Dental management of patients with adrenal disorders

The adrenal glands produces steroid hormones from the cortex and catecholamines from medulla. When both adrenal glands have been destroyed or removed ( primary adrenal insufficiency), replacement of steroid hormones, particularly the glucocorticoids, is essential. Replacement of catecholamines is not need. Removal of one adrenal gland does not usually require steroid replacement therapy.
The therapeutic use of corticosteroids is the most common cause of adrenal suppression.
Corticosteroids are used in management of some inflammatory and immune disorders ( eg rheumatoid arthritis, severe dermatological conditions, severe asthma). Treatment with prednisolone or prednisone at dose greater than 10mg daily for more than 3 weeks can be sufficient to cause adrenal suppression.
Dental issues
It is important to ascertain if a patient is taking corticosteroids and, if so, their underlying condition and current drug regimen. Also check if they are taking biphosphonates to treat steroid induced osteoporosis . If a patient requires long term treatment with corticosteroids, they generally have a serious underlying condition. Consultation with patient's medical practitioner is usually appropriate before processing with dental treatment or making any temporary alterations to to the patient's corticosteroid dose.
Dental treatment may be physiologically stressful, particularly tooth extractions, root planing and extended restorative treatment. If a patient with adrenal insufficiency or suppression cannot produce sufficient steroid hormones ( particularly glucocorticoids) following such stress, addisonian ( adrenal) crisis may occur. This presents as a progressive hypotension occurring 6 to 12 hours after the dental treatment. The patient may initially feel faint , become confused and collapse.
If a patient has adrenal insufficiency and is taking replacement therapy, their dose of replacement steroid should be increased on the day before and the day of dental treatment to simulate the normal increase in glucocorticoid secretion that occurs in response to stress . If the treatment is more extensive ( eg full dental clearance), or if the patient has been fasting or vomiting, the dose may need to be trebled or quadrupled.
Stressful dental treatment should be performed in the morning so that if an Addisonian crisis occurs, symptoms present while the patient is awake. If treatment is performed in afternoon, the condition may manifest at night and progress while the patient is asleep; this can result in death. After dental treatment , the patient should remain in the presence of responsible adult for rest of the day. If symptoms occur, the patient's medical practitioner must be contacted.

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