Adrenal

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Adrenal

  1. 1. RISK STARTIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ADRENAL DYSFUNCTION Géza T. Terézhalmy, D.D.S., M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio
  2. 2. Adrenal Dysfunction <ul><li>Adaptive stress response </li></ul><ul><ul><li>Physiological stressors activate the HPA axis and ANS </li></ul></ul><ul><ul><ul><li>Locus ceruleus (LC) and other noradrenergic cell components  norepinephrine (NE) levels </li></ul></ul></ul><ul><ul><ul><ul><li>NE is a potent stimulator of CRH </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CRH stimulates the LC/NE </li></ul></ul></ul></ul><ul><ul><ul><li>Sympathetic efferents to adrenal medulla </li></ul></ul></ul><ul><ul><ul><ul><li> epinephrine levels </li></ul></ul></ul></ul>
  3. 3. Adrenal Dysfunction <ul><ul><li>Physiological stressors </li></ul></ul><ul><ul><ul><li>Cold </li></ul></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Emotional stress </li></ul></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><ul><ul><li>Cytokines </li></ul></ul></ul><ul><ul><ul><ul><li>IL-1  , IL-6, and TNF-  </li></ul></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Exercise </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage </li></ul></ul></ul>
  4. 4. Adrenal Dysfunction <ul><ul><li>Hypothalamic-pituitary-adrenal (HPA) axis </li></ul></ul><ul><ul><ul><li>Hypothalamus </li></ul></ul></ul><ul><ul><ul><ul><li>Corticotropin-releasing hormone (CRH) </li></ul></ul></ul></ul><ul><ul><ul><li>Pituitary </li></ul></ul></ul><ul><ul><ul><ul><li>ACTH </li></ul></ul></ul></ul><ul><ul><ul><li>Adrenal cortex </li></ul></ul></ul><ul><ul><ul><ul><li>Cortisol (10-13 mg daily) </li></ul></ul></ul></ul>
  5. 5. Adrenal Dysfunction
  6. 6. Adrenal Dysfunction <ul><li>Cortisol </li></ul><ul><ul><li>Regulates cell metabolism </li></ul></ul><ul><ul><ul><li>Transcription </li></ul></ul></ul><ul><ul><ul><li>Translation </li></ul></ul></ul><ul><ul><li>Stimulates peripheral fat and protein catabolism </li></ul></ul><ul><ul><ul><li>Substrates for hepatic production of glucose </li></ul></ul></ul>
  7. 7. Adrenal Dysfunction <ul><ul><li>Suppresses inflammation </li></ul></ul><ul><ul><ul><li> leukocyte migration </li></ul></ul></ul><ul><ul><ul><li> cytokine production </li></ul></ul></ul><ul><ul><li>Suppresses the immune system </li></ul></ul><ul><ul><ul><li> T cell proliferation </li></ul></ul></ul><ul><ul><li>Plays a permissive role (synergism) </li></ul></ul><ul><ul><ul><li>Angiotensin II </li></ul></ul></ul><ul><ul><ul><li>Catecholamines </li></ul></ul></ul>
  8. 8. Adrenal Dysfunction <ul><li>Adaptive stress response </li></ul><ul><ul><li>Significant disruption or imbalance in the adoptive stress response </li></ul></ul><ul><ul><ul><li>Influences the development and progression of various disease states </li></ul></ul></ul>
  9. 9. Adrenal Dysfunction Severe chronic disease Anorexia nervosa Melancholic depression Obsessive-compulsive disorder Panic disorder Malnutrition Chronic excessive exercise Hyperthyroidism Diabetes mellitus Atypical depression Seasonal depression Postpartum depression Chronic fatigue syndrome Fibromyalgia Hypothyroidism Nicotine withdrawal Menopause Rheumatoid arthritis Increased HPA axis activity Decreased HPA axis activity
  10. 10. Adrenal Dysfunction <ul><li>Glucocorticoids in the top 200 </li></ul><ul><li>prednisone </li></ul><ul><li>fluticasone propionate </li></ul><ul><li>Advair Diskus (fluticasone propionate w/salmeterol) </li></ul><ul><li>Flovent HFA (fluticasone propionate) </li></ul><ul><li>Nasonex (mometasone furoate) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Decrease inflammation </li></ul></ul></ul><ul><ul><ul><li>Suppress the immune system </li></ul></ul></ul>
  11. 11. Adrenal Dysfunction <ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Addison’s disease </li></ul></ul></ul><ul><ul><ul><ul><li>Adrenal insufficiency </li></ul></ul></ul></ul><ul><ul><ul><li>Inflammatory conditions </li></ul></ul></ul><ul><ul><ul><li>Autoimmune diseases </li></ul></ul></ul><ul><ul><ul><li>Immunosuppression in organ transplant patients </li></ul></ul></ul><ul><ul><ul><li>Lymphocytic leukemia </li></ul></ul></ul><ul><ul><ul><li>Allergic rhinitis and asthma </li></ul></ul></ul>
