This document provides guidelines for dental treatment of patients with adrenal insufficiency. It discusses adrenal insufficiency and adrenal crisis, noting that dental procedures can potentially cause adrenal crisis due to stress. It recommends corticosteroid supplementation for dental patients based on the type and severity of the dental procedure, with no supplementation needed for nonsurgical procedures, 25mg hydrocortisone for minor oral surgery, and 50-100mg hydrocortisone for more extensive procedures. The guidelines aim to safely manage dental patients' adrenal insufficiency and prevent adrenal crisis during and after dental treatment.
In this lecture I explain in step-by-step fashion the basics of Dental Management of patient with Hypertension. a photo guide is attached to the guide to aid in better understanding of the topic
This lecture talk about the disturbance of adrenal gland hormones and how it affect health. it also discuss in brief how to manage such condition in your dental clinic
This lecture talk about the disturbance of adrenal gland hormones and how it affect health. it also discuss in brief how to manage such condition in your dental clinic
Chronic Obstructive Pulmonary Disease Dental Management LectureIraqi Dental Academy
This lecture discuss an important subject in dental clinic. COPD is the third leading cause of death in united state. this lecture is oriented to the level of mind of undergraduate students.
Corticosteroids in Dentistry| Application and Adverse Effect of CorticosteroidDr. Rajat Sachdeva
Corticosteroids are very similar to Steroid hormones produced naturally in Adrenal Cortex of humans.
Protein, Carbohydrates and Fat metabolism, maintenance of fluid electrolytes and adapting the body to stress.
Corticosteroids are antinflammatory, analgesics, effective on ulceration promotes the healing of nerve injuries.
Oral Sub-mucus Fibrosis, Central Giant Cell Granuloma, Lichen Planus (for 5 min, 0.5% application of Clobetasol Propionates with Nystatin) in a Gingival Tray.
Bullous and Mucous Pemphigoid, Melkerson Rosenthal syndrome, Bell's Palsy, Post-Herpetic neuralgia.
In this lecture I explain in step-by-step fashion the basics of Dental Management of patient with Hypertension. a photo guide is attached to the guide to aid in better understanding of the topic
This lecture talk about the disturbance of adrenal gland hormones and how it affect health. it also discuss in brief how to manage such condition in your dental clinic
This lecture talk about the disturbance of adrenal gland hormones and how it affect health. it also discuss in brief how to manage such condition in your dental clinic
Chronic Obstructive Pulmonary Disease Dental Management LectureIraqi Dental Academy
This lecture discuss an important subject in dental clinic. COPD is the third leading cause of death in united state. this lecture is oriented to the level of mind of undergraduate students.
Corticosteroids in Dentistry| Application and Adverse Effect of CorticosteroidDr. Rajat Sachdeva
Corticosteroids are very similar to Steroid hormones produced naturally in Adrenal Cortex of humans.
Protein, Carbohydrates and Fat metabolism, maintenance of fluid electrolytes and adapting the body to stress.
Corticosteroids are antinflammatory, analgesics, effective on ulceration promotes the healing of nerve injuries.
Oral Sub-mucus Fibrosis, Central Giant Cell Granuloma, Lichen Planus (for 5 min, 0.5% application of Clobetasol Propionates with Nystatin) in a Gingival Tray.
Bullous and Mucous Pemphigoid, Melkerson Rosenthal syndrome, Bell's Palsy, Post-Herpetic neuralgia.
This easy and fresh lecture explain to undergraduate and newly-graduated dentists an important topic in dentistry, pain-relievers. Analgesics are used very often in dentistry and a clinical guide seems necessary.
In this lecture I explain in step-by-step fashion the basics of Dental Management of Ischemic Heart Diseases. a photo guide is attached to the guide to aid in better understanding of the topic
This lecture discuss the topic of dental management of medically compromised patient who suffers from diabetes mellitus. it's simple lecture that directed to the level of mind of undergraduate students. thanks for viewing and reading, and please share the knowledge!
