Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons¹ with disorders of the adrenal gland.

Disorders of the adrenal gland

Terminology used in this Advisory

Resources consulted

• Adrenal Crisis in Emergency Medicine, Medscape
• Adrenal Gland Disorders, NIH MedlinePlus
• Adrenal Gland Disorders, NIH National Institute of Child Health and Human Development
• Adrenal Insufficiency and Addison’s Disease, National Institute of Diabetes and Digestive and Kidney Diseases
• Androgen Excess, Medscape
• Congenital Adrenal Hyperplasia, Medscape
• Cushing’s Syndrome, Merck Manuals
• Cushing’s Syndrome, NIH National Institute of Child Health and Human Development
• Functions of the Adrenal Steroid Hormones, The Medical Biochemistry Page
• Hyperaldosteronism, Merck Manuals
• Hyperaldosteronism, Primary, Medscape
• Pheochromocytoma, Merck Manuals
• The Hormone Foundation, Pituitary Disorders Overview 

Disorders of the adrenal gland chiefly comprise

1. Addison’s disease
2. Congenital adrenal hyperplasia
3. Cushing’s disease
4. Cushing’s syndrome
5. Hyperaldosteronism
6. Pheochromocytoma
7. Virilization 

1. Adenoma, a benign tumor in glands.
2. Addisonian crisis, a severe, acute and potentially life-threatening condition that occurs when the adrenal glands fail to produce sufficient cortisol.
3. Addison’s disease is
   1. a disorder that occurs when the adrenal glands do not produce enough of their hormones 
   2. also called  
      1. adrenal insufficiency
      2. adrenocortical hypofunction
      3. chronic adrenocortical insufficiency
      4. primary adrenal insufficiency.
4. Adrenal glands, also called the suprarenal glands, which
   1. are situated at the top of the kidneys
   2. are responsible for 
      1. maintaining metabolic processes, such as 
         1. managing blood sugar levels
         2. regulating inflammation 
      2. regulating the balance of salt and water 
      3. controlling the “fight-or-flight” response to stress 
      4. maintaining pregnancy 
      5. initiating and controlling sexual maturation during childhood and puberty
   3. comprise two parts, each with different functions
      1. outer, the adrenal cortex, which secretes corticosteroid hormones 
      2. inner, the adrenal medulla, which
         1. is not essential to life
         2. helps in combating physical and emotional stress
         3. secretes
            1. epinephrine (adrenaline), which
               1. increases the
                  1. heart rate
                  2. force of heart contractions
               2. facilitates blood flow to the muscles and brain
               3. relaxes smooth muscles
               4. helps conversion of glycogen to glucose in the liver, and other activities
            2. norepinephrine (noradrenaline), which
               1. is strongly vasoconstrictive
               2. increases blood pressure
   4. work with the hypothalamus, which
      1. normally triggers the adrenal glands to release cortisol into the bloodstream in the right amount for the body’s needs  
      2. may cause the adrenal glands to produce excess cortisol when there are problems with the 
         1. adrenal glands
         2. pituitary gland,  which may cause it to over-stimulate the adrenal glands, setting up a harmful feedback loop
         3. the hypothalamus itself.
5. Adrenal hyperplasia, adrenal enlargement, of which the most common cause is Cushing’s syndrome, also occurs as congenital adrenal hyperplasia.
6. Adrenal insufficiency, when the adrenal glands do not produce enough of certain hormones
   1. primary adrenal insufficiency describes the cause of Addison’s disease
   2. secondary adrenal insufficiency occurs when the pituitary gland fails to produce enough adrenocorticotropin.
7. Adrenocorticotropin (ACTH), a hormone that stimulates the adrenal glands to produce cortisol.
8. Aldosterone, a mineralocorticoid hormone that  
   1. is produced in the adrenal cortex in response to low salt levels
   2. regulates the balance of salt and water in the body. 
