A case of acromegaly identified after patient complaint of apertognathia

Challenges in the management of late developing malocclusions in adulthood: A case report of acromegaly

The development of a malocclusion in adulthood can present as a diagnostic and management challenge to an orthodontist. It is prudent to identify the aetiology of changes to the occlusion which will influence the management plan. Uncommon causes include acromegaly. Orthodontists are in a good position to identify certain underlying disorders based on a patient's presenting malocclusion that may otherwise go unnoticed and undiagnosed until other systemic signs and symptoms present themselves at the latter stages of the condition. This case report highlights possible aetiological factors of a developing malocclusion in adulthood and presents the clinical manifestations and joint orthodontic-surgical management of a patient with a developing skeletal III base attributed to acromegaly.

Oro-dental pathologies in acromegaly

PURPOSE

Oro-dental pathologies (ODP) such as enlargement of the tongue, mandibular prognathism, and spaced teeth are characteristic features of acromegaly. Their frequency of occurrence during the course of the disease is largely unresolved. Purpose of this study was to assess ODP and oro-dental treatments in patients with acromegaly with regard to the length of the diagnostic process, tumor histology, and quality of life (QoL).

METHODS

Single-center retrospective survey study using questionnaires on dental symptoms, diagnostic process, and treatment in patients with acromegaly operated on a growth hormone-secreting pituitary adenoma. The association between ODP and QoL was assessed using the Short-Form 36 (SF-36) Health Survey.

RESULTS

145/314 patients completed the questionnaires. 80.7% were affected by any ODP, most frequently enlargement of the tongue (57.9%), spaced teeth (42.8%), mandibular growth (24.1%), and mandibular prognathism (22.1%). ODP were significantly more frequent in patients with sparsely vs. densely granulated adenomas (p = 0.045). Early diagnosis within 2 years was associated with significantly fewer ODP than later diagnosis (68.5 vs. 87.2%, p = 0.009). Treatments included dental crowns (16.6%), dental bridges (12.4%), dental implants (9.7%), dental prostheses (3.4%), orthodontal (i.e., braces, 6.9%), and surgical correction of the teeth (2.1%). Physical QoL was significantly lower in patients with ODP than in those without (p = 0.014).

CONCLUSION

In our large series of patients, four of five patients were affected by ODP at any time during the course of the disease. The results highlight the importance of early identification and treatment of oro-dental problems in patients with acromegaly as hallmarks of the disease.

What the mind knows but the eyes may still miss: reducing the 'Acromegalic Window'

A 46-year-old Asian man was referred to our endocrine unit (April 2013) by his general practitioner for investigation of a neck mass. Ultrasound scan of the neck and serum thyroid-stimulating hormone levels revealed a euthyroid multinodular goitre. He presented with symptoms of frequent headaches, polydypsia, polyuria, perspiration and night sweats and demonstrated classic physical features of acromegaly. In retrospect, the patient's medical history included encounters with numerous physicians from an array of specialties for over 20 years, mostly for symptoms well recognised to be attributed to growth hormone (GH) excess. Random insulin-like growth factor-1 level was elevated at 103 nmol/L (normal 13-37 nmol/L) and oral glucose tolerance test showed non-suppressible GH secretion (15.06 mIU/L at 120 min). MRI revealed a mildly enlarged pituitary gland. The patient has been referred for surgery. This case highlights that, even with classic features of acromegaly, there may be a wide-ranging 'Acromegalic Window' between first presentation and clinical suspicion to eventual diagnosis.

Oral manifestations in growth hormone disorders

Growth hormone is of vital importance for normal growth and development. Individuals with growth hormone deficiency develop pituitary dwarfism with disproportionate delayed growth of skull and facial skeleton giving them a small facial appearance for their age. Both hyper and hypopituitarism have a marked effect on development of oro-facial structures including eruption and shedding patterns of teeth, thus giving an opportunity to treating dental professionals to first see the signs and symptoms of these growth disorders and correctly diagnose the serious underlying disease.

Mandibular prognathism caused by acromegaly - a surgical orthodontic case

A 22-year-old man presented for orthodontic surgery because of mandibular prognathism. Clinical symptoms suggested acromegaly, and diagnosis was verified by an endocrinologist as well as by radiograph. Bilateral mandibular prognathism often represents the first and most striking physical characteristic of acromegaly; usually, it is also the main reason why patients seek help from orthodontists or maxillo-facial surgeons. This case report recapitulates the clinical and histopathological findings in pituitary growth hormone (GH) adenomas and emphasises their importance in surgical orthodontic planning. Mandibular prognatism, macroglossia and abnormal growth of hands and feet represent strong indicators for the diagnosis of acromegaly. This disease and its complications not only affect the entire body but increase mortality if the pituitary gland tumour remains untreated.

Oral manifestations of systemic diseases

In the clinical examination for systemic diseases, inspection of the oral cavity is often overlooked. This area provides a wide array of clinical signs that may help the clinician establish a diagnosis. This article provides a summary of the more common oral manifestations of systemic disease.

Acromegaly identified in a patient with a complaint of malocclusion

Acromegaly in a female patient was first diagnosed after a dental examination at which time the patient complained of the inability to incise properly. An elevated serum growth hormone level and enlarged sella turcica confirmed the diagnosis of acromegaly. Based on examination of her plaster study models, it was apparent the patient had been developing a change in her dentition for years.