This presentation gives an insight to management of diabetic patient with regard to dental treatments or procedures.
It also highlight the major emergencies that arises in treatment of diabetic patient and how to manage such incidences.
This lecture present to you the very basics of dental management of asthmatic patient in dental clinics. I kept it short and comprehensive as I can, for more info please refer to the reference mentioned in the lecture
Dental Management of Patient with Diabetes Mellitus PresentationIraqi Dental Academy
This lecture discuss the topic of dental management of medically compromised patient who suffers from diabetes mellitus. it's simple lecture that directed to the level of mind of undergraduate students. thanks for viewing and reading, and please share the knowledge!
This lecture present to you the very basics of dental management of asthmatic patient in dental clinics. I kept it short and comprehensive as I can, for more info please refer to the reference mentioned in the lecture
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICSJasmine Arneja
precise knowledge of management of medically compromised patients in any dental practice is a must, to avoid any unforeseen complication. this presentation deals with the commonly encountered medical situations and their management.
This easy and fresh lecture explain to undergraduate and newly-graduated dentists an important topic in dentistry, pain-relievers. Analgesics are used very often in dentistry and a clinical guide seems necessary.
In this lecture I explain in step-by-step fashion the basics of Dental Management of Ischemic Heart Diseases. a photo guide is attached to the guide to aid in better understanding of the topic
This lecture discuss the topic of dental management of medically compromised patient who suffers from diabetes mellitus. it's simple lecture that directed to the level of mind of undergraduate students. thanks for viewing and reading, and please share the knowledge!
This presentation gives an insight to management of diabetic patient with regard to dental treatments or procedures.
It also highlight the major emergencies that arises in treatment of diabetic patient and how to manage such incidences.
This lecture present to you the very basics of dental management of asthmatic patient in dental clinics. I kept it short and comprehensive as I can, for more info please refer to the reference mentioned in the lecture
Dental Management of Patient with Diabetes Mellitus PresentationIraqi Dental Academy
This lecture discuss the topic of dental management of medically compromised patient who suffers from diabetes mellitus. it's simple lecture that directed to the level of mind of undergraduate students. thanks for viewing and reading, and please share the knowledge!
This lecture present to you the very basics of dental management of asthmatic patient in dental clinics. I kept it short and comprehensive as I can, for more info please refer to the reference mentioned in the lecture
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICSJasmine Arneja
precise knowledge of management of medically compromised patients in any dental practice is a must, to avoid any unforeseen complication. this presentation deals with the commonly encountered medical situations and their management.
Dental Implant 1 /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
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A review article on adrenal crisis nejm 2019Tanvirul Islam
This is a review article on adrenal crisis by R. Louise Rushworth, M.B., B.S., Ph.D., David J. Torpy, M.B., B.S., Ph.D., and Henrik Falhammar, M.D., Ph.D. It was published on The New England Journal of Medicine 381;9 AUGUST 29, 2019. I presented the article on one of our morning sessions.
Clinical assessment scoring system for tracheostomy (CASST) criterion: Objec...DrKamini Dadsena
Tracheotomy has been used for many centuries as a means to bypass upper airway obstruction.
Head and neck cancers are often associated with anatomic changes which can create a potentially difficult airway.
CARNOY’S SOLUTION AS A SURGICAL MEDICAMENT IN THETREATMENT OF KERATOCYSTIC O...DrKamini Dadsena
The term keratocyst was coined by Philipsen in 1956.
Unlike the other cystic lesion KOT, has got strong tendency for recurrence.
Treatment of these lesions remains controversial and has a number of dilemmas about the choice of treatment whether to use carnoys solution as an adjunct therapy after removal of the lesion.
Temporomandibular disorders (TMDs) are considered the major cause of orofacial pain. Internal derangement (ID) of the temporomandibular joint (TMJ), which is classified as disc displacement with or without reduction, is one of the disorders of the TMJ that is frequently seen.
