Oral health in the acromegalic patient
Featured Products Promotional FeaturesPosted by: Dental Design 17th May 2024
When a patient presents with a general health complication that they manage in their everyday life, dental professionals will often have to consider it as part of their treatment plans.
Acromegaly is an obscure condition that creates this need. Whilst its rarity means some dentists may not encounter many patients living with the disorder, understanding how it presents and the associated oral health implications is essential.
To emphasise its rarity, the Pituitary Foundation estimates that, in a year, only around 4-6 new cases are diagnosed for every million of the population[i] (however other estimates inflate this number as high as 116.9 new cases per million per year)[ii]. For the UK, a reserved approximation rounds out to more than 270 new diagnoses every year when considering the latest population estimates.[iii]
But what is acromegaly, and what do dental professionals need to know about the condition?
A greater problem
With small incidence rates, acromegaly’s impact can be larger than life. The production of too much growth hormone leads to tissue and bones developing at an increased speed.[iv] This is because of the presence of a commonly benign tumour that grows within the pituitary gland.[v]
The results are features that may be abnormally large, most often hands and feet. However, as time goes on, patients may see gradual changes to facial features like their brow, nose and lips, and develop thick and coarse skin, combined with general tiredness, joint pain and headaches.iv The average diagnosis age ranges between 40-50, but it can also be identified earlier in life, which is of course optimal.[vi] Notable public figures who lived with the disease include André the Giant[vii] and actor Richard Kiel, who played every dental professional’s favourite Bond villain, Jaws.[viii]
Affecting the dentition
The condition’s impacts on oral health range widely. Oro-facial manifestations are some of the earliest signs of the diseases,[ix] placing dental professionals in an ideal position to help those in the preliminary stages of its development.
It is no surprise that the enhanced growth of oro-facial features in acromegalic patients can affect occlusion. Mandibular growth is reported in nearly a quarter of those living with the disease, which can lead to prognathism in 20-22% of patients and the development of a class III dental and skeletal pattern.[x] The condition reactivates the condylar growth centres, leading to periosteal bone apposition. This has an aesthetic impact that may affect an individual’s mental health and social connections, but could also inflict physical pain through the temporomandibular joint and masticatory muscles.x
Noticing a patient exhibits these traits when they seek out orthodontic treatment to amend a class III malocclusion, for example, could be the key for helping them find a wider range of suitable treatments.
Fighting gingivitis
Patients may also present with other intraoral concerns, such as an increased interdental spacing, or diastema, as a potential result of acromegaly.[xi] It is even more common than the protrusion of the mandible, with an incidence in 40-43% of acromegalic patients.x When these large spaces appear, not only could they produce non-aesthetic “black triangles”, but they could result in occasional speech problems, or food impaction.[xii]
Food that is left on the gumline, trapped in the enlarged spaces left between the teeth, must be removed. Shifting interdental plaque and food that builds up within these areas is key in the effort to prevent interproximal caries.[xiii] Acromegaly is sometimes a cause for a thick gingival biotype which has been touted as potential protection against severe periodontal disease,[xiv] but dental professionals must remember this isn’t consistent with every acromegalic individual, and effective oral hygiene is still necessary in each case.
Patients must be aware of the need to brush regularly and effectively, twice a day, and clean interdentally once per day. It can be helpful to recommend specific interdental cleaning solutions, such as the Waterpik® Cordless Slide Water Flosser. It effectively removes up to 99.9% plaque from treated areas,[xv] and is clinically proven to be up to 50% more effective than string floss for improving gum health.[xvi] The Cordless Slide’s small stature – that can collapse to 50% of its original size – is perfect for easy storage in any bathroom, and even for travel.
Acromegaly is a rare condition that many clinicians may only encounter on few occasions throughout their career. However, with apt knowledge to identify the condition early, and provide effective care around it, patients can minimise difficulties associated with the condition and enjoy improved oral health.
For more information on Waterpik® Water Flosser products visit www.waterpik.co.uk. Waterpik® products are available from Amazon, Costco UK, Argos, Boots, Superdrug and Tesco online and in stores across the UK and Ireland.
