- Email: [email protected]
Some Endocrine Factors in Dental Development and Maintenance
H
36
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
13. H a r r i s , H . L .: Effect of Loss of V er tical Dimension on Anatomic Structures of Head and Neck. J.A .D .A ., 2 5 :17 5 , February 1938; Anatomy of Temporomandibular A r ticulation and Adjacent Structures. Ibid., : 584, April 1932. 14. W i t t i n g , E. G., and H u g h s o n , W .: Larygoscope, 50:259, M arch 1940.
19
15. F o w l e r ,
28 ,
E. P.,
J r .:
Acta Otolaryg.,
1940 . 16. F l e t c h e r ,
H.: Speech and Hearing. New York: D. V an Nostrand Co., Inc., 1929. 1 7 . H i g l e y , L . B. : Practical Application of New and Scientific Method of Producing Tem poromandibular Roentgenograms. J.A.D .A., : , February 1937.
24 222
SOME ENDOCRINE FACTORS IN DENTAL DEVELOPMENT AND MAINTENANCE By E.
P e r r y M c C u lla g h ,
M .D ., and
C h a r le s
H E health of the teeth m ay be im paired by disorders of the endo crine glands in two fundam entally different ways. 1. Directly, by interference with nor mal tooth formation and eruption. 2. Indirectly, by interference with nor mal growth or maintenance o f the sup porting structures. T h e first type of change can take place only during the stage o f formation, growth and eruption o f the tooth. The second may occur at any time of life, although its effects are chiefly postnatal. Before formation of the bony structure of the jaws, at about the eighth week of embryonal life, the tooth buds and the enamel organs of the deciduous teeth are formed. The enamel organs of the per manent teeth begin to form at about the sixteenth week of intra-uterine life. At birth, all the teeth but the second and third molars have begun to develop and the crowns of the deciduous teeth are partially or completely formed. A t about 6 to 8 months, the first deciduous tooth
T
From the Cleveland Clinic. Read before the Section on Operative Den tistry, M ateria M edica and Therapeutics at the Eighty-Second Annual Meeting of the American Dental Association, September 11, -
1940
Jour. A .D .A ., V o l. 28, Septem ber 1941
A.
R esch ,
D.D.S., Cleveland, Ohio
erupts ; at about 2 years of age, the last one- erupts. T h e first permanent molar erupts at about 6 years o f age. These facts, well known to dentists, remind us of the early age at which vari ous conditions m ay operate to affect the health of both deciduous and permanent teeth. M any conditions o f prime impor tance, such as the results of infectious disease and nutrition, especially those relating to minerals and vitamins, are intimately associated with the changes in metabolism governed by the endocrine glands. In clinical practice, the separa tion of these various conditions m ay be impracticable. O n ly the endocrine fac tors are within the scope of this paper. h y p o t h y r o id is m
The endocrine disorder most clearly related to dental formation and rate of eruption appears to be thyroid deficiency. As pointed out above, such a deficiency is o f the greatest importance during pregnancy and in early childhood. In the adult, hypothyroidism of a severe degree produces myxedema. It can be diagnosed readily if kept in mind. M ild thyroid failure, however, must be searched for with care. It is especially common in certain areas where the soil and water are deficient in iodine. In
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
modern times, people move so freely from one location to another that geo graphic distribution of the disease is not so evident as it was previously. In such areas as the Great Lakes region, where goiter is common, the condition should be considered a possibility in all expec tant mothers and treated thoroughly if found. Such treatment would be of great value in the prevention o f poor dental health in children. W henever a suspicion of hypothyroidism is present, dentists m ight remind the obstetrician of such a possibility or recommend consid eration of a possibility o f hypothyroidism of mild degree in expectant mothers who come under their care.
1437
memory, irritability, drowsiness and, at times, digestive and menstrual disorders. The most obvious sign is edema o f the eyelids or, in more advanced cases, o f the face, hands and feet. There m ay be a gain in weight, although obesity is seldom extreme. T h e most striking changes are the low basal metabolic rate, which re sponds completely to thyroid therapy, and blood cholesterol levels exceeding 225 mg. per hundred cubic centimeters. From a dental point o f view, the condi tion is unimportant in the adult, but it is important that it be recognized and treated during pregnancy. In infancy and childhood, thyroid de ficiency varies greatly in severity. It
Fig. 1 (Case 1).— Age 7 years; epiphyseal age, approximately 3 years.
The widespread use of iodine in such a form as iodized salt is a great step for ward in the prevention of goiter and thyroid deficiency, particularly in chil dren. Such a practice, if continued through several generations, will go far toward the prevention o f hypothyroid ism and its effects. In the adult, common symptoms of hypothyroidism include diminished en ergy and endurance, dryness o f the skin and hair, brittleness of the nails, transient numbness o f the hands and feet, a tend ency to coldness, diminished acuteness of
usually is considered in two fo rm s: (1) congenital hypothyroidism, or cretinism, and (2) juvenile hypothyroidism. In congenital hypothyroidism, or cretinism, the condition usually is more severe, and it having existed before birth, irrepar able damage usually has been done, so that even the most energetic treatment has limited results. W hen the dis ease arises during childhood, it varies from mild to very severe forms. T he typical cretin is overweight at birth and m ay nurse poorly and be rela tively inactive. T h e disease generally is
•438
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
suspected in the first year o f life because of a normal increase in weight but not in stature. T h e face looks puffy and sal low and the tongue is large and m ay protrude. Goiter is not uncommon. T he abdomen is prominent and an umbilical hernia is commonly present. W alking and talking are delayed and the intelli gence is markedly impaired. T h e slow growth is associated with marked re tardation o f bony development, the cen ters o f ossification appearing late and the epiphyseal lines and fontanels closing late. As in adult hypothyroidism, the blood cholesterol is high. In such cases, dentition m ay be de layed m arkedly and the teeth are often
cases not noticeably impaired. In m any instances, the disease is diagnosed be cause the parents have noticed that the child is not growing at a normal rate or that dentition has been delayed or the deciduous teeth are lost late. In some of the mildest cases recogniz able with certainty and which have come under our care, the presenting symptom has been irregular alinement o f the teeth or late dentition. In such instances as this, the fam ily dentist or the orthodon tist is likely to be the first to have the opportunity of recognizing the possible presence of thyroid deficiency. It is in instances of this kind that a study of epiphyseal development and of blood
Fig. 2 (Case 1).— Age 7 years; dental age between 5 and 6 years; spacing and occlusion normal; no caries present. No permanent teeth have erupted.
poorly formed and liable to caries. Some o f our cases have shown marked dental retardation, but with no signs of caries, apparently because unusual attention was given to the nutrition, a well-balanced diet with large quantities of calcium and vitamins A , D and G having been fed from early life. Exfoliation of the teeth m ay be late as well, and the eruption of permanent teeth greatly retarded or ob structed. In juvenile hypothyroidism, the disease seldom is so severe. M an y of the symptoms mentioned in cretinism m ay be present, but the intellect m ay be normal and physical activity in some
cholesterol m ay be of great value in arriving at the diagnosis. T h e determ ina tion of the basal metabolic rate in chil dren under 8 or 9 years of age is likely to be undependable. T o make a correct diagnosis is a matter of practical impor tance since it is to be expected that the use o f orthodontic appliances, no matter how skilful, could not assure so satis factory a result alone as when used in conjunction with a correction of the metabolic defect. In addition, thyroid feeding results in complete normality if sufficient amounts are continued from an early age.