Displacement of the articular disc can result in decreased joint space, joint noise (clicking, popping, or crepitation), arthritis, condylar resorption, inflammation, and compression of the bilaminar tissue, all of which can cause various degrees of pain and dysfunction.
Changing Guidelines of CPR & BLS For General Dental Practitioners & O...DrKamini Dadsena
The tolerance of the heart to anoxia is relatively high, but the central nervous system will show irreversible lesions if anoxia lasts for more than 3–4 min.
Though unusual, there are reports of deaths due to CPA in dental offices during dental treatment.
Cardiopulmonary resuscitation (CPR) is a vital skill which must be mastered by all health care professionals.
Therefore the thorough knowledge of CPR and Basic Life Support is of utmost importance to the dentist.
Neck Dissection: Nomenclature, Classification, and TechniqueDrKamini Dadsena
Removal of the at-risk lymphatic basins serves two important purposes.
First, it allows the removal and identification of occult metastasis in patients in whom cervical metastasis are a risk, - Elective neck dissection.
Secondly, it allows the removal of disease in patients in whom metastasis are highly suspected based on imaging, clinical examination or fine needle aspiration, - Therapeutic neck dissection.
Clinical use of botulinum toxins in oral and maxillofacial surgeryDrKamini Dadsena
Purified botulinum toxin (BTX) was the first bacterial toxin used as a medicine. Since its introduction into clinical use, over 30 years ago, it has become a versatile drug in various fields of medicine.
Its mechanism of inhibiting acetylcholine release at neuromuscular junctions following local injection is unique for the treatment of facial wrinkles.
Other dose-dependent anti-neuroinflammatory effects and vascular modulating properties have extended its spectrum of applications.
Cavernous sinus thrombosis represents a rare but devastating disease process that may be associated with significant long-term patient morbidity or mortality. The prompt recognition and management of this problem is critical.
In 1989, Shetty and Freymiller [7] reviewed indications for removal of teeth in the line of fracture. They recommended the following indications:
1. Significant periodontal disease with gross mobility and periapical pathology
2. Partially erupted third molars with pericoronitis or cystic areas
3. Teeth preventing the reduction of fractures
4. Teeth with fractured roots
5. Teeth with exposed root apices or teeth in which the entire root surface from the apex to the gingival margin is exposed
6. Excessive delay from the time of fracture to the time of definitive treatment
In addition to these indications, another indication that requires extraction of teeth in the line of fracture is an acute, recurring abscess at the site of the fracture despite antibiotic therapy(8)
Assessment of lingual nerve injury using different surgical variables for man...DrKamini Dadsena
Assessment of lingual nerve injury using different surgical variables for mandibular third molar surgery
The objective of this study was to investigate the incidence of sensory impairment of the lingual nerves following lower third molar surgery and to compare the outcome with various operative variables.
Factors that predicted lingual nerve injury were lingual flap retraction, tooth sectioning, and buccal guttering.
Instruments in major oral and maxillofacial surgeryDrKamini Dadsena
A surgical instrument is a specially designed tool or device for performing specific actions and carrying out desired effects during surgery or operations.
Fracture is a break in the structural continuity of bone, And starts immediately after the fracture occurs.
fracture results in a well-defined progression of tissue responses that are designed to remove tissue debris, to reestablish vascular supply and to produce a new skeletal matrix.
Traditional classification were given 100 years back when RTA , assaults, sports injuries, industrial accidents were minimal.
Over the past 100 years RTA (high speed & Low speed) assaults, sports injuries (high contact/ low contact), industrial accidents have increased.
Fracture patterns which are not matching the traditional injuries pattern.
Can speed up diagnosis and treatment planning
Cohorting / clubbing of complication to Specific Fractures.
It facilitate communication between peers and assist documentation and research.
It also have prognostic value for patients and assist Surgeons in planning their management.
It serves as a basis for treatment and for evaluation of the results.
