Dental Management of Patient With Adrenal Cortex Disorder

Adrenal Gland Disorder

Dr.Tarek Nageib Zaid

By

Treatment And Dental Management Of Gland Problems

TO BE DISCUSS IN PRESENTATION topics

1- Physiology Of Adrenal Gland Action 2-Type of Adrenal Gland Disorder3- The Signs And Symptoms 4- Treatment And Dental Management

THE ADRENAL GLANDS

Are Small (6 To 8 G) Endocrine GlandsThat Are Located Bilaterally At The Superior Pole Of EachKidney. Each Gland Contains An Outer Cortex And An InnerMedulla.

The Adrenal Medulla Functions As A Sympathetic Ganglion Secretes Catecholamines, Primarily Epinephrine,

The Adrenal cortex secrete multiple steroids with multiple function Eg : Aldosterone (mineralocorticoids)

androgens cortisone ( glucocorticosteroid )

THE ADRENAL GLANDS

Aldosterone (mineralocorticoids

Regulates Physiologic Levels Of Sodium And Potassium And Is Relatively Independent Of Pituitary Gland Feedback (depend mainly on angiotensin renin system)

androgens

Maturation of sexual organs

THE ADRENAL GLANDS

Cortisone ( Glucocorticosteroid )

• Regulation Of Carbohydrate, Fat, And Protein Metabolism• Maintenance Of Vascular Reactivity• Inhibition Of Inflammation, And Maintenance Of Homeostasis• During Periods Of Physical Or Emotional Stress• Cortisol Acts As An Insulin Antagonist :

1-increasingnblood Levels And Peripheral Use Of Glucose2-increasing Liver Glucose Output3-initiating Lipolysis, Proteolysis, and Gluconeogenic Mechanisms

• Anti Inflammatory Action : As It Inhibit1-lysosome Release

2-prostaglandin Production3-eicosanoid And Cytokine Release4-the Function Of Leukocytes5-endothelial Cell Expression Of Intracellular And Extracellular Adhesion Molecules That Attract Neutrophils

Corticotropin-Releasing Hormone

Regulation of cortisol secretion

Regulation of cortisol secretion occurs via the hypothalamic-pituitary-adrenal (HPA) axis

AdrenocorticoTropicHormone

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2

3

4

HPA AXIS

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2

3

4

Stress : Trauma-illness- Burns, Fever-hypoglycemia-emotional Upset

Hypothalamus Stimulation And Release Of CRH Which Stimulate The Pituitary Gland To Release ACTH

Acth Stimulate The Adrenal Cortex To Release The Glucocorticosteroid

When The Level Of Cortisone Increse In Blood Negative Feed Back Occur On Pitutray Gland To Inhibit The Secretion Of ACTH

HPA AXIS

Cortisol secretion normally follows a diurnal pattern.Peak levels of plasma cortisol occur about the time ofawakening in the morning and are lowest in the afternoonand evening3

The normal secretion rate of cortisol overa 24-hour period is approximately 20 mg. During periods of stress, the HPA axis is stimulated, resulting inincreased secretion of cortisol

Diagram showing cortisone level during

the day

Disorders that affect the adrenal glands result in

Under production of gland

secretion

Over production of gland

secretion

Increase The Production Of : • Androgens• Estrogens• Aldosterone• Glucocorticosteriods

The Most Common Overproduction Is Glucocortiocosteriods Cushing’s

disease

Primary DeficiencyResult From Destruction Of Adrenal Cortex Due To : Autoimmune DiseasesInfection As Tuberculosis Mainly In Developing Countries

Secondary Deficiency As Result From -Pituitary Hypothalamic Problems-Secondary To Corticosteroid Drug Administration

Addison’s disease

Addison disease is rare endocrinal disorder characterized by excessive loss of adrenal gland cortex secretion , in the developed nations it usually related to auto-immune disorder but in the developing nations it is widely associated with tuberculosis (decrease in cortisol and aldosterone hormones)

Addison’s disease

Impaired metabolism of glucose, fat, and protein

hypotension

increased ACTH secretion

impaired fluid excretion

inability to tolerate stress

excessive pigmentation

Aldosterone deficiency results in aninability to conserve sodium and eliminate potassium andhydrogen ions, leading to Hypovolemia hyperkalemiaacidosis.

Weakness And Fatigue

Abnormal Pigmentation Of The Skin And Mucous Membranesa

Hypotension, anorexia, and weight loss

If a patient with Addison’sdisease is challenged by stress

adrenal crisismay be precipitated

is severe exacerbation of the patient’s condition including :

sunken eyes, profusesweating, hypotension, weak pulse, cyanosis, nausea,vomiting, weakness, headache, dehydration, fever,dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia.If not treated rapidly, the patient may develophypothermia, severe hypotension, hypoglycemia, andcirculatory collapse that can result in death.

