Adrenal Insufficiency. Adrenal cortex secretions. Adrenal Insufficiency. Adrenal Insufficiency. Acute Adrenal Insufficiency

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1 Adrenal cortex secretions Cortisol secretion Diurnal pattern 24 hour secretion = Stress = demands 30 mg 300 mg to meet physiological Adrenal Insufficiency PRIMARY ADDISON S DISEASE Autoimmune Infection (TB) Malignancy SECONDARY ADDISON S DISEASE Exogenous corticosteroid drugs Adrenal Insufficiency SYMPTOMS Weakness, fatigue Hyperpigmentation- skin, mucosa Hypotension Anorexia, weight loss Adrenal Insufficiency Oral complications Mucosal pigmentation Infection Delayed healing Acute Adrenal Insufficiency Clinical manifestations Mental confusion Muscle weakness, general fatigue Intense abdominal pain, lower back, legs Nausea, vomiting Hypotension, syncope, coma 1

2 Exogenous corticosteroids- Rx EQUIVALENT DOSES mg Cortisone 25 Hydrocortisone 20 Prednisone 5 Prednisolone 5 Triamcinolone 4 Dexamethasone 0.75 Betamethasone 0.6 Exogenous corticosteroids- Rx Short-acting <12 hrs. = Cortisone Intermediate- acting :12-36 hrs. = Prednisone Long-acting > 36 hrs. Cushing s syndrome Hyperadrenalism- high dose corticosteroids Unusual weight gain Moon-shaped facies Buffalo hump Abdominal striae Cushing s syndrome Hypertension Congestive Heart Failure Osteoporosis Diabetes mellitus Depression, psychoses Corticosteroid supplementation With adequate pain and anxiety control MOST routine dental procedures including extractions can be performed without corticosteroid supplementation Adequate anesthesia Adequate anxiety and stress management Effective post-operative pain control 2

3 Corticosteroid supplementation Complex, stressful procedures, anxious patients, significant post-operative pain Double the daily dose of steroid day of Tx Possibly Double the daily dose of steroid day following Tx Corticosteroid supplementation for complex oral surgery General anesthesia HOSPITALIZATION 100mg Hydrocortisone am of surgery 100mg Hydrocortisone 1 hr. before surgery Double the daily dose of steroid day following Tx Corticosteroid supplementation HISTORY of CORTICOSTEROID USE < 2 weeks : most procedures = normal dose complex procedures = DOUBLE dose > 2 weeks : most procedures = normal dose Topical or inhaled steroids = normal dose SYMPTOMS Nervousness, fatigue,weakness Weight loss, increased appetite Sweating, heat intolerance Palpitations, tachycardia Dyspnea Eye problems SIGNS Tachycardia, atrial fibrillation Goiter Skin problems Tremor Eye problems-exophthalmos Bruit over thyroid THYROID SECRETIONS T3 = Triiodothyronin T4 = Thyroxin Calcitonin Synthesis of T3 and T4 must have Iodine Dietary iodine ( MDR= 75 mg) Stored in thryoid 3

4 Patient identificationdetection Anterior neck scars Goiter, nodules on thyroid Post. Dorsal tongue tumors Midline nodules ( thyroglossal duct) Hyperthyroid = THYROTOXICOSIS Hypothyroid = MYXEDEMA ( CRETINISM) THYROID TUMORS HYPOTHYROIDISM is 5 times more common than Hyperthyroidism But.watch for THYROTOXICOSIS in patients on levothyroxine!!! Causes of hyperthyroidism Excess T3and T4 in blood Excess or ectopic thyroid tissue Graves disease Thyroid adenoma Pituitary disease Multinodal goiter Cardiovascular problems with thyrotoxicoxsis Arrhythmias, tachycardia Cardiomegaly Angina CHF NEUROLOGICAL problems : Anxiety, nervous, restlessness, tremors, insomnia SKIN problems : Erythema, alopecia Hyperpigmentation EYE problems :Exophthalmos; Retraction of upper eyelid; Corneal ulcers Increased risk for diabetes, arrhythmias, CHF, Thrombocytopenia Sensitivity to heat Hyperthyroid Rx- acute phase Propylthiouracil Methimazole Propanolol Dexamethasone Lithium 4

