Endocrinology

Question 1

Adrenal Gland
Comprised of adrenal cortex and adrenal
medulla
◦ Inner –
◦ Outer –
— Adrenal cortex produces about –
different chemicals
— Those with pharmacologic properties:
(3)

Answer 1

medulla
– secretes catecholamines

cortex
– secretes adrenal steroids

50

– Mineralocorticoids
– Glucocorticoids, cortisol
– Androgens

Question 2

3 layers within cortex
◦ zona glomerulosa: produces —
◦ zona fasciculata produces —
◦ zona reticularis: produces — hormones, mostly
— and small amount of —

Answer 2

mineralocorticoids
glucocorticoids
sex, androgens, glucocorticoids

Question 3

Mineralocorticoids (produced in zona glomerulosa)
— Regulate water and electrolyte balance
(2)

Answer 3

◦ Sodium (Na +), Potassium (K+) and fluid balance
◦ Provide important homeostatic functions

Question 4

Mineralocorticoids
— Aldosterone – main endogenous hormone
(2)

Answer 4

◦ essential for blood pressure regulation and electrolyte and fluid
homeostasis - helps to maintain normal blood pressure and
electrolyte balance
◦ acts on the Mineralocorticoid Receptor (MR)

Question 5

◦ acts on the Mineralocorticoid Receptor (MR)
(3)

Answer 5

– MR present in kidneys impacts fluid and electrolyte balance
– Extra-renal MR plays a relevant role in the control of cardiovascular and
metabolic functions
– Overactivation of the MR is implicated in the pathophysiology of aging related
to cardiovascular, metabolic and kidney dysfunction and progress of disease

Question 6

Aldosterone Basics
(3)

Answer 6

— Increases Na+ reabsorption by distal tubules in kidney
with concomitant increased excretion of K + and H +
— Increases BP and blood volume – balance/control the
amount of sodium and fluids in the body
— Work on specific intercellular receptors in kidney

Question 7

Pharmacotherapeutic use of medications involving
mineralocorticoid effects
(2)

Answer 7

— Replacement therapy Addison’s Disease/Adrenal
Insufficiency
◦ Fludrocortisone (Florinef) - mineralocorticoid

Question 8

— Replacement therapy Addison’s Disease/Adrenal
Insufficiency
◦ Addison’s Disease (autoimmune disease)/Adrenal Insufficiency –

Answer 8

adrenal do not produce enough of the steroid hormones, cortisol
and aldosterone.

Question 9

◦ Fludrocortisone (Florinef) - mineralocorticoid
(4)

Answer 9

– Functionally similar to aldosterone
– Most mineralocorticoid effect of available steroids
– Other steroids have much smaller amounts of mineralocorticoid effects
(example: hydrocortisone, prednisone) or no mineralocorticoid effects
(example: dexamethasone, methylprednisolone)
– Other indications: orthostatic hypotension, septic shock

Question 10

Drugs that Inhibit Aldosterone
— Imbalances in

Answer 10

aldosterone and overactivity of the mineralocorticoid
receptor contribute to hypertension, kidney insufficiency, heart failure
and potentially other cardiovascular disease
◦ Due to idiopathic adrenal hyperactivity (most common) or benign tumor (Conn’s
syndrome)

Question 11

Spironolactone (Aldactone) and Eplerenone (Inspra)
(4)

– Common Indications:
(3)

Answer 11

– competitive aldosterone antagonist at receptor sites in distal renal tubules (block higher
concentration of kidney-specific MR), increasing sodium chloride and water excretion while
conserving potassium and hydrogen ions – prevents mineralocorticoid effects of adrenal steroids on
the renal tubule
– Steroidal structure
– Also known as a potassium sparing diuretic

– Hyperaldosteronism (secondary cause of hypertension and causes low potassium)
– Heart failure
– Hypertension

Question 12

Drugs that Inhibit Aldosterone (Non-steroidal)
— Finerenone (Kerendia)
(4)

Answer 12

◦ Blocks Mineralocorticoid receptor (MR) in kidney and heart
◦ Selectively blocks (antagonist) mineralocorticoid receptor-mediated
sodium reabsorption and overactivation of kidney, blood vessel, and heart
tissues, reducing fibrosis and inflammation
◦ MR overactivation is an important factor associated with CV events and
Chronic Kidney Disease (CKD) progression

