In: Martin J, Ryan R (eds). London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2012
Gibson N, Ferguson JW. Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature. Br Dent J. 2004; 197:681-685
Miller CS, Little JW, Falace DA. Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsiderations of the problem. J Am Dent Assoc. 2001; 132:1570-1579
What steroid supplementation is required for a patient with primary adrenal insufficiency undergoing a dental procedure? Simone Henderson Dental Update 2024 41:4, 707-709.
Authors
SimoneHenderson
BPharm
Medicines Information Pharmacist, North West Medicines Information Centre and National Dental Medicines Information Service, Pharmacy Practice Unit, 70 Pembroke Place, Liverpool L69 3GF, UK
Patients with primary adrenal insufficiency (Addison's disease) lack the endogenous steroid hormones cortisol and aldosterone and require daily steroid therapy (usually hydrocortisone and fludrocortisone) to replace them. These patients are unable to adapt physiologically to stress and may need supplemental steroid therapy when having dental procedures, to prevent adrenal crisis. This paper provides guidance on dental procedures for which steroid supplementation may be required in patients with primary adrenal insufficiency and gives advice on doses and timing of supplementation. It does not address the management of patients with secondary adrenal insufficiency caused by long-term use of high doses of steroids. This document is for guidance only. Patients with primary adrenal insufficiency should be assessed individually as steroid requirements will vary.
Clinical Relevance: Although patients with primary adrenal insufficiency (Addison's disease) are invariably very well informed about their steroid requirements prior to a dental procedure, dental staff should have an understanding of the steroid supplementation that may be required.
Article
Primary adrenal insufficiency (Addison's disease) is a rare disorder of the adrenal glands. It affects the production of two steroid hormones, cortisol and aldosterone, by the outer layer (the cortex) of the adrenals.1 Cortisol has glucocorticoid activity and weak mineralcorticoid activity2 and regulates extracellular fluid, helping to control the amount of fluid in the body. Lack of cortisol causes symptoms such as muscle weakness, poor concentration and low blood sugar.1 Aldosterone has mineralcorticoid activity and regulates salt and water balance, which maintains blood volume and blood pressure.1,2 Production of cortisol and aldosterone normally increases when the body experiences stress, for example, during surgery, trauma or serious infection.
The most frequent cause of Addison's disease is destructive atrophy when an over-active immune system attacks the body's own organs, in this case the adrenal glands. This accounts for around 70% of all cases and affects more women than men. In common with other autoimmune diseases, the exact reason for the atrophy is unknown. Other causes of Addison's include fungal infections, adrenal cancer and adrenal haemorrhage.1
Patients with primary adrenal insufficiency must take life-long corticosteroid replacement therapy, usually prescribed as a combination of hydrocortisone tablets (a glucocorticoid which is given to replace cortisol) and fludrocortisone tablets (a mineralocorticoid which is given to replace aldosterone).2 A daily dose of 20–30 mg of hydrocortisone is normally required and given in two or three doses. A larger dose is taken in the morning on waking and a smaller dose at lunchtime and/or in the early evening in order to mimic the normal diurnal rhythm of cortisol secretion.2 A 50–300 microgram (mcg) dose of fludrocortisone is given once daily. Prednisolone and dexamethasone, which are longer acting glucocorticoids, may sometimes be used as an alternative to hydrocortisone. A 5 mg dose of prednisolone is roughly equivalent to hydrocortisone 20 mg.2
Patients with primary adrenal insufficiency may require their usual glucocorticoid dose to be increased or supplemented at times of stress as they are unable to adapt physiologically to stress by producing more endogenous corticosteroid. Without additional steroid cover the patient may suffer shock known as Addisonian, or adrenal, crisis. Symptoms of Addisonian crisis include extreme weakness, a drop in blood pressure and confusion. A crisis is usually preceded by the symptoms of adrenal insufficiency, including headache, dizziness, nausea, vomiting and hypoglycaemia.1
Which dental procedures require additional steroid cover and what cover should be given?
The risk of adrenal crisis associated with dental procedures, and hence the need for steroid supplementation, is dependent on the type of dental procedure.1 Where supplementation is required this is given as additional or increased doses of hydrocortisone (or other glucocorticoid); supplemental fludrocortisone is not required. Suggestions for doses for steroid supplementation and the timing of these doses given below are for guidance only. Patients with primary adrenal insufficiency are invariably well informed about their medical condition and will probably be aware of their steroid requirements prior to a dental procedure. Discussion with the patient in advance of the procedure is vital to plan additional steroid needs and timing of the dental appointment (Table 1).
Discuss the dental procedure and steroid cover with the patient in advance. Most patients with Addison's disease will be knowledgeable about their steroid requirements.
Provide written advice on any supplementation and top-up doses of hydrocortisone required.
Ensure the patient has sufficient doses of hydrocortisone (or other glucocorticoid) to take prior to the dental procedure and after the procedure, if required.
Ensure that the patient knows what to do if symptoms of adrenal insufficiency occur after the procedure.
Agree with the patient whether they will bring their own emergency hydrocortisone kit or if the surgery needs to obtain one.