Crisis

Patient with :Sings and symptoms

Clinical case study

26 years old FEMALE

Complain and medical history Bleeding Gum And Bad Breath, Since Last 10 Months. Patient Was Anxious, But Evidently Fatigued, Weakened, And Easily Irritable. Patient Also Gave A History Of Occasional Abdominal Pain, Amenorrhea, Nausea, And Vomiting, Dysphagia, Weight Loss And Hypotension. She Also Gave History Of Sleep Disturbances Occasionally, Which Is Usually Accompanied By The Exacerbation Of Abdominal Pain.

• Thin And Brittle Nail, Scanty Body Hair

Clinical examination

• Hyperpigmentation Of Skin In The Neck

• Pulse Of 106 Bpm,

• Blood Pressure 90/65 Mmhg

Intra Oral Examination

Pigmentation With Bilateral Involvement Of Buccal Mucosa,

Gingival,

Mucosal Surface Of Lower Lip,

Alveolar Mucosa,

And Hard Palate

The Gingiva Appears To Be Blunt With Apical Positioning Of Gingival Margins, Significant Loss Of Attachment With

Pocket Depth Between 3 And 5 Mm

Intra Oral Examination

Tongue Appears To Be Smooth With Loss Of The Papilla With Pigmentation

On The Posterior Surface

Laboratory investigation

• Anemia With Hemoglobin Level =7.8 G/Dl

• Normal Red Blood Cell Morphology

• Erythrocyte Sedimentation Rate (Esr)= 59 Mm/H,

• Fasting Blood Sugar =70 Mg/Dl.

• Early Morning Cortisol Level Was Well Below Normal Level 2.2 Μg/Dl.

• Anti-hiv, Anti Hepatitis C Virus Hepatitis B Surface Antigen (Hcv Hbsag) Factors Were Negative

• Mantoux Tuberculin Skin Test Was Negative And Chest Radiograph Also Ruled Out Tuberculosis

Laboratory investigation

• Anemia With Hemoglobin Level =7.8 G/Dl

• Normal Red Blood Cell Morphology

• Erythrocyte Sedimentation Rate (Esr)= 59 Mm/H,

• Fasting Blood Sugar =70 Mg/Dl.

• Early Morning Cortisol Level Was Well Below Normal Level 2.2 Μg/Dl.

• Anti-hiv, Anti Hepatitis C Virus Hepatitis B Surface Antigen (Hcv Hbsag) Factors Were Negative

• Mantoux tuberculin skin test was negative and chest radiograph also ruled out tuberculosis

After History & Investagation And Clinical Finding ….Final Diagnosis Is Addison’s Dieses Which Precipitated By

Acute Malarial Attack

Secondary adrenal insufficiency

Causes :

Long duration of large

corticosteroids dose

Pituitary or hypothalamic

problems

Inhibit the secretion of ACTH from

pituitary gland

Due To

Sign and symptoms partial insufficiency that is limited to glucocorticoids

The condition usually does not produce any symptoms unless the patient is significantly stressed and does not have adequate circulating cortisol during times surrounding stress.

In this event, an adrenal crisis is possible. However, an adrenal crisis in a patient with secondary adrenal suppression is rare and tends not to be as severe as that seen with primary adrenal insufficiency because aldosterone secretion is normal.

Decrease the secretion of ACTH from

pituitary gland

Treatment and dental management

ttt of addision diseaes

• Elimination of cause

Hormonal Replacement aldosterone Glycocorticosteroids

20 -30 mg hydrocortisoneor

30 mg cortisone0r

7.5 mg prednisone

Fludrocortisone .05 to .1 mg

Current practice recommends that twothirds of the dose should be given in the morning and one third in the later afternoon to reflect the normal diurnal cycle.

Patient In Adrenal Crisis

Management of

Drag picture to placeholder or click icon to addAdrenal crisis is an acute adrenal insufficiency

This condition requires immediate treatment including:

IV injection of a glucocorticoid—usuallya 100-mg hydrocortisone

fluid and electrolyte replacement

Over the first 24 hours, 100 mg is administered IVslowly every 6 to 8 hour

if needed, blood pressure issupported with fluid replacement and vasopressors, alongwith correction of hypoglycemia

Alternate days

Secondary adrenal insufficiency

Drug dose modificationDaily dose 2/3 of the

dose at Morning

long-term steroid use result in partial adrenal insufficiency

Steroids Are Prescribed In The Management Of Non Endocrine Disorders For Their Anti-inflammatory And Immunosuppressive Properties

The Goal Of Treatment Is To Achieve Resolution Of Disease Symptoms While Minimizing Adverse Effects So The Technique Of Drug Administration must Modify

This method allows ….the adrenal glandto function normally during the off day and thus does not tend to cause axis suppression.

