Case Study: Audrey Hepburn
Audrey Hepburn is a 36 year old WNWD
Caucasian female who presents to the
dental clinic for a routine examination.
Case Study:
Audrey Hepburn
During your examination and review of her
medical history, you notice that she has
checked “yes” to the question about
having taken corticosteroids in the past.
Adrenal Insufficiency
She has been fatigued lately and had a
few unusual infections. You notice during
your physical exam that she presents with
a generalized bronze-brown color over
her skin as well as similar spots on the
gingivae and oral mucosa.
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Audrey Hepburn: SIGNS
Background: ADRENAL GLANDS
Main Secretory Product
Mineralocorticoids
aldosterone
!
corticosteroids ! adrenal insufficiency
!
fatigue & unusual infections
Glucocorticoids:
cortisol
Sex Steroids: androgens
Catecholamines: E and NE
!
generalized bronze-brown color over her skin
!
similarly colored spots inside her mouth
Salt, Sugar, Sex:
The deeper you go, the sweeter it gets.
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Background: SECRETORY PRODUCTS
Adrenal Disorders: INCIDENCE & PREVALENCE
ALDOSTERONE
! acts on collecting ducts of kidney to maintain Na+ and K+ balance
! release is controlled by the renin-angiotensin system, ACTH, and Na+ and K+ levels
HOW COMMON IS THIS?
CORTISOL
! 40-60 per 1 million people
! many functions: anti-inflammatory; regulates fat, protein, and carbohydrate metabolism;
increases blood glucose, increases glomerular filtration; modulates emotions
! approximately 5% of adults in U.S. chronically use corticosteroids, which puts
them at risk for secondary adrenocortical insufficiency
! release regulated by hypothalamus and pituitary; released in response to stress
! a dental practice serving 2,000 adults can expect to encounter 50 patients
who use steroids or who have potential adrenal abnormalities
ANDROGENS
! main androgen secreted is dehydroepianderosterone
! effect is similar to testicular androgens but has 1/5 the activity
also
secretes estrogen precursors
!
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Adrenal Disorders: OVERVIEW
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Adrenal Disorders: ADRENAL INSUFFICIENCY
Primary Adrenal Insufficiency
(aka Addison’s Disease)
Two categories of adrenal disorders:
! deficiency of aldosterone and cortisol
1. OVERPRODUCTION
! most common: Cushing’s Syndrome, "" glucocorticoid
! # aldosterone: hypovolemia,
hyperkalemia, metabolic acidosis
! hypertension, weight gain, moon face, habitus
! # cortisol: hypotension, impaired
metabolism, inability to tolerate stress,
hypoglycemia
! Cushing’s Syndrome vs. Cushing’s Disease
! syndrome = any condition causing overproduction of
cortisol
Secondary Adrenal Insufficiency
! 5x more common
! may be caused by:
! hypothalamic or pituitary disease
! long-term corticosteroid use
! limited to glucocorticoid deficiency
! disease = when the pituitary gland is the cause
! usually autoimmune
! slow onset (90% of cortex must be
destroyed)
2. UNDERPRODUCTION
! asymptomatic unless patient
significantly stressed
! Primary Adrenal Insufficiency
! Secondary Adrenal Insufficiency
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Adrenal Insufficiency: LAB FINDINGS
Serum Cortisol
< 20 %g/dL
severe stress
adrenal insufficiency
ACTH
Audrey Hepburn: SIGNS
CORTISOL DEFICIENCY
! measured in urine, plasma, and saliva
! saliva most sensitive
! normal 24 hr secretion = 30 mg; periods of stress = 300 mg
< 7 %g/dL
adrenal insufficiency
PROVOCATIVE (STIMULATION) TESTS
Other Tests
CRH Test:
determines whether
ACTH dependent or
ACTH independent
Dexamethansone
Supression Test:
used for adrenal
hyperfunction
!
corticosteroid use ! adrenal insufficiency
!
fatigue & unusual infections ! immune system
!
bronze-brown color over her skin ! hyperpigmentation
!
similarly colored spots inside her mouth
! cortisol secretion varies: circadian rhythm, diet, and stress
" synthetic ACTH most reliable
" how it works: inject ACTH, plasma cortisol level should increase
! determine baseline serum cortisol
Could she have secondary adrenal insufficiency?
! administer 250 mg ACTH intravenously
! draw serum cortisol 30, 45, and 60 minutes after ACTH
administration
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Audrey Hepburn: SIGNS
Secondary Adrenal Insufficiency
" signs and symptoms are the same for both Addison’s disease and secondary
adrenal insufficiency
! secondary adrenal insufficiency $ due to long-term corticosteroid use
SIGNS and SYMPTOMS
"
"
"
"
"
"
hyperpigmentation of skin
dark spots on oral mucosa
weight loss
hypotension
infection
delayed healing
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! drug effect ! body decreases
cortisol production
! during periods of stress, body
cannot secrete enough
! condition may persist for up to 1 yr
!
corticosteroid use ! adrenal insufficiency
!
fatigue & unusual infections ! immune system
!
bronze-brown color over her skin ! hyperpigmentation
!
similarly colored spots inside her mouth
We don’t call them “spots.”
Dr. Loper, what do we call them?
! corticosteroids used for a wide
variety of conditions
! allergies, cardiovascular diseases,
pulmonary diseases, skin diseases,
GI diseases...
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Questions To Ask
Questions To Ask
ASK ABOUT HER SIGNS & SYMPTOMS
! Infections
! Corticosteroid Use
Tell me about your infections. When did they occur?