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
The following cases are presented as examples of cretinism and childhood hypothyroidism o f moderate severity and of mild degree. r epo r t o f cases
C a s e i .— Cretinism .— A girl, Italian, aged 7 years, born at Akron, Ohio, walked at 3 years and obviously was mentally re tarded. She began to talk at 4 years of age. Speech was slow and indistinct and response to questions very slow. T he face was pale and puffy. There was no goiter. T he ab domen was prominent, but there was no umbilical hernia. The skin tended to be dry and the hair rather coarse. The height was
!439
and the occlusion was normal. The only dental abnormality of note in this case was retardation of eruption. C a s e 2.— C h ildh ood hypothyroidism .— A Jewish girl, aged 9 years and 3 months, height 45.6 inches (normal average 52 inches), the chief complaint being failure to grow, had her first tooth at 6 months. She talked at 1 year and walked at 15 months. When 2 years of age, it was noted that her growth was slow. When examined, she was bright and active and answered questions well. She had made an average record at school. Examination revealed dryness of the skin. T he abdomen was prominent. A t 8 years of age, the basal metabolic rate was — 36 per cent and it was now — 21 per cent. The blood cholesterol was 264 mg. per hun dred cubic centimeters (normal, 150 to 200).
Fig. 4 (Case 2 ).— Age 9 years and 3 months; dental age approximately 6 to 7 years; no visible caries. Fig. 3 (Case 2 ).— Juvenile hypothyroidism; age, 9 years and 3 months; epiphyseal age, between 3 J and 4 years.
40 inches, the average (normal) for that age being 50 inches. The epiphyseal age was approximately 3 years. (Fig. 1.) The blood cholesterol was 214 mg. per hundred cubic centimeters (normal, 150 to 200) and there were 3,610,000 red blood cells, with 63 per cent hemoglobin. The dental age of this patient approxi mated 6 years inasmuch as all the deciduous teeth were present and no permanent teeth had erupted. (Fig. 2.) Spacing of the de ciduous teeth appeared to be proceeding normally; there was no evidence of caries,
T he epiphyseal age was 3J to 4 years. (Fig. 3.) T he lower central incisors erupted at 8 years. T he upper central incisors were not erupted. T he dental development had been greatly delayed. (Fig. 4.) T he dental age was approximately 6 to 7 years. C a s e 3 . — Juvenile hypothyroidism . — A boy, aged 8£ years, height 46 inches (average normal, 50.1 inches), the chief complaint being failure to grow normally, was active and energetic. The skin was dry and the abdomen prominent. The basal metabolic rate was — 9 per cent. T he blood cholesterol was 344 mg. per hundred cubic centimeters (fasting). T he epiphyseal age was 3 years; dental age, approximately 3J to 4 years. There
144°
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
was marked underdevelopment of the dental arches. The first permanent molars were in the process of eruption. There was marked caries of the second deciduous molars and some caries of the erupting molars, due to developmental defects. C a s e 4 .— Juvenile hypothyroidism, m ild .— A girl, aged 11, when first examined in 1934 was 53.7 inches tall, (normal average, 53.4 inches). The weight was 89 pounds (normal, 69 pounds). A diffuse goiter was present. In the preceding months, the patient had be come inactive and irritable and wept readily. The bone age was slightly retarded, no pisiform bone being present. The basal meta bolic rate was — 18 per cent and — 21 per cent. In July 1934, the upper lateral incisor teeth had been partially erupted for two
adult life. The condition is uncommon. As m ight be expected, overproduction of thyroid hormone has a result the reverse of a deficiency as long as the disease is compatible with a degree of health that permits growth. The skeleton grows more rapidly and matures more rapidly than normal and the teeth appear before the normal time. One similarity in effect of hypothyroidism and hyperthyroidism exists, a tendency to caries. In hypo thyroidism, this is the result o f a lack of ability o f the tissues to utilize available nutrim ent; whereas, in hyperthyroidism, the bodily demand for elements of nutri tion is increased and there is in addition
Fig. 5 (Case 6 ).— Pituitary dwarfism; age, 23 years; prim ary amenorrhea; ovarian deficiency evidenced by sexual infantilism; height, 58 inches; skull changes typical of pituitary dwarfism; dental arches small, necessitating removal of lower first molars; teeth well formed but small; some caries ; anomalous roots of lower second bicuspids and third molars.
years. Because of the low basal metabolic rate and retarded bone age, desiccated thyroid was given in doses of three-quarters grain to i | grains per day. After three months of therapy, in October 1934, the teeth were completely erupted and were in normal alinement. The permanent teeth were well formed. Small carious areas were frequent. h y p e r t h y r o id is m
Hyperthyroidism in childhood may take on all the features of the disease in
an abnormally rapid excretion of calcium from the body. T h e following is an example o f child hood hyperthyroidism. C a s e 5 . — Juvenile hyperthyroidism. — A girl, aged 4J, first seen in October 1934, was hyperactive and extremely irritable. The pulse rate was 130 per minute. The child had a diffuse goiter and pronounced exophthalmos. In December 1934, the basal metabolic rate was plus 32 per cent. T h y roidectomy was performed in December 1934, and, because of recurrence, a second
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
operation was performed in April 1935. In May 1935, when the patient was 4 years and 11 months old, the first permanent molars were beginning to erupt and the lower permanent central incisors were erupt ing. The deciduous teeth were separating normally, but marked caries was present. In August 1940, at the age of 10 years and 2 months, the epiphyseal age was 13 years. There were no remaining deciduous teeth. The second permanent molars were ready to erupt. These teeth and the third molars were the only ones that remained unerupted. The teeth were well formed, with no evidence of caries. p a r a th y r o id
d e fic ie n c y
in
c h ild h o o d
It has been w ell dem onstrated that ex-
Fig. 6 (Case 7 ) .— Cast demonstrating crowding of teeth and underdevelopment of dental arches, especially lower, with abnormal bite and occlusion.
perim ental parath yroid deficiency in an i mals d u rin g the period o f dental fo rm a tion w ill result in pronounced hypoplasia o f the dentin and enam el.1 T h ere is a considerable parallelism betw een such effects as these and those o f vitam in D deficiency and rickets in the hum an being. T ru e parath yroid deficiency in the hum an being d u rin g in fa n cy and childhood is so rarely encountered as to
render its discussion here unw arranted. O n e o f the m a n y causes of dw arfism is a deficiency in horm one production by the anterior lobe o f the p itu itary gland. In cases o f dw arfism in w h ich gro w th is im paired and there is sexual infantilism , the condition is know n as L o ra in -L ev i dwarfism . H yp othyroidism m a y exist as an integral p a rt o f such a condition. In this state, one encounters striking d evia tion from the norm al bone form ation. In addition to shortness in stature, the bones are delicate in structure and narrow , w ith thin cortices. T h e skull shows the most interesting changes. H ere, the d e velopm ent o f the fa cia l bones is espe cially defective. T h e va u lt o f the skull approaches norm al size, but the inner and outer tables are thin and close to gether, the diploe b ein g scant. T h e sinuses are poorly developed and lack pneum atization, so th a t the fa cia l struc tures are crow ded together. T h e dental arches are sm all. A t times, the m andible is com paratively sm aller than the m a x illae, w hile in some the fa ce is so small that there is a relative prognathism . Such changes as these h a ve been studied especially b y M o rtim e r.2 In rats, after hypophysectom y, he observed that the dental eruption and gro w th w ere m ark edly d elayed, the tooth outline was de form ed and the p u lp cavities w ere largely obliterated. Schour and V a n D y k e ,3 in studying the m olar teeth in hypophysectom ized rats, observed retarded eruption and hypoplasia of the enam el and dentin. Schour also m entioned a h yp ercalcifica tion o f the alveolar bone in anim als w ith a long postoperative life. A sim ilar bony sclerosis throughout the skulls o f patients w ith long-standing p itu ita ry disease, previously em phasized b y M o rtim er et al., m ore recently has been corroborated by G oldzieher4 in a study o f 500 cases o f pitu itary disease. T h e follow in g cases are exam ples of pituitary dwarfism. Case 6.— Pituitary dwarfism .— A woman,
1442
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
aged 23, presented a typical case of dwarf ism of the Lorain-Levi type. Her height is 58 inches, weight 108 pounds. She had never menstruated. The breasts were small and underdeveloped. There was scant pubic hair, but no axillary hair. The vagina and uterus were infantile. Roentgen examination of the sella turcica afforded no evidence of pituitary tumor. The visual fields were normal. On two assays, the urinary estrogens were two and three units, respectively, the normal level being above thirty units. This confirms the pres ence of hypo-ovarianism, so obvious clini cally. The basal metabolic rate was — 2 per cent and the blood cholesterol 164 mg.