A tapered dosage

schedule

Dose of drug decrease gradually until time of treatment finished ( gradual reverse of gland function )

to reflect the normal diurnal cycle of cortisone secretion

current recommendations

For surgical procedure

Normal patient

Preoperative Intraoperative Postoperative

The Normal Response To Surgical Stresses

Plasma cortisol level

20 mg

Adults Secrete 75 To 150 Mg A Day In Response To Major Surgery And 50 Mg A Day During Minor Procedures. Cortisol Secretion In The First 24 Hours After Surgery Rarely Exceeds 200 Mg

200 mg

Factors affecting level of cortisol after surgery • The Magnitude Of The Surgery

• Whether General Anesthesia Is Used.

• The Duration And Severity Of Surgery And Level Of Pain Control

• The Amount Of Cortisol Produced During The Physiologic Response To Surgical Stress

• The Overall Health Of The Patient Who Takes Daily Steroids

The Need For Glucocorticoid Replacement On Three Factors :

the glucocorticoid target

Glycocorticosteriods Replacement ProtocolLow Cortisol Level After Surgery (Adrenal Insufficiency )

Minor Surgical Stress

25 mg of hydrocortisone equivalent on the dayof surgery.

Example

An Asthmatic Patient WhoTakes 5 Mg Of Prednisone Every Other Day ShouldReceive 5 Mg Of Prednisone On The Day Of Surgery Preoperatively


moderate surgical stress

50 to 75 mg per day of hydrocortisoneequivalent for up to 1 to 2 days

Example A patient with systemic lupus erythematosus who takes 10 mg prednisone daily should receive 10 mg of prednisone (or parenteral equivalent) preoperatively and 50 mg of hydrocortisone intravenously intraoperatively. On the first postoperative day, 20 mg of hydrocortisone is administered intravenously every 8 hours The patient is returned to the preoperative glucocorticoid dose on postoperative day 2




For major surgical stress

100 to 150 mg per day of hydrocortisoneequivalent given for 2 to 3 days.

Example

patient with Crohn’s disease who takes 40 mgprednisone daily for several years should receive40 mg prednisone (or the parenteral equivalent)preoperatively and 50 mg hydrocortisoneintravenously every 8 hours after the initial dose for the first 48 to 72 hours after surgery.

Evidence indicates that the vast majority of patientswith adrenal insufficiency may undergo routine dental treatment without the need for supplemental glucocorticoids. Individuals at risk for adrenal crisis are those who undergo stressful surgical procedures and have no or extremely low adrenal function because of primary or secondary adrenal insufficiency

To Determine Who Is At Risk For Adrenal Insufficiency Or Crisis (By Using Laboratry Steps Determine The Status And Stabilitiy Of ACTH And CRH ) 1- ACTH Test 2-CRH Test

Dental Management Steps With Patient With Possible Adrenal Insufficiency

Cushion syndrome

Over production of glucocorticosteriods

Sign and symptoms

weight gain, round or moon-shaped facies

“buffalo hump” on the upper back

abdominal striae, hypertension Hirsutism acne

glucose intolerance(e.g., diabetes mellitus), heart failure

Osteoporosis and bone fractures

psychiatric disorders (mental depression, mania, anxiety disorders)

cognitive dysfunction psychosis

Insomnia

peptic ulceration

cataract formation

glaucoma

growth suppression

delayed wound healing

“Buffalo Hump” On The Upper Back

Moon Face Appearance

weight gain, round or moon-shaped faciesabdominal striae

Cushion syndrome

Before after

Dental Management

Patients With Hyperadrenalism Have An Increased Likelihood Of Hypertension And Osteoporosis And Increased Risk For Peptic Ulcer Disease.

To Minimize The Risk

Blood Pressure Should Be Taken At Baseline And Monitored During Dental Appointments

Osteoporosis Has A Relationship With Periodontal Bone Loss, Implant Placement, And Bone Fracture. Treatment Planning Should Address The Risk For Periodontal Bone Loss,And Measures Should Be Instituted That Promote Bone Mineralization And Avoid Extensive Neck Manipulation If Osteoporosis Is Severe.

Because Of The Risk Of Peptic Ulceration, Postoperative Analgesics Selection Should Not Include Aspirin And Non Steroidal Anti-inflammatory Drugs For Long-term Steroid Users.

Important

Manifestation Appear After 90 % Destruction Of The Gland And Oral Manifestation Appear First So Dentist Can Make Earrly Diagnosis Of The Disease

Addison's Diseases Is Primary Under Production Of Adrenal Cortex Secretion Include The Aldosterone And Cortisone

Patient Secondary Adrenal Insufficiency May Be Without Any Manifestation Until Be Under Stress Like Surgical Stresses Due To The Partial Adrenal Insufficiency

Cushion Disease Is Overproduction Of Cortisone From Adrenal Cortex

Patient With Cushion Disease Has Liability For Peptic Ulcer So Avoid Aspirin & The Non Steroidal Analgesics And Anti Cox2 Is Best Choice

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Dental Management of Patient With Adrenal Cortex Disorder