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Medically Compromised Patient Care

Course Number: 628

Adrenal Gland Disorders

Patients may present with primary or secondary adrenal insufficiency. Addison’s disease is an example of primary adrenal insufficiency resulting in underproduction of cortisol. Symptoms include bronzing of the skin and melanotic macules. A medical emergency that can occur when receiving dental treatment is adrenal crisis, which is caused by a severe lack of cortisol. The necessary treatment involves activating the Emergency Medical System, giving the patient oxygen and IV glucocorticoids. Secondary adrenal insufficiency occurs when there is an insufficient amount of adrenocorticotropic hormone (ACTH), but the patient still secretes aldosterone. This condition is more common than primary insufficiency. Patients with Cushing’s syndrome, or hypercortisolism, experience symptoms of a moon shaped face and buffalo hump.

Synthetic glucocorticoids may be used for treating the following conditions: adrenal insufficiency, rheumatoid arthritis, systemic lupus, asthma, hepatitis, or as immunosuppressive therapy for organ transplantation or joint replacement. Dental providers should be familiar with the corticosteroid equivalent doses as shown in Table 18.

Table 18. Corticosteroid Equivalent Doses
Cortisone25 mg
Hydrocortisone (Cortisol)20 mg
Prednisone5 mg

When planning dental care for patients with disorders of the adrenal gland, nitrous oxide can be used and is helpful for minimizing stress and reducing the cortisol demand. Local anesthesia with vasoconstrictor is ok as profound anesthesia is necessary for stress reduction for the patient. Premedication is not necessary unless there is an acute infection and a medical consult is required to determine that. A medical consult would be necessary if the patient was poorly controlled, had an acute infection, and to inquire about supplemental steroid use for surgical procedures or infection.

The following questions are helpful to ask patients who present to the dental office with adrenal gland disorders (Table 19).

Table 19. Follow-Up Questions for Patients with Adrenal Gland Disorders1
  • When were you diagnosed?
  • Are you controlled?
  • How are you feeling today?
  • What are your symptoms?