vious hypogonadism and right cryptorchid ism. The basal metabolic rate was — 8 per cent. T he bone age was approximately 9^ years. A t that age, only nineteen permanent teeth had erupted, the normal being twentyeight. The teeth were large and well formed, but the dental arches were small. There were a few small pits on the occlusal sur faces in the posterior region. The mucosa and gums were normal. The second bi cuspids were then in the process of root formation. In April 1939, at the age of 18, the height was 52.25 inches. In October 1939, the height was 53 inches, as compared with an average normal of 68.2 inches. The basal
Fig. 7 (Case 9).— Juvenile adrenogenital syndrome; age, 6 years; epiphyseal age approxi mately 14 years, paralleling sexual age.
per hundred cubic centimeters, so that ap parently no concomitant hypothyroidism existed. T he skull showed changes typical of pitu itary deficiency. The dental arches were small, which had necessitated the removal of the upper third molars and lower first molars. The teeth were well formed, but somewhat smaller than normal. Some caries was present. The alveolar bone and gums were normal. (Fig. 5.) C a s e 7. — Pituitary dwarfism. — A boy, aged 16, height 51 inches (normal 66.8), when examined in August 1937 had an ob
metabolism was — 9 per cent and blood cholesterol 263 mg. per hundred cubic centi meters. By February 1940, the height had in creased to 53.5 inches, a growth of approxi mately 1.5 inches in a year. Between Febru ary and August 1940, the patient received methyl testosterone orally and his height increased to 55.7 inches, a growth of ap proximately 4.5 inches in a year, or three times the preceding rate of growth. T he in crease in sexual age was obvious. In August 1940, the bone age was approxi mately 12J years. The teeth were still badly
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
crowded, w ith resultant malocclusion. T he dental age exceeded 12 years as judged by the developm ent o f the upper third molars. T h e teeth themselves were w ell formed and showed no caries. T h e cast shown indicates the sm all size o f the low er jaw . (Fig. 6.) T h e rapid growth being produced in the skeleton under the present treatment gives decided hope of decreasing the dental crowd ing and aiding m aterially in correction of the malocclusion. f r o e h l ic h ’s sy n d r o m e
In adiposogenital dystrophia, the out standing clinical signs are obesity and aplastic genitalia. T he condition is the result o f a lesion o f the pituitary and hypothalamus. Here, the teeth are no
'443
adrenal cortex are not very uncommon. A n outstanding feature in nearly all such cases is the abnormally early ap pearance of signs o f puberty. In some o f those related to adrenal tumors, other features of adrenal disease such as obesity, polycythemia and alteration in sodium and potassium levels in the blood m ay be seen. In some, there is marked muscle hypertrophy. In some, a very high titer o f male hormone has been found in the urine. It does not seem remarkable that, in some cases of this type, the marked ac celeration o f bone growth and advanced epiphyseal m aturity might be associated with precocious dental developm ent;
Fig. 8 (Case 9 ).— A ge, 6 years; height, 55 inches (normal average, 46 inches); sexual age, advanced to approximately normal for 14 to 15 years, which parallels epiphyseal age; dental age paralleling chronologic age; no carious teeth.
tably well formed and excellent in every way. p u b e r t a s p r a e c o x a n d j u v e n il e a d r e n o g e n it a l s y n d r o m e
Tumors of the pineal gland, testicle or ovary causing pubertas praecox are ex tremely rare. Pubertas praecox associ ated with adrenal tumor and appearing at times as part of the juvenile adreno genital syndrome is less rare, but cases in which the condition is presumed to be due to functional hyperactivity of the
but it does seem remarkable that the in stances which have come to our attention show extreme changes in the skeleton with m arkedly advanced epiphyseal age, yet the dental development parallels the chronologic age. T h e following cases are examples of pubertas praecox and the adrenogenital syndrome in children. C a s e 8 . — Adrenogenital syndrome with pubertas praecox.— A boy, first seen when 4 years old, and now 6, was 55.7 inches tall (normal average 46 inches) and had the
144 4
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
appearance of a boy much older, his sexual m aturity belying both his size and his years. His voice was gruff and low and he had acne of the puberal type. A xillary and pubic hair were abundant. T h e penis was normal in size for an adult, the scrotum was de veloped and the testes were the size of peas. Roentgen exam ination of the adrenal area after perirenal air injection revealed a round tumor mass in the region of the left adrenal gland. U rinary androgens (male hormone) reached 14.0 units per day (nor m al for adults, 18 to 80 units). T h e bone age was approxim ately 14 years. T h e dental age, on the other hand, corresponded to the chronologic age. T h e lower lateral incisors had erupted and the upper central incisors were beginning to erupt. T h e first perma
and axillary and pubic hair was present. T h e penis was enlarged to a size comparable to normal for the age of 14 years. H yp o spadias was present. T h e scrotum was poorly developed and there was bilateral cryptor chidism. T h e skeletal age was approxim ately 14 years. (F ig. 7.) T h e dental age, as in Case 8, approxim ated the chronologic age; namely, 6 years. T h e low er first permanent molars had erupted and the upper molars appeared ready to do so. T h e deciduous lateral incisors all showed root absorption, with the succeeding permanent teeth ready to erupt. T h e permanent lower central in cisors and upper right central incisors had erupted. O ne proxim al carious area was noted on the lower deciduous molar. T h e deciduous teeth were normal in form, size
Fig. 9 (Case 10).— Acromegaly. T he mandible and maxilla had enlarged in all diameters, the teeth separating uniformly. T he gums were hypertrophied and soft and there was incipient pocket formation. There was slight uniform alveolar resorption. There were no carious lesions of the teeth.
nent molars had erupted and were in normal alinement. T h e lower deciduous central in cisors were in place and the permanent lower central incisors were missing on the roentgenogram (anodontia). T h e de ciduous left molars and deciduous right second molars were present. T here was no apparent abnorm ality of the permanent teeth. C a s e 9 .-— Pubertas praecox.— A boy, aged 6 years, brought in because of too rapid development, was 55 inches in height (normal average, 46 inches). He had facial acne
and alinement. (Fig. 8.)
