pathology of the endocrine system 2008 of the endocrine... · malocclusion and tooth gaps ......

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Pathology of the Endocrine SystemPathology of the Endocrine System

JantimaJantima TanboonTanboon, MD, MD

2210/27/200810/27/2008

1. Endocrine 2. Paracrine

3. Autocrine 4. 4. NeuroendocrineNeuroendocrine

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HYPOTHALAMUS

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PITUITARY GLAND

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Bitemporal Hemianopsia

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Craniopharyngioma

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Normal Anterior and Posterior Pituitary GlandNormal Anterior and Posterior Pituitary Gland

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10/27/2008 13Reticulin stain

Pituitary AdenomaMacroadenoma > 1 cm

Microadenoma

Hormone produced +/-

Mass effect/Stalk effect

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Prolactin from Lactotroph

Prolactinoma: 1st MC pituitary adenoma

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Hyperprolactinemia

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Growth Hormone from Somatotroph

Growth hormone adenoma: 2nd MCMacroadenomaPituitary dwarfism: GH deficiency in Children

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Hypothalamus

Anterior pituitary

Growth hormoneGrowth hormoneGrowth promotingGrowth promoting action AntiAnti--insulin effectinsulin effect

LiverLiver

Protein synthesisProtein synthesis

Bone and cartilage

Body organs

Muscle

Linear growth

Size and function

Muscle mass

Adipose tissue

CHO metabolism

LipolysisFFA use

Glucose use

Adiposity Blood

glucose

IGF-1

insulin level (at initial)insulin level (at initial)insulin resistant (prolong GH insulin resistant (prolong GH

excess) at periphery despite excess) at periphery despite insulin increase soinsulin increase so…… 10/27/2008 18Gigantism Acromegaly

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Coarsening of facial featuresMacroglossiaMalocclusion and tooth gapsAcral enlargement

Thick and coarse skin

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ACTH from Corticotroph

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Cushing diseaseCushing disease

HypercortisolismHypercortisolism by pituitary adenomaby pituitary adenomaHyperpigmentationHyperpigmentation

NN-- terminal fragmentterminal fragment ACTHACTH ββ--LPHLPH

γ-MSH α-MSH CLIP γ-LPH ββ--endorphinendorphin

ProopiomelanocortinProopiomelanocortin: : POMCPOMC

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Cushing syndromeCushing syndrome

Adrenal glandAdrenal glandEctopic ACTHEctopic ACTH

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Nelson syndromeNelson syndrome

Corticotroph adenoma

After adrenalectomy

Loss of inhibitory effect

Mass effects

Hyperpigmentation

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LH, FSH from Gonadotroph

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HypopituitarismHypopituitarism

7070--90% (90% (≥≥75%) 75%) parenchymalparenchymal losslossCongenital (rare)Congenital (rare)AcquiredAcquiredNonNon--functioning adenomafunctioning adenomaIschemic necrosisIschemic necrosisAblation by surgery or radiationAblation by surgery or radiationInflammatory lesionInflammatory lesionMutation PitMutation Pit--11

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Sheehan syndromeSheehan syndrome

Postpartum necrosis of anterior pituitaryPostpartum necrosis of anterior pituitary

PregnancyPregnancyHypertrophy/Hyperplasia of Hypertrophy/Hyperplasia of LactotrophLactotroph

Not increase blood supplyNot increase blood supply

Blood loss during deliveryBlood loss during delivery

AgalactiaAgalactia, amenorrhea, hypothyroidism, , amenorrhea, hypothyroidism, adrenocorticaladrenocortical insufficiencyinsufficiency

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Pituitary apoplexyPituitary apoplexy

SSudduddenen neurologic impairment neurologic impairment

HHeadacheeadache,, visualvisual symptomssymptoms,, alteredalteredmentalmental statusstatus,, andand hormonalhormonal dysfunctiondysfunction

Hemorrhage and/or infarctionHemorrhage and/or infarction

Tumor (adenoma)/ normal pituitaryTumor (adenoma)/ normal pituitary

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Oxytocin

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Vasopressin: Antidiuretic hormone

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Diabetes Diabetes InsipidusInsipidus: DI: DI

ADH deficiencyADH deficiencyClinical: Clinical: PolyuriaPolyuria, thirst, , thirst, polydipsiapolydipsiaCentral DICentral DINephrogenicNephrogenic DIDI¼¼ associated with associated with craniopharyngiomacraniopharyngioma

