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Adrenal Insufficiency (Hypoadrenalism)

Risks to the dental patient

Management During Treatment

Questions to Ask 

Clinical Findings 

Prevention 

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Oral and Maxillofacial Pathology. Neville, Damm Allen, Bouquot.  3rd Edition.

Medical Consultation Recommended 

Introduction

Post Operative

  • Primary (Addison's Disease)

    • Results from progressive destruction of the adrenal glands.

    • Causes include tuberculosis and other granulomatous diseases, autoimmune disorders and neoplasias

    • If patient is challenged by stress (illness, infection, surgery) an adrenal crisis may be precipitated which could lead to death - adequate amounts of cortisol not available 

    • Treatment is with exogenous glucocorticoids corresponding to normal physiologic output of adrenal cortex.

      • Supplemental doses are required when surgery is planned because patient is unable to provide additional glucocorticoids to respond to stress.

  • Secondary 

    • Much more common

    • Most commonly due to administration of exogenous corticosteroids, particularly long term which suppresses the HPA axis.  The patient may not be able to produce endogenous steroids in the presence of additional stress.

      • Causes only partial insufficiency (as opposed to primary)

      • Significant stress with inadequate circulating cortisol may lead to adrenal crisis; although less common than with primary adrenal insufficiency

      • Steroids are prescribed in the management of inflammatory and autoimmune disorders for anti-inflammatory and immunosuppressive properties.

      • Supplemental doses are not recommended for surgery

    • Structural lesions of the hypothalamus or pituitary gland (tumor)

    • Administration of specific drugs

    • Critical illness (burns, trauma, systemic infection)

  • Acute adrenal insufficiency - adrenal crisis

    • Most commonly with Addison's disease and NOT secondary adrenal insufficiency

  • ​Patients with secondary adrenal insufficiency may be at risk for:

    • Delayed healing

    • Increased susceptibility to infection

    • Adrenal crisis if the insufficiency is severe

  • Increased risk with dental treatment due to STRESS.

  • Do you have primary or secondary adrenal insufficiency?

  • If secondary, why are you taking corticosteroids?

  • Have you ever had an adrenal crisis?

  • What medication are you taking for this condition and what is the dosage?

  • How often do you see your physician?

  • How do you feel about dental treatment? Do you feel anxious or fearful?

  • Primary adrenal insufficiency may result in

    • Diffuse or focal brown macular pigmentation of the oral mucous membranes

    • Pigmentation (bronzing) of sun-exposed skin

    • The oral lesions are often the first manifestation of the disease

    • The oral and skin lesions may resolve with treatment

  • In cases of serious infection where an increase in steroid dose may be required.

  • Dental treatment should be delayed and consultation sought for the patient with undiagnosed or untreated adrenal insufficiency.

  • Additional measures to minimize risk of adrenal crisis associated with surgical stress

    • Schedule in the morning when cortisol levels are highest

    • Use of long-acting local anesthetics with epinephrine also provide good post-op pain control

    • Monitor intraoperative blood pressure

    • Stress reduction protocol

    • Inhalation or oral sedation

    • Keep appointments to less than one hour to keep stress minimal

  • Adequate pain control

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