Adrenal Gland Disorder Dr.Tarek Nageib Zaid By Treatment And Dental Management Of Gland Problems
Adrenal Gland Disorder
Dr.Tarek Nageib Zaid
By
Treatment And Dental Management Of Gland Problems
TO BE DISCUSS IN PRESENTATION topics
1- Physiology Of Adrenal Gland Action 2-Type of Adrenal Gland Disorder3- The Signs And Symptoms 4- Treatment And Dental Management
THE ADRENAL GLANDS
Are Small (6 To 8 G) Endocrine GlandsThat Are Located Bilaterally At The Superior Pole Of EachKidney. Each Gland Contains An Outer Cortex And An InnerMedulla.
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 )
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
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 Glucose2-increasing Liver Glucose Output3-initiating Lipolysis, Proteolysis, and Gluconeogenic Mechanisms
• Anti Inflammatory Action : As It Inhibit1-lysosome Release
2-prostaglandin Production3-eicosanoid And Cytokine Release4-the Function Of Leukocytes5-endothelial Cell Expression Of Intracellular And Extracellular Adhesion Molecules That Attract Neutrophils
Corticotropin-Releasing Hormone
Regulation of cortisol secretion
Regulation of cortisol secretion occurs via the hypothalamic-pituitary-adrenal (HPA) axis
AdrenocorticoTropicHormone
١
2
3
4
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
HPA AXIS
Cortisol secretion normally follows a diurnal pattern.Peak levels of plasma cortisol occur about the time ofawakening in the morning and are lowest in the afternoonand evening3
The normal secretion rate of cortisol overa 24-hour period is approximately 20 mg. During periods of stress, the HPA axis is stimulated, resulting inincreased secretion of cortisol
Diagram showing cortisone level during
the day
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 DeficiencyResult From Destruction Of Adrenal Cortex Due To : Autoimmune DiseasesInfection As Tuberculosis Mainly In Developing Countries
Secondary Deficiency As Result From -Pituitary Hypothalamic Problems-Secondary To Corticosteroid Drug Administration
Addison’s disease
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)
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 aninability to conserve sodium and eliminate potassium andhydrogen ions, leading to Hypovolemia hyperkalemiaacidosis.
Weakness And Fatigue
Abnormal Pigmentation Of The Skin And Mucous Membranesa
Hypotension, anorexia, and weight loss
If a patient with Addison’sdisease is challenged by stress
adrenal crisismay be precipitated
is severe exacerbation of the patient’s condition including :
sunken eyes, profusesweating, hypotension, weak pulse, cyanosis, nausea,vomiting, weakness, headache, dehydration, fever,dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia.If not treated rapidly, the patient may develophypothermia, severe hypotension, hypoglycemia, andcirculatory collapse that can result in death.
Crisis
Patient with :Sings and symptoms
Clinical case study
26 years old FEMALE
Complain and medical history 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
Clinical examination
• Hyperpigmentation Of Skin In The Neck
• Pulse Of 106 Bpm,
• Blood Pressure 90/65 Mmhg
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
Intra Oral Examination
Tongue Appears To Be Smooth With Loss Of The Papilla With Pigmentation
On The Posterior Surface
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
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
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
Treatment and dental management
ttt of addision diseaes
• Elimination of cause
Hormonal Replacement aldosterone Glycocorticosteroids
20 -30 mg hydrocortisoneor
30 mg cortisone0r
7.5 mg prednisone
Fludrocortisone .05 to .1 mg
Current practice recommends that twothirds of the dose should be given in the morning and one third in the later afternoon to reflect the normal diurnal cycle.
Patient In Adrenal Crisis
Management of
Drag picture to placeholder or click icon to addAdrenal crisis is an acute adrenal insufficiency
This condition requires immediate treatment including:
IV injection of a glucocorticoid—usuallya 100-mg hydrocortisone
fluid and electrolyte replacement
Over the first 24 hours, 100 mg is administered IVslowly every 6 to 8 hour
if needed, blood pressure issupported with fluid replacement and vasopressors, alongwith correction of hypoglycemia
Alternate days
Secondary adrenal insufficiency
Drug dose modificationDaily 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 glandto 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
current recommendations
For surgical procedure
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
Factors affecting level of cortisol after surgery • 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 :
the glucocorticoid target
Glycocorticosteriods Replacement ProtocolLow Cortisol Level After Surgery (Adrenal Insufficiency )
Minor Surgical Stress
25 mg of hydrocortisone equivalent on the dayof surgery.
Example
An Asthmatic Patient WhoTakes 5 Mg Of Prednisone Every Other Day ShouldReceive 5 Mg Of Prednisone On The Day Of Surgery Preoperatively
the glucocorticoid target
moderate surgical stress
50 to 75 mg per day of hydrocortisoneequivalent for up to 1 to 2 days
Example A patient with systemic lupus erythematosus who takes 10 mg prednisone daily should receive 10 mg of prednisone (or parenteral equivalent) preoperatively and 50 mg of hydrocortisone intravenously intraoperatively. On the first postoperative day, 20 mg of hydrocortisone is administered intravenously every 8 hours The patient is returned to the preoperative glucocorticoid dose on postoperative day 2
Glycocorticosteriods Replacement ProtocolLow Cortisol Level After Surgery (Adrenal Insufficiency )
Glycocorticosteriods Replacement ProtocolLow Cortisol Level After Surgery (Adrenal Insufficiency )
the glucocorticoid target
For major surgical stress
100 to 150 mg per day of hydrocortisoneequivalent given for 2 to 3 days.
Example
patient with Crohn’s disease who takes 40 mgprednisone daily for several years should receive40 mg prednisone (or the parenteral equivalent)preoperatively and 50 mg hydrocortisoneintravenously every 8 hours after the initial dose for the first 48 to 72 hours after surgery.
Evidence indicates that the vast majority of patientswith adrenal insufficiency may undergo routine dental treatment without the need for supplemental glucocorticoids. Individuals at risk for adrenal crisis are those who undergo stressful surgical procedures and have no or extremely low adrenal function because of primary or secondary adrenal insufficiency
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
Dental Management Steps With Patient With Possible Adrenal Insufficiency
Cushion syndrome
Over production of glucocorticosteriods
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
“Buffalo Hump” On The Upper Back
Moon Face Appearance
weight gain, round or moon-shaped faciesabdominal striae
Cushion syndrome
Before after
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.
Important
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
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