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Syndrome of inappropriate ADH Syndrome of inappropriate ADH secretion: SIADHsecretion: SIADH

Water retention, Water retention, hyponatremiahyponatremia, , hypotonicityhypotonicity

Excess ADH: Excess ADH: ParaneoplasticParaneoplastic secretion: Small cell lung CAsecretion: Small cell lung CA

Tumor trauma inflammationTumor trauma inflammationPulmonary lesionPulmonary lesion

Brain lesionBrain lesion

Drugs Drugs

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PINEAL GLAND

Melatonin: sleep inducerSerotonin: neurotransmitterGerm cell tumorsPineocytoma

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THYROID GLAND

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Thyroglossal Duct Cyst

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Follicular cell

Colloid

Thyroglobulin

T4

T3

Parafollicular cell (C-cell)

Calcitonin

Thyroid gland

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Essential for normal development of CNS and skeleton

Essential for cell division and maturation

Neonatal cells

Lipolysis, glycolysis, and gluconeogenesisincreased to raise blood metabolite levels and cellular metabolite use

Increases expresstion of enzymes necessary for energy production

Nucleus

Increased heat production, oxygen demand, heat rate, and stroke volume

Stimulates growth, replication and activity; basal metabolic rate is raised

Mitochondria

Increased demand for metabolites, e.g. glucose

Stimulates the Na+/K+

ATPase pumpCell membrane

Physiological results

Intracellular effectsSite of actionActions of T3Actions of T3

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Hypothyroidism

Cretinism Myxedema

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Congenital hypothyroidismCongenital hypothyroidism

CretinismCretinism

Endemic cretinismEndemic cretinismNeurologic cretinismNeurologic cretinism

Hypothyroid cretinismHypothyroid cretinism

NonNon--endemic cretinismendemic cretinismThyroid Thyroid dysgenesisdysgenesis

Others Others

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Proteoglycans accumulation in extracellular matrix: Myxedema

Boggy face, puffy eyelids

Edema of hands and feets

Enlarged tongue

Thickening mucous membrane in larynx

Ecchymoses

Lethargic somnolent

Memory loss, slow mental process

Paronoid/depression/severe agitation

Sensory defect

Cerebellar ataxia, slow DTR

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GoitrousGoitrous hypothyroidismhypothyroidism

Impaired synthesis of thyroid hormoneImpaired synthesis of thyroid hormone

Dietary iodine deficiencyDietary iodine deficiency

TSH compensateTSH compensate euthyroideuthyroid

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Diffuse Non-Toxic Goiter

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Nodular/Multinodular Goiter

Further develop toxic nodular goiter

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Hashimoto Hashimoto thyroiditisthyroiditis

MC for nonMC for non--endemic hypothyroidismendemic hypothyroidismChronic lymphocytic Chronic lymphocytic thyroiditisthyroiditis, , strumastrumalymphomatosalymphomatosaAutoimmune disease: Autoimmune disease: antithyroidantithyroid antibodyantibodyEarly stage: Early stage: HashitoxicosisHashitoxicosisCan develop: Can develop: Other autoimmune diseases, BOther autoimmune diseases, B--cell cell LymphomaLymphoma

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Graves disease

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Graves diseaseAutoimmune diseaseAutoimmune disease

ThyroidThyroid--stimulating stimulating immunoglobulin (TSI)immunoglobulin (TSI)******

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Other Other ThyroiditisThyroiditis

Acute Acute thyroiditsthyroidits

SubacuteSubacute ((granulomatousgranulomatous) ) thyroiditisthyroiditis

Silent Silent thyroiditisthyroiditis

Riedel Riedel thyroiditisthyroiditis

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Acute Acute thyroiditisthyroiditis

Infectious: Bacteria, fungusInfectious: Bacteria, fungus

Fever, chill, malaise, swollen neckFever, chill, malaise, swollen neck

MC: MC: Streptococcus, Staphylococcus, Streptococcus, Staphylococcus,

PneumococcusPneumococcus

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SubacuteSubacute ((granulomatousgranulomatous) ) thyroiditisthyroiditis

GranulomatousGranulomatous thyroiditisthyroiditisDe De QuervainQuervain thyroiditisthyroiditisNon Non suppurativesuppurative thyroiditisthyroiditisViral infection:Viral infection:CoxackieCoxackie, Mumps, Influenza, , Mumps, Influenza, EchoviruresEchovirures,,AdenovirusesAdenoviruses