Dental procedures can be split into three categories depending on the associated physical stress:
Minor dental procedure, eg scale and polish, replacement of a filling, root canal treatment.
Minor oral surgery, eg tooth extraction.
Major dental surgical procedure, eg multiple tooth extraction under general anaesthetic.
Minor dental procedure, eg scale and polish, replacement of a filling, root canal treatment
Most minor dental procedures undertaken by General Dental Practitioners (GDPs) and performed under local anaesthetic are at low risk of causing adrenal crisis and steroid supplementation is not usually required.1,3,4,5 However, some patients may be more sensitive to anaesthetics and the demands of dental procedures than others and may need to take an additional dose of hydrocortisone (or equivalent glucocorticoid), if symptoms of adrenal insufficiency, such as headache, dizziness, nausea and vomiting, occur after the procedure.1
The patient should be advised to take his/her usual morning dose of steroid on the day of the procedure and continue taking the usual daily dose(s) after the procedure.1
Patients may take a small top-up dose (eg 5 mg hydrocortisone) just before the procedure if they find dental work emotionally stressful.1
Minor oral surgery, eg tooth extraction
A double dose of hydrocortisone should be taken one hour prior to surgery, up to a maximum dose of hydrocortisone 20 mg (or equivalent glucocorticoid). Advice from the Addison's disease self-help group and local endocrinology experts is to continue taking a double dose for a full 24 hours after the procedure, before returning to the usual dose.4 Some patients may feel this unnecessary based on previous experience.
On the day of the procedure:
Take the usual morning dose;
One hour before the procedure, take a double dose of the next dose due, to a maximum of 20 mg hydrocortisone (or equivalent);
Double all the other doses due that day to a maximum of 20 mg hydrocortisone (or equivalent) per dose.
The day after the procedure:
Double the morning dose, to a maximum of 20 mg hydrocortisone (or equivalent). Continue to double dose until 24 hours after the procedure.
The following are examples of additional dosing requirements for patients undergoing minor oral surgery. These are for guidance only and requirements may differ between patients.
Example 1:
The patient normally takes 10 mg hydrocortisone twice daily (at 7.30 am and 5 pm) and the dental appointment is at 10 am:
Take 10 mg at 7.30 am;
Take 20 mg at 9 am (one hour before procedure);
Take 20 mg at 5 pm;
Take 20 mg at 7.30 am the morning after the procedure;
Resume normal dosing at 5 pm (ie take 10 mg as usual).
Example 2:
The patient takes 15 mg hydrocortisone at 8 am and 5 mg at 6 pm and the dental appointment is at 2.30 pm:
Take 15 mg at 8 am;
Take 10 mg at 1.30 pm (one hour before procedure);
Take 10 mg at 6 pm;
Take 20 mg at 8 am the morning after the procedure;
Resume normal dosing at 6 pm (ie take 5 mg as usual).
Example 3:
The patient takes 20 mg hydrocortisone at 7 am, 5 mg at 1 pm and 5 mg at 6 pm and the dental appointment is at 12 noon:
Take 20 mg at 7 am;
Take 10 mg at 11 am (one hour before procedure);
Take 10 mg at 1 pm;
Take 10 mg at 6 pm;
Take 20 mg at 7 am the morning after the procedure;
Resume normal dosing at 1 pm (ie take 5 mg as usual).
Major dental surgical procedure, eg multiple tooth extraction under general anaesthetic
Patients needing a major dental surgical procedure will be managed in secondary care. They will be given intramuscular or intravenous hydrocortisone pre-operatively. After surgery, the usual oral dose of steroid should be doubled for the next 24 hours.
What can dentists do to prevent Addisonian (adrenal) crisis?
Discuss the dental procedure and steroid cover with the patient in advance (Table 1);
Plan the procedure for the morning when steroid levels will be higher.5
Ensure the patient has taken the correct dose of steroid prior to the procedure;
Ensure an Addison's emergency hydrocortisone injection kit is available.
Most patients will have their own emergency injection kit; determine whether they will bring this with them or whether the surgery will obtain a kit to be used if necessary;
Keep the patient relaxed and ensure the procedure is made as pain free and stress free as possible;
If in doubt, discuss treatment with the patient's endocrinology team (consultant endocrinologist or endocrinology specialist nurse) prior to the procedure.
What about patients who are seen as an emergency
Patients with Addison's disease presenting as an emergency with pain and dental swelling will require immediate treatment to establish drainage. Delaying treatment prolongs the stress;
Establish the patient's usual corticosteroid replacement dose regimen;
Establish when the last dose was taken and what this dose was. The patient may have already increased his/her dose to cover the stress of the dental pain/swelling;
If an extraction is required, additional supplementation will be required (see above). The patient should take a double dose of the next dose of hydrocortisone due (to a maximum of 20 mg), ideally one hour before the procedure as it takes approximately one hour for peak blood concentrations of hydrocortisone to be reached.6
If a simple incision or root canal treatment under local anaesthetic is planned, no additional doses may be required.