  12. 12. Adrenal Dysfunction <ul><li>STRATEGIES FOR DENTAL MANAGEMENT </li></ul><ul><ul><li>Disease-related variable </li></ul></ul><ul><ul><li>Patient-related variables </li></ul></ul><ul><ul><li>Procedure-related variables </li></ul></ul>
  13. 13. Adrenal Dysfunction <ul><li>Disease-related variable </li></ul><ul><ul><li>Addison’s disease </li></ul></ul><ul><ul><ul><li>Primary adrenal insufficiency </li></ul></ul></ul><ul><ul><ul><ul><li>Autoimmune polyglandular syndrome type 1 (APS-1) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Adrenal insufficiency, hypoparathyroidism, and chronic mucocutaneous candidiasis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Autoimmune polyglandular syndrome type 2 (APS-1) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Adrenal insufficiency, type 1 diabetes mellitus, thyroid disease </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Infection of the adrenal gland (tuberculosis, HIV) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inflammation, cancer, shock, and hemorrhage </li></ul></ul></ul></ul>
  14. 14. Adrenal Dysfunction <ul><ul><ul><li>Secondary adrenal insufficiency </li></ul></ul></ul><ul><ul><ul><ul><li>ACTH deficiency </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Anterior pituitary dysfunction, destruction, or neoplasia </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Tertiary adrenal insufficiency </li></ul></ul></ul><ul><ul><ul><ul><li>HPA-axis suppression </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypothalamic dysfunction or failure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Exogenous glucocorticoid therapy (most common) </li></ul></ul></ul></ul></ul>
  15. 15. Adrenal Dysfunction <ul><ul><ul><li>Signs and symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Nausea, vomiting, abdominal pain, diarrhea, anorexia, salt craving, and weight loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypoglycemia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> gluconeogenesis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Decreased cardiac output, hypotension, cardiac arrhythmias, and muscle weakness </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hyponatremia and hyperkalemia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Lethargy, reduced libido, and amenorrhea </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperpigmentation of skin and oral mucosa </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> ACTH and  -MSH </li></ul></ul></ul></ul></ul>
  16. 16. Adrenal Dysfunction
  17. 17. Adrenal Dysfunction <ul><ul><ul><li>Adaptive stress response </li></ul></ul></ul><ul><ul><ul><ul><li>Unable to produce sufficient levels of ACTH or cortisol to meet physiologic demand </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stressors may precipitate an Addisonian crisis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cardiogenic shock </li></ul></ul></ul></ul></ul>
  18. 18. Adrenal Dysfunction <ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><ul><li>Plasma cortisol level </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Following injection of synthetic ACTH-Cosyntropin (Cortrosyn  ) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Provocative physiologic testing </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Insulin tolerance test </li></ul></ul></ul></ul></ul>
  19. 19. Adrenal Dysfunction <ul><ul><ul><li>Medical management </li></ul></ul></ul><ul><ul><ul><ul><li>Daily corticosteroids </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hydrocortisone, 30 mg </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Prednisone, 5 mg </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dexamethasone </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Daily mineralocorticoids </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fludrocortisone, 0.05-0.20 mg </li></ul></ul></ul></ul></ul>