Transient:Transient:Pain, fever, malaise, fatigue, enlarged thyroid, Pain, fever, malaise, fatigue, enlarged thyroid, tender tender

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Silent Silent thyroiditisthyroiditis

Painless Painless thyroiditisthyroiditis

Lymphocytic Lymphocytic thyroiditisthyroiditis

Painless thyroid enlargementPainless thyroid enlargement

SelfSelf--limited hypothyroidismlimited hypothyroidism

Post partum periodPost partum period

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ReidelReidel thyroiditisthyroiditisExtrathyroidal soft tissue

Fibrosis of other organs

Hard/ fixed → suspicious CA

Unknown etiology

Autoimmune ?

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NeoplasmsNeoplasms of the thyroidof the thyroid

Solitary nodulesSolitary nodules

Young patientsYoung patients

Nodules in malesNodules in males

HxHx of radiationof radiation

Hot nodules (benign)Hot nodules (benign)

AdenomaAdenoma

Papillary CA (75Papillary CA (75--85%)85%)

Follicular (10Follicular (10--20%)20%)

MedullaryMedullary CA (5%)CA (5%)

AnaplasticAnaplastic CA (<5%)CA (<5%)

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Follicular Adenoma

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Follicular CarcinomaCapsular invasion

Vascular invasion

Hematogenous spread

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Papillary Thyroid CarcinomaPapillary Thyroid Carcinoma

MC thyroid carcinomaMC thyroid carcinomaLymphatic spreadLymphatic spreadMC in children and young adolescentMC in children and young adolescentIodine excessIodine excessRadiationRadiationGenetic factorsGenetic factorsFamilial Familial adenomatousadenomatous polyposispolyposisMutation of Mutation of RETRET (10q11.2)(10q11.2)

10/27/2008 58Papillary Carcinoma

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Fine Needle Aspiration Cytology (FNA) Thyroid Gland

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AnaplasticAnaplastic carcinomacarcinoma

Undifferentiated thyroid carcinomaUndifferentiated thyroid carcinoma

ElderlyElderly

Develop fromDevelop fromLongLong--standing goiterstanding goiter

LowLow--grade thyroid cancergrade thyroid cancer

Radiation Radiation

Rapid enlarged mass, Aggressive tumor:Rapid enlarged mass, Aggressive tumor:

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MedullaryMedullary thyroid carcinomathyroid carcinoma

CC--cellcellCalcitoninCalcitonin, serotonin, ACTH, , serotonin, ACTH, somatostatinsomatostatinPrecursor lesion: CPrecursor lesion: C--cell hyperplasiacell hyperplasiaMutation of RETMutation of RET

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PARATHYROID GLANDS

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HypercalcemiaHypercalcemia

Solid tumor: lung, breast, head and neck, Solid tumor: lung, breast, head and neck,

renal cancerrenal cancer

Hematologic malignancy: multiple Hematologic malignancy: multiple

myelomamyeloma

Clinically apparent Clinically apparent hypercalcemiahypercalcemia

Asymptomatic Asymptomatic hypercalcemiahypercalcemia

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Hyperparathyroidism

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Hyperparathyroidism

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ENDOCRINE PANCREAS

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Endocrine pancreasEndocrine pancreas

EndodermalEndodermal derivativesderivativesFour major cell types:Four major cell types:ββ 68% insulin 68% insulin αα 20% glucagon20% glucagonδδ 10% 10% somatostatinsomatostatinPP 2% pancreatic polypeptidePP 2% pancreatic polypeptide

Two minor cell types:Two minor cell types:D1 D1 vasoactivevasoactive polypeptidepolypeptideEnterochromaffinEnterochromaffin cell serotonincell serotonin

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Obesity

BMI 25-29.9 = overweight

BMI >40 = obese

Male

Waist > 102 cm (40 inch)

Waist: hip ratio > 0.9

Female

Waist > 88 cm (35 inch)

Waist: hip ratio > 0.85

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Hyperglycemia Hyperglycemia Advanced Advanced glycationglycation end product (AGE)end product (AGE)

CrosslinkingCrosslinking polypeptidespolypeptidesResistant to Resistant to proteolyticproteolytic enzymeenzymeAGE residues in plasma proteinsAGE residues in plasma proteins