Question 13

Drugs that Inhibit Aldosterone (Non-steroidal)
— Finerenone (Kerendia)
◦ Indications:

Answer 13

– Chronic kidney disease (CKD) associated with type 2 diabetes
to reduce the risk of kidney function decline, kidney failure,
cardiovascular death, non-fatal heart attacks, and hospitalization for
heart failure in adults with type 2 diabetes and chronic kidney disease

Question 14

Glucocorticoids (endogenously produced in zona fasciculata)
— Mechanism of action –

Answer 14

complex: work through specific
glucocorticoid intracellular receptors to regulate several vital cell
activities
◦ Metabolic
◦ Immune function

Question 15

Glucocorticoids (endogenously produced in zona fasciculata)
— Widespread actions on intermediate metabolism, affecting
(3) metabolism
— Potent regulatory effects on host defense mechanisms including
(2) function
◦ Glucocorticoid receptors up regulate expression of anti-
inflammatory proteins and down regulate expression of pro-
inflammatory proteins

Answer 15

carbohydrate (glucose), protein and fat

inflammation and immune

Question 16

Glucocorticoids = Corticosteroids
— Main endogenous hormone in humans

Answer 16

– hydrocortisone
(also called cortisol)

◦ Produce 24-30 mg endogenous hydrocortisone/cortisol
◦ Use up to 300 mg/day in times of significant stress
— Secreted in circadian rhythm in healthy humans
◦ highest concentrations in early morning

Question 17

HPA Axis Pathway:

Answer 17

◦ Hypothalamus releases Corticotrophin-Releasing Hormone [CRH]
◦ Adrenocorticotropic hormone [ACTH] released from the anterior
Pituitary
◦ Adrenals release glucocorticoids
◦ Negative feedback mechanism to inhibit CRH and
ACTH when glucocorticoid concentrations increase in the
blood

Question 18

Therapeutic Use of Corticosteroids
— Many have partial mineralocorticoid
and glucocorticoid properties
— Most are used for anti-inflammatory
and immunosuppressive properties
— Common indications:
(5)

Answer 18

◦ Addison’s disease/Adrenal
Insufficiency (deficiency in
corticosteroid production)
◦ Cancer therapy (usually in
combination with cytotoxic drugs or
to reduce edema in brain tumors)
◦ Anaphylaxis (use in combination with
epinephrine, antihistamines – note:
steroids have slow onset)
◦ Hypersensitivity states (severe
allergic reactions)
◦ Shock

Question 19

Therapeutic Use of Corticosteroids
Common indications, continued:
(7)

Answer 19

◦ Autoimmune disease
– Systemic Lupus Erythematosus
– Rheumatoid arthritis
– Inflammatory bowel disease
– Connective Tissue Diseases
◦ Asthma (inhaled)
◦ Chronic obstructive pulmonary disease
(inhaled)
◦ Respiratory distress syndrome in infants
◦ Suppressing rejection of skin grafts or graft-
versus-host disease following organ transplant
◦ Acute renal insufficiency
◦ Inflammatory conditions of eyes, ears, nose or
skin /rashes of the skin (topical application)

Question 20

Use of Steroids in Dentistry
(7)

Answer 20

— Use for anti-inflammatory, pain management and auto-immune
properties
— Oral lesions
— Restorative dentistry/pain management
— Bell’s palsy
— Post herpetic neuralgia
— Temporomandibular joint disorder
— Temporal arteritis

Question 21

— Oral lesions
(7)

Answer 21

◦ Aphthous ulcers/stomatitis
◦ Oral lichen planus
◦ Erythema multiforme
◦ Behcet’s disease
◦ Pemphigus
◦ Bullous pemphigoid
◦ Systemic lupus erythematosus

Question 22

Formulations of Corticosteroids

Answer 22

— Dental (topical oral) applications
◦ Pastes, ointments/orabase, gels, lozenges, intralesional therapy, rinses – commercially
available or compounded
◦ Importance of contact time with lesion
◦ Example of commercially available product:
– Kenalog® in Orabase® / Triamcinolone Dental Paste
◦ Patient education:
* Using a cotton swab, press (do not rub) a small amount of paste onto the area to be treated
until the paste sticks and a smooth, slippery film forms. Do not try to spread the medicine
because it will become crumbly and gritty.
* (Usually applied 2-3 times per day – see dosing information of the product). Apply the paste at
bedtime so the medicine can work overnight. The other applications of the paste should be
made following meals.