  20. 20. Adrenal Dysfunction <ul><ul><li>Cushing’s syndrome </li></ul></ul><ul><ul><ul><li>Endogenous </li></ul></ul></ul><ul><ul><ul><ul><li>ACTH-dependent </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Autonomous ACTH secreting anterior pituitary tumor </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Ectopic ACTH production (small-cell lung cancer) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Excess CRH synthesis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>ACTH-independent </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Benign adrenal adenomas </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Malignant adrenal carcinomas </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Exogenous </li></ul></ul></ul><ul><ul><ul><ul><li>Chronic corticosteroid therapy (most common) </li></ul></ul></ul></ul>
  21. 21. Adrenal Dysfunction <ul><ul><ul><li>Signs and symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Truncal obesity with violaceous striae of the skin, bufallo hump, facial fullness (moon facies),facial plethora, acne, hirsutism, easy bruising, muscle wasting and myopathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Psychological symptoms (impaired cognitive and memory function, and psychoses) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperpigmentation of skin and oral mucosa </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> ACTH and  -MSH </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Stunted linear growth in children and delayed eruption of teeth </li></ul></ul></ul></ul>
  22. 22. Adrenal Dysfunction
  23. 23. Adrenal Dysfunction <ul><ul><ul><ul><li>Osteoporosis (ribs, vertebrae, and long bones) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Altered calcium homeostasis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperglycemia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> gluconeogenesis and  glycogenolysis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypernatremia and hypokalemia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Impaired wound healing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Predispose to and mask infection </li></ul></ul></ul></ul>
  24. 24. Adrenal Dysfunction <ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><ul><li>24-hour urinary free cortisol (UFC) assay </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Overnight 1 mg dexomethasone suppression test </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Salivary cortisol level (> 0.22  g/dL) </li></ul></ul></ul></ul><ul><ul><ul><li>Medical management </li></ul></ul></ul><ul><ul><ul><ul><li>Treatment appropriate to deal with cause </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Surgical resection or radiotherapy, which lead to permanent hypoadrenocorticism </li></ul></ul></ul></ul></ul>
  25. 25. Adrenal Dysfunction <ul><ul><li>Patients on chronic glucocorticoid therapy (Cushing's syndrome) </li></ul></ul><ul><ul><ul><li>May not be able to produce sufficient levels of ACTH and cortisol to meet physiological demand </li></ul></ul></ul><ul><ul><ul><ul><li>Physiological stressors may precipitate an Addisonian crisis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Shock </li></ul></ul></ul></ul></ul>
  26. 26. Risk stratification of patients with AD <ul><ul><li>Wide variability in HPA axis suppression in patients on exogenous glucocorticoids </li></ul></ul><ul><ul><ul><li>In general, it does not correlate well with the </li></ul></ul></ul><ul><ul><ul><ul><li>patient’s age and sex </li></ul></ul></ul></ul><ul><ul><ul><ul><li>dosage administered </li></ul></ul></ul></ul><ul><ul><ul><ul><li>duration of treatment </li></ul></ul></ul></ul><ul><ul><ul><li>The persistence of HPA axis suppression after cessation of systemic glucocorticoid therapy is equivocal </li></ul></ul></ul><ul><ul><ul><li>Topical and inhaled corticosteroids can suppress the HPA axis but rarely cause clinical adrenal insufficiency </li></ul></ul></ul>
  27. 27. Adrenal Dysfunction <ul><ul><ul><ul><li>No HPA axis suppression </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Less than 5 mg of prednisone or equivalent per day for any duration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Alternate-day single morning dose of a short-acting glucocorticoid (hydrocortisone) of any dose or duration </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Any dose of a glucocorticoid for less than 3 weeks </li></ul></ul></ul></ul></ul>