Activation of protein Activation of protein kinasekinase CCVEGFVEGFVasoconstrictor: Vasoconstrictor: endothelinendothelin 11Vasodilator: endothelial nitric oxide Vasodilator: endothelial nitric oxide synthasesynthase

((eNOSeNOS))ProfibrinogenicProfibrinogenic molecules (TGFmolecules (TGF--ββ))ProcoagulantProcoagulant molecule (PAImolecule (PAI--1)1)ProPro--inflammatory cytokinesinflammatory cytokines

PolyolPolyol pathways in nerve lens kidneyspathways in nerve lens kidneys

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ADRENAL GLANDS: CORTEX

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Adrenal glandsAdrenal glands

1.1. GlucocorticoidsGlucocorticoids ((cortisolcortisol): ):

Z Z fasciculatafasciculata/Z /Z reticularisreticularis

2.2. MineralocorticoidsMineralocorticoids ((aldosteronealdosterone):):

Z Z glomerulosaglomerulosa

3.3. Sex steroids (estrogens and Sex steroids (estrogens and

androgens):androgens): 808010/27/200810/27/2008

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Hypercortisolism

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HypercortisolismHypercortisolism

Endogenous Endogenous hypercortisolismhypercortisolism

7070--80% primary ACTH 80% primary ACTH hypersecretionhypersecretionACTHACTH--producing producing microadenomamicroadenoma****

CorticotrophCorticotroph cell hyperplasiacell hyperplasia

20% primary adrenal 20% primary adrenal neoplasmsneoplasmsAdrenal adenoma/ adrenal carcinomaAdrenal adenoma/ adrenal carcinoma

Primary cortical hyperplasiaPrimary cortical hyperplasia

10% ectopic ACTH by non10% ectopic ACTH by non--pituitary tumorspituitary tumorsS ll ll i f h l ***S ll ll i f th l ***

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Physiological effects of Physiological effects of cortisolcortisol and the symptoms of and the symptoms of CushingCushing’’s syndromes syndrome

infection, poor healing, infection, poor healing, peptic ulcerationpeptic ulceration

Suppresses the action Suppresses the action and production of and production of immune cells; inhibits immune cells; inhibits the production of the production of cytokines and cytokines and antibodiesantibodies

Immune systemImmune system

Fat redistributed to the Fat redistributed to the face, trunk, causing a face, trunk, causing a moon face, buffalo moon face, buffalo hump and abdominal hump and abdominal stretch marksstretch marks

Stimulate Stimulate lipolysislipolysis and and fatty acid level in the fatty acid level in the

bloodblood

Fat metabolismFat metabolism

Related pathology Related pathology in Cushingin Cushing’’s s

syndromesyndrome

Effect of Effect of cortisolcortisolProcess/Process/system affectedsystem affected

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Depression Depression insominainsominapsychosis and psychosis and confusionconfusion

Influences fetal and Influences fetal and neonatal neuron neonatal neuron development; development; influences behavior influences behavior and cognitive function, and cognitive function, augment the actions of augment the actions of the sympathetic the sympathetic systemsystem

Nervous systemNervous system

Suppression of growth Suppression of growth in childrenin children

Suppresses the Suppresses the secretion of anterior secretion of anterior pituitary hormones pituitary hormones ACTH, LH, FSH, TSH ACTH, LH, FSH, TSH and GHand GH

Endocrine systemEndocrine system


syndromesyndrome


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Muscle weakness Muscle weakness and wasting; thin and wasting; thin easily bruising skineasily bruising skin

protein protein breakdown in breakdown in skeletal muscle, skeletal muscle, skin and bone to skin and bone to release amino acidrelease amino acid

Protein metabolismProtein metabolism

Hyperglycemia and Hyperglycemia and diabetesdiabetes

blood glucoseblood glucoseStimulate Stimulate gluconeogenesisgluconeogenesisPrevent glucose Prevent glucose uptakeuptake

CHO metabolismCHO metabolism


syndromesyndrome


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Osteoporosis Osteoporosis Ca absorption from Ca absorption from the gut the gut

Ca excretion in the Ca excretion in the kidney kidney

Ca Ca resorptionresorption from from bonesbones

Calcium metabolismCalcium metabolism

Hypertension and heart Hypertension and heart failurefailure

Weak Weak mineralocorticoidmineralocorticoidactions; raise Na and actions; raise Na and water retentionwater retention