Occlusion
was
normal.
ENDOCRINE D EN TA L R E L ATIO N SH IPS IN TH E ADULT
In the adult, the teeth m ay be dam aged by endocrine disorders which change the structure of the jaw, as in acromegaly or parathyroid disease, or by disease of the soft tissues, as in diabetes mellitus. Thyroid disease in the adult, pituitary
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
or gonadal deficiency, adrenal deficiency or tumor causes no notable changes in the teeth, jaws or gums. Pregnancy still is considered by many to cause metabolic defects affecting the teeth, but this is probably not true, unless such effects are a part of changes of the chemical condi tions in the mouth. Such careful studies as those of Ziskin5 would appear to re fute such statements, since, after a study of 324 pregnant women, he concluded that pregnancy per se does not increase dental caries, but actually tends to pre vent it. PAR ATH YR O ID DISEASE IN T H E A D U L T
In parathyroid tetany in the adult, the serum calcium level falls as a result o f a deficiency of parathyroid hormone. The blood phosphorus rises and there is an increase in neuromuscular excitability, typified by spastic contractions of the muscles, especially of the hands and feet. In chronic cases, trophic changes, such as cataract or ridging or loss o f the nails, occur. In some cases, the teeth become extremely loose so that they can be moved about freely. Is this looseness due to trophic disturbances affecting the health of the peridental membranes? W hatever m ay be the cause, administra tion of large doses of calcium, such as 1 or 2 teaspoonfuls of calcium lactate three times a day, will be followed by fixation of the teeth within a few days. T he structure of the tooth itself remains un affected. In hyperparathyroidism6 such as is seen in cases of parathyroid tumor, the chief changes are an increase in serum calcium to above 11 mg. per hundred cubic centimeters and usually phosphorus levels o f 2.5 or less. T h e excess of cal cium in the blood is drawn from the skeleton, which becomes weak and brittle, and may result in the formation of multiple cysts of the jaws, which must not be confused with local cysts of other origin. A t times, the jaw m ay become so decalcified that the teeth fall out. It is
1445
of extraordinary interest that, under these conditions, the teeth do not become decalcified. Here, Nature has arranged one of the best possible demonstrations of the fact that the teeth of the adult are free from decalcifying effects that can harm the skeleton. DIABETES M EL LITU S
In diabetes mellitus, the gums are par ticularly subject to infection. This is part o f the generally lowered resistance. Here, careful cooperation between the intern ist and the dentist is essential, since good care in the diabetic state includes free dom from infection, and, conversely, the health of the gums requires adequate control of the metabolic disorder. E x traction of a tooth may, in some cases, be sufficient to make diabetes uncon trollable or even to precipitate acute acidosis. In our practice, in diabetes, when dental extraction is necessary, we prefer to keep the patient in the hospital for a few days. There, the diet m ay be modified, if soft foods are needed, while dietary control is maintained. Also, urine and blood tests can be made as frequently as is required, and thus com plete control of the diabetic condition is insured. P IT U IT A R Y H Y P E R A C T IV IT Y IN T H E A D U L T
T he most striking changes in the jaws and teeth encountered in adulthood as the result of endocrine disease are found in gigantism and acromegaly, the latter condition resulting from hyperactivity of the anterior lobe of the pituitary gland, including hypersecretion o f the growth hormone. I f the disease begins before growth has ceased, gigantism results and may merge with acromegaly. In this disease, the bones and soft tis sues grow, especially those of the ex tremities and the head. The skull is affected in a manner which is the anti thesis o f that seen in dwarfism. The vault o f the skull grows thick, the tables being increased in thickness and separated by
T i-ie J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n
an enlarged diploe. The sinuses become enlarged and hyperaerated, the size of the face increasing. T he dental arches grow, the diastema increasing. The m an dible increases in length, with resultant malocclusion, the teeth being subjected to excess trauma. Finally, because the gums are poorly protected, there is a tendency to pocket formation and peri dental infection. T h e following cases illustrate some of the outstanding features of this disease. C a s e i o . — Acromegaly.— A white woman, aged 32, height 64 inches, and w eight 154 pounds, complained o f increasing enlarge ment of the face, hands and feet over a period o f ten years, and of progressive weakness. Roentgen examination of the skull re vealed signs typical of acrom egaly. T h e mandible appeared enlarged in all diam eters, separation o f the teeth resulting. T he tongue was enlarged, w ith pronounced hyper trophy of the papillae. T h e gums were hypertrophied, soft and pale. T h ere was early pocket formation, but no periapical disease. Hypercementosis was present in the second upper bicuspids. T here was no al veolar resorption. A ll remaining teeth were sound. (Fig. 9.) C a s e i i . — Acrom egaly.— A man, aged 47, who had had progressive growth of the jaw with increasing spacing of the teeth for nine or ten years, in the past five years had had noticeable enlargement of the hands and head. T h ere was a substemal goiter with hyperthyroidism. T h e basal m etabolic rates on two occasions averaged + 3 2 and + 3 1 per cent. U rinary androgens were high, be ing 93 international units in twenty-four hours. A rterial hypertension was present. Roentgen examination showed erosion o f the sella turcica caused by a pituitary tumor. T h e m andible was m arkedly prognathic. T h e angle of the m andible w ith the ramus had changed from the normal until they formed an arc. T he width of the m an dible had altered little. T h e alveolar bone appeared unusually dense. T h ere was rather
advanced macroglossia. T h ere was a marked diastema. Some teeth showed peridental pro liferation, due probably to traum a, and there were incipient pockets, but no suppuration and no caries. SU M M A RY
T h e endocrine disorder producing the commonest and most extensive dental effects is thyroid deficiency. It operates chiefly from prenatal life until tooth formation is complete. T h e endocrine disease producing the most marked changes in the jaws is pituitary disease, which m ay result in dwarfism in childhood or gigantism or acromegaly in adult life. T h e jaws m ay be m arkedly demineral ized in instances of parathyroid hyper activity. T h e investing soft tissues are the primary site of oral disease in diabetes mellitus. B IB LIO G R A PH Y
1. S c h o u r , I s a a c , et al.: Changes in Teeth Following Parathyroidectomy; Effect of Para thyroid Extract and Calciferol on Incisor of Rat. Am. J. Path., 13:971-984, November
1937-
2. M o r t i m e r , H .; L e v e n e , G., and R o w e , A. W .: Cranial Dysplasias of Pituitary Origin. Radiology, 29:135, August; 279, September
'937-
3. S c h o u r , I s a a c , a n d V a n D y k e , H. B.: Changes in Teeth Following Hypophysectomy; Changes in Molar of White Rat. /. D. Res., 1 4 : 6 9 - 9 1 , April 1 9 3 4 . 4. G o l d z i e h e r , M . A .: Diagnostic Signifi cance of Cranial Roentgenograms in Pituitary Disease. Endocrinology, 27:185-190, August 1940. 5. Z i s k i n , D. E., and H o t e l l i n g , H .: Ef fects of Pregnancy, Mouth Acidity, and Age on Dental Caries. J. D. Res., 16:507-509, December 1937. 6. A l b r i g h t , F .; A u b , J. C., and B a u e r , W i l l i a m : Hyperparathyroidism: Common and Polymorphic Condition as Illustrated by Seven teen Proved Cases from O ne Clinic. J.A.M .A., 102:1276-1286, April 21, 1934. Euclid Avenue and Ninety-Third Street.
