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FACT SHEET: Cushing Syndrome1 (also known as “Cushing’s syndrome” [CS], “hyperadrenocorticism”, and “hypercortisolism”; includes “Cushing disease” [also known as “Cushing’s disease” or “CD”] and “iatrogenic Cushing syndrome”)

Date of Publication: June 20, 2019
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Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No.  

Is medical consult advised?

  • Yes, if previously undiagnosed Cushing syndrome is suspected2. 
  • Yes, if previously diagnosed Cushing syndrome (or its underlying contributory cause) is suspected to be suboptimally managed.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes, pending clearance by physician (typically endocrinologist or family physician)

Is medical consult advised?

  • See above.

Is medical clearance required?

  • Yes, hypercortisolism predisposes the patient/client to immunosuppression. 
  • Yes, prolonged use and/or high doses of systemic glucocorticosteroids3 (implicated in causation of iatrogenic CS)4 may predispose the patient/client to secondary adrenal insufficiency, particularly in the context of abrupt exogenous glucocorticoid withdrawal or peri-procedure stress.
  • Yes, for patients/clients on long-term glucocorticoid therapy, in order to assess, advise, and prescribe (as appropriate) possible glucocorticoid supplementation prior to dental/dental hygiene procedures5.

Is antibiotic prophylaxis required?

  • Possibly. Antibiotic prophylaxis should be considered for patients/clients at risk of immunosuppression and hence infection (e.g., incompletely treated Cushing disease, or prolonged use and/or high doses of systemic steroids for underlying disease management). 

Is postponing treatment advised?

  • Yes, if patient/client has previously undiagnosed or inadequately managed Cushing syndrome.
  • Yes, if patient/client is medically unstable.
  • Yes, if status of associated medical conditions poses a risk to the patient/client (e.g., uncontrolled, severe hypertension) or the dental hygienist (e.g., mania or psychosis).

Oral management implications

  • From a dental hygienist perspective, Cushing syndrome is of less acute concern than adrenal insufficiency (i.e., inadequate production of endogenous glucocorticoids). Nonetheless, Cushing syndrome does have a number of oral management implications.
  • For patients/clients on chronic glucocorticosteroid therapy (which can result in secondary adrenal insufficiency), determination should be made whether glucocorticoid supplementation is required before dental/dental hygiene treatment. For most patients/clients, however, steroid supplementation is not indicated for dental hygiene procedures. 
  • Dental/dental hygiene management includes prevention of infections and prevention of pathologic fractures during chair transfers and during dental surgery. 
  • The dental hygienist should be alert for cognitive impairment associated with untreated Cushing syndrome. Furthermore, associated conditions such as hypertension and diabetes should be appropriately assessed (e.g., taking of blood pressure prior to implementing procedures).
  • Because of the increased risk of peptic ulcer disease in patients/clients using long-term steroids, aspirin and other non-steroidal anti-inflammatory medications (NSAIDs) should generally be avoided for pain control.

Oral manifestations

  • Alveolar bone loss (i.e., osteoporosis of the jaw) can result from hypercortisolism. This in turn can contribute to tooth loss, as can periodontal disease resulting from decreased white cell migration.
  • Oral candidiasis occurs at elevated rates. 
  • Risk of infection may be increased with complex dental procedures.