9. Androgens, hormones associated with masculine characteristics, which
   1. are produced in
      1. males, from the testes 
      2. females, primarily from the adrenal glands and the ovaries
   2. in excess are responsible for the most common endocrine disorder in women of reproductive age, with various clinical features such as 
      1. acne
      2. hirsutism
      3. reproductive dysfunction
      4. virilization.
10. Catecholamines, powerful hormones that 
    1. induce high blood pressure
    2. include
       1. dopamine
       2. epinephrine (adrenaline)
       3. norepinephrine (noradrenaline)
11. Congenital adrenal hyperplasia, a genetic disorder resulting in adrenal gland deficiency, in which the body 
    1. produces insufficient cortisol
    2. may be affected by other hormone imbalances, such as 
       1. insufficient aldosterone
       2. excess androgens.
12. Corticosteroids, hormones that are chemically classed as steroids, which may be synthesized in the laboratory, and which include
    1. glucocorticoid hormones, such as cortisol, which
       1. maintain glucose control
       2. suppress the immune response
       3. help the body respond to stress
    2. mineralocorticoid hormones, such as aldosterone, which regulate
       1. sodium balance
       2. potassium balance
    3. sex hormones, affecting sexual development and sex drive, called
       1. androgens 
       2. estrogens 
13. Cushing’s disease, a form of Cushing’s syndrome, in which 
    1. the pituitary gland releases too much adrenocorticotropin, leading to overproduction of cortisol by the adrenal cortex
    2. the pituitary gland usually has a small adenoma.
14. Cushing’s syndrome, a condition which 
    1. results from excess of cortisol
    2. displays the clinical picture resulting from cortisol excess from any cause.
15. Estrogens, are
    1. produced in 
       1. women, mainly in the ovaries, in the placenta during pregnancy and in the adrenals
       2. in men, by the adrenal glands and testes
       3. in both sexes by many tissues in the body, especially fat and muscle
    2. responsible for female sexual development and function, such as breast development and the menstrual cycle. 
16. Glucocorticoids, hormones such as cortisol, which
    1. control inflammation
    2. govern the metabolism of carbohydrates and, to a lesser extent, fats and proteins
    3. are produced in the adrenal cortex or are manufactured chemically in the laboratory.
17. Hyperaldosteronism, overproduction of aldosterone which leads to fluid retention and increased blood pressure, weakness, and, rarely, periods of paralysis. 
18. Hypothalamus, a region of the brain that controls numerous bodily functions. 
19. Incidence, the total of new cases of an illness diagnosed during a specific time period.
20. Pheochromocytoma, a tumour that 
    1. usually originates in the adrenal glands
    2. causes overproduction of catecholamines. 
21. Pituitary gland, the size of a pea, the master gland of the body that
    1. is situated at the base of the brain
    2. produces hormones that stimulate other glands, including the adrenal glands, to produce various other hormones
    3. controls biochemical processes important to well-being.
22. Pituitary tumours, benign, which may 
    1. restrict the release of hormones from the pituitary gland
    2. reduce 
       1. the adrenal gland’s release of hormones needed for the “fight-or-flight” response to stress
       2. the body’s ability to handle physiological stress resulting in Addison’s disease, which can be fatal
    3. lead to a form of Cushing’s syndrome called Cushing’s disease.
23. Prevalence, the number of people currently with an illness in a given year.
24. Thrush, also termed oral candidiasis or oral moniliasis, is
    1. a yeast infection of the mouth or throat 
    2. most commonly caused by Candida albicans. 
25. Virilization, the development of exaggerated masculine characteristics, usually in women, often as a result of the adrenal glands overproducing androgens.