Question 23

Formulations of Corticosteroids, continued
— Systemic
(3)
— Others
(3)

Answer 23

◦ Oral/IM/IV
◦ Pulse dosing/bursts
◦ Life-long replacement for adrenal suppression

◦ Topical/external (creams/ointments) – skin/joints
◦ Intra-articular – joints
◦ Inhalation – asthma/COPD

Question 24

Steroid Dosing Consideration
(7)

Answer 24

— Consider the potency of steroids and formulations
— Weigh pros/cons of oral topical vs. systemic therapy
— Topical/other types of administration may cause systemic effects
◦ Depends on potency, amount, surface area covered, absorption,
permeability of tissue, dosing frequency, site treated, etc.
— Use lowest effective dose for shortest duration
— Monitor for adverse events
— If patient on systemic therapy longer than 14 days, taper dose off.
DO NOT STOP ABRUPTLY – use taper
— Consult with the patient’s provider for management of patients
with Addison’s Disease, chronic steroid use or steroid tapering
plans, when needed

Question 25

Steroid Dosing — Systemic considerations (2) — Prednisone (3)

Answer 25

◦ Low dose < 10 mg prednisone/day ◦ Moderate dose 10-20 mg prednisone/day ◦ High dose > 20 mg prednisone/day ◦ Usually, lowest cost oral steroid ◦ Available in wide range of strength for titration ◦ Morning dosing/can split larger doses to BID, but give earlier in the day to minimize insomnia and mimic higher endogenous steroid production in the AM

Question 26

Use of IV Steroids — Intra-operative administration (3)

Answer 26

◦ Example: 3rd molar extractions with IV sedated patient – IV dexamethasone or IV methylprednisolone ◦ Provides anti-inflammatory effect (reduces pain and swelling) ◦ Helps reduce post-op nausea from the sedation

Question 27

HPA Axis Suppression/Adrenal Suppression — When providing supraphysiologic doses of corticosteroids (> 25-30 mg of hydrocortisone/cortisol equivalents) X 14 days or more = HPA Axis SUPPRESSION (4)

Answer 27

— May take weeks to months to fully recover function — Use of chronic exogenous corticosteroids = suppression of adrenal gland = atrophy — Inability of the adrenals to respond to stress can result in adrenal crisis — Patient may develop chronic adrenal insufficiency (AI) from various causes

Question 28

Chronic Adrenal Insufficiency (AI) (4)

Answer 28

— Primary Chronic AI – Addison’s Disease (autoimmune) — Secondary AI – damage/disease of the pituitary or hypothalamus ◦ Also caused from long-term use of glucocorticoids — Treatment for chronic primary AI often includes oral hydrocortisone +/- fludrocortisone — Other options for treatment of AI – prednisone, dexamethasone

Question 29

Adrenal crisis prophylaxis — Acute adrenal crisis = medical emergency (rare) (4)

Answer 29

◦ Life-threatening condition ◦ Predicated in patients with chronic adrenal insufficiency (AI) with increased significant stress such as from infection, trauma or surgery ◦ Symptoms –fever, abdominal pain, weakness, hypotension, dehydration, nausea, vomiting, slow, sluggish movement, fatigue, profound weakness, rapid heart rate, rapid respiratory rate, confusion, loss of consciousness/coma ◦ Laboratory findings – low K + , low Na + , acidosis, uremia

Question 30

Management of Acute Adrenal Insufficiency (AI) in Surgery – Steroid Cover (5)

Answer 30

— IV fluids (5% dextrose in Normal Saline) — Hydrocortisone — Hydrocortisone – IV initially then change to oral when patient is stable — Current evidence shows that routine dental care and minor oral surgical procedures under local anesthesia, including uncomplicated dental extractions, do not increase stress levels enough to precipitate an adrenal crisis — Consider 10 mg-25 mg hydrocortisone equivalents orally(po) stress dose cover for those at highest risk (Addison’s Disease) undergoing major dental surgery with general anesthesia (steroid cover)

Question 31

— Hydrocortisone (4)

Answer 31

◦ 20-25 mg/day- Primary AI (Addison’s Disease – idiopathic, most commonly auto-immune) ◦ 15-20 mg/day – Secondary AI (exogenous corticosteroids or disease/disorders of hypothalamus or pituitary) – Secondary AI selectively causes glucocorticoid deficiency; therefore, mineralocorticoid function is better maintained – Adrenal crisis less likely than in primary AI