Related signs and symptoms

  • Cushing syndrome is a constellation of clinical features related to either exposure to excess levels of cortisol secreted endogenously from the adrenal glands6 (e.g., due to Cushing disease7, adrenal adenoma8, or bilateral adrenal hyperplasia) or to chronic excess levels of exogenous glucocorticoid (“cortisol-like”) medication9 (e.g., prednisone).10
  • Cushing disease (comprising about 80% of endogenous CS) is uncommon, with population prevalence estimated at 5.5 per 100,000 population (equating to about 880 active cases in Ontario and 2,255 cases in Canada), with diagnosis peaking in the fourth decade of life with female predominance. However, Cushing syndrome as a whole (all causes, including Cushing disease) is thought to be much more common, given that exogenous glucocorticoids — used to treat many diseases — are the most common cause of CS. 
  • Classic signs/symptoms include: weight gain (particularly central obesity); a broad, round face (“moon face”); a collection of fat (“buffalo hump”) on the upper back; purple abdominal striae (i.e., linear “stretch” marks); thinned skin; hirsutism (excessive body hair) in women; acne; proximal muscle weakness; wasting of extremities; and hypertension.    
  • Associated conditions may include: menstrual irregularity; decreased libido; erectile dysfunction and reduced fertility in men; extreme fatigue; glucose intolerance (leading to diabetes mellitus); dyslipidemia; premature atherosclerosis; thromboembolic disease; heart failure; osteoporosis (contributing to vertebral and other bone fractures); impaired healing; and psychiatric disorders (e.g., cognitive dysfunction, anxiety disorders, depression, mania, and psychosis). Blood cell distribution may also be altered, resulting in lymphopenia and eosinopenia (i.e., decrease in certain white blood cells).
  • Long-term use of glucocorticosteroid medications can increase risks for insomnia, cataract formation, glaucoma, peptic ulceration, growth suppression in children, and delayed wound healing.
  • Patients/clients at risk of developing iatrogenic Cushing syndrome include those on chronic glucocorticoid therapy for a variety of inflammatory and autoimmune diseases, such as chronic asthma, rheumatoid arthritis, lupus erythematosus, Crohn’s disease, and ulcerative colitis.
  • Unlike the acute, life-threatening situation that may occur with acute cortisol deficiency (i.e., adrenal crisis), cortisol hypersecretion does not usually result in a medical emergency. However, poorly controlled cortisol levels in patients/clients with Cushing disease can lead to repeated hospitalizations, significant morbidity, and premature death.

References and sources of more detailed information


Date: October 29, 2018
Revised: May 27, 2024


FOOTNOTES

1 The definition of Cushing syndrome varies according to the authority, sometimes being limited to endogenous causes only. This fact sheet takes a more encompassing definitional approach and thus also includes exogenous causation.
2 Tests for diagnosis of Cushing syndrome include the dexamethasone suppression test; urine, blood, and saliva tests for cortisol; and certain medical imaging scans.
3 The terms “glucocorticosteroid” and “glucocorticoid” are used synonymously to describe certain steroids that are either produced endogenously in the body (primarily cortisol, the “stress hormone”) or are administered exogenously. These types of steroids have many functions, including maintaining blood pressure, suppressing inflammation, and regulating blood glucose. They differ substantially from androgenic-anabolic steroids (male sex characteristic/muscle-building steroids, such as testosterone), estrogenic steroids (female sex characteristic steroids), and mineralocorticoids (such as aldosterone, which promotes sodium reabsorption in the kidneys, salivary glands, and colon).
4 Iatrogenic Cushing syndrome is usually seen the in context of prolonged use of systemic glucocorticoids prescribed for certain medical conditions, although case reports exist for unintentional glucocorticoid misuse via complementary/alternative health supplements as well as for misuse of certain anabolic androgenic steroids (e.g., for body-building or sports performance purposes).
5 Most patients/clients on chronic glucocorticosteroid therapy (and therefore at risk of secondary adrenal insufficiency) do not require supplemental doses of steroid for general, routine dental/dental hygiene procedures or even for most oral surgical procedures.
6 The adrenal glands are small glands located on the superior pole of each kidney. The adrenal cortex (90% of the gland) produces and secretes corticosteroid hormones (including glucocorticoids, mineralocorticoids, and androgens). The adrenal medulla secretes catecholamines; namely, epinephrine and norepinephrine.
7 In Cushing disease, the cause of cortisol hypersecretion is a pituitary tumour (usually a benign adenoma) that oversecretes adrenocorticotropic hormone (ACTH), thus overstimulating the adrenal glands’ cortisol production. Transphenoidal surgery may be used to selectively remove the tumour. Second-line therapies include radiotherapy, drug therapy, or bilateral adrenalectomy.
8 An adrenal adenoma (also known as adrenocortical adenoma) is a benign tumour (usually unilateral) of the adrenal cortex. It can present as Cushing syndrome, primary aldosteronism, or hyperandrogenism. Treatment may involve removal of part or all of the adrenal gland, which may be preceded by drug therapy to reduce cortisol production prior to surgery.
9 Glucocorticoid medication-induced Cushing syndrome is known as iatrogenic Cushing syndrome. Treatment may involve gradual reduction in glucocorticoid medication over time.
10 The high levels of glucocorticoid alter protein, fat, and carbohydrate metabolism, as well as vasculature homeostasis and the effects of insulin.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.