Overview of disorders of the adrenal gland

Resources consulted

• Adrenal Crisis in Emergency Medicine, Medscape
• Adrenal Gland Disorders, NIH MedlinePlus
• Adrenal Gland Disorders, NIH National Institute of Child Health and Human Development
• Adrenal Insufficiency and Addison’s Disease, National Institute of Diabetes and Digestive and Kidney Diseases
• Androgen Excess, Medscape
• Congenital Adrenal Hyperplasia, Medscape
• Cushing’s Syndrome, Merck Manuals
• Cushing’s Syndrome, NIH National Institute of Child Health and Human Development
• Functions of the Adrenal Steroid Hormones, The Medical Biochemistry Page
• Hyperaldosteronism, Merck Manuals
• Hyperaldosteronism, Primary, Medscape
• Pheochromocytoma, Merck Manuals
• The Hormone Foundation, Pituitary Disorders Overview

1. Addison’s disease 
   1. results from damage to the adrenal cortex, which
      1. causes the cortex to produce less of its hormones
      2. may be caused by 
         1. autoimmune diseases, which may result from genetic defects, such as
            1. chronic thyroiditis (CDHO Advisory)
            2. dermatis herpetiformis 
            3. Graves’ disease (CDHO Advisory)
            4. hypoparathyroidism 
            5. hypopituitarism 
            6. myasthenia gravis 
            7. pernicious anemia (CDHO Advisory)
            8. testicular dysfunction
            9. type I diabetes (CDHO Advisory)
            10. vitiligo 
         2. infections such as 
            1. tuberculosis (CDHO Advisory)
            2. HIV (CDHO Advisory)
            3. thrush and other fungal infections  
         3. hemorrhage
         4. tumours
         5. anticoagulants
   2. may produce a severe, potentially life-threatening acute state, the Addisonian crisis, which 
      1. is characterized by 
         1. dehydration
         2. loss of consciousness
         3. low blood pressure
         4. severe vomiting and diarrhea
         5. sudden, penetrating pain in the lower back, abdomen, or legs
      2. may be the first indication of Addison’s disease
   3. produces in the chronic state gradually developing symptoms or signs that
      1. start with the most common, which are
         1. loss of appetite
         2. muscle weakness
         3. persistent, worsening fatigue
         4. weight loss
      2. include 
         1. craving for salty foods, owing to salt loss
         2. diarrhea, which may be persistent
         3. fatigue
         4. headache
         5. hypoglycemia
         6. in women, irregular or absent menstrual periods
         7. irritability and depression
         8. orthostatic hypotension, low blood pressure that falls further with standing, resulting in acute manifestations such as
            1. dizziness
            2. fainting
         9. nausea
         10. sweating
         11. vomiting
         12. mouth lesions on the buccal mucosa
         13. movements that are slow, sluggish
         14. skin changes, such as 
             1. hyperpigmentation, most visible on
                1. scars
                2. skin folds
                3. pressure points such as the elbows, knees, knuckles, and toes
                4. lips and mucous membranes such as the buccal mucosa.
             2. patchy or unnatural colouring
             3. paleness
      3. may be recognized only after a stressful event such as illness, accident, surgery or, possibly, invasive procedures in oral healthcare, which causes worsening of the condition
   4. in the chronic state is treated with hormone replacement therapy, using medications
      1. for the hormones that the adrenal glands are not producing, especially
         1. cortisol, replaced with a synthetic glucocorticoid 
         2. aldosterone, replaced with a mineralocorticoid, which may require increase in oral salt intake
      2. except where the cause, such as tuberculosis (CDHO Advisory), is treatable
   5. during an Addisonian crisis (also known as “adrenal crisis”) is treated with
      1. intravenous injections of glucocorticoids
      2. large volumes of intravenous saline solution with dextrose
      3. immediate post-crisis care with 
         1. oral fluids and medications 
         2. gradual adjustment of glucocorticoids and, if required, a mineralocorticoid.
2. Congenital adrenal hyperplasia
   1. is caused by an error on a single gene
   2. is inherited
   3. results in
      1. deficiency of 
         1. cortisol
         2. aldosterone
      2. excess of androgens
   4. presents symptoms and signs that vary from unnoticeable to severe
      1. in the mild form may include
         1. acne 
         2. for children 
            1. height shorter than that of parents at a similar age
            2. early signs of puberty
         3. for women
            1. irregular periods
            2. difficulty becoming pregnant 
            3. excess facial hair
      2. in the severe form may include
         1. dehydration 
         2. blood pressure abnormally low
         3. blood sugar low
         4. external genitalia in girls: altered development noted at birth that may require surgical correction 
         5. for children 
            1. height shorter than that of parents at a similar age
            2. early signs of puberty
         6. for men
            1. benign testicular tumours
            2. infertility
         7. for women
            1. irregular periods
            2. difficulty becoming pregnant 
            3. excess facial hair
         8. salt retention: impairment
   5. is routinely screened for in newborns in Ontario and elsewhere; signs include
      1. ambiguous genitalia 
      2. salt wasting while a diagnosis is being established 
      3. abnormal weight loss or lack of expected weight gain