Different fractures/ Areas of fracture has different treatment plan / approaches.
Undisplaced fracture : conservative/ surgical
Displaced Fractures: Surgical/ conservative with traction
Trauma is a global problem and continues to be a leading cause of disability and death.
Approximately 25% to 30% of deaths caused by trauma can be prevented when a systematic and organized approach is used.
The main goal of the initial assessment
Recognize the patient who does have life-threatening injuries
Establish treatment priorities, and
Manage them aggressively
A flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site) while maintaining its own blood supply or from a anastomised vessel.
Flaps come in many different shapes and forms. They range from simple advancements of skin to composites of many different types of tissue
The International Association for the Study of Pain (IASP)1 defines trigeminal neuralgia (TN) as a sudden, usually unilateral, severe brief stabbing recurrent pain in one or more branches of the fifth cranial nerve
synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
In 1677 John Locke, a American physician and philosopher, accurately identified the major clinical features of TN
In 1756 the French physician Nicolaus Andre coined the term “Tic douloureux” to the condition.
The English physician John Fothergill in 1773 published detailed description of TN, since then, it has been referred to as ‘Fothergill’s disease’.
Peripheral injections
Long acting LA
Alcohol
Glycerol
Peripheral neurectomy/ nerve avulsion
Cryotherapy
Gasserian ganglion procedures
Percutaneous stereotactic radiofrequency thermal lesioning of the trigeminal ganglion and/or root (rfl)
percutaneous glycerol gangliolysis of the trigeminal ganglion
percutaneous balloon microcompression of the trigeminal ganglion
Intracranial procedures
MVD
Partial sensory rhizotomy
Gamma knife radiation to the trigeminal root entry zone GKR
An oroantral communication is an unnatural perforation between oral cavity and maxillary sinus.
Oroantral fistula is an epithelized, pathological, communication between these two cavities. A fistulous tract present more than 14 days should be considered as chronic fistula.
The practice of surgery rests on certain fundamental principles which remain unchanged, though to apply them the surgeon may have to modify techniques to suit the anatomical field, the type of operation and the conditions obtaining at the time.
Obstructive sleep apnea (OSA) is a prevalent chronic disease characterized by pharyngeal collapse during sleep.
Sleep disorder that involves cessation or significant decrease in airflow through the upper airway in the presence of breathing effort.
Obstructive sleep apnea is the second most common sleep disorder, insomnia being the most common.
Associated with recurrent oxyhemoglobin desaturations and arousals from sleep
Apnea index- no. of apneas /hr of total sleep time.
AHI (APNEA-HYPOPNEA INDEX)- No of apneas and hypoapneas/hr of total sleep time.
RDI (Respiratory Disturbance Index) – no. of apneas, hypoapneas and respiratory effort related arousals(RERA)/hr of total sleep time.
Pain pathway gate control theory
Pain management
An unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to CNS where it is interpreted as such.
1. Exteroceptors: arising from receptors from skin & mucosa. sensed at conscious level
E.g. Merkel corpuscles : Tactile receptors.
Free Nerve ending :Perceive superficial pain.
2. Proprioceptors : From musculoskeletal structures.
The presence , positions & movement of body. below conscious levels.
E.g. 1) Muscle spindles : Skeletal muscle fibers. Mechanoreceptors.
2) Free nerve ending : Perceive deep somatic pain & other sensations.
3. Interoceptors : From viscera of body below conscious level.
E.g. Pacinian corpuscles : perception of touch-pressure.
Free nerve ending : Perceive visceral pain & other sensations.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
2. Supplemental corticosteroids for
dental patients with adrenal
insufficiency
Reconsideration of the problem
Presented By
Dr Kamini Dadsena
Journal of the American Dental Association. 2001 Nov 30;132(11):1570-9.
MILLER CS, LITTLE JW, FALACE DA.
