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Dental Management of Patient With Adrenal Cortex Disorder

a presentation describe the physiology of adrenal gland and focuses on line of treatment and dental management of patient with adrenal cortex problems as over and under production of adrenal secretions

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Dental Management of Patient With Adrenal Cortex Disorder

  1. 1. Adrenal Gland Disorder Dr.Tarek Nageib Zaid By
  2. 2. TO BE DISCUSS IN PRESENTATION topics 1- Physiology Of Adrenal Gland Action 2-Type of Adrenal Gland Disorder 3- The Signs And Symptoms 4- Treatment And Dental Management
  3. 3. THE ADRENAL GLANDS Are Small (6 To 8 G) Endocrine Glands That Are Located Bilaterally At The Superior Pole Of Each Kidney. Each Gland Contains An Outer Cortex And An Inner Medulla. The Adrenal Medulla Functions As A Sympathetic Ganglion Secretes Catecholamines, Primarily Epinephrine, The Adrenal cortex secrete multiple steroids with multiple function Eg : Aldosterone (mineralocorticoids) androgens cortisone ( glucocorticosteroid )
  4. 4. THE ADRENAL GLANDS Aldosterone (mineralocorticoids Regulates Physiologic Levels Of Sodium And Potassium And Is Relatively Independent Of Pituitary Gland Feedback (depend mainly on angiotensin renin system) androgens Maturation of sexual organs
  5. 5. THE ADRENAL GLANDS Cortisone ( Glucocorticosteroid ) • Regulation Of Carbohydrate, Fat, And Protein Metabolism • Maintenance Of Vascular Reactivity • Inhibition Of Inflammation, And Maintenance Of Homeostasis • During Periods Of Physical Or Emotional Stress • Cortisol Acts As An Insulin Antagonist : 1-increasingnblood Levels And Peripheral Use Of Glucose 2-increasing Liver Glucose Output 3-initiating Lipolysis, Proteolysis, and Gluconeogenic Mechanisms • Anti Inflammatory Action : As It Inhibit 1-lysosome Release 2-prostaglandin Production 3-eicosanoid And Cytokine Release 4-the Function Of Leukocytes 5-endothelial Cell Expression Of Intracellular And Extracellular Adhesion Molecules That Attract Neutrophils
  6. 6. Corticotropin-Releasing Hormone Regulation of cortisol secretion Regulation of cortisol secretion occurs via the hypothalamic-pituitary-adrenal (HPA) axis AdrenocorticoTropic Hormone ١ 2 3 4
  7. 7. HPA AXIS ١ 2 3 4 Stress : Trauma-illness- Burns, Fever-hypoglycemia-emotional Upset Hypothalamus Stimulation And Release Of CRH Which Stimulate The Pituitary Gland To Release ACTH Acth Stimulate The Adrenal Cortex To Release The Glucocorticosteroid When The Level Of Cortisone Increse In Blood Negative Feed Back Occur On Pitutray Gland To Inhibit The Secretion Of ACTH
  8. 8. HPA AXIS Cortisol secretion normally follows a diurnal pattern. Peak levels of plasma cortisol occur about the time of awakening in the morning and are lowest in the afternoon and evening3 The normal secretion rate of cortisol over a 24-hour period is approximately 20 mg. During periods of stress, the HPA axis is stimulated, resulting in increased secretion of cortisol Diagram showing cortisone level during the day
  9. 9. Disorders that affect the adrenal glands result in Under production of gland secretion Over production of gland secretion Increase The Production Of : • Androgens • Estrogens • Aldosterone • Glucocorticosteriods The Most Common Overproduction Is Glucocortiocosteriods Cushing’s disease Primary Deficiency Result From Destruction Of Adrenal Cortex Due To : Autoimmune Diseases Infection As Tuberculosis Mainly In Developing Countries Secondary Deficiency As Result From -Pituitary Hypothalamic Problems -Secondary To Corticosteroid Drug Administration Addison’s disease
  10. 10. Addison disease is rare endocrinal disorder characterized by excessive loss of adrenal gland cortex secretion , in the developed nations it usually related to auto-immune disorder but in the developing nations it is widely associated with tuberculosis (decrease in cortisol and aldosterone hormones)
