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Physical signs for the general dental practitioner

From Volume 39, Issue 7, September 2012 | Page 521

Authors

Steve Bain

Professor of Medicine (Diabetes), University of Wales, Swansea

Articles by Steve Bain

Andrew Lees

F1, ABMU Health Board, Wales, Singleton Hospital, Swansea

Articles by Andrew Lees

Article

Steve Bain
Dr Andrew Lees

‘Physical Signs for the General Dental Practitioner’ aims:

  • To increase awareness of the value of identifying general clinical signs.
  • To enable the interpretation of selected clinical signs that are visible in the clothed patient.
  • To indicate the potential relevance of these clinical signs to the dental management of the patient.

    • The series will contribute to non-verifiable CPD requirements

    This man complains of difficulty rising from a chair. Over the past year he has developed hypertension and diabetes and he bruises easily. His wife has commented that he often looks very red in the face.

  • What features does this image show?
  • What is the most likely diagnosis?
  • How can this diagnosis be made?
  • What is the treatment?

    • Answers: Case 97

  • This image shows proximal muscle wasting affecting both thighs. The slow, progressive nature of this process typically means that loss of muscle mass is not noted and patients complain of weakness, eg difficulty climbing stairs.
  • Cushing's syndrome. This is a collection of symptoms which result from an excess of glucocorticoid hormones. There may also be stretch marks (striae) and hirsuitism. A rounded facial shape is described as ‘moon face’ and truncal obesity with proximal muscle wasting is labelled ‘orange on sticks’ appearance.
  • Measurementof 24-hour urinary free cortisol can be used to confirm (with a level 1-4 times greater than normal) or exclude (with three results in the normal range) Cushing's syndrome and is used as a screening tool. A dexamthasone suppression test is for sensitive-1mg dexamethasone which should suppress cortisol release. Finally, late night serum and salivary cortisol levels can be used; high levels of cortisol at this time is in dicative of Cushing's.
  • Treatment depends on the cause. If exogenous steroids are being administered (eg for rheumatoid or chronic chest conditions) then attempts should be made to reduce their use. In patients with Cushing's disease, caused by an ACTH-producing anterior pituitary tumour, or when there is an adrenal adenoma, then surgical options may be considered.