5 Hyperthyroid Rx- second phase Surgery Radioiodine Thyrotoxicosis Medical complications from dental treatment Sensitivity to epinephrine Lethal arrhythmias CHF Thyrotoxic crisis: HTN, MI! Thyrotoxicosis SUDDEN ONSET Surgery, infection, stress, trauma Nausea, vomiting, high fever tachycardia, hypertension followed by hypotension, coma, death EMERGENCY: CPR, hydrocortisone, cool down Thyrotoxicosis ORAL COMPLICATIONS Osteoporosis Increased caries and periodontal disease Rapid jaw and tooth development DENTAL MANAGEMENT Determine nature, causes and severity Past therapies Present medications Current status: history and clinical findings MEDICAL CONSULTATION DENTAL MANAGEMENT AVOID EPINEPHRINE CLOSELY MONITOR VITAL SIGNS STRESS-ANXIETY MANAGEMENT CAUTION WITH SURGERY AND INFECTIONS AGGRESSIVELY TREAT INFECTIONS AVOID THYROTOXIC CRISIS 5

6 HYPOTHYROID Myxedema- adult Cretinism- child = dwarfism, overweight, large lips and tongue, hoarse, stubby hands, pale skin, mentally retarded,eyes wide apart, broad nose, malocclusion, delayed tooth eruption HYPOTHYROID Congenital ( Cretinsim) or acquired Acquired by ; thyroid or pituitary failure Radiation of thyroid Removal of thyroid Excessive anti-thyroid medication HYPOTHYROID clinical manifestations Muscle weakness, fatigue Anemia Constipation Weight gain Sensitivity to cold HYPOTHYROID- medical problems exacerbated by dental treatment Exaggerated response to CNS depressants MYXEDEMA COMA Infection, stress, cold, trauma, surgery, CNS depressants ( narcotics, barbiturates, tranquilizers, etc.) HYPOTHYROID medical treatment Synthetic thyroid hormones Levothyroxine (LT4) Liothyroxine (LT3) 6

7 DENTAL MANAGEMENT Determine nature, causes and severity Past therapies Present medications Current status: history and clinical findings MEDICAL CONSULTATION DENTAL MANAGEMENT AVOID EPINEPHRINE CLOSELY MONITOR VITAL SIGNS STRESS-ANXIETY MANAGEMENT CAUTION WITH SURGERY AND INFECTIONS AGGRESSIVELY TREAT INFECTIONS AVOID THYROTOXIC CRISIS Corticosteroid use: routine dental procedures Rx > 2 wks. d/c w/i 30 days = Rx previous d/c Rx > 30 days ago = none topical = none current Rx ( any dose) = none alt. day Rx = tx on that day Monitor BP, good anesthesia, post-op analgesia, etc. Corticosteroid use: complex dental procedures Rx >2 wks. d/c w/i 30 days = Rx previous Rx d/c > 30 days ago = none topical = none current Rx( any dose) = double + alt. day Rx = double + tx on that day Monitor BP, good anesthesia, post-op + Rx + analgesia, etc. 7

8 NEUROLOGICAL problems with thyrotoxicoxsis Anxiety, nervousness, restlessness tremors Insomnia, sleep disturbances Impaired concentration, emotional instability SKIN problems with thyrotoxicoxsis Erythema Hyperpigmentation Thin, fine hair; alopecia Soft nails Ocular problems with thyrotoxicoxsis Exophthalmos Retraction of upper eyelid Corneal ulcerations Ocular muscle weakness Other problems with thyrotoxicoxsis Osteosclerosis, weight loss pernicious anemia Increased risk for diabetes Thrombocytopenia Sensitivity to heat 8