  11. 11. Addison’s disease Impaired metabolism of glucose, fat, and protein hypotension increased ACTH secretion impaired fluid excretion inability to tolerate stress excessive pigmentation Aldosterone deficiency results in an inability to conserve sodium and eliminate potassium and hydrogen ions, leading to Hypovolemia hyperkalemia acidosis. Weakness And Fatigue Abnormal Pigmentation Of The Skin And Mucous Membranesa Hypotension, anorexia, and weight loss If a patient with Addison’s disease is challenged by stress adrenal crisismay be precipitated is severe exacerbation of the patient’s condition including : sunken eyes, profuse sweating, hypotension, weak pulse, cyanosis, nausea, vomiting, weakness, headache, dehydration, fever, dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia. If not treated rapidly, the patient may develop hypothermia, severe hypotension, hypoglycemia, and circulatory collapse that can result in death. Crisis Patient with : Sings and symptoms
  12. 12. 26 years old FEMALE Bleeding Gum And Bad Breath, Since Last 10 Months. Patient Was Anxious, But Evidently Fatigued, Weakened, And Easily Irritable. Patient Also Gave A History Of Occasional Abdominal Pain, Amenorrhea, Nausea, And Vomiting, Dysphagia, Weight Loss And Hypotension. She Also Gave History Of Sleep Disturbances Occasionally, Which Is Usually Accompanied By The Exacerbation Of Abdominal Pain. • Thin And Brittle Nail, Scanty Body Hair • Hyperpigme ntation Of Skin In The Neck • Pulse Of 106 Bpm, • Blood Pressure 90/65 Mmhg
  13. 13. Intra Oral Examination Pigmentation With Bilateral Involvement Of Buccal Mucosa, Gingival, Mucosal Surface Of Lower Lip, Alveolar Mucosa, And Hard Palate The Gingiva Appears To Be Blunt With Apical Positioning Of Gingival Margins, Significant Loss Of Attachment With Pocket Depth Between 3 And 5 Mm
  14. 14. Intra Oral Examination Tongue Appears To Be Smooth With Loss Of The Papilla With Pigmentation On The Posterior Surface
  15. 15. Laboratory investigation • Anemia With Hemoglobin Level =7.8 G/Dl • Normal Red Blood Cell Morphology • Erythrocyte Sedimentation Rate (Esr)= 59 Mm/H, • Fasting Blood Sugar =70 Mg/Dl. • Early Morning Cortisol Level Was Well Below Normal Level 2.2 Μg/Dl. • Anti-hiv, Anti Hepatitis C Virus Hepatitis B Surface Antigen (Hcv Hbsag) Factors Were Negative • Mantoux Tuberculin Skin Test Was Negative And Chest Radiograph Also Ruled Out Tuberculosis
  16. 16. Laboratory investigation • Anemia With Hemoglobin Level =7.8 G/Dl • Normal Red Blood Cell Morphology • Erythrocyte Sedimentation Rate (Esr)= 59 Mm/H, • Fasting Blood Sugar =70 Mg/Dl. • Early Morning Cortisol Level Was Well Below Normal Level 2.2 Μg/Dl. • Anti-hiv, Anti Hepatitis C Virus Hepatitis B Surface Antigen (Hcv Hbsag) Factors Were Negative • Mantoux tuberculin skin test was negative and chest radiograph also ruled out tuberculosis After History & Investagation And Clinical Finding ….Final Diagnosis Is Addison’s Dieses Which Precipitated By Acute Malarial Attack
  17. 17. Secondary adrenal insufficiency Causes : Long duration of large corticosteroids dose Pituitary or hypothalamic problems Inhibit the secretion of ACTH from pituitary gland Due To Sign and symptoms partial insufficiency that is limited to glucocorticoids The condition usually does not produce any symptoms unless the patient is significantly stressed and does not have adequate circulating cortisol during times surrounding stress. In this event, an adrenal crisis is possible. However, an adrenal crisis in a patient with secondary adrenal suppression is rare and tends not to be as severe as that seen with primary adrenal insufficiency because aldosterone secretion is normal. Decrease the secretion of ACTH from pituitary gland
  18. 18. Treatment and dental management
  19. 19. ttt of addision diseaes • Elimination of cause aldosterone Glycocorticosteroids 20 -30 mg hydrocortisone or 30 mg cortisone 0r 7.5 mg prednisone Fludrocortisone .05 to .1 mg Current practice recommends that two thirds of the dose should be given in the morning and one third in the later afternoon to reflect the normal diurnal cycle.