Question 32

Acute Adverse Effects to Long-term Effects

Answer 32

— CV: tachycardia, hypertension — DERM: acne, delayed wound healing, facial flushing — ENDO: hyperglycemia (caution in diabetes) — GI: abdominal distention, diarrhea, constipation, heartburn, increased appetite, peptic ulcers, and GI bleeds — INFECTION: suppression of response to infection, including opportunistic effects or injury/candidiasis — NEURO: anxiety, insomnia, mood swings, euphoria, hallucinations, depression — BONE: osteoporosis — MUSCLE: muscle wasting and weakness — GROWTH: inhibition in children — EYES: glaucoma in genetically predisposed), increased incidence in cataracts — Adrenal suppression (sudden withdrawal – acute adrenal insufficiency) — Cushing syndrome

Question 33

Drug interactions/Contraindications Interactions: (5) Contraindications: (1)

Answer 33

— Increased prothrombin time/INR with warfarin — Risk of hypokalemia with potassium-depleting diuretics (hydrochlorothiazide, others) — Increased risk of cardiac toxicity and arrhythmias with cardiac glycosides (digoxin) — Interferes with calcium absorption in food — Absorption of glucocorticoids is decreased in presence of St. John’s wort — Severe infections, severe hypertension, severe heart failure, severe renal impairment

Question 34

Corticosteroids: dental implications summary — Effective in decreasing swelling/inflammation and pain ◦ Alternative to NSAIDS or opioids for pain in some cases or may decrease need for opioids — Altered responses to infection and wound healing — Oral thrush from inhaled steroids (advise patients to rinse mouth after each inhaler use) — Contribute to tooth decay, periodontal disease, decreased bone density (long- term) — Patients with chronic adrenal insufficiency (AI): risk of developing acute adrenal crisis when placed in a stressful situation such as major dental procedures — General Considerations (5)

Answer 34

◦ Pulse steroid/lowest effective dose/shortest duration ◦ Systemic antibiotic therapy – if indicated ◦ For inhaled steroids - rinse/spit and spacers ◦ Anxiety control – for all patients, especially those with AI ◦ Increased administration of glucocorticoids (steroid cover)? - only in patients with AI at high risk/major dental procedures/surgery

Question 35

Patient Education for Steroid Use — Purpose: (3) — Dose/frequency/dosing instructions: (4)

Answer 35

◦ Relieve the discomfort and redness, swelling/inflammation of some mouth and gum problems or during/after dental procedures ◦ Useful for pain ◦ Timeframe for expected improvement ◦ Take in AM for systemic administration – Adjustment if patient to receive steroid prescription (Medrol) in the afternoon to get all tablets in the first day – If taper is involved, specifics of taper, what dose to take each day ◦ Length of therapy ◦ Specific instructions for dental paste/topical application ◦ Do not use more often or for a longer time than your medical doctor or dentist ordered

Question 36

Patient Education for Steroid Use, continued — Common (short-term) side effects: (6)

Answer 36

◦ Insomnia/difficulty sleeping (one of the most common complaints) – Taking all in AM may help – Use of sleep agent for 1-2 nights? (risk vs. benefit) ◦ Agitation/changes in mood/irritability ◦ Leg swelling ◦ Weight gain (more with long-term use) ◦ Risk of increased blood glucose (especially in diabetics) ◦ Risk of increased blood pressure (especially if already elevated)

Question 37

Thyroid Gland — Secretes 3 main hormones (5) – T3 is converted to T4 primarily in the liver and kidney but also in many other tissues ◦ calcitonin — T3 and T4 (combined are referred to as thyroid hormone) (3) — Calcitonin (1)

Answer 37

◦ thyroxine (T4) – large storage – high serum concentrations in body ◦ tri-iodothyronine (T3) – small storage – low serum concentrations in body (fast turnover rate) – 80% of T3 daily production is a result of peripheral conversion of T4 →T3 ◦ normal growth and development in children (brain and body) ◦ control energy/metabolism ◦ involved in normal functioning of almost every organ system including the brain, heart, liver, and muscles ◦ control of plasma calcium (Ca2+ )

Question 38

Basics of Regulation of Thyroid Function (5)