36
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
13. H a r r i s , H . L .: Effect of Loss of V er tical Dimension on Anatomic Structures of Head and Neck. J.A .D .A ., 2 5 :17 5 , February 1938; Anatomy of Temporomandibular A r ticulation and Adjacent Structures. Ibid., : 584, April 1932. 14. W i t t i n g , E. G., and H u g h s o n , W .: Larygoscope, 50:259, M arch 1940.
19
15. F o w l e r ,
28 ,
E. P.,
J r .:
Acta Otolaryg.,
1940 . 16. F l e t c h e r ,
H.: Speech and Hearing. New York: D. V an Nostrand Co., Inc., 1929. 1 7 . H i g l e y , L . B. : Practical Application of New and Scientific Method of Producing Tem poromandibular Roentgenograms. J.A.D .A., : , February 1937.
24 222
SOME ENDOCRINE FACTORS IN DENTAL DEVELOPMENT AND MAINTENANCE By E.
P e r r y M c C u lla g h ,
M .D ., and
C h a r le s
H E health of the teeth m ay be im paired by disorders of the endo crine glands in two fundam entally different ways. 1. Directly, by interference with nor mal tooth formation and eruption. 2. Indirectly, by interference with nor mal growth or maintenance o f the sup porting structures. T h e first type of change can take place only during the stage o f formation, growth and eruption o f the tooth. The second may occur at any time of life, although its effects are chiefly postnatal. Before formation of the bony structure of the jaws, at about the eighth week of embryonal life, the tooth buds and the enamel organs of the deciduous teeth are formed. The enamel organs of the per manent teeth begin to form at about the sixteenth week of intra-uterine life. At birth, all the teeth but the second and third molars have begun to develop and the crowns of the deciduous teeth are partially or completely formed. A t about 6 to 8 months, the first deciduous tooth
T
From the Cleveland Clinic. Read before the Section on Operative Den tistry, M ateria M edica and Therapeutics at the Eighty-Second Annual Meeting of the American Dental Association, September 11, -
1940
Jour. A .D .A ., V o l. 28, Septem ber 1941
A.
R esch ,
D.D.S., Cleveland, Ohio
erupts ; at about 2 years of age, the last one- erupts. T h e first permanent molar erupts at about 6 years o f age. These facts, well known to dentists, remind us of the early age at which vari ous conditions m ay operate to affect the health of both deciduous and permanent teeth. M any conditions o f prime impor tance, such as the results of infectious disease and nutrition, especially those relating to minerals and vitamins, are intimately associated with the changes in metabolism governed by the endocrine glands. In clinical practice, the separa tion of these various conditions m ay be impracticable. O n ly the endocrine fac tors are within the scope of this paper. h y p o t h y r o id is m
The endocrine disorder most clearly related to dental formation and rate of eruption appears to be thyroid deficiency. As pointed out above, such a deficiency is o f the greatest importance during pregnancy and in early childhood. In the adult, hypothyroidism of a severe degree produces myxedema. It can be diagnosed readily if kept in mind. M ild thyroid failure, however, must be searched for with care. It is especially common in certain areas where the soil and water are deficient in iodine. In
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
modern times, people move so freely from one location to another that geo graphic distribution of the disease is not so evident as it was previously. In such areas as the Great Lakes region, where goiter is common, the condition should be considered a possibility in all expec tant mothers and treated thoroughly if found. Such treatment would be of great value in the prevention o f poor dental health in children. W henever a suspicion of hypothyroidism is present, dentists m ight remind the obstetrician of such a possibility or recommend consid eration of a possibility o f hypothyroidism of mild degree in expectant mothers who come under their care.
1437
memory, irritability, drowsiness and, at times, digestive and menstrual disorders. The most obvious sign is edema o f the eyelids or, in more advanced cases, o f the face, hands and feet. There m ay be a gain in weight, although obesity is seldom extreme. T h e most striking changes are the low basal metabolic rate, which re sponds completely to thyroid therapy, and blood cholesterol levels exceeding 225 mg. per hundred cubic centimeters. From a dental point o f view, the condi tion is unimportant in the adult, but it is important that it be recognized and treated during pregnancy. In infancy and childhood, thyroid de ficiency varies greatly in severity. It
Fig. 1 (Case 1).— Age 7 years; epiphyseal age, approximately 3 years.
The widespread use of iodine in such a form as iodized salt is a great step for ward in the prevention of goiter and thyroid deficiency, particularly in chil dren. Such a practice, if continued through several generations, will go far toward the prevention o f hypothyroid ism and its effects. In the adult, common symptoms of hypothyroidism include diminished en ergy and endurance, dryness o f the skin and hair, brittleness of the nails, transient numbness o f the hands and feet, a tend ency to coldness, diminished acuteness of
usually is considered in two fo rm s: (1) congenital hypothyroidism, or cretinism, and (2) juvenile hypothyroidism. In congenital hypothyroidism, or cretinism, the condition usually is more severe, and it having existed before birth, irrepar able damage usually has been done, so that even the most energetic treatment has limited results. W hen the dis ease arises during childhood, it varies from mild to very severe forms. T he typical cretin is overweight at birth and m ay nurse poorly and be rela tively inactive. T h e disease generally is
•438
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
suspected in the first year o f life because of a normal increase in weight but not in stature. T h e face looks puffy and sal low and the tongue is large and m ay protrude. Goiter is not uncommon. T he abdomen is prominent and an umbilical hernia is commonly present. W alking and talking are delayed and the intelli gence is markedly impaired. T h e slow growth is associated with marked re tardation o f bony development, the cen ters o f ossification appearing late and the epiphyseal lines and fontanels closing late. As in adult hypothyroidism, the blood cholesterol is high. In such cases, dentition m ay be de layed m arkedly and the teeth are often
cases not noticeably impaired. In m any instances, the disease is diagnosed be cause the parents have noticed that the child is not growing at a normal rate or that dentition has been delayed or the deciduous teeth are lost late. In some of the mildest cases recogniz able with certainty and which have come under our care, the presenting symptom has been irregular alinement o f the teeth or late dentition. In such instances as this, the fam ily dentist or the orthodon tist is likely to be the first to have the opportunity of recognizing the possible presence of thyroid deficiency. It is in instances of this kind that a study of epiphyseal development and of blood
Fig. 2 (Case 1).— Age 7 years; dental age between 5 and 6 years; spacing and occlusion normal; no caries present. No permanent teeth have erupted.
poorly formed and liable to caries. Some o f our cases have shown marked dental retardation, but with no signs of caries, apparently because unusual attention was given to the nutrition, a well-balanced diet with large quantities of calcium and vitamins A , D and G having been fed from early life. Exfoliation of the teeth m ay be late as well, and the eruption of permanent teeth greatly retarded or ob structed. In juvenile hypothyroidism, the disease seldom is so severe. M an y of the symptoms mentioned in cretinism m ay be present, but the intellect m ay be normal and physical activity in some
cholesterol m ay be of great value in arriving at the diagnosis. T h e determ ina tion of the basal metabolic rate in chil dren under 8 or 9 years of age is likely to be undependable. T o make a correct diagnosis is a matter of practical impor tance since it is to be expected that the use o f orthodontic appliances, no matter how skilful, could not assure so satis factory a result alone as when used in conjunction with a correction of the metabolic defect. In addition, thyroid feeding results in complete normality if sufficient amounts are continued from an early age.