Water metabolismWater metabolism


syndromesyndrome


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Cushing Disease, Cushing syndrome

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DexamethasoneDexamethasone suppression testsuppression test1.1. Cushing diseaseCushing disease (pituitary)(pituitary)

ACTH highLow dose cannot suppressHigh dose can

2.2. Ectopic ACTHEctopic ACTHACTH highBoth low dose and high dose cannot

3.3. Adrenal tumorAdrenal tumorACTH lowBoth low dose and high dose cannot

Cushing syndrome Cushing syndrome DxDxurine 24 hrs free cortisol

Loss of diurnal pattern of cortisol secretion

Cause of Cushing Cause of Cushing

syndromesyndrome

Dexamethasone

Serum ACTH

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Conn disease

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Secondary Secondary aldosteronismaldosteronism

Diagnosis:Diagnosis: aldosteronealdosterone, , serum serum reninrenin

renal perfusion renal perfusion

arteriolar arteriolar nephrosclerosisnephrosclerosis, renal artery , renal artery

stenosisstenosis

Arterial Arterial hypovolemiahypovolemia and edema (CHF, and edema (CHF,

cirrhosis, NS)cirrhosis, NS)

Pregnancy (estrogen induced increasesPregnancy (estrogen induced increases929210/27/200810/27/2008

HypoaldosteronismHyperaldosteronismAction Of Aldosterone

Clinical symptoms of hyper and hypoaldosteronism

Volume depletion and postural hypotension

Hypertension *Maintains extracellular fluid volume

Mild metabolic acidosisMetabolic alkalosisDecreases plasma H

HyperkalemiaHypokalemia* Decreases plasma K

Loss Na and loss waterPlasma Na concentration NOT change

Hypernatremia rarely occurs because of other mechanism regulating fluid volume

Increases plasma Na

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Ambiguous genitaliaAmbiguous genitalia

Hermaphroditism

True hermaphroditism

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17α-hydroxylase deficiencysex hormonecortisol

mineralocorticoidHypertension, hypokalemia: female no maturation

21β-hydroxylase deficiencycortisolmineralocorticoidsex hormone

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Salt wasting (classic) Salt wasting (classic) adrenogenitalismadrenogenitalismSalt wasting, hyponatremia, hyperkalemia

Acidosis, hypotension, CVS collapse, death

Shift production- virilization

Simple Simple virilizingvirilizing adrenogenitalismadrenogenitalism without without salt wastingsalt wasting

Less 21-hydroxylase defect

Genital ambiguity

NonclassicNonclassic adrenogenitalismadrenogenitalism

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11β-hydroxylase deficiencycortisolaldosterone and corticosteronesex hormone

Masculinization, hypertension (11-deoxycorticosterone acts as weak mineralocorticoid)

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Adrenal insufficiencyAdrenal insufficiencyPrimary acute Primary acute adrenocorticaladrenocortical insufficiencyinsufficiency

1.1. Chronic Chronic adrenocorticaladrenocortical insufficiency (crisis)insufficiency (crisis): : Stress Stress

2.2. Exogenous corticosteroidsExogenous corticosteroidsRapid withdrawalRapid withdrawal

Stress Stress

3.3. Massive adrenal hemorrhage Massive adrenal hemorrhage NewbornNewborn

Anticoagulant therapyAnticoagulant therapy

Post surgical pt with DICPost surgical pt with DIC

Bacterial infection: WaterhouseBacterial infection: Waterhouse--FriderichsenFriderichsen syndromesyndrome

Primary chronic Primary chronic adrenocorticaladrenocortical insufficiency: Addisoninsufficiency: Addison

Secondary Secondary adrenocorticaladrenocortical insufficiencyinsufficiency

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WaterhouseWaterhouse--FriderichsenFriderichsen SyndromeSyndrome

Bacterial infectionBacterial infectionNeisseriaNeisseria meningitidismeningitidis******HemophilusHemophilus influenzaeinfluenzaePseudomonasPseudomonasPneumoccociPneumoccociStreptococciStreptococciRapid progressive hypotension, Rapid progressive hypotension, shockshockDIC, skin DIC, skin purpurapurpuraAcuteAcute adrenocorticaladrenocortical insufficiencyinsufficiency

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Addison diseaseAddison disease