Author: Sharon Kidd
GDC – 4566Diploma in Dental Hygiene 1993Hygienist
Sharon qualified as a dental nurse in The Royal London Dental Hospital in 1988. She trained as a dental hygienist in the Royal Army Dental Corps in 1993. Sharon has experience working as a hygienist in a variety of different settings including dental hospital, domiciliary home visits, military, private and general practice. She works with specialists and general dental practitioners to support patients with different needs includin g those who are nervous to visit the dentist. Sharon is also a Professional Educator for Waterpik.
[i] The Pituitary Foundation, (N.D). Acromegaly. (Online) Available at: https://www.pituitary.org.uk/information/acromegaly/ [Accessed January 2024]
[ii] O. Adigun, O., Nguyen, M., J. Fox, T., Anastasopoulou, C., (2023). Acromegaly. StatPearls. (Online) Available at: https://www.ncbi.nlm.nih.gov/books/NBK431086/ [Accessed January 2024]
[iii] Office for National Statistics, (2022). United Kingdom population mid-year estimate. (Online) Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/timeseries/ukpop/pop [Accessed January 2024]
[iv] NHS, (2020). Acromegaly. (Online) Available at: https://www.nhs.uk/conditions/acromegaly/ [Accessed January 2024]
[v] Cancer Research UK, (2023). Pituitary tumours. (Online) Available at: https://www.cancerresearchuk.org/about-cancer/brain-tumours/types/pituitary-tumours [Accessed January 2024]
[vi] Zahr, R., & Fleseriu, M. (2018). Updates in diagnosis and treatment of acromegaly. European endocrinology, 14(2), 57.
[vii] Stirrups, R. (2014). A wrestler of unusual size. The Lancet Diabetes & Endocrinology, 2(9), 690.
[viii] Gibley, R., (2014). Richard Kiel obituary, The Guardian. (Online) Available at: https://www.theguardian.com/film/2014/sep/11/richard-kiel [Accessed January 2024]
[ix] Tuculina, M. J., Dascălu, I. T., Diaconu, O. A., Turcu, A., Nicola, A., Popescu, S. M., … & Carsote, M. (2022). Acromegaly and teeth. Romanian Journal of Oral Rehabilitation, 14(1).
[x] De Stefani, A., Dassie, F., Wennberg, A., Preo, G., Muneratto, A., Fabris, R., … & Bruno, G. (2022). Oral manifestations and maxillo-facial features in the acromegalic patient: a literature review. Journal of Clinical Medicine, 11(4), 1092.
[xi] Atreja, G., Atreja, S. H., Jain, N., & Sukhija, U. (2012). Oral manifestations in growth hormone disorders. Indian journal of endocrinology and metabolism, 16(3), 381-383.
[xii] Corbet, E., & Smales, R. (2012). Oral diagnosis and treatment planning: part 6. Preventive and treatment planning for periodontal disease. British dental journal, 213(6), 277-284.
[xiii] Amarasena, N., Gnanamanickam, E. S., & Miller, J. (2019). Effects of interdental cleaning devices in preventing dental caries and periodontal diseases: a scoping review. Australian dental journal, 64(4), 327-337.
[xiv] Roumeau, S., Thevenon, J., Ouchchane, L., Maqdasy, S., Batisse-Lignier, M., Duale, C., … & Devoize, L. (2020). Assessment of oro-dental manifestations in a series of acromegalic patients, the AcroDent study. Endocrine Connections, 9(8), 824-833.
[xv] Gorur, A., Lyle, D. M., Schaudinn, C., & Costerton, J. W. (2009). Biofilm removal with a dental water jet. Compendium, 30(1), 1.
[xvi] Rosema, N. A., Hennequin-Hoenderdos, N. L., Berchier, C. E., Slot, D. E., Lyle, D. M., & van der Weijden, G. A. (2011). The effect of different interdental cleaning devices on gingival bleeding. J Int Acad Periodontol, 13(1), 2-10.
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