What drug were you taking?
Did you see a physician and receive treatment?
What condition were you taking them for?
What did your physician say about your infections?
When were you taking them?
Does anybody in your family have a history of adrenal disorder?
! Hyperpigmentation
! Fatigue
Have you been out in the sun or tanning?
Have you also experienced any nausea, vomiting, or diarrhea?
Have you noticed a change in your skin color? The spots in your mouth?
How is your appetite? Do you have any cravings for salt?
When did you first notice these changes?
Have you had any problems sleeping or staying awake?
Have you had any feelings of confusion or fear?
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Audrey Hepburn: WHAT DOES SHE HAVE?
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Major Concern: ADRENAL CRISIS
! major concern for both forms of adrenal insufficiency is adrenal crisis
! rare and potentially life-threatening
! triggered by stress (e.g., illness, infection, surgery)
Tinkerbell says:
“Secondary Adrenal Insufficiency”
symptoms include:
• profuse sweating
• hypotension, weak pulse
• nausea, vomiting, headaches
• fever, weakness
if untreated:
• hypothermia
• severe hypotension
• hypoglycemia
• circulatory collapse
• death
! medical emergency: requires immediate treatment
! IV injection of glucocorticoids
! fluid & electrolyte replacement
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Adrenal Insufficiency: DENTAL MANAGEMENT
Medical & Dental Management
Primary Adrenal Insufficiency
Secondary Adrenal Insufficiency
ROUTINE DENTAL CARE
1. Manage the disease.
! eliminate infectious agent or
malignant disease
2. Hormone replacement therapy
! daily doses of glucocorticoid
and mineralocorticoid
supplements
! caused by long-term steroid use
! most dental patients with adrenal insufficiency can undergo routine dental work without
supplemental glucocorticoids
! Alternate Day Method
(long-term users)
ORAL SURGERIES
! allows adrenal gland to function
! supplemental glucocorticoids are used instead for patients in high stress surgical
procedures or that have no or extremely low adrenal function
normally on the off day, therefore
less inhibition of cortisol production
! consider type and severity of adrenal disorder
! Surgery Replacement Protocol
! minor or major surgery
(episodic)
! provide exogenous cortisol during
! GOAL = avoid adrenal crisis!
and after surgery
! 4 factors: type of surgery, patient health, other drugs, and pain control
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Avoiding Adrenal Crisis: 4 FACTORS
SEVERITY OF SURGERY
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In the Dental Office: MINIMIZING STRESS
DRUG COMPLICATIONS
minor: 25 mg (day of surgery)
moderate: 50-75 mg (2 days)
major: 100-150 mg (2-3 days)
barbiturates: enhance metabolism of
cortisol, decreasing serum levels;
consult physician and have pt. stop 24
hrs before surgery
amts are hydrocortisone equivalents and
are per day
anti-coagulants: increase risk for postop bleeding and hypotension
! morning appointments
! cortisol levels are highest in the a.m.
! keep appointments under 1 hour
! > 1 hour, possible glucocorticoid supplementation
! nitrous oxide or benzodiazepene sedation
GENERAL HEALTH of PATIENT
! degree of adrenal insufficiency
! already on glucocorticoids?
! how much?
! reduce stress and decrease cortisol demand
POST-OP PAIN
! monitor blood pressure
! stress is highest post-operatively
! due to pain and loss of anesthesia
! can last for several days
! reduce blood loss
! losing blood causes hyptotension and adrenal insufficiency
! give longer-lasting anesthetic
! extend glucocorticoid therapy
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Adrenal Crisis: WHAT TO DO
Physical Status: ASA PS III
IF Audrey has secondary primary
insufficiency caused by corticosteroid use,
her condition would normally be
asymptomatic.
Symptoms would appear only if she was
significantly stressed because she does not
have enough circulating cortisol.
IMMEDIATE TREATMENT IS REQUIRED
! administer 100 mg of hydrocortisone or 4 mg dexamethasone IV
Refer to physician for testing of cortisol
levels and stabilization of her condition.
! immediate transportation to a medical facility
Until we understand the severity of her
disease, we should refrain from
treatment.
Once medically stable, treatment
modifications will not be required.
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Dental Algorithm
Dental Algorithm
A
C
• antibiotics
not indicated; no contraindications
• anesthetics
provide good post-op pain control with long-acting local anesthetic (e.g.,
bupivacaine) at the end of the procedure
• cardiac
no additional cardiac concerns
D
• analgesics
no contraindications
B
• complications
post-op recovery complicated by other factors that exacerbate adrenal insufficiency:
liver dysfunction, febrile illness, sepsis, nausea and vomiting, and some drugs
if hyperadrenalism, avoid aspirin and NSAIDs (risk of peptic ulcers)
• bleeding
significant blood loss contributes to hypotension and hypoglycemia
• bacteremias
pts. with secondary adrenal insufficiency may be prone to delayed healing and have
increased susceptibility to infection
E
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• drugs
drugs that enhance metabolism of cortisol and decrease existing levels:
-
aminoglutethimide
eomidate
ketoconazole
inducers of hepatic cytochrome P450 oxygenases (e.g., barbiturates,
phenytoin, rifampin)
anticoagulants: increased risk for post-surgical bleeding and hypotension
• emergency treatment
adrenal crisis: administer 100 mg of hydrocortisone or 4 mg dexamethasone IV and
immediate transportation to a medical facility
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Thank You
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feedback!
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