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
The following cases are presented as examples of cretinism and childhood hypothyroidism o f moderate severity and of mild degree. r epo r t o f cases
C a s e i .— Cretinism .— A girl, Italian, aged 7 years, born at Akron, Ohio, walked at 3 years and obviously was mentally re tarded. She began to talk at 4 years of age. Speech was slow and indistinct and response to questions very slow. T he face was pale and puffy. There was no goiter. T he ab domen was prominent, but there was no umbilical hernia. The skin tended to be dry and the hair rather coarse. The height was
!439
and the occlusion was normal. The only dental abnormality of note in this case was retardation of eruption. C a s e 2.— C h ildh ood hypothyroidism .— A Jewish girl, aged 9 years and 3 months, height 45.6 inches (normal average 52 inches), the chief complaint being failure to grow, had her first tooth at 6 months. She talked at 1 year and walked at 15 months. When 2 years of age, it was noted that her growth was slow. When examined, she was bright and active and answered questions well. She had made an average record at school. Examination revealed dryness of the skin. T he abdomen was prominent. A t 8 years of age, the basal metabolic rate was — 36 per cent and it was now — 21 per cent. The blood cholesterol was 264 mg. per hun dred cubic centimeters (normal, 150 to 200).
Fig. 4 (Case 2 ).— Age 9 years and 3 months; dental age approximately 6 to 7 years; no visible caries. Fig. 3 (Case 2 ).— Juvenile hypothyroidism; age, 9 years and 3 months; epiphyseal age, between 3 J and 4 years.
40 inches, the average (normal) for that age being 50 inches. The epiphyseal age was approximately 3 years. (Fig. 1.) The blood cholesterol was 214 mg. per hundred cubic centimeters (normal, 150 to 200) and there were 3,610,000 red blood cells, with 63 per cent hemoglobin. The dental age of this patient approxi mated 6 years inasmuch as all the deciduous teeth were present and no permanent teeth had erupted. (Fig. 2.) Spacing of the de ciduous teeth appeared to be proceeding normally; there was no evidence of caries,
T he epiphyseal age was 3J to 4 years. (Fig. 3.) T he lower central incisors erupted at 8 years. T he upper central incisors were not erupted. T he dental development had been greatly delayed. (Fig. 4.) T he dental age was approximately 6 to 7 years. C a s e 3 . — Juvenile hypothyroidism . — A boy, aged 8£ years, height 46 inches (average normal, 50.1 inches), the chief complaint being failure to grow normally, was active and energetic. The skin was dry and the abdomen prominent. The basal metabolic rate was — 9 per cent. T he blood cholesterol was 344 mg. per hundred cubic centimeters (fasting). T he epiphyseal age was 3 years; dental age, approximately 3J to 4 years. There
144°
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
was marked underdevelopment of the dental arches. The first permanent molars were in the process of eruption. There was marked caries of the second deciduous molars and some caries of the erupting molars, due to developmental defects. C a s e 4 .— Juvenile hypothyroidism, m ild .— A girl, aged 11, when first examined in 1934 was 53.7 inches tall, (normal average, 53.4 inches). The weight was 89 pounds (normal, 69 pounds). A diffuse goiter was present. In the preceding months, the patient had be come inactive and irritable and wept readily. The bone age was slightly retarded, no pisiform bone being present. The basal meta bolic rate was — 18 per cent and — 21 per cent. In July 1934, the upper lateral incisor teeth had been partially erupted for two
adult life. The condition is uncommon. As m ight be expected, overproduction of thyroid hormone has a result the reverse of a deficiency as long as the disease is compatible with a degree of health that permits growth. The skeleton grows more rapidly and matures more rapidly than normal and the teeth appear before the normal time. One similarity in effect of hypothyroidism and hyperthyroidism exists, a tendency to caries. In hypo thyroidism, this is the result o f a lack of ability o f the tissues to utilize available nutrim ent; whereas, in hyperthyroidism, the bodily demand for elements of nutri tion is increased and there is in addition
Fig. 5 (Case 6 ).— Pituitary dwarfism; age, 23 years; prim ary amenorrhea; ovarian deficiency evidenced by sexual infantilism; height, 58 inches; skull changes typical of pituitary dwarfism; dental arches small, necessitating removal of lower first molars; teeth well formed but small; some caries ; anomalous roots of lower second bicuspids and third molars.
years. Because of the low basal metabolic rate and retarded bone age, desiccated thyroid was given in doses of three-quarters grain to i | grains per day. After three months of therapy, in October 1934, the teeth were completely erupted and were in normal alinement. The permanent teeth were well formed. Small carious areas were frequent. h y p e r t h y r o id is m
Hyperthyroidism in childhood may take on all the features of the disease in
an abnormally rapid excretion of calcium from the body. T h e following is an example o f child hood hyperthyroidism. C a s e 5 . — Juvenile hyperthyroidism. — A girl, aged 4J, first seen in October 1934, was hyperactive and extremely irritable. The pulse rate was 130 per minute. The child had a diffuse goiter and pronounced exophthalmos. In December 1934, the basal metabolic rate was plus 32 per cent. T h y roidectomy was performed in December 1934, and, because of recurrence, a second
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
operation was performed in April 1935. In May 1935, when the patient was 4 years and 11 months old, the first permanent molars were beginning to erupt and the lower permanent central incisors were erupt ing. The deciduous teeth were separating normally, but marked caries was present. In August 1940, at the age of 10 years and 2 months, the epiphyseal age was 13 years. There were no remaining deciduous teeth. The second permanent molars were ready to erupt. These teeth and the third molars were the only ones that remained unerupted. The teeth were well formed, with no evidence of caries. p a r a th y r o id
d e fic ie n c y
in
c h ild h o o d
It has been w ell dem onstrated that ex-
Fig. 6 (Case 7 ) .— Cast demonstrating crowding of teeth and underdevelopment of dental arches, especially lower, with abnormal bite and occlusion.
perim ental parath yroid deficiency in an i mals d u rin g the period o f dental fo rm a tion w ill result in pronounced hypoplasia o f the dentin and enam el.1 T h ere is a considerable parallelism betw een such effects as these and those o f vitam in D deficiency and rickets in the hum an being. T ru e parath yroid deficiency in the hum an being d u rin g in fa n cy and childhood is so rarely encountered as to
render its discussion here unw arranted. O n e o f the m a n y causes of dw arfism is a deficiency in horm one production by the anterior lobe o f the p itu itary gland. In cases o f dw arfism in w h ich gro w th is im paired and there is sexual infantilism , the condition is know n as L o ra in -L ev i dwarfism . H yp othyroidism m a y exist as an integral p a rt o f such a condition. In this state, one encounters striking d evia tion from the norm al bone form ation. In addition to shortness in stature, the bones are delicate in structure and narrow , w ith thin cortices. T h e skull shows the most interesting changes. H ere, the d e velopm ent o f the fa cia l bones is espe cially defective. T h e va u lt o f the skull approaches norm al size, but the inner and outer tables are thin and close to gether, the diploe b ein g scant. T h e sinuses are poorly developed and lack pneum atization, so th a t the fa cia l struc tures are crow ded together. T h e dental arches are sm all. A t times, the m andible is com paratively sm aller than the m a x illae, w hile in some the fa ce is so small that there is a relative prognathism . Such changes as these h a ve been studied especially b y M o rtim e r.2 In rats, after hypophysectom y, he observed that the dental eruption and gro w th w ere m ark edly d elayed, the tooth outline was de form ed and the p u lp cavities w ere largely obliterated. Schour and V a n D y k e ,3 in studying the m olar teeth in hypophysectom ized rats, observed retarded eruption and hypoplasia of the enam el and dentin. Schour also m entioned a h yp ercalcifica tion o f the alveolar bone in anim als w ith a long postoperative life. A sim ilar bony sclerosis throughout the skulls o f patients w ith long-standing p itu ita ry disease, previously em phasized b y M o rtim er et al., m ore recently has been corroborated by G oldzieher4 in a study o f 500 cases o f pitu itary disease. T h e follow in g cases are exam ples of pituitary dwarfism. Case 6.— Pituitary dwarfism .— A woman,
1442
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
aged 23, presented a typical case of dwarf ism of the Lorain-Levi type. Her height is 58 inches, weight 108 pounds. She had never menstruated. The breasts were small and underdeveloped. There was scant pubic hair, but no axillary hair. The vagina and uterus were infantile. Roentgen examination of the sella turcica afforded no evidence of pituitary tumor. The visual fields were normal. On two assays, the urinary estrogens were two and three units, respectively, the normal level being above thirty units. This confirms the pres ence of hypo-ovarianism, so obvious clini cally. The basal metabolic rate was — 2 per cent and the blood cholesterol 164 mg.
