This lecture talk about the disturbance of adrenal gland hormones and how it affect health. it also discuss in brief how to manage such condition in your dental clinic

1. Adrenal Glands
Cortisol
HPA Axis
Stress And Cortisol
Synthetic Corticosteroids
Adrenal Secretion Disturbance
Primary Adrenal Insufficiency
Secondary Adrenal Insufficiency
Hyperadrenalism Or Cushing’s Disease
Adrenal Crisis
Treatment Plan
Dental Management
Oral Manifestations Of Adrenal Insufficiency
ADRENAL GLANDS
Adrenal glands are located at the top of each
kidney. Each gland is divided into two parts: cortex and
medulla. Adrenal cortex makes up about 90% of the
gland and consist of three zones: the outer zone is zona
glomerulosa, the middle zone is zona fasciculata, and
the inner zone is zona reticularis.
Cells of zona glomerulosa mainly secret aldosterone
(mineralocorticoid). The zona fasciculata secrets
glucocorticoids and the zona reticularis secrets
androgens or sex hormones.
CORTISOL
The primary glucocorticoid hormone. Cortisol has
several important physiological actions on
metabolism, cardiovascular function, the immune
system, and for maintaining homeostasis during
period of physical or emotional stress. Cortisol works
in the opposite way to insulin (i.e. insulin antagonist). It
increase blood level of glucose, activate
lipolysis. It also increase blood pressure and reduce
anti-inflammatory action of immune system.
Cortisol also activate osteoclast and inhibit osteoblast
(thatiswhylong-termuseofcorticosteroidscouldcause
osteoporosis).
Dental Management of Adrenal
Insufficiency
Osama Asadi, B.D.S, Published for Iraqi Dental Academy Blog
Adrenal glands are small endocrine glands located bilaterally at the superior pole of each kidney. They are
an important glands that regulate how human body respond to stress, and their deficiency or hypersecretion
can lead to undesirable effects.
It is estimated that a dental clinic that receive 2000 patients, there are 100 of them taking corticosteroids or
suffering from adrenal abnormality. Adrenal insufficiency if not diagnosed and mistreated can lead to adre-
nal crisis which is a very serious condition.
LECTURE OUTLINE
CHAPTER
1

2. 2
HPA AXIS
Cortisol secretion is regulated by hypothalamic-
pituitary-adrenal axis or HPA Axis. When the
body is under a stress, the central nervous system
send signals to the hypothalamus to secret CRH
hormone which stimulate pituitary gland to
secret ACTH that reach to the adrenal gland and
stimulate it to secrete cortisol. When plasma level of
cortisol is increased, both CRH and ACTH is
reduced, therefore completing a negative feed-
back loop, which reduce cortisol secretion.
STRESS AND CORTISOL
When body is stressed, cortisol is secreted. The
dailydoseofcortisolsecretedbybodyisabout20mg.
The highest level of cortisol is secreted at waking up
in the morning and lowest at the evening and night.
This pattern is reversed for people who wake up at
night and sleep in the morning.
During period of stress, illness, or surgery,
cortisol demands by the body is increased, and adrenal
gland is activated to secrete more cortisol. However,
people with adrenal insufficiency can not secret this
additional cortisol and needs exogenous
synthetic corticosteroid supplementation.
SYNTHETIC CORTICOSTEROIDS
The following are some commercially available
synthetic corticosteroids with their potency relative to
cortisol:
Note that cortisone and hydrocortisone are of lowest
potency and dexamethasone and betamethasone are
very potent.
Synthetic corticosteroids are used in the following
medical conditions:
• Addison disease
• adrenalectomy
• asthma
• Rheumatiod arthritis
• Lupus erythrematosus
• Ulcerative colitis
• Crohn disease
• Any organ transplant
Complications of systemic corticosteroid therapy:
• Cardiovascular: MI, Cerebrovascular accidents
• Dermatological: acne, bruising, hirsutism (exces-
sive hair)
• Gastrointestinal: peptic ulcer
• Immunosuppressive: increase susceptibility to
infection
• Neurological: cataracts, mood change, psychosis
• Metabolic: Fat redistribution (moon face and buf-
falo hump, growth retardation, diabetes mellitus,
weight gain, osteoporosis.
ADRENAL SECRETION DISTURBANCE
Excessive secretion of glucocorticoids due to
pathological disease is called Cushing’s disease.
While adrenal insufficiency or hyposecretion is
divided into two types: primary adrenal insufficiency
or Addison’s disease (which is due to destruction of
adrenal gland) and secondary adrenal insufficiency
(which is due to hypothalamic, or pituitary diseases, or

