradiol: Apri
Which hormone's mechanism of action is to inhibit the release of gonadotropin-releasing hormone and reduce the release of FSH and LH?
What does this action permit? how?
- the use of estrogen as an anticontraception
- reduces thinning of mucosal of vaginal area and prevents vasomotor symptoms
List 6 therapeutic indications for the use of estrogen.
- atrophic vaginitis
- primary ovarian failure
- menopausal symptoms
- prostatic carcinoma
- prevention of osteoporosis
true or false. Oral contraceptives may use both estrogen and progesterone.
What are the 3 different preparations and cycles of oral contraceptives?
true or false. A recent study found that oral contraceptive users had poorer periodontal health than nonusers.
What are 5 indications for use of oral contraceptives?
- prevention of pregnancy
- reduce acne
- female hypogonadism
Estrogens are well absorbed after ______ administration but tend to be extensively ______________ by the liver during _______________
- first pass
Name 6 ADEs that may be caused by estrogens that affect dental hygiene management.
- peripheral edema
- myocardial infarction
_____________________ in pts taking estrogens increases the risk for thromboembolism, stroke, and MI.
What are 2 potential medical emergencies that may happen in the dental office with pts taking estrogens?
- hypertensive syndrome
- conditions involving intravascular blood clot formation: angina pectoris, MI, stroke
true or false. There have been NO documented interactions between estrogen and drugs used in the dental officde
What are 3 potential drug interactions that SHOULD be commnicated to the pt taking estrogens when APAP or antibiotics are prescribed by the dentist?
- decreased analgesic effect of acetaminophen
- decreased contraceptive effect with: fluconazole, ketoconazole, systemic tetracyclines, cephalosporins, macrolides, metronidazole, and penicillins
- variable psychomotor impairment with single doses of oral diazepam, and possibly other benzodiazepines
Is Hypertension more associated with taking estrogens for contraception or menopause?
What association recommends that dental management includes monitoring BP annually in all pts taking estrogens?
true or false. There is no pharmacokinetic data to support the contention that antibacterial agents reduce the efficay of oral contraceptives
What do the AMA and ADA council of scientific affairs recommend in regards to this?
- they say that such interactions can not be completely discounted and that the pts should be advised of the potential risk
The _______ gland is located in the neck in ________ of the trachea.
Which endocrine gland secretes the hormones thyroxine and tri-iodothyronine?
What do each of the following terms mean in regards to thyroid function?
- normal circulating hormone levels
- inadequate circulating hormone levels
- excessive circulating hormone levels
Name 3 drugs in the TOP 200 used to treat hypothyroidism.
- Levothyroxine: Levoxyl, levothroid, synthroid
- Liothyronine: cytomel, triostat
- Liotreix: Thyrolar
Of the 3 drugs in the top 200 used to treat hypothyroidism which is the drug of choice? Which is next in line? Which is used when the conversion of levothyroxine from T4-T3 is abnormal?
Which type of drugs mechanism of action is to promote oxygen consumption by tissues, increasing basal metabolic rate and metabolism of carbohydrates, lipids, and proteins?
Thyroid hormones act synergistically with epi to stimulate ______________ and enhance tissue sensitivity to catecholamines
glycogenolysis: resulting in hyperglycemia
Which type of drug is indicated in pts who have effects of hypothyroidism, and to return them to euthyroid state, or used in treatment or prevention of goiters and management of thyroid cancer?
Name 6 ADEs from thyroid drugs that might affect the DH treatment plan.
- shortness of breath
How are cardiovascular side effects from thyroid drugs determined?
- monitoring vital signs and qualities
- pt interview
true or false. epinepherine interaction with increased levels of thyroid hormones is possible so dental hygienist's should administer local anesthetics with caution.
What techniques are recommended?
- use aspirating technique
- low concentration of vasoconstrictor: 2 cartridges 1:100,000 or 4 cartridges of 1:200,000
What is a clinical disease state produced by the effect of excessibe thyroid hormone on peripheral tissue?
Hyperthyroidism is characteristics of _______ disease
What are 2 therapeutic stragegies for managing pts with hyperthyroidism? Which of the 2 is the primary tx or cornerstone in the management of it?
- reduce thyroid hormone: if pt is being treated for hypothyroidism
- controlling hyperthyroidism with antithyroid for 1 yr: followed by partial resection of the thyroid gland if needed
- ANTITHYROID drugs are the primary tx before surgery or radioiodine therapy
Antithyroid drugs are usually stopped or tapered after ____________ of therapy
Name 4 common antithyroid drugs.