Answer 38

— Thyrotrophin releasing hormone (TRH) stimulated from hypothalamus — Thyroid stimulating hormone (TSH) from anterior pituitary — Thyroid hormone synthesis resulting in release of T3 and T4 — Negative feedback on anterior pituitary with T3 more active than T4 ( thyroid hormone = TSH) — Plasma iodine also impacts thyroid hormone production (decrease of iodine = hormone production and TSH)

Question 39

Actions of Thyroid Hormones — Effects on metabolism (2) — Effects on growth and development (3)

Answer 39

◦ increased metabolism on carbohydrates, fats and protein (most effects in conjunction with other hormones) ◦ T3 3-5X more active than T4 ◦ direct action and indirectly influences growth hormone – skeletal development – growth and maturation of CNS

Question 40

HYPERthyroidism (Thyrotoxicosis) — Diffuse toxic goiter (Graves Disease/exopthalmic goiter) (2) — Toxic nodular goiter (1)

Answer 40

◦ autoimmune disease (autoantibodies to TSH receptor) ◦ protruding eyeballs (exophthalmos) ◦ benign neoplasm or adenoma

Question 41

HYPERthyroidism Symptoms * “Overactive” thyroid * Common:

Answer 41

* Nervousness or irritability * Fatigue * Muscle weakness * Trouble tolerating heat * Trouble sleeping * Tremor, usually in your hands * Rapid and irregular heartbeat * Frequent bowel movements and/or diarrhea * Weight loss * Mood swings * Goiter, an enlarged thyroid that may cause neck to look swollen. * If large, may cause trouble with breathing or swallowing

Question 42

HYPERthyroidism treatments

Answer 42

— Surgery — Radioactive Iodine (RAI)- 131 I (destroys thyroid follicles) ◦ hypothyroidism usually results from surgery or RAI — Drug Therapy (oral) ◦ Propylthiouracil (PTU) ◦ Methimazole (MMI) – MOA → inhibit biosynthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gland; blocks synthesis of thyroxine (T 4) and triiodothyronine (T 3); does not inactivate circulating T 4 and T 3 – ADRs – neutropenia, agranulocytosis, aplastic anemia, liver toxicity ◦ Beta Blockers (propranolol): symptomatic relief only! ◦ Glucocorticoids for exophthalmos in Graves Disease

Question 43

HYPOthyroidism

Answer 43

— General Definition: ◦ Free thyroxine (fT4) is: sub-normal/low (normal range 0.8 – 2.8 mg/dl) and Thyroid- Stimulating Hormone (TSH) is usually elevated/high (normal range 0.45 mIU/L - 4.12 mIU/L-varies depending on lab) ◦ Myxedema – term used for severe hypothyroidism – dermatologic changes that can occur (swelling in legs/eyes) – coma that can occur as an extreme complication — Subclinical Hypothyroidism (early hypothyroidism) ◦ Free thyroxine (fT4) is: normal ◦ Thyroid-Stimulating Hormone (TSH) is: elevated/high ◦ Mild to no symptoms of hypothyroidism — Overt Hypothyroidism ◦ Free thyroxine (fT4) is: sub-normal/low ◦ Thyroid-Stimulating Hormone (TSH) is usually: elevated (normally > 10 U/ml)

Question 44

HYPOthyroidism Causes — Worldwide: (1) — Iodine sufficient countries:

Answer 44

◦ Iodine deficiency ◦ Chronic Autoimmune Thyroiditis (AITD/Hashimoto’s) – reaction against thyroglobulin or other thyroid tissue – Women > Men – Age – Other autoimmune disorders – Goiter may or may not be present

Question 45

Subjective Symptoms — Causes low metabolic rate — Common:

Answer 45

◦ Dry skin ◦ Cold sensitivity/intolerance ◦ Fatigue ◦ Muscle cramps ◦ Voice changes (hoarseness) ◦ Slow speech ◦ Constipation ◦ Weight gain ◦ Thickened skin (myxedema)

Question 46

Goal of therapy (4)

Answer 46

— Restore euthyroid state — TSH – usually 0.45 mIU/L - 4.12 mIU/L for reference population — Alleviate symptoms — Reduction in size of goiter (if present) — Avoidance of overtreatment (iatrogenic thyrotoxicosis)

