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Endocrine disorders & Steroid Therapy Dental Overview. Adrenal Gland. Adrenal Gland. Cortex Zona glomerulosa  Aldosterone Zona fasciculata  Cortisol Zona reticularis  Sex hormones Medulla  Cathecolamines (Epinephrine)

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adrenal gland1
Adrenal Gland
  • Cortex
    • Zona glomerulosa  Aldosterone
    • Zona fasciculata  Cortisol
    • Zona reticularis  Sex hormones
  • Medulla Cathecolamines (Epinephrine)
    • Glucocorticoids (cortisol): essential for metabolism, anti-inflammatory, homeostasis during stress
    • Mineralocorticoids (aldosterone): fluid, sodium and potassium balance
    • Androgens
adrenal gland physiology
Adrenal Gland Physiology

Stress stimulates the hypothalamus to secrete CRH

CRH stimulates the pituitary to produce ACTH

ACTH stimulates the adrenal cortex to produce cortisol

Cortisol level increases within minutes after stimulation

adrenocortical hyperfunction
Hormones produced by adrenal cortex:

Cortisol

Aldosterone

Sex hormones (androgens)

Syndromes:

Cushing Syndrome

Hyperaldosteronism (Conn syndrome)

Adrenogenital (virilizing) syndromes

Adrenocortical Hyperfunction
cushing syndrome
Cushing Syndrome

Endogenous

  • Pituitary hypersecretion of ACTH
  • Adrenal hypersecretion of cortisol (adenoma, carcinoma, nodular hyperplasia)
  • Ectopic ACTH (small cell lung cancer)

Exogenous (Cushing syndrome )

4. Administration of exogenous glucocorticoids

cushing syndrome clinical features
Cushing Syndrome – Clinical Features
  • Hypertension
  • Weight gain:
    • Truncal obesity
    • “moon” face
    • “buffalo hump”
  • Decreased muscle mass
  • Hyperglycemia
  • Catabolic effect on proteins with loss of collagen: cutaneous striae, easy brusing, osteoporosis
  • Hirsutism, amenorrhea
  • Increased risk of infections (because of decreased immune response)
slide11
Only ACTH producing etiologies are associated with coloration changes due to the stimulation of melanocytes by ACTH.

Skin atrophy

adrenocortical insufficiency
Adrenocortical Insufficiency
  • Acute
    • Massive adrenal hemorrhage (DIC, sepsis = Waterhouse-Friderichsen syndrome.)
    • Sudden withdrawal of long-term corticosteroid therapy
    • Stress in patients with chronic adrenocortical insufficiency
  • Chronic (Addison disease)
    • Autoimmune, infections (TB, fungal), AIDS, metastatic cancers
addison disease clinical features
Addison disease : Clinical features:

Progressive Weakness

Fatigue

Weight loss

Inability to tolerate stress

GI symptoms: anorexia, vomiting, weight loss

Hyperpigmentation (ACTH stimulates melanocytes )

Low aldosterone: hyponatremia, hypovolemia , hypotension

hyperkalemia , acidosis

Low cortisol: hypoglycemia

Death if untreated

oral manifestations dental aspects
Oral manifestations/ dental aspects:

Diffuse patchy brown macular pigmentation of the oral mucosa

Consider steroid cover before treatment

adrenal crisis acute adrenal insufficiency
Adrenal Crisis(Acute Adrenal Insufficiency)
  • Hypotension
  • Severe weakness
  • Progressive mental confusion
  • Nausea and vomiting
  • Abdominal, lower back or leg pain
  • Hyperthermia
  • Hypoglycemia
  • Hyperkalemia
  • Improve CAD
  • Loss of consciousness
  • Coma
  • death
slide24

Adrenal Crisis

Weight Loss

Fatigue

Weakness

Severe Hypotension

Abdominal Symptoms

management of acute adrenal insufficiency

Hydrocortisone 100mg

Dexamethasone 5mg

Management of Acute Adrenal Insufficiency:
  • Terminate all procedures
  • Supine position with leg elevation
  • Administer hydrocortisone 100~200mg or Decardron 5~10mg
  • Administer O2
  • Monitor vital signs
  • Set up IV line
  • Start BLS if indicated
  • Transportation to a medical facility as soon as possible
dental management of the patient taking corticosteroids
Dental Management of the Patient Taking Corticosteroids

Routine procedures (excluding surgery)

a. Good local anesthesia & postoperative pain control if necessary

b. Monitor blood pressure during procedure

Dental extractions or surgery

a. Corticosteroid dose generally will need to be increased, consult patient’s MD prior to the procedure

  • Dental aspects:
    • Steroid cover in the “syndrome” cases
    • Complications
hyperaldosteronism
Hyperaldosteronism
  • Na retention and K excretion HTN, hypokalemia
  • Primary (Conn syndrome)
    • Adrenal cortical adenoma
    • Suppression of RAA: plasma renin = low
  • Secondary
    • Due to decreased renal perfusion (renal artery stenosis, arteriolar nephrosclerosis, CHF)
    • Activation of RAA: plasma renin = high
functions of corticosteroid
Functions of Corticosteroid
  • Regulation of carbohydrate, fat, protein
  • Anti-inflammation action by inhibit lysosome, prostaglandin, cytokines release.
  • Regulate the function of leucocyte.
  • Increase gluconeogenic, proteolysis, lipolysis and blood sugar
clinical application of steriod
Clinical Application of Steriod
  • Immunosuppressive: Rheumatoid arthritis, SLE, organ transplantation, asthma…
  • Anti-inflammation: hepatitis, dermatoses, mucositis, post-op edema…
  • Analgesia: reduction of pain
  • Replacement for Adrenal Insufficiency
adverse effect of corticosteroids
Adverse effect of Corticosteroids
  • Receive long-term, high-dose steroid
  • Hypertension, heart failure
  • Osteoporosis, DM, impaired wound healing, mental depression and psychosis
  • Peptic ulcer, Cataract, glaucoma, growth suppression, hypocalcemia, PTH increased
  • Cushing syndrome
  • Secondary adrenal insufficiency
dental uses of corticosteroids
Dental uses of Corticosteroids
  • Topical use: non-infections, ulcerative diseases in oral cavity. Inhibit the inflammatory reaction, redness and edema
  • Systemic use: Pre-prosthetic surgery, Reconstructive oral surgery & surgery
slide36

Condition

Administration

dental patient taking steroid supplementation not required
Dental patient taking Steroid Supplementation NOT required
  • Patient taking low dose (<20 mg of cortisol daily)
  • Patient taking large dose:

For less than 2 weeks

For minor dental procedure with minimal stress

dental patient taking steroid supplementation required
Dental patient taking Steroid Supplementation Required
  • Patient taking large dose: for greater than 2 weeks

for extensive major or stressful dental procedure

# Double usual daily dose on the day before, the day

of, and the day after surgery

# Appointment in the morning

# Good pain control

# Resume normal maintenance dose post-op 2 days.

dental patient taking steroid supplementation required1
Dental patient taking Steroid supplementation Required
  • If the patient received at least 20mg of cortisol for more than 2 weeks within past year

#60mg cortisol (or equivalent) the day before

and the day of surgery at morning

# On first 2 post-op days, 40mg cortisol

# Then take 20mg cortisol thereafter, until

post-op 6 days.