vious hypogonadism and right cryptorchid ism. The basal metabolic rate was — 8 per cent. T he bone age was approximately 9^ years. A t that age, only nineteen permanent teeth had erupted, the normal being twentyeight. The teeth were large and well formed, but the dental arches were small. There were a few small pits on the occlusal sur faces in the posterior region. The mucosa and gums were normal. The second bi cuspids were then in the process of root formation. In April 1939, at the age of 18, the height was 52.25 inches. In October 1939, the height was 53 inches, as compared with an average normal of 68.2 inches. The basal
Fig. 7 (Case 9).— Juvenile adrenogenital syndrome; age, 6 years; epiphyseal age approxi mately 14 years, paralleling sexual age.
per hundred cubic centimeters, so that ap parently no concomitant hypothyroidism existed. T he skull showed changes typical of pitu itary deficiency. The dental arches were small, which had necessitated the removal of the upper third molars and lower first molars. The teeth were well formed, but somewhat smaller than normal. Some caries was present. The alveolar bone and gums were normal. (Fig. 5.) C a s e 7. — Pituitary dwarfism. — A boy, aged 16, height 51 inches (normal 66.8), when examined in August 1937 had an ob
metabolism was — 9 per cent and blood cholesterol 263 mg. per hundred cubic centi meters. By February 1940, the height had in creased to 53.5 inches, a growth of approxi mately 1.5 inches in a year. Between Febru ary and August 1940, the patient received methyl testosterone orally and his height increased to 55.7 inches, a growth of ap proximately 4.5 inches in a year, or three times the preceding rate of growth. T he in crease in sexual age was obvious. In August 1940, the bone age was approxi mately 12J years. The teeth were still badly
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
crowded, w ith resultant malocclusion. T he dental age exceeded 12 years as judged by the developm ent o f the upper third molars. T h e teeth themselves were w ell formed and showed no caries. T h e cast shown indicates the sm all size o f the low er jaw . (Fig. 6.) T h e rapid growth being produced in the skeleton under the present treatment gives decided hope of decreasing the dental crowd ing and aiding m aterially in correction of the malocclusion. f r o e h l ic h ’s sy n d r o m e
In adiposogenital dystrophia, the out standing clinical signs are obesity and aplastic genitalia. T he condition is the result o f a lesion o f the pituitary and hypothalamus. Here, the teeth are no
'443
adrenal cortex are not very uncommon. A n outstanding feature in nearly all such cases is the abnormally early ap pearance of signs o f puberty. In some o f those related to adrenal tumors, other features of adrenal disease such as obesity, polycythemia and alteration in sodium and potassium levels in the blood m ay be seen. In some, there is marked muscle hypertrophy. In some, a very high titer o f male hormone has been found in the urine. It does not seem remarkable that, in some cases of this type, the marked ac celeration o f bone growth and advanced epiphyseal m aturity might be associated with precocious dental developm ent;
Fig. 8 (Case 9 ).— A ge, 6 years; height, 55 inches (normal average, 46 inches); sexual age, advanced to approximately normal for 14 to 15 years, which parallels epiphyseal age; dental age paralleling chronologic age; no carious teeth.
tably well formed and excellent in every way. p u b e r t a s p r a e c o x a n d j u v e n il e a d r e n o g e n it a l s y n d r o m e
Tumors of the pineal gland, testicle or ovary causing pubertas praecox are ex tremely rare. Pubertas praecox associ ated with adrenal tumor and appearing at times as part of the juvenile adreno genital syndrome is less rare, but cases in which the condition is presumed to be due to functional hyperactivity of the
but it does seem remarkable that the in stances which have come to our attention show extreme changes in the skeleton with m arkedly advanced epiphyseal age, yet the dental development parallels the chronologic age. T h e following cases are examples of pubertas praecox and the adrenogenital syndrome in children. C a s e 8 . — Adrenogenital syndrome with pubertas praecox.— A boy, first seen when 4 years old, and now 6, was 55.7 inches tall (normal average 46 inches) and had the
144 4
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
appearance of a boy much older, his sexual m aturity belying both his size and his years. His voice was gruff and low and he had acne of the puberal type. A xillary and pubic hair were abundant. T h e penis was normal in size for an adult, the scrotum was de veloped and the testes were the size of peas. Roentgen exam ination of the adrenal area after perirenal air injection revealed a round tumor mass in the region of the left adrenal gland. U rinary androgens (male hormone) reached 14.0 units per day (nor m al for adults, 18 to 80 units). T h e bone age was approxim ately 14 years. T h e dental age, on the other hand, corresponded to the chronologic age. T h e lower lateral incisors had erupted and the upper central incisors were beginning to erupt. T h e first perma
and axillary and pubic hair was present. T h e penis was enlarged to a size comparable to normal for the age of 14 years. H yp o spadias was present. T h e scrotum was poorly developed and there was bilateral cryptor chidism. T h e skeletal age was approxim ately 14 years. (F ig. 7.) T h e dental age, as in Case 8, approxim ated the chronologic age; namely, 6 years. T h e low er first permanent molars had erupted and the upper molars appeared ready to do so. T h e deciduous lateral incisors all showed root absorption, with the succeeding permanent teeth ready to erupt. T h e permanent lower central in cisors and upper right central incisors had erupted. O ne proxim al carious area was noted on the lower deciduous molar. T h e deciduous teeth were normal in form, size
Fig. 9 (Case 10).— Acromegaly. T he mandible and maxilla had enlarged in all diameters, the teeth separating uniformly. T he gums were hypertrophied and soft and there was incipient pocket formation. There was slight uniform alveolar resorption. There were no carious lesions of the teeth.
nent molars had erupted and were in normal alinement. T h e lower deciduous central in cisors were in place and the permanent lower central incisors were missing on the roentgenogram (anodontia). T h e de ciduous left molars and deciduous right second molars were present. T here was no apparent abnorm ality of the permanent teeth. C a s e 9 .-— Pubertas praecox.— A boy, aged 6 years, brought in because of too rapid development, was 55 inches in height (normal average, 46 inches). He had facial acne
and alinement. (Fig. 8.)
Occlusion
was
normal.