  28. 28. Adrenal Dysfunction <ul><ul><ul><ul><li>HPA axis suppression uncertain </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>5-20 mg of prednisone or equivalent for more than 3 weeks within the past year </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Low-dose ACTH stimulatory test to determine HPA axis suppression </li></ul></ul></ul></ul></ul>
  29. 29. Adrenal Dysfunction <ul><ul><ul><ul><li>HPA axis suppression presumed or documented </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>More than 20 mg of prednisone or equivalent per day for more than 3 weeks within the past year </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cushingoid appearance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Biochemical adrenal insufficiency on low-dose ACTH stimulation test </li></ul></ul></ul></ul></ul>
  30. 30. Adrenal Dysfunction <ul><li>Procedure-related variables </li></ul><ul><ul><li>Major surgical stress </li></ul></ul><ul><ul><ul><li>Example: cardiac surgery involving cardiopulmonary bypass </li></ul></ul></ul><ul><ul><ul><ul><li>Hydrocortisone, 100 to 150 mg, or equivalent for 2 to 3 days OR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hydrocortisone, 100 mg, IV, prior to induction anesthesia, THEN Hydrocortisone, 50 mg, q8h, for 48 to 72 hours (then resume normal regimen) </li></ul></ul></ul></ul>
  31. 31. Adrenal Dysfunction <ul><ul><li>Moderate surgical stress </li></ul></ul><ul><ul><ul><li>Example: segmental colon resection </li></ul></ul></ul><ul><ul><ul><ul><li>Hydrocortisone, 50 to 75 mg, or equivalent for 1 to 2 days OR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hydrocortisone, 50 mg, IV, prior to induction anesthesia, THEN Hydrocortisone, 25 mg, q8h, for 48 to 72 hours (then resume normal regimen) </li></ul></ul></ul></ul>
  32. 32. Adrenal Dysfunction <ul><ul><li>Minor surgical stress </li></ul></ul><ul><ul><ul><li>Example: inguinal hernia repair, </li></ul></ul></ul><ul><ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul></ul></ul>
  33. 33. Risk stratification of patients with AD <ul><ul><li>Dental procedure-related risk </li></ul></ul><ul><ul><ul><li>Procedure-specific variables </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid shifts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duration of the procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physiological stress </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>General anesthesia </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Low to very low risk </li></ul></ul></ul><ul><ul><ul><ul><li>Recommended prophylaxis </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul></ul></ul></ul><ul><li>Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46. </li></ul><ul><li>Arch Intern Med 2001;161:1509-1512. </li></ul><ul><li>ADA 2001;132:1570-1579. </li></ul>
  34. 34. Risk stratification of patients with AD <ul><ul><li>“ Stress dose” corticosteroids </li></ul></ul><ul><ul><ul><li>The decision to give supplemental glucocorticoids must weigh the risks </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid retention </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperglycemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased risk of infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impaired wound healing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gastrointestinal bleeding </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Psychiatric disturbances </li></ul></ul></ul></ul><ul><ul><ul><li>Administer corticosteroids only in the amount equivalent to the normal physiological response to surgical stress (“stress dose”) </li></ul></ul></ul>
  35. 35. Adrenal Dysfunction <ul><ul><li>Functional capacity </li></ul></ul><ul><ul><ul><li>Ability of the CV system to meet metabolic demand for oxygen </li></ul></ul></ul><ul><ul><ul><ul><li>Poor functional capacity is defined as <4 METs </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cardiac and, therefore, Addisonian risk is increased in patients unable to meet a 4-MET demand for oxygen </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>4 METs is equivalent to the effect of 0.045 mg of epinephrine </li></ul></ul></ul></ul></ul><ul><li>* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181. </li></ul><ul><li>*JADA 2001;132:1570-1579. </li></ul>