3. Outline
• Adrenal Insufficiency
• Adrenal Crisis
• Medical recommendation
• General anaesthesia
• Adrenal crisis and identification of risk in dentistry
• Guideline for perioperative coverage in dentistry
• Dental management guideline for patient with
adrenal insufficiency
• Conclusion
• References
4. Adrenal Insufficiency
Primary Adrenal Insufficiency:
• It is caused by a progressive destruction of the
adrenal cortex, usually of an idiopathic nature
(most commonly autoimmune), but also results
from hemorrhage, sepsis, infectious diseases (such
as tuberculosis, human immunodeficiency virus,
cytomegalovirus and fungal infection), malignancy,
adrenalectomy, amyloidosis or drugs.
6. FEATURES OF ADRENAL INSUFFICIENCY
VARIABL
E
PRIMARY ADRENAL
INSUFFICIENCY
SECONDARY ADRENAL
INSUFFICIENCY
CUSHING’S SYNDROME ADRENAL CRISIS
Underlyi
ng
Problem
Glucocorticoid and
mineralocorticoid deficiency
due to destruction or atrophy
of adrenal gland
Glucocorticoid deficiency due
to hypothalamic or pituitary
disease
Potential glucocorticoid
insufficiency due to long-term
administration of
corticosteroid for
inflammatory condition or
organ Transplantation
severe glucocorticoid
deficiency with or without
mineralocorticoid deficiency
due to stress (for example,
surgery, infection) and inability
of adrenal cortex to meet
demand
Clinical
Features
Weakness, fatigability, weight
loss, hypotension (may be
orthostatic),
hyperpigmentation
of skin, mucous membranes
and creases; less common are
anorexia, nausea, vomiting,
abdominal pain, salt craving,
myalgia, personality changes,
diarrhea, malaise; hair
loss in women.
Similar to primary adrenal
insufficiency except less
dramatic, no
hyperpigmentation
and patients tend not to be
salt-depleted or extracellular
volume–depleted
Cushingoid features: weight
gain, moon face, thin skin,
buffalo hump (that is, fat
pad on neck), central obesity,
acne, bruisability,
Hypertension
Major categories:
• Gastrointestinal (nausea,
vomiting, diarrhea, stomach
cramps)
• Hypotension, weak pulse,
profuse sweating,
weakness, fatigue
• Headache, sunken eyes,
cyanosis
• Fever, dehydration, dyspnea
progressing to hypothermia
• Myalgias, Arthralgia
Laborato
ry
Features
Hyponatremia, hyperkalemia,
elevated BUN,‡ occasionally
hypercalcemia, low serum
glucose level with sensitivity
to fasting, mild anemia,
Eosinophilia
Fluid and electrolyte
disturbances are less common
than in primary disease except
mild hyponatremia,
hypoglycemia, mild anemia
and Eosinophilia
Can be normal or abnormal
based on underlying Condition
Hyponatremia and
eosinophilia,
hypoglycemia, Azotemia
Therapy Glucocorticoid and
mineralocorticoid
Glucocorticoid Addition of steroidsparing
Drugs (azathioprine,
methotrexate can reduce the
adverse effects of steroids)
Intravenous bolus of 100
milligrams of hydrocortisone,
fluid and electrolyte
Replacement
7. ADRENAL CRISIS
• This event can occur when a patient with AI is challenged by stress and, in
response adrenal gland is unable to synthesize adequate amounts of cortisol
and aldosterone.
• profuse sweating, hypotension, weak pulse, cyanosis, nausea, vomiting,
weakness, headache, dehydration, fever, sunken eyes, dyspnea, myalgias,
arthralgia, hyponatremia and eosinophilia.
• If not treated rapidly, the patient may develop hypothermia, severe
hypotension, hypoglycemia, confusion and circulatory collapse that can
culminate in death.
8. ADRENAL CRISIS
• Adrenal crisis requires immediate intravenous administration of a
glucocorticoid—usually a 100-mg hydrocortisone bolus—and intravenous
fluid and electrolyte replacement to restore the blood pressure.