- Propylthiouracil (PTU)
- methimazole (Tapazole)
- iodine or iodide
What are 3 potential medical emergencies that may occur in pts taking thyroid hormones, or in pts with uncontrolled hyperthyroidism?
- hypertensive crisis
- angina pectoris
- cardiac arrhythmia: thyroid storm, leading to acute coronary syndrome
What is the extreme manifestation of hyperthyroidism, and what are 3 signs and symptoms that this is occuring?
- THYROID STORM
- hypertensive crisis, angina pectoris, cardiac arrhythmia
In most cases, what 2 precautions can be taken to result in little to no risk for a cardiac-related emergency in pts with controlled hyperthyroidism?
- careful administration of small doses of vasoconstrictors
- monitor vitals
Why is it importance to balance the use of LA with low vasoconstrictor and in using profound anesthesia?
because profound LA can reduce physiologic stress associated with pain
We should NOT treat pts if ther MET does not meet the demand of _____
Which type of thyroid dysfunction poses the greates risk during dental hygiene procedures, and we should not treat?
What is expressed in terms of metabolic equivalents (METs), it is a measure of an individual's ability to perform a spectrum of daily tasks?
At what measurement is a pt at an increased cardiac risk?
if they are unable to meed a 4-MET demand during normal daily activities
Which type of hormone is used to treat postmenopausal women with osteoporosis at hight risk for fracture, and also men with osteoporosis to increase bone mass?
What is the name of a parathyroid hormone that is administered subcutaneously once a day into the thigh or abdomen, is used for bone growth stimulation, and has warnings of an increased risk for osteosarcoma?
What are 2 ADEs seen in the use of teriparatide (Forteo)? What are drug interactions?
What is a clinical consideration for using the parathyroid hormone teriparatide (Forteo)? What are 3 precautions to take?
- potential for periodontal attachment loss
- evaluate perio condition
- refrain from excessive pressure on jaw (extractions)
- no DH tx prohibitions
What type of parathyroid hormone derivatives can lead to osteoclast apoptosis (cell death)?
bisphosphonate derivatives (BIS)
What type of parathyroid hormone is most commonly used to treat or prevent osteoporosis (Paget's disease of the bone) and in cancer chemotherapy?
What are 3 drugs that are used to prevent or treat osteoperosis; paget's disease of the bone, and cancer chemotherapy, that are Nitrogen-containing bisphosphonate oral formulations?
- alendronate: Fosamax
- risedronate: Actonel
- ibandronate: Boniva
What are 2 drugs that are Nitrogen-containing bisphosphonate formulations administered by IV? (parathyroid hormones)
- pamidronate: Aredia
- zoledronate: Zometa, Reclast
Name 2 drugs (parathyroid) that are non-Nitrogen-containing bisphosphonate formulations used in the treatment of Paget's disease of the bone.
- tiludronate: Skelid
- etidronate: Didronel
Which type of drug's mechanism of action is to inhibit bone resorption by suppressive action on osteoclasts or osteoclasts precursors?
what is the main indication for oral doseforms of BIS? When are they indicated at higer dose forms?
- to prevent or treat osteoporosis
- higher dose for treatment of Paget disease of the bone
IV formulations of BIS have recently been approved for the treamtne of osteoporosis and Paget disease of the bone. Name 2 BIS IV formulations.
- zoledronate: Zometa
- pamidronate: Aredia
What is the most important ADE associated with the use of BIS drugs? What doseform are these ADEs most common with?
- Osteonecrosis of the jaw (ONJ)
- most often with IV formulations
true or false. The mechanism for ONJ from BIS is unclear but is related to the suppresion of osteoclast action and increase apoptosis.
List 2 different cases where reports of ONJ and BIS have been reported.
- after oral surgery and dental or periodontal infections
- spontaneous reports of it
desquamation of the mucosa revelaing exposed bone in the jaw, pain and purulent exudate being present, condition mostly affects mandible but can affect either jaw, are lesion characteristics of what condition?
osteonecrosis of the jaw (ONJ) related to BIS intake
What are 2 other potential ADEs with BIS besides ONJ that may affect the DH tx plan?
- gastroesophageal reflux disease
How does the dental hygeinist play a role in the AAOM recommendations for individuals having taken a BIS?
they can tell them prevention and management considerations and provide pt info to prevent ONJ
What are 7 topics to discuss with the pt to help prevent BIS associated ONJ prior to them taking the drug?