Primary chronic adrenal insufficiencyPrimary chronic adrenal insufficiency

Destruction of adrenal glandDestruction of adrenal gland

Detect when Detect when ≥≥ 90% has been destroyed90% has been destroyed

Autoimmune diseaseAutoimmune disease*** ***

Infection: TBInfection: TB**, , HistoplasmaHistoplasma, , CoccidioidesCoccidioides, ,

AIDS: MAC Kaposi sarcomaAIDS: MAC Kaposi sarcoma

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Autoimmune Autoimmune polyendocrinepolyendocrine syndrome syndrome type 1 (APS1)type 1 (APS1)

= Autoimmune = Autoimmune PolyendocrinopathyPolyendocrinopathy, , CandidiasisCandidiasis, , EctodermalEctodermal dystrophy dystrophy (APECED)(APECED)

Autoimmune Autoimmune adrenalitisadrenalitis, , hypoparathyroidismhypoparathyroidism, idiopathic , idiopathic hypogonadismhypogonadism, pernicious anemia, pernicious anemia

AIREAIRE 21q2221q22

Autoimmune Autoimmune polyendocrinepolyendocrine syndrome syndrome type 2 (APS2)type 2 (APS2)

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Gradual onsetGradual onset

Asthenia: progressive weakness, easy Asthenia: progressive weakness, easy

fatigabilityfatigability

HyperpigmentationHyperpigmentation**: ACTH: ACTH

Arterial hypotension: Arterial hypotension: MineralocorticoidMineralocorticoid

activity, activity, hyperkalemiahyperkalemia, , hyponatermiahyponatermia, ,

AddisonAddison’’s diseases disease

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ADRENAL GLANDS:

MEDULLA

Neural crest

Cathecolamine

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Pheochromocytoma

Cathecholamine producing

Hypertension (surgically correctable)

Urine VMA/metanephrine

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Neuroblastoma

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MULTIPLE ENDOCRINE NEOPLASIA

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Multiple Endocrine Neoplasia (MEN) syndrome

Medullarycarcinoma+++

Medullarycarcinoma+++

C-cell HyperplasiaThyroid

MucocutaneousganglioneuromasMarfanoid habitus

Extraendocrinechanges

AdenomasPituitary

MEN IIB or IIIMEN II or IIA(Sipple syndrome)

MEN I (Werner)

RETRETMEN IMutant gene locus

Pheochromocytoma+++

Pheochromocytoma++

Cortical Hyperplasia++

Adrenal

Hyperplasia +AdenomasCarcinoma++

Pancreatic islets

Hyperplasia +++Hyperplasia +Adenomas

Hyperplasia +++Adenomas+

Parathyroid

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ParaneoplasticParaneoplastic syndromessyndromes: : EndocrinopathiesEndocrinopathies

ADH,ADH,ANFANF

Small cell CA lungSmall cell CA lungIntracranial tumorsIntracranial tumors

SIADHSIADH

ACTH, ACTH, ACTHACTH--like substancelike substance

Small cell CA lungSmall cell CA lungCA pancreasCA pancreasNeural tumorsNeural tumors

Cushing syndromeCushing syndrome

Causal mechanismCausal mechanismMajor form of Major form of underlying cancerunderlying cancer

Clinical syndromesClinical syndromes

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Insulin Insulin Insulin like Insulin like substancesubstance

FibrosarcomaFibrosarcomaOther Other mesenchymalmesenchymalsarcomasarcomaHCCHCC

Hypoglycemia Hypoglycemia

PTHPTH--related peptiderelated peptideTGFTGF--ααILIL--11

SquamousSquamous cell CA cell CA lunglungCA breastCA breastCA kidneyCA kidneyCA ovaryCA ovaryAdult T cell Adult T cell leukemia/lymphomaleukemia/lymphoma

HypercalcemiaHypercalcemia



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ErythropoietinErythropoietinRenal cell CARenal cell CAHemangioblastomaHemangioblastomaHCCHCC

PolycythemiaPolycythemia

Serotonin, Serotonin, Brady Brady kininkinin, , ?Histamine?Histamine

CarcinoidCarcinoid tumortumorCA pancreasCA pancreasCA stomachCA stomach

CarcinoidCarcinoid syndromesyndrome



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pathology of the endocrine system 2008 of the endocrine... · malocclusion and tooth gaps ......

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