ENDOCRINE D EN TA L R E L ATIO N SH IPS IN TH E ADULT
In the adult, the teeth m ay be dam aged by endocrine disorders which change the structure of the jaw, as in acromegaly or parathyroid disease, or by disease of the soft tissues, as in diabetes mellitus. Thyroid disease in the adult, pituitary
M c C u l l a g h a n d R e s c h — E n d o c r in e F a c t o r s
or gonadal deficiency, adrenal deficiency or tumor causes no notable changes in the teeth, jaws or gums. Pregnancy still is considered by many to cause metabolic defects affecting the teeth, but this is probably not true, unless such effects are a part of changes of the chemical condi tions in the mouth. Such careful studies as those of Ziskin5 would appear to re fute such statements, since, after a study of 324 pregnant women, he concluded that pregnancy per se does not increase dental caries, but actually tends to pre vent it. PAR ATH YR O ID DISEASE IN T H E A D U L T
In parathyroid tetany in the adult, the serum calcium level falls as a result o f a deficiency of parathyroid hormone. The blood phosphorus rises and there is an increase in neuromuscular excitability, typified by spastic contractions of the muscles, especially of the hands and feet. In chronic cases, trophic changes, such as cataract or ridging or loss o f the nails, occur. In some cases, the teeth become extremely loose so that they can be moved about freely. Is this looseness due to trophic disturbances affecting the health of the peridental membranes? W hatever m ay be the cause, administra tion of large doses of calcium, such as 1 or 2 teaspoonfuls of calcium lactate three times a day, will be followed by fixation of the teeth within a few days. T he structure of the tooth itself remains un affected. In hyperparathyroidism6 such as is seen in cases of parathyroid tumor, the chief changes are an increase in serum calcium to above 11 mg. per hundred cubic centimeters and usually phosphorus levels o f 2.5 or less. T h e excess of cal cium in the blood is drawn from the skeleton, which becomes weak and brittle, and may result in the formation of multiple cysts of the jaws, which must not be confused with local cysts of other origin. A t times, the jaw m ay become so decalcified that the teeth fall out. It is
1445
of extraordinary interest that, under these conditions, the teeth do not become decalcified. Here, Nature has arranged one of the best possible demonstrations of the fact that the teeth of the adult are free from decalcifying effects that can harm the skeleton. DIABETES M EL LITU S
In diabetes mellitus, the gums are par ticularly subject to infection. This is part o f the generally lowered resistance. Here, careful cooperation between the intern ist and the dentist is essential, since good care in the diabetic state includes free dom from infection, and, conversely, the health of the gums requires adequate control of the metabolic disorder. E x traction of a tooth may, in some cases, be sufficient to make diabetes uncon trollable or even to precipitate acute acidosis. In our practice, in diabetes, when dental extraction is necessary, we prefer to keep the patient in the hospital for a few days. There, the diet m ay be modified, if soft foods are needed, while dietary control is maintained. Also, urine and blood tests can be made as frequently as is required, and thus com plete control of the diabetic condition is insured. P IT U IT A R Y H Y P E R A C T IV IT Y IN T H E A D U L T
T he most striking changes in the jaws and teeth encountered in adulthood as the result of endocrine disease are found in gigantism and acromegaly, the latter condition resulting from hyperactivity of the anterior lobe of the pituitary gland, including hypersecretion o f the growth hormone. I f the disease begins before growth has ceased, gigantism results and may merge with acromegaly. In this disease, the bones and soft tis sues grow, especially those of the ex tremities and the head. The skull is affected in a manner which is the anti thesis o f that seen in dwarfism. The vault o f the skull grows thick, the tables being increased in thickness and separated by
T i-ie J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n
an enlarged diploe. The sinuses become enlarged and hyperaerated, the size of the face increasing. T he dental arches grow, the diastema increasing. The m an dible increases in length, with resultant malocclusion, the teeth being subjected to excess trauma. Finally, because the gums are poorly protected, there is a tendency to pocket formation and peri dental infection. T h e following cases illustrate some of the outstanding features of this disease. C a s e i o . — Acromegaly.— A white woman, aged 32, height 64 inches, and w eight 154 pounds, complained o f increasing enlarge ment of the face, hands and feet over a period o f ten years, and of progressive weakness. Roentgen examination of the skull re vealed signs typical of acrom egaly. T h e mandible appeared enlarged in all diam eters, separation o f the teeth resulting. T he tongue was enlarged, w ith pronounced hyper trophy of the papillae. T h e gums were hypertrophied, soft and pale. T h ere was early pocket formation, but no periapical disease. Hypercementosis was present in the second upper bicuspids. T here was no al veolar resorption. A ll remaining teeth were sound. (Fig. 9.) C a s e i i . — Acrom egaly.— A man, aged 47, who had had progressive growth of the jaw with increasing spacing of the teeth for nine or ten years, in the past five years had had noticeable enlargement of the hands and head. T h ere was a substemal goiter with hyperthyroidism. T h e basal m etabolic rates on two occasions averaged + 3 2 and + 3 1 per cent. U rinary androgens were high, be ing 93 international units in twenty-four hours. A rterial hypertension was present. Roentgen examination showed erosion o f the sella turcica caused by a pituitary tumor. T h e m andible was m arkedly prognathic. T h e angle of the m andible w ith the ramus had changed from the normal until they formed an arc. T he width of the m an dible had altered little. T h e alveolar bone appeared unusually dense. T h ere was rather
advanced macroglossia. T h ere was a marked diastema. Some teeth showed peridental pro liferation, due probably to traum a, and there were incipient pockets, but no suppuration and no caries. SU M M A RY
T h e endocrine disorder producing the commonest and most extensive dental effects is thyroid deficiency. It operates chiefly from prenatal life until tooth formation is complete. T h e endocrine disease producing the most marked changes in the jaws is pituitary disease, which m ay result in dwarfism in childhood or gigantism or acromegaly in adult life. T h e jaws m ay be m arkedly demineral ized in instances of parathyroid hyper activity. T h e investing soft tissues are the primary site of oral disease in diabetes mellitus. B IB LIO G R A PH Y
1. S c h o u r , I s a a c , et al.: Changes in Teeth Following Parathyroidectomy; Effect of Para thyroid Extract and Calciferol on Incisor of Rat. Am. J. Path., 13:971-984, November
1937-
2. M o r t i m e r , H .; L e v e n e , G., and R o w e , A. W .: Cranial Dysplasias of Pituitary Origin. Radiology, 29:135, August; 279, September
'937-
3. S c h o u r , I s a a c , a n d V a n D y k e , H. B.: Changes in Teeth Following Hypophysectomy; Changes in Molar of White Rat. /. D. Res., 1 4 : 6 9 - 9 1 , April 1 9 3 4 . 4. G o l d z i e h e r , M . A .: Diagnostic Signifi cance of Cranial Roentgenograms in Pituitary Disease. Endocrinology, 27:185-190, August 1940. 5. Z i s k i n , D. E., and H o t e l l i n g , H .: Ef fects of Pregnancy, Mouth Acidity, and Age on Dental Caries. J. D. Res., 16:507-509, December 1937. 6. A l b r i g h t , F .; A u b , J. C., and B a u e r , W i l l i a m : Hyperparathyroidism: Common and Polymorphic Condition as Illustrated by Seven teen Proved Cases from O ne Clinic. J.A.M .A., 102:1276-1286, April 21, 1934. Euclid Avenue and Ninety-Third Street.