• After the initial treatment, 100 mg of hydrocortisone is administered slowly
intravenously every six to eight hours during the first 24 hours, along with
fluid replacement, vasopressors and correction of hypoglycemia.
9. MEDICAL RECOMMENDATIONS
• Since the mid-1950s, supplemental steroids have been recommended before
and during surgery to prevent adrenal crisis in patients who receive steroid
therapy.
• The consensus among the medical community has been to provide “stress
coverage” of 200 mg of hydrocortisone or its equivalent in the morning and 100
mg in the evening during periods of acute stress (such as surgery), trauma or
illness.
10. MEDICAL RECOMMENDATIONS
Surgery
• Surgery is known to cause increased plasma corticosteroid levels
during and after operations, with plasma cortisol levels reaching
their peak between four and 10 hours after surgery.
• The level of response is based on the magnitude of the surgery
and whether general anesthetic is used.
• the plasma cortisol levels decline after postoperative
administration of an analgesic
11. MEDICAL RECOMMENDATIONS
General anesthesia
• General anesthesia in corticosteroid-treated patients significantly depresses the
plasma cortisol response to surgery compared with that in patients who have
not received corticosteroid drugs.
• This may be an effect of steroid-induced AI or the use of barbiturate anesthetic
drugs that can lower cortisol Production for minor surgery,
12. MEDICAL RECOMMENDATIONS
• Salem and colleagues suggested that clinicians replace glucocorticoids
only in an amount equivalent to the normal physiological response to
surgical stress, and that the risk of an adverse outcome depends on the
duration and severity of the surgery, the preoperative glucocorticoid
dose and the overall health of the patient
• Kehlet and Binder and Hume and colleagues estimated that an average
adult secretes 75 to 150 mg a day in response to major surgery, and 50
mg a day during minor procedures.
13. Adrenal Crisis &
Identification of Risk in
Dentistry
1. The stress of multiple extractions and the presence of oral
infection;
2. hypovolemia resulting from recent diarrhea or bleeding from
the surgical site;
3.Inadequate circulating plasma cortisol (or glucose) levels as a
result of AI, a fasting state, use of a barbiturate-containing
general anesthetic that can metabolize circulating cortisol, or
inadequate or inappropriate dosing of hydrocortisone before
and during the procedure.
14. Adrenal Crisis &
Identification of Risk in
Dentistry
1. The stress of multiple extractions and the presence of oral
infection;
2. hypovolemia resulting from recent diarrhea or bleeding from
the surgical site;
3.Inadequate circulating plasma cortisol (or glucose) levels as a
result of AI, a fasting state, use of a barbiturate-containing
general anesthetic that can metabolize circulating cortisol, or
inadequate or inappropriate dosing of hydrocortisone before
and during the procedure.
15. GUIDELINES FOR
PERIOPERATIVE
COVERAGE IN DENTISTRY
1. the magnitude of surgery
2. use of general anesthetic
3. overall health of the patient (for example, stable
vs. ongoing infection)
4. the degree of pain control
16. Dental Procedures And Recommended
Corticosteroid Supplementation In
Patients With Adrenal Insufficiency.
NEGLIGIBLE RISK CATEGORY
• Nonsurgical dental procedures
• Regimen: No supplementation required
17. Dental Procedures And Recommended
Corticosteroid Supplementation In
Patients With Adrenal Insufficiency.
MILD RISK CATEGORY
• Minor oral surgery: A few simple extractions, biopsy, Minor periodontal surgery
• Regimen: The glucocorticoid target is about 25 milligrams of hydrocortisone
equivalent (5 mg of prednisone) the day of surgery
18. Dental Procedures And Recommended
Corticosteroid Supplementation In
Patients With Adrenal Insufficiency.