Question 47

Drug Therapy

Answer 47

— Levothyroxine/Synthroid (synthetic T4 ) – most common therapy ◦ usual dose 50-100 mcg ◦ lower doses in patients with coronary artery disease — Liothyronine/Cytomel, Triostat (synthetic T3 ) — Liotrix / Thyrolar (4:1 ratio of synthtic T4 :T3 ) — Thyroid desiccated /Armour Thyroid (“natural” – pig - T4 +T3 ) — Clinical Pearls ◦ Dosing dependent on age, sex and body size ◦ Onset of action 1-2 weeks, full effects 4-6 week ◦ Take on an empty stomach 30-60 minutes before meals (in morning) and before other medications! ◦ Recommended to a consistent product to minimize variability! (narrow therapeutic index) ◦ Dangers of using thyroid supplementation for weight loss in euthyroid patients

Question 48

“Adverse Effects” of thyroid treatments

Answer 48

* Too much or too little supplementation/thyroid hormone

Question 49

Drug Interactions with Thyroid Supplementation — Interference with absorption (5) — Decreased hormone production/secretion (2) — Peripheral metabolism of T4 (1) — Altered secretion of TSH (5) — Increased clearance of T4 (2)

Answer 49

◦ Bile acid sequestrants ◦ PPIs ◦ Oral bisphosphonates ◦ Iron and calcium supplements ◦ Orlistat ◦ Amiodarone (can also cause hyperthyroidism - iodine rich) ◦ Lithium ◦ Glucocorticoids, amiodarone ◦ Dopamine (and dopaminergic agonists) ◦ Glucocorticoids ◦ Octreotide ◦ St John’s Wort ◦ Amphetamine ◦ Many antiepileptics ◦ Quetiapine

Question 50

Levothyroxine – Narrow Therapeutic Index Drug — Narrow therapeutic index (NTI) drugs ◦ Small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity — Evidence from studies hasn’t showing any clinical difference in brand, generic or switching generic manufacturers — Because absorption can be decreased by other vitamins, minerals and/or medications, it’s recommended to be taken

Answer 50

on an empty stomach (usually in the morning), 30-60 minutes before food or other medication intake to avoid erratic absorption

Question 51

Dental Implications — Undiagnosed – — Hyperthyroidism (3) — Hypothyroidism (@)

Answer 51

be aware of hyper/hypo-thyroid symptoms and refer to provider ◦ identification of enlarged thyroid/goiter ◦ increased sensitivity to sympathomimetic drugs/vasopressors such as epinephrine - hypertensive crisis, tachycardia, and/or dysrhythmia ◦ decrease effectiveness of CNS depressants ◦ symptoms mistaken for anxiety ◦ increased respiratory and cardiac depression with benzodiazepines (diazepam, alprazolam), barbiturates (sodium thiopental), and opioid analgesics (hydrocodone) ◦ Over supplementation could result in cardiovascular symptoms seen in hyperthyroidism

Question 52

Dental Implications (3)

Answer 52

— If euthyroid (treated thyroid disorders) – manage normally during dental interventions /treatment /procedures — Hyper/hypo-thyroid symptoms - consider decreasing or avoiding: ◦ sympathomimetics/ vasopressors in symptomatic hyperthyroidism ◦ CNS depressants in symptomatic hypothyroidism — Severe/uncontrolled hyper/hypo-thyroid condition – consider postponing dental treatment until consultation from provider or condition better managed (may take weeks to months)

Question 53

Dental Implications (2)

Answer 53

— On Propylthiouracil (PTU) or Methimazole (MMI) for hyperthyroidism- caution with bleeding from agranulocytosis or risk of infection from neutropenia — Absorption issues or other drug interactions for patients on thyroid supplementation

Question 54

— Corticosteroids – The good, the bad and the ugly (3)

Answer 54

◦ Useful role in dental practice ◦ Caution with ADRs ◦ Long-term use = HPA Axis suppression

Question 55

— --- for adrenal crisis in patients with Adrenal Insufficiency only needed for patients undergoing major dental surgery — Both (2) can impact dental care decisions

Answer 55

Steroids hyperthyroidism and hyperthyroidism

Question 56

◦ Hyperthyroidism (1) ◦ Hypothyroidism (2)

Answer 56

– Drug therapy may be used as bridge until surgery or radioactive iodine or may be used long-term – Levothyroxine mainstay of therapy – Narrow therapeutic index drug/many drug interactions