  20. 20. Patient In Adrenal Crisis
  21. 21. Adrenal crisis is an acute adrenal insufficiency This condition requires immediate treatment including: IV injection of a glucocorticoid—usually a 100-mg hydrocortisone fluid and electrolyte replacement Over the first 24 hours, 100 mg is administered IV slowly every 6 to 8 hour if needed, blood pressure is supported with fluid replacement and vasopressors, along with correction of hypoglycemia
  22. 22. Alternate days Secondary adrenal insufficiency Drug dose modification Daily dose 2/3 of the dose at Morning long-term steroid use result in partial adrenal insufficiency Steroids Are Prescribed In The Management Of Non Endocrine Disorders For Their Anti-inflammatory And Immunosuppressive Properties The Goal Of Treatment Is To Achieve Resolution Of Disease Symptoms While Minimizing Adverse Effects So The Technique Of Drug Administration must Modify This method allows ….the adrenal gland to function normally during the off day and thus does not tend to cause axis suppression. A tapered dosage schedule Dose of drug decrease gradually until time of treatment finished ( gradual reverse of gland function ) to reflect the normal diurnal cycle of cortisone secretion
  23. 23. current recommendations For surgical procedure
  24. 24. Normal patient Preoperative Intraoperative Postoperative The Normal Response To Surgical Stresses Plasma cortisol level 20 mg Adults Secrete 75 To 150 Mg A Day In Response To Major Surgery And 50 Mg A Day During Minor Procedures. Cortisol Secretion In The First 24 Hours After Surgery Rarely Exceeds 200 Mg 200 mg
  25. 25. Factors affecting level of cortisol after surge • The Magnitude Of The Surgery • Whether General Anesthesia Is Used. • The Duration And Severity Of Surgery And Level Of Pain Control • The Amount Of Cortisol Produced During The Physiologic Response To Surgical Stress • The Overall Health Of The Patient Who Takes Daily Steroids The Need For Glucocorticoid Replacement On Three Factors :
  26. 26. the glucocorticoid target Glycocorticosteriods Replacement Protoc Low Cortisol Level After Surgery (Adrenal Insufficiency ) Minor Surgical Stress 25 mg of hydrocortisone equivalent on the day of surgery. Example An Asthmatic Patient Who Takes 5 Mg Of Prednisone Every Other Day Should Receive 5 Mg Of Prednisone On The Day Of Surgery Preoperatively
  27. 27. the glucocorticoid target moderate surgical stress 50 to 75 mg per day of hydrocortisone equivalent for up to 1 to 2 days Example A patient with systemic lupus erythematosus who takes 10 mg prednisone daily should receive of prednisone (or parenteral equivalent) preoperatively and of hydrocortisone intravenously intraoperatively. On the first postoperative day, of hydrocortisone is administered intravenously every 8 hours The patient is returned to the preoperative glucocorticoid dose on postoperative day 2 Glycocorticosteriods Replacement Protoc Low Cortisol Level After Surgery (Adrenal Insufficiency )
  28. 28. Glycocorticosteriods Replacement Protoc Low Cortisol Level After Surgery (Adrenal Insufficiency ) the glucocorticoid target For major surgical stress 100 to 150 mg per day of hydrocortisone equivalent given for 2 to 3 days. Example patient with Crohn’s disease who takes 40 mg prednisone daily for several years should receive 40 mg prednisone (or the parenteral equivalent) preoperatively and 50 mg hydrocortisone intravenously every 8 hours after the initial dose for the first 48 to 72 hours after surgery.
  29. 29. Evidence indicates that the vast majority of patients To Determine Who Is At Risk For Adrenal Insufficiency Or Crisis (By Using Laboratry Steps Determine The Status And Stabilitiy Of ACTH And CRH ) 1- ACTH Test 2-CRH Test
  30. 30. Dental Management Steps With Patient With Possible Adrena Insufficiency
  31. 31. Cushion syndrome Over production of glucocorticosteriods
  32. 32. Sign and symptoms weight gain, round or moon-shaped facies “buffalo hump” on the upper back abdominal striae, hypertension Hirsutism acne glucose intolerance (e.g., diabetes mellitus), heart failure Osteoporosis and bone fractures psychiatric disorders (mental depression, mania, anxiety disorders) cognitive dysfunction psychosis Insomnia peptic ulceration cataract formation glaucoma growth suppression delayed wound healing
  33. 33. “Buffalo Hump” On The Upper Back
  34. 34. Moon Face Appearance
  35. 35. weight gain, round or moon-shaped facies abdominal striae
  36. 36. Cushion syndrome Before after
  37. 37. Dental Management Patients With Hyperadrenalism Have An Increased Likelihood Of Hypertension And Osteoporosis And Increased Risk For Peptic Ulcer Disease. To Minimize The Risk Blood Pressure Should Be Taken At Baseline And Monitored During Dental Appointments Osteoporosis Has A Relationship With Periodontal Bone Loss, Implant Placement, And Bone Fracture. Treatment Planning Should Address The Risk For Periodontal Bone Loss, And Measures Should Be Instituted That Promote Bone Mineralization And Avoid Extensive Neck Manipulation If Osteoporosis Is Severe. Because Of The Risk Of Peptic Ulceration, Postoperative Analgesics Selection Should Not Include Aspirin And Non Steroidal Anti-inflammatory Drugs For Long-term Steroid Users.
  38. 38. Important
  39. 39. Manifestation Appear After 90 % Destruction Of The Gland And Oral Manifestation Appear First So Dentist Can Make Earrly Diagnosis Of The Disease Addison's Diseases Is Primary Under Production Of Adrenal Cortex Secretion Include The Aldosterone And Cortisone Patient Secondary Adrenal Insufficiency May Be Without Any Manifestation Until Be Under Stress Like Surgical Stresses Due To The Partial Adrenal Insufficiency Cushion Disease Is Overproduction Of Cortisone From Adrenal Cortex Patient With Cushion Disease Has Liability For Peptic Ulcer So Avoid Aspirin & The Non Steroidal Analgesics And Anti Cox2 Is Best Choice