MILD RISK CATEGORY
• Minor oral surgery: A few simple extractions, biopsy, Minor periodontal surgery
• Regimen: The glucocorticoid target is about 25 milligrams of hydrocortisone
equivalent (5 mg of prednisone) the day of surgery
19. Dental Procedures And Recommended
Corticosteroid Supplementation In
Patients With Adrenal Insufficiency.
MODERATE-TO-MAJOR RISK CATEGORY
• Major oral surgery: Multiple extractions, quadrant periodontal surgery,
extraction of bony impactions, osseous surgery, osteotomy, bone resections,
cancer surgery, surgical procedures involving general anesthesia, procedures
lasting more than one hour, procedures associated with significant blood loss
• Regimen: The glucocorticoid target is about 50 to 100 mg per day of
hydrocortisone equivalent the day of surgery and for at least one postoperative
day.
20. Guidelines for perioperative
Coverage in Dentistry
• Salem and colleagues. Higher doses may be needed if excessive
bleeding or complications are encountered. Patients should take
their usual steroid dose before the procedure, and supplemental
intravenous hydrocortisone should be administered during
surgery to achieve a total glucocorticoid level of 100 mg.
• Hydrocortisone (25 mg) usually is prescribed every eight hours
after surgery for 24 to 48 hours, depending on the procedure and
the anticipated level of postoperative pain.
21. Dental Management
Guidelines For Patients With
Adrenal Insufficiency.
• Define the risk of adrenal insufficiency through medical history and clinical
examination. An increased risk of adrenal insufficiency exists when there
is a history of tuberculosis or human immunodeficiency virus infection,
since opportunistic infectious agents can attack the adrenal glands.
• Ensure that patients with adrenal insufficiency take their usual
glucocorticoid dose before a stressful surgical procedure.
• Schedule surgery in the morning, when cortisol levels usually are highest.
22. Dental Management
Guidelines For Patients With
Adrenal Insufficiency.
• Provide proper stress reduction, since anxiety can increase cortisol
demand.
• Minor surgeries require minimal steroid coverage. The patient’s usual daily
dose typically is sufficient.
• Major surgeries and those lasting more than one hour or involving general
anesthesia should be performed in a hospital with steroid supplementation.
• Use of nitrous oxide-oxygen or intravenous or oral benzodiazepine sedation
is helpful, since plasma cortisol levels are not reduced by these agents.
23. Dental Management Guidelines For
Patients With Adrenal Insufficiency.
• Avoid general anesthesia for outpatient procedures, since it increases glucocorticoid
demand. Avoid the use of barbiturates, since these drugs increase the metabolism of
cortisol and reduce blood levels of cortisol.
• Discontinue drug therapy that decreases cortisol levels (for example, ketoconazole)
at least 24 hours before surgery, with the consent of the patient’s physician.
• Provide adequate pain control during the operative and postoperative phases of
care. Clinicians should ensure good postoperative pain control by administering
long-acting local anesthetics (for example, bupivicaine) at the end of the procedure,
as well as regular analgesic dosing.
24. Dental Management
Guidelines For Patients With
Adrenal Insufficiency.
• Blood and other fluid volume loss, as well as the use of anticoagulants can
exacerbate hypotension and increase the risk of adrenal insufficiency-like
symptoms. Thus, methods to reduce blood loss should be used.
• Monitor blood pressure throughout the procedure and before the patient
leaves the dental office. Patients whose blood pressure is at or below
100/60 millimeters of mercury should receive fluid replacement (5
percent dextrose), vasopressors or, if needed, glucocorticoids.
• Recognize the signs of hypotension, hypoglycemia and hypovolemia and
take corrective action quickly.
25. Conclusion
• Analysis of the literature suggests that adrenal crisis is rare in
dentistry, specific risk factors increase the risk of an adverse event
developing in patients who have AI, and perioperative
glucocorticoid supplementation can be prescribed in a more
rationale manner than is currently the case.
• As new evidence becomes available, the suggested
recommendations for perioperative glucocorticoid
supplementation in dentistry may need to be modified.