  36. 36. Adrenal Dysfunction <ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li><90/50 mm Hg </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable sign of shock </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>May suggest severe Addison’s disease </li></ul></ul></ul></ul></ul><ul><ul><ul><li><180/110 mm Hg </li></ul></ul></ul><ul><ul><ul><ul><li>Not an independent risk factor </li></ul></ul></ul></ul><ul><ul><ul><li>>180/110 mm Hg </li></ul></ul></ul><ul><ul><ul><ul><li>A medical emergency </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>May suggest severe Cushing’s syndrome </li></ul></ul></ul></ul></ul>
  37. 37. Adrenal Dysfunction <ul><ul><li>Pulse pressure, rate and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor for significant CVD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate <50 or >100 beats/min </li></ul></ul></ul><ul><ul><ul><ul><li>Constitutes a medical emergency </li></ul></ul></ul></ul>
  38. 38. Adrenal Dysfunction Routine referral for medical management <ul><li>Routine dental care </li></ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul><ul><li>BP </li></ul><ul><ul><li>>90/50 or </li></ul></ul><ul><ul><li><180/110 mm Hg </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Pulse </li></ul><ul><ul><li>Normal pressure, rate, and rhythm </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Functional capacity </li></ul><ul><ul><li>>4 METs </li></ul></ul><ul><li>Dental care </li></ul><ul><ul><li>Minor surgical stress </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Local anesthesia </li></ul><ul><ul><li>Minor physiological stress </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian risk factors
  39. 39. Adrenal Dysfunction Routine referral for medical management <ul><li>Limited dental care </li></ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul><ul><li>BP </li></ul><ul><ul><li>>90/50 or </li></ul></ul><ul><ul><li><180/110 mm Hg </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Pulse </li></ul><ul><ul><li>Normal pressure, rate, and rhythm </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Functional capacity </li></ul><ul><ul><li><4 METs </li></ul></ul><ul><li>Dental care </li></ul><ul><ul><li>Minor surgical stress </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Local anesthesia </li></ul><ul><ul><li>Minor physiological stress </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian risk factors
  40. 40. Adrenal Dysfunction <ul><li>Asymptomatic patient </li></ul><ul><ul><li>Routine referral for medical management </li></ul></ul><ul><li>Symptomatic patient </li></ul><ul><ul><li>Immediate referral for medical management </li></ul></ul><ul><li>Emergency dental care </li></ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul><ul><li>BP </li></ul><ul><ul><li><90/50 or </li></ul></ul><ul><ul><li>>180/110 mm Hg </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Pulse </li></ul><ul><ul><li>Abnormal pressure, rate, and rhythm </li></ul></ul><ul><li>Dental care </li></ul><ul><ul><li>Minor surgical stress </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><li>Local anesthesia </li></ul><ul><ul><li>Minor physiological stress </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian risk factors
  41. 41. Adrenal Dysfunction <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conventional vs. electromechanical toothbrushes </li></ul></ul></ul><ul><ul><li>Antibacterial mouthwashes </li></ul></ul><ul><ul><li>Topical fluorides </li></ul></ul><ul><ul><li>Sialagogues </li></ul></ul><ul><ul><ul><li>Pilocarpine (Salagen) </li></ul></ul></ul><ul><ul><ul><li>Cevimeline (Evoxac) </li></ul></ul></ul>
  42. 42. Adrenal Dysfunction <ul><li>Medical emergencies </li></ul><ul><ul><li>The likelihood of an Addisonian crisis is very remote </li></ul></ul><ul><ul><ul><li>Other potential emergencies predicated on patient’s overall health </li></ul></ul></ul>
  43. 43. Risk stratification of patients with AD <ul><li>Huber MA, Terezhalmy GT. Risk stratification and dental management of patients with adrenal dysfunction. Quintessence Int 2007;38:325-338. </li></ul><ul><li>Pickett FA, Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2 nd ed. Baltimore: Wolters Kluwer Health / Lippincott Williams & Wilkins, 2009. </li></ul>

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