   6. is incurable but can be treated with medications, without which the severe form can be life-threatening.
3. Cushing’s disease
   1. is a form of Cushing’s syndrome in which the pituitary gland releases too much adrenocorticotropin, which results in excess production of cortisol
   2. is caused by lesions in the pituitary, including
      1. tumour
      2. hyperplasia 
   3. is treated  by
      1. surgery to remove one or other of the
         1. pituitary tumour
         2. adrenal glands
      2. radiotherapy (CDHO Advisory) to shrink or destroy the tumour
   4. may require medications
      1. during post-operative recovery
      2. where surgery is incompletely successful.
4. Cushing’s syndrome
   1. in incidence 
      1. for endogenous causes (including Cushing’s disease), ranges from 0.7 to 5.0 per million population per year
      2. may be more common than previously thought (particularly when taking into account exogenous, iatrogenic causes)
   2. in populations of obese persons with type 2 diabetes (CDHO Advisory) especially those with poor blood glucose control and hypertension, the reported prevalence is between 2 percent and 5 percent, singalling that it is not rare in association with diabetes, especially when this is poorly controlled
   3. is hyperfunction of the adrenal cortex due to
      1. hypersecretion of adrenocorticotropin by the pituitary gland
      2. secretion of adrenocorticotropin by a non-pituitary tumour
      3. adrenal adenoma, tumours of the ovary, and other organs
      4. therapeutic administration of corticosteroids
   4. is diagnosed by tests that show for cortisol
      1. increased production 
      2. abnormal suppression
   5. arises when medications
      1. cause the body to make too much cortisol
      2. contain extra cortisol which has brought the body level above normal
   6. may occur with
      1. adrenal tumours 
      2. ectopic ACTH syndrome 
      3. genetic Cushing’s syndrome
      4. pituitary tumours 
   7. exhibits clinical manifestations which may be so variable that they are misinterpreted, with consequent delay in diagnosis that increases morbidity and mortality
   8. commonly exhibits signs and symptoms such as
      1. blood pressure, raised
      2. blood sugar, raised
      3. growth rates that are slow in children 
      4. moodiness, irritability, or depression 
      5. muscle and bone weakness 
      6. obesity of the upper body, roundness of the face and neck, and thinning of the arms and legs
      7. skin problems, such as acne or reddish-blue streaks in the skin 
   9. in women may cause 
      1. growth of hair on the face and body
      2. menstrual irregularities
   10. in men may reduce
       1. fertility
       2. sex drive 
   11. is medically investigated  for excess cortisol production with 
       1. blood, urine and, sometimes, saliva tests 
       2. examinations to determine the cause of the excess production
   12. is treated for the cause of the excess of cortisol in the body resulting from
       1. medication used for the Cushing’s syndrome or another disorder, which is managed by
          1. dose reduction
          2. medication change 
       2. excess production by the body arising from
          1. surgery
          2. radiation
          3. combination of treatments
   13. can usually be successfully treated with medications.
5. Hyperaldosteronism
   1. though rare is considered one of the more common causes of secondary hypertension (CDHO Advisory)
   2. may be 
      1. caused by tumor in an adrenal gland
      2. a response to various diseases
   3. may, through high aldosterone levels, cause 
      1. high blood pressure
      2. low potassium levels leading to
         1. weakness
         2. tingling
         3. muscle spasms
         4. periods of temporary paralysis
   4. is medically assessed with blood-level measurements of
      1. sodium
      2. potassium
      3. aldosterone 
   5. is treated by
      1. removal of the tumour
      2. medications to block the action of aldosterone.
6. Pheochromocytoma, the tumour, the effects of which are 
   1. characterized by 
      1. high blood pressure, the most important symptom
      2. fast and pounding pulse
      3. excessive sweating
      4. light-headedness when standing
      5. rapid breathing
      6. severe headaches
   2. medically investigated by
      1. measurements of blood-level of catecholamines
      2. tumour detection by imaging
   3. is treated by 
      1. medications to control blood pressure until the pheochromocytoma is removed
      2. surgical removal of the pheochromocytoma.
7. Virilization is 
   1. caused by excess production of androgens
      1. usually resulting from causes such as
         1. enlargement of the hormone-producing portions of the adrenal cortex (adrenal hyperplasia)
         2. hormone-producing tumour in the adrenal gland
      2. occasionally resulting from 
         1. a tumour outside the adrenal gland that produces androgens
         2. cystic enlargement of the ovaries
         3. enzyme abnormalities
      3. sometimes resulting from consumption by athletes of large quantities of androgens, referred to as anabolic steroids, to increase muscle bulk  
   2. is characterized by 
      1. excess facial and body hair
      2. baldness
      3. acne
      4. deepening of the voice
      5. increased muscularity
      6. increased sex drive associated with the development of exaggerated masculine characteristics, usually in women, often as a result of the adrenal glands overproducing androgens
   3. is medically assessed by
      1. the physical appearance of virilization
      2. the dexamethasone suppression test
   4. is treated by
      1. surgical removal of the tumor
      2. medications to reduce the excess hormone production.