- discuss ADA pt info sheet
- describe signs and symptoms of ONJ
- perform oral exam to identify disease or inflammation
- remove dental/periodontal disease
- place on 3-6 m maintenance schedule
- evaluate fit of removable and fixed appliaces and third molars
- instruct in biofilm removal to prevent perio infection
What is the best procedure to do in pts that report taking a BIS who also have pulpal inflammation? What about extractions?
- endodontic therapy
- most dentists and oral surgeons will not remove teeth.
Have their been any documented cases of medical emergencies or drug-drug interactions in the dental setting of pts taking bisphosphonate?
What are the 2 pancreatic hormones that are synthesized by pancreatic cells?
Reducing fasting blood glucose levels to less than 120 mg/dL and HbA1c (A1C) levels to less than 6% is the goal of therapy for what?
the individual pt in managment of diabetes mellitus (w/pancreatic hormones)
Which type of DM is described?
absolute deficiency of insulin; treated with short, intermediate, or long acting injectable insulin preparations, and inhaled insulin
Which type of DM is described?
decreased release of insulin or decreased number of insulin receptors; they are treated initially with an orally administered hypoglycemic agent, this type may progress to insulin-dependancy
The goal of what drug therapy is to provide adequate glucose control through each 24-hour period while minimizing the number of injections required?
insulins and antidiabetic drugs
most insulin/antidiabetic drug regimens combine ____________ insulin with an _______________ agent
- intermediate or long-acting
What is the main ADE risk for pts taking insulin/antidiabetic drugs, in the dental office? What is the best way to prevent this from occuring?
- hypoglycemia: most likely to occur when insulin is at peak affect
- treat pt in morning after taking agent and eating a normal breakfast: place pt in oral health care setting before peak of activity of agent is reached
What is the test for pts with DM that determines long-term control and is completed at quarterly medical appointments?
Name 4 first-generation sulfonylureas. (drugs used in the tx of DM/pancreatic hormones)
What are 2 drugs used for DM that are under the meglitinide classification and are used uncommonly?
Name 3 combination products that companies are providing, used in the tx of DM.
- second-generation sulfonylureas and metformin
- glitazones and metformin
- glitazones and sulfonylureas
Oral antidiabetics/insulin agents have various actions according to the type of drug. List 3 different mechanisms of action for them.
- stimulate insulin release from pancreatic beta-cells (sulfonylureas)
- reduce glucose output from the liver (biguanides)
- increase sensitivity of peripheral target cells in insulins (thiazolidenediones)
Which type of antidiabetic agent is the most likely to cause hypoglycemia?
What type of antidiabetic agent is indicated for type 1 DM? which is for type 2 DM? What is one way the form of DM can be determined?
- insulin hormone
- insulin hormone, oral antidiabetic agents, or a combination of both
- based on the type of drug used
true or false. It is important to investigate each antidiabetic agent in a drug reference to determine ADEs. It is also important to question pt for ADEs with relationship to oral health care appointments
both are TRUE
In the pain management for pts taking pancreatic hormones for DM, describe features of each of the following:
opioid/ASA vs opioid/Ibu combos
- salicylates: possible increased hypoglycemic effect with large doses
- opioid/ASA: usual therapeutic doses of ASA have little effect; and is more appropriate to take than opioid/ibu formulation
- opioid/APAP combination: used as a secondary therapeutic agent
What is the most common potential medical emergency that may occur in pts taking pancreatic hormones? Who does this most often effect, and is it common in the dental office?
- hypoglycemia: hyperglycemic crisis (diabetic coma)
- rarely occurs in dental office; most commonly effects uncontrolled individuals - infection and stress can promote development of it
The following drug-drug interactions in the dental setting are ones to be aware of in pts taking what?
glipizide and fluconazole - may cause hypoglycemic coma
epi - but at levels in dental setting should not raise blood glucos levels too much
ACE inhibitors and beta-adrenergic receptor antagonists
pts taking pancreatic hormones
The following are clinical signs and symptoms for what condition?
lack of concentration
When is the best time to treat pts with DM?
soon after breakfast
Why is it important to monitor vital signs in pts with DM?
they often develop hypertension
true or false. No studies support recommendation of administration of antimicrobial prophylaxis before dental therapy
What are 3 important actions to take when you treat a pt with DM who presents with significant oral infection?
- consult primary physician
- instruct pt to practice meticulous oral hygiene
- recall at regular intervals to monitor resolution of infections and compliance with recommended preventive measures
endocrine diseases are __________ conditions that are not ___________ with drugs, but are ___________ with drugs.
true or false. For most endocrine diseases, the drugs are taken for a lifetime.