What are the dental considerations for treating patients suffering from acute adrenal insufficiency?

Cortisol, a glucocorticoid produced by adrenal cortex is essential for the human body to survive in stressful situations. The deficiency of cortisol in the human body leads to adrenal insufficiency which in turn can compromise the individual’s ability to adapt to a stressful situation, such as a dental appointment.

Adrenal insufficiency can manifest as loss of consciousness, a decrease in peripheral vascular resistance, shock, and ventricular asystole leading to death.

Based on the underlying pathophysiology, adrenal insufficiency can be classified as primary adrenal insufficiency (Addison’s disease) due to autoimmune adrenalitis, and secondary adrenal insufficiency due to disuse atrophy of the adrenal cortex induced by the exogenous use of the gluococorticosteroids. At present, secondary adrenal insufficiency is more common and the incidences of acute adrenal crisis are much higher among people with secondary adrenal insufficiency.

What are the predisposing factors of acute adrenal insufficiency and how can it be prevented?

The major predisposing factor of acute adrenal insufficiency is the inability of adrenal cortex to produce additional cortisol in stressful situations. Mechanisms leading to adrenal insufficiency can include the sudden withdrawal of steroid hormones from a person suffering from Addison’s disease or secondary adrenal insufficiency, physiological or psychological stress, adrenalectomy and destruction of adrenal or pituitary gland due to trauma, tumor or infection. In a dental office, the primary precipitating factor of acute adrenal insufficiency is stress.

This true emergency condition can be best prevented by taking the proper medical history of the patient and modifying the treatment protocol accordingly. The medical history questionnaire should not only seek information regarding the previous use of glucocorticosteroids, but also the dose of the drug administered, the duration of steroid therapy, the frequency, the time, and the route of administration. All the above factors influence the return of adrenocortical function to a normal physiological level after the use of exogenous glucocorticosteroid therapy. Acute adrenal insufficiency can occur, if the patient has had glucocorticosteroids in any two of the given situations; 20mg of hydrocortisone or its equivalent; continuous use > 2 weeks via oral or parental route; and received steroid therapy within the last 2 years.

What are the considerations for dental treatment?

Current evidence shows that routine dental care and minor oral surgical procedures, including uncomplicated dental extractions, do not increase stress levels enough to precipitate an adrenal crisis. Thus, no corticosteroid supplementation is indicated, if patients have taken their usual dose within 2 hours of the procedure and maintained circulating glucocorticoids level at 25 mg hydrocortisone or the equivalent. However, major surgical procedures may require steroid supplementation, usually a two to four fold increase in the regular dose of steroid.

Additionally, the risk of the acute emergency situation can further be minimized by implementing an appropriate stress reduction protocol, premedication, achieving an adequate level of local anesthesia, and post -surgical pain/stress management using analgesics and benzodiazepines.

How should dentists manage patients with acute adrenal insufficiency?

Depending on the consciousness level of the patient, proper management of an emergency situation of acute adrenal insufficiency includes the following steps:

Conscious patient

1. Terminate dental treatment as soon as the initial signs of adrenal insufficiency, such as mental confusion, abdominal pain, nausea and/or vomiting, become evident in a person on glucocorticoisteroid therapy.
2. If signs of hypotension are evident, place the patient in a supine position with legs slightly elevated. However, in the absence of such signs, placing the patient in their preferred comfortable position is recommended.
3. Provide basic life support and maintain proper circulation, airway and breathing.
4. Provide definitive care that includes monitoring vital signs, activating emergency medical assistance, oxygen administration, if needed (5-10ml/min), and administration of glucocorticosteroids. In the case of a patient with chronic adrenal insufficiency, 50-100mg of hydrocortisone should be administered intravenously; re-administration should follow every 6-8 hrs.
5. If the patient has no known history of adrenal insufficiency or gluococorticosteroid administration, but exhibits the diagnostic signs and symptoms of adrenal insufficiency, 4 mg dexamethasone phosphate (IV) should be administered immediately rather than waiting for the lab results (ACTH stimulation test). The drug should be re-administrated every 6-8 hours, as needed.
6. Additional management may include the administration of 1L of normal saline, and management of hypoglycemia by administration of 50-100 mL of 50% dextrose solution.

Unconscious patient

1. Determine the unconsciousness and place the patient in a supine position with legs elevated.
2. Provide basic life support, maintain circulation, airway and breathing. Usually the pulse is rapid, weak and thready, but in rare circumstances the pulse might be absent, which warrants immediate initiation of external chest compressions.
3. Definitive care includes the administration of oxygen and emergency medicines. Emergency medical assistance should be activated at this stage. If the patient’s medical history indicates the possibility of adrenal insufficiency, 100 mg hydrocortisone should be administered via IV or IM route. An additional 100mg of hydrocortisone should be administered by IV infusion (over 2 hrs.) or IM route. Further, management may include administration of 1ml of normal saline and 50% dextrose solution.
4. If the cause of unconsciousness cannot be established, no drug administration is indicated, and basic life support (BLS) steps should be continued until the arrival of emergency medical assistance.

Reference

Malamed, S.F. (2015). Medical Emergencies in the Dental Office (7th ed.). St. Louis, Missouri: Mosby Elsevier.