Multimedia and images

Hypothalamus
Pituitary

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with disorders of the adrenal gland but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice, especially with disorders of the adrenal gland.

1. Addison’s disease 
   1. anorexia nervosa 
   2. autoimmune disorders
   3. irritability and depression
   4. type 1 Diabetes
2. Cushing’s disease
   1. cardiovascular disease
   2. diabetes
   3. hypertension, which may not fully recover following successful treatment of the Cushing’s disease
   4. immune system disorders
   5. psychiatric disorders

Oral health considerations

Resources consulted

• Addison Disease, Medscape
• Adrenal crisis provoked by dental infection: case report and review of the literature, PubMed
• Adrenal Disease and Pregnancy, Medscape
• Candidiasis, Medscape
• Dental management of patients with endocrine disorders, J Clin Exp Dent
• Management of patients with adrenocortical insufficiency in the dental clinic, PubMed
• Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature, British Dental Journal
• Supplemental corticosteroids for dental patients with adrenal insufficiency, Journal of the American Dental Association

1. Addison’s disease
   1. is a serious condition that requires the dental hygienist, as a matter of routine, to  consult with the patient/client’s family physician
      1. about the need for supplementary medication 
         1. during pregnancy
         2. for children and adults with adrenal insufficiency 
      2. to explain the nature of the intended dental hygiene procedures 
   2. may cause signs  and symptoms that the dental hygienist should draw to the attention of the primary care physician, such as
      1. mouth lesions, such as sores, including chronic mucocutaneous candidiasis 
      2. patchy hyperpigmentation of the oral mucosa, and various skin sites, associated with increased melanin 
      3. bronzing of the skin
   3. requires oral healthcare to follow a general clinical plan that involves
      1. recognizing the possibility of orthostatic hypotension
      2. providing treatment in the morning
      3. minimizing physical and psychological stresses, for which dental hygiene may be a cause
      4. interrupting treatment in an Addisonian crisis
   4. is treated with a synthetic glucocorticoid to replace the missing endogenous cortisol, the effects of which may complicate oral healthcare procedures, including
      1. delayed wound healing
      2. increased capillary fragility
      3. alveolar bone loss, with the possibility of pathological fractures
   5. produces Addisonian crisis only rarely in oral healthcare though the risk
      1. may be increased with dental infection in children with adrenal insufficiency, and thus may require antibiotic treatment or prophylaxis
      2. is somewhat higher with primary adrenal insufficiency than with secondary adrenal insufficiency
   6. when resulting either from  primary adrenal insufficiency or secondary adrenal insufficiency does not normally require cortisol supplementation or related cover for
      1. nonsurgical periodontal treatment
      2. minor surgical procedures under local anesthesia
   7. during pregnancy, treatment is continued  throughout with glucocorticoid and mineralocorticoid replacement dosages; some patients/clients may require additional glucocorticoid in the third trimester
2. Cushing’s syndrome and Cushing’s disease
   1. are risk factors for oral candidiasis and may require antifungal prophylaxis
   2. require removal of dental appliances from the mouth during imaging for differential diagnosis
   3. require recognition that Cushing’s syndrome is not rare in association with diabetes (CDHO Advisory) especially when poorly controlled
   4. may increase the risk of
      1. infection with complex dental procedures
      2. cardiovascular collapse, in which the heart stops pumping blood 
   5. may be associated with 
      1. hypertension, in connection with which the dental hygienist may measure the blood pressure prior to implementing procedures
      2. hyperglycemia 
   6. may display signs that the dental hygienist should report to the primary care physician if the patient/client is unaware of them and their possible significance, such
      1. facial edema (“moon face”)
      2. skin that appears tanned
      3. blotchy gingiva, palate, and buccal mucosa 
   7. may in Cushing’s syndrome be caused by the effect of corticosteroids used to treat other conditions, resulting in the risk of
      1. delayed wound healing
      2. increased capillary fragility
      3. alveolar bone loss.

1. Promoting health through oral hygiene for persons who have disorders of the adrenal gland.
2. Reducing the adverse effects, such as stress and anxiety by
   1. consultation with the primary or other care provider prior to implementation of the Procedures
   2. generally increasing the comfort level of persons in the course of dental-hygiene interventions 
   3. using appropriate techniques of communication
   4. providing advice on scheduling and duration of appointments.
3. Reducing the risk that oral health needs are unmet.

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III