3. 3
exogenous administration of corticosteroids).
PRIMARY ADRENAL INSUFFICIENCY
Also called addison’s disease. It is caused by
progressive destruction of the adrenal cortex,
usually because of autoimmune disease, HIV infection,
cytomegalovirus infection, and fungal infection.
Also may be caused by malignancy, drugs, or genetic
mutation.
Addison disease cause lack of secretion of cortisol
and aldosterone from the adrenal cortex which lead to
impaired metabolism of glucose, fat, and protein,
as well as hypotension, impaired fluid excretion,
excessive pigmentation, and inability to tolerate stress.
Patient with addison’s disease usually
complain of weakness, fatigue, abdominal pain,
hyperpigmentation of the skin and mucous
membrane,hypotension,anorexia,saltcraving,myalgia,
hypoglycemia, and weight loss.
SECONDARY ADRENAL INSUFFICIENCY
This disease characterize by normal adrenal glands,
however, there is an abnormality in HPA axis which
lead to hyposecretion of adrenal hormones. It is more
common than Primary adrenal insufficiency and
usually affect women. It is caused by structural lesions
of the hypothalamus or pituitary gland (e.g., tumor)
or administration of exogenous corticosteroids. Also
could be caused by critical illness (burn, trauma, sys-
temic infection).
Due to lesions in the pituitary or hypothalamus, they
do not response well to plasma levels of cortisol and
thus cortisol secretion is reduced leading to partial
insufficiency.
This condition does not produce any symptoms unless
patient is significantly under stress and does not have
adequate circulating cortisol during time surrounding
the stress.
Adrenal crisis could occur but it is rare because only
glucocortcoids secretion is affected and aldosterone
secretion is normal.
Figure 1. Pigmentation of the lower lip in patient with Addison’s
disease
HYPERADRENALISM OR CUSHING
DISEASE
It is characterized by excessive secretion of
glucocortoids by adrenal glands. This lead to
symptoms of weight gain, broad round face
“moon face,” a “buffalo hump” on the upper back,
abdominalstraie,hypertension,hirustism,andacne.Other
symptoms include dibetes mellitus, heart failure,
osteoporosis, bone fracture, impaired healing,
psychiatric disorders. Long-term steroids use could
also cause peptic ulcer.
ADRENAL CRISIS
If patient with adrenal insufficiency was not
diagnosed and not treated, and went through a stress-
ful
situation (such as surgery), it could results in life-
threatening condition named adrenal crisis. It devel-
ops over few hours and characterize by sunken eyes,
profuse
sweating, hypotension, weak pulse, cyanosis, nausea,
vomiting, weakness, headache, dehydration, fever,
dyspnea, myalgias, arthralgia. It require immediate
treatment with IV 100 mg hydrocortisone, fluid
replacement and referral for medical care.
If not treated, leads to hypothermia, severe
hypotension, hypoglycemia, confusion, circulatory
collapse and can result in death.
Figure 2. Characteristic “moon face” of patient with
cushing’s disease
Figure 3. Buffalo hump in patient with cushing’s disease

4. 4
TREATMENT PLAN
Treatment plan for patient with adrenal insufficiency who taking corticosteroids currently is as follow:
Procedure Primary adrenal insuffecency Secondary adrenal insufficency
Routine dentistry No supplementation required No supplementation required
Minor surgery
25 mg hydrocortisone, preoperatively on
the day of procedure
Daily therapeutic dose
Moderate surgical stress
50-75 mg on the day of surgery and up
to 1 day. After that, return to normal
dose on day 2
Daily therapeutic dose
Major surgical stress
100-150 mg of hydrocortisone per day
for 2-3 days before the procedure. After
that, 50 mg hydrocortisone IV is given
every 8 hours postoperatively for 2-3
days.
Daily therapeutic dose
DENTAL MANAGEMENT
• Investigate type and degree of adrenal dysfunction,
and the type of dental procedure to be done.
• Patient with hyperadrenalism or who take
corticosteroids for prolonged period have an
increased likelihood of having hypertension,
diabetes, delayed wound healing, osteoporosis and
peptic ulcer, which should be managed separately
if present.
• Blood pressure should be taken before the dental
procedure, and repeated every 5 minutes during
dental procedure.
• Blood glucose should be taken, and dental
procedure performed under good glycemic control.
• Aspirin and NSAIDs should be avoided for patient
on long-term corticosteroid therapy, because these
patient may suffer from peptic ulcer and NSAIDs
could aggravate its condition.
• Latest studies show that patient with secondary
adrenal insufficiency require no corticosteroid
supplementation.
• Currently, only patient with primary adrenal
insufficiency require corticosteroids
supplementation.
• Dental surgery should be scheduled in the morning
when cortisol level is highest.
• Nitrous oxide and benzodiazepine are helpful in
reducing stress, therefore reducing cortisol
demands by body
• Barbiturates should be used with caution because
they enhance metabolism of cortisol leading to
cortisol that diminishes rapidly.
• Blood loss should be reduced because it increase
probability of hypotension.
• Undiagnosed and untreated adrenal insufficiency
should be referred for medical care and dental
procedure is postponed.
• It is recommended to use long-acting local
anesthetic (I.e. bupivacaine) at the end of the
procedure to minimize pain, thus minimizing
postoperative stress.
• Use supine position for patient with adrenal
insufficiency to reduce hypotension.
• Some drugs (e.g., ketoconazole, aminoglutethim-
ide) should be discontinued by the patient 24
before dental surgery in consultation with patient’s
physician because they lead to inhibition of corti-
costeroids production.
ORAL MANIFESTATIONS OF ADRENAL
INSUFFICIENCY
• Pigmentation of oral mucous membrane
• Delayed healing
• Possible oral infection
REFERENCE
Little and Falace’s Dental Management of the Medi-
cally Compromised Patient. 8th edition.