• 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.

• 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 steroids (implicated in causation of iatrogenic CS) may predispose the patient/client to secondary adrenal insufficiency, particularly in the context of abrupt exogenous steroid withdrawal or peri-procedure stress.
• Yes, for patients/clients on long-term glucocorticoid therapy, in order to assess, advise, and prescribe (as appropriate) possible corticosteroid supplementation prior to dental/dental hygiene procedures³.

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).

• 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 corticosteroid therapy (which can result in secondary adrenal insufficiency), determination should be made whether corticosteroid 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.

• 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.

• Cushing syndrome is a constellation of clinical features related to either exposure to excessive levels of cortisol⁴ secreted endogenously from the adrenal glands⁵ (e.g., due to Cushing disease⁶, adrenal adenoma⁷, or bilateral adrenal hyperplasia) or to chronic excessive levels of exogenous glucocorticoid (“cortisol-like”) medication⁸ (e.g., prednisone).
• Cushing disease (comprising about 80% of endogenous CS) is uncommon, with population prevalence estimated at 5.5 per 100,000 population (equating to about 800 active cases in Ontario and 2000 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’s 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); acne; proximal muscle weakness; wasting of extremities; and hypertension. Blood cell distribution may also be altered, resulting in lymphopenia and eosinopenia.   
• Associated conditions may include: menstrual irregularity; decreased libido; 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).
• Long-term use of steroid 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 diseases, such as chronic asthma, rheumatoid arthritis, and lupus erythematosus. 
• 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.

• College of Dental Hygienists of Ontario, CDHO Advisory Disorders of the Adrenal Gland, 2011-02-01.
  https://cdho.org/advisories/disorders-of-the-adrenal-gland/
• Sharma ST, Nieman LK, Feelders RA. Cushing’s syndrome: epidemiology and developments in disease management. Clin Epidemiol. 2015;7:281-93. Published 2015 Apr 17. doi:10.2147/CLEP.S44336.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4407747/ 
• Carlos Fabue L, Jiménez Soriano Y, Sarrión Perez MG. Dental management of patients with endocrine disorders. J Clin Exp Dent. 2010;2(4):e196-203.
  http://www.medicinaoral.com/odo/volumenes/v2i4/jcedv2i4p196.pdf
• Uum SV, Hurry M, Petrella R, et al. Management of Patients with Cushing’s Disease: A Canadian Cost of Illness Analysis. J Popul Ther Clin Pharmacol. 2014;21(3):e503-e517.
  http://www.jptcp.com/articles/management-of-patients-with-cushings-disease-a-canadian-cost-of-illness-analysis.pdf
• Nieman LK. Cushing’s Syndrome: Update on signs, symptoms and biochemical screening. Eur J Endocrinol. 2015;173(4):M33-M38.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553096/
• National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
  https://www.niddk.nih.gov/health-information/endocrine-diseases/cushings-syndrome 
• National Institute of Neurological Disorders and Stroke, National Institutes of Health
  https://www.ninds.nih.gov/Disorders/All-Disorders/Cushings-Syndrome-Information-Page 
• The Pituitary Society
  https://pituitarysociety.org/patient-education/pituitary-disorders/cushings/what-are-cushings-disease-and-cushings-syndrome 
• American Association of Neurological Surgeons
  https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Cushings-Disease 
• Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8^th edition). St. Louis: Elsevier Mosby; 2013.
• Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.

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 Cushing’s syndrome include the dexamethasone suppression test, as well as urine and saliva cortisol tests.
³ Most patients/clients on chronic corticosteroid 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.
⁴ The high levels of glucocorticoid alter protein, fat, and carbohydrate metabolism, as well as the effects of insulin and vasculature homeostasis.
⁵ 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.
⁶ 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.
⁷ 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.
⁸ Glucocorticoid medication-induced Cushing syndrome is known as iatrogenic Cushing syndrome.

* 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.