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The adrenal cortex produces mineralocorticoids and glucocorticoids that are important in maintaining fluid volume.
Cortisol, the principal glucocorticoid, maintains extracellular fluid, whereas aldosterone, the principal mineralocorticoid, regulates salt and water balance.
Insufficient production of these hormones can result from primary or secondary adrenal disease.
In the absence of hypothalamic or pituitary function, the adrenal cortex undergoes irreversible atrophy
In contrast, long-term administration of corticosteroids blunts adrenal cortical function, with variable and reversible effects
1 The most significant acute adverse outcome of AI is adrenal crisis
3 This potentially life-threatening emergency usually evolves slowly during a few hours and then is manifested by severe exacerbation of the condition, including
Adrenal crisis is rare in patients with secondary AI, because the majority of these patients have normal aldosterone levels
Since the manifestations usually are limited to those of glucocorticoid deficiency, the features of rapid hypotension, dehydration and shock seldom are
encountered in patients with secondary AI.
X Features more commonly involve hypoglycemia, weakness, gastrointestinal complaints and a slowly evolving hypotension.
This regimen is based on clinical inferences from case reports that the cortisol secretion rate increases during acute stress and can reach levels in the range of 100 to 300 mg per day
3 Postoperative pain also is contributory,
A significant proportion of patients receiving prednisone therapy (5 to 50 mg daily) for between six days and 10 years who stopped therapy before surgery produced plasma cortisol levels similar to those of healthy subjects for up to seven days after minor or major surgery, and followed a normal postoperative course
Based on these findings, Salem and colleagues made the following general surgery and general anesthesia recommendations.
The authors of this study searched medical literature using MEDLINE from 1966 through 2000 for reports that addressed adrenal crisis in dentistry.
their analysis resulted in the identification of only four reports an adrenal crisis related to dental treatment.
They identified the following additional factors that could have increased the patients’ risk of developing hypotension and features of adrenal crisis:
From these studies, four factors appear to contribute to the risk of adrenal crisis during the perioperative period of oral surgery. These include
Based on these data suggest guidelines for risk stratification of patients who have AI Three categories are introduced, primarily on the basis of the type and magnitude of the procedure performed and the risk of adrenal crisis.
vast majority of patients with AI can undergo routine, nonsurgical dental treatment without the need for supplemental glucocorticoids.
This conclusion is supported by the fact that routine, nonsurgical dental procedures do not stimulate cortisol production at levels comparable to those of oral surgery,49 and local anesthetic blocks neuralstress pathways required for ACTH secretion
1 Patients at risk of experiencing adrenal crisis are those who undergo stressful surgical procedures and have no, or extremely low, adrenal function as a result of primary or secondary AI. Evidence10,14,26 indicates that the risk of adrenal crisis is greater for primary AI than for secondary AI due to hypothalamic or pituitary disease or destruction Patients who receive less than 30 mg/day of cortisol equivalent, or who receive topical or inhaled steroid therapy rarely have adrenal suppression
Some Studies have investigated the stress response to minor general and oral surgical procedures have concluded that significant cortisol increases generally are not seen before or during the operation, but occur in the postoperative period, approximately one to five hours after the start of the procedure The postoperative increase in plasma cortisol levels likely is a response to pain, since postoperative increases in cortisol levels correlate with the loss of local anesthesia54 and are blunted by the use of analgesics.
Stress reduction measures should be implemented. Benefits can be gained from use of the following:
oral, inhalation or intravenous sedation that provides stress reduction;
intravenous fluids (that is, 5 percent dextrose) that can prevent hypovolemiaand hypoglycemia;
long-acting local anesthetics;
adequate postoperative analgesics
They increase the demand for cortisol because of postoperative pain. Also, blood loss is greater, thus increasing the risk of developing hypovolemia and hypotension.
(for example, multiple extractions, quadrant periodontal surgery, extraction of bony impactions, osseous surgery, osteotomy, bone resections, oral cancer surgery),