Dentists, orthodontists play key role in recognizing facial manifestations of acromegaly
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Dentists and orthodontists are uniquely positioned to identify the early facial manifestations of acromegaly, though new survey data suggest more awareness of the condition is needed to improve early diagnoses.
Facial features of people with acromegaly include mandibular prognathism, development of supraorbital ridges and cheekbones, alteration in the size of the nose and ears, thickening of soft tissues and lips, and asymmetry of the face, Francesca Dassie, MD, of the faculty of dentistry at University of Padua, Italy, and colleagues wrote in the study background. Up to 80% of patients present with oral characteristics, including mandibular growth, bite impairment, dental malocclusion, dental diastema and macroglossia, all of which may contribute to the development of obstructive sleep disorders.
“Facial dysmorphism and oro-dental alterations are among the most common and earliest manifestations of acromegaly,” the researchers wrote. “The appearance of facial dysmorphisms can precede acromegaly diagnosis by up to 10 years.”
Dassie and colleagues administered a questionnaire to evaluate the ability of 220 dentists and 206 orthodontists to recognize the early recognition of the oro-facial manifestations of acromegaly. The questionnaire included photos with facial and oral-dental details and lateral teleradiography of patients with acromegaly.
Upon reviewing the photos, dentists most often observed mandibular prognathism and lips projection; orthodontists also reported the impairment of relative soft tissue. “Orthodontists, who usually use photos to document patients’ oral-facial characteristics, paid more attention to oral-facial impairment than dentists,” the researchers wrote.
During dental assessment, 90% of the participants usually evaluated tongue size and appearance, diastemas presence and signs of sleep impairment. Orthodontists were also more able to identify sella turcica enlargement at teleradiography. Among participants, 10.8% had patients with an acromegaly diagnosis and 11.3% referred at least one patient for acromegaly suspicion.
“Dentists could play a strategic role in identifying patients with acromegaly and their comorbidities; however, the fact that only a very small percentage of them have claimed to have intercepted the suspects suggests that there is not yet enough knowledge and sensitivity with respect to the pathology,” the researchers wrote. “Raising the awareness of dentists on clinical issues of patients with acromegaly, the availability of tools such as ACROSCORE for non-endocrinological specialists, and the use of photos with patients’ facial and oral details may improve acromegaly early diagnosis.”
Perspective
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Adriana G. Ioachimescu, MD, PhD, FACE
Despite advances in biochemical and radiological techniques, acromegaly diagnosis is delayed by several years from the onset of initial manifestations. Longer time to diagnosis has been associated with the number of comorbidities and mortality. Patients often seek care from non-endocrinologists for acromegaly manifestations, including oral-facial changes.
In their study, Preo and colleagues used telematic questionnaires and patients’ photographs (acromegaly and control) to evaluate the recognition of acromegaly changes by many dentists and orthodontists. The theme of the questionnaire was “facial harmony” to avoid suggesting the diagnosis of acromegaly. Although dentists and orthodontists reported they routinely evaluate patients for presence of mandibular prognathism, lips projection, tongue size and diastemas, they suspected a systemic condition only in two of the 19 acromegaly cases presented. The study found that more than 90% of dentists and orthodontists inquire about headaches, whereas 79% of orthodontists and 50% dentists inquire about sleep problems. In addition, 60% of orthodontists and 39% of dentists identified anatomical abnormalities of the sella turcica on patients’ radiographs presented.
The study has two potential important corollaries with impact on delivery of education and research in acromegaly. First, dentists and orthodontists would benefit from targeted educational programs to increase awareness of acromegaly. Dentists are uniquely positioned to detect acromegaly early because they provide chronic long-term evaluations to the general population. Use of acromegaly-specific questionnaires at the dentist or orthodontist appointment could be impactful in patients with pathognomonic oral-facial changes, especially if they also report headaches or sleep problems.
From a research perspective, dental radiographs and facial analysis software programs could be enhanced by machine learning algorithms for earlier detection of acromegaly.
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