Addison's & Adrenal Insufficiency: Advice for Dentists

When having a regular dental check-up or cleaning, you should not need any extra hydrocortisone. However due to having Addison’s or adrenal insufficiency, you will require extra hydrocortisone medication for certain dental work. We’ll help you understand why you require extra steroid cover for certain procedures and the action you need to take ahead of your appointment.

General Dentists have training in relation to adrenal insufficiency but are unlikely to have many patients that have the condition. It is important you and your dentist discuss and recognise the physical stress of any invasive dental procedure and ensure that adequate glucocorticoid cover is provided.

This can range from an extra hydrocortisone dose prior to minor procedures such as replacement filling, to more significant extra cover for a tooth extraction, or during a course of antibiotics for a tooth abscess.

Therefore, it is important that:

You discuss the dental guidelines below with your Dentist.
You make the Dentist aware of your condition at every appointment.
You always carry your emergency injection kit and steroid card.
You ask your Dentist if they would be prepared to give you an emergency injection if necessary.
You make your injection kit readily available and accessible.

If in any doubt, it is best to consult with your endocrinologist when planning for a major or invasive dental procedure to check your need for extra medication and that you receive the correct level of steroid cover.

If you cannot contact your endocrinologist before your appointment, it is best to err on the side of caution and ensure you receive additional glucocorticoid cover sufficient to ensure the procedure is risk-free. An overly generous dose will do no harm, where under-medicated dental procedures are a recognised cause of adrenal crisis.

Dental Guidelines

The below guidelines offer illustrative guidance for major and minor dental procedures. Click to download and print.

Please ask your Dentist to scan both the ADSHG surgical guidelines, plus the ADSHG adrenal crisis guidelines, into your patient notes, along with a list of your regular steroid medications. Both these publications can downloaded for free via the links above.

Children

Please contact your child's endocrinologist or you can read more information from Great Ormond Street Hospital (GOSH) about dental work in children on cortisol replacement. Visit their website or download their 'Cortisol deficiency and steroid replacement therapy' document.

Show your dentist your child's British Society for Paediatric Endocrinology and Diabetes (BSPED) Paediatric Steroid Treatment Card for Adrenal Insufficiency. For more information on steroid cards, visit the ADSHG Steroid Emergency Card page.

Risk of Adrenal Crisis

A 2013 UK survey of steroid-dependent patients, conducted by the ADSHG, found that dental procedures were a trigger factor for adrenal crisis reported by 8% of patients. Thus, patients should generally be encouraged to bring their next scheduled hydrocortisone dose forward and take it ahead of any dental work, especially where this involves a local anaesthetic.

Dental anaesthetic containing adrenaline is suitable for use with steroid-dependent patients. An extra dose of oral hydrocortisone medication is likely to be required for all procedures involving anaesthetic.

Since they were first launched in 2005, the ADSHG surgical guidelines have been endorsed in several clinical/endocrine publications. You can read these endorsements in the links below.

Husebye et al. 2014 Consensus statement on the diagnosis, treatment and follow up of patients with primary adrenal insufficiency. Journal of Internal Medicine 275 104-115
Allolio 2015 Adrenal crisis European Journal of Endocrinology 172 R115-R124
Puar et al. 2016 Adrenal crisis: still a deadly event in the 21st century. The American Journal of Medicine 129 339.e1-339.e9
NICE Clinical Knowledge Summaries: Addison's disease, last revised March 2016

This guidance has been approved by the Addison’s Clinical Advisory Panel (ACAP). The Addison's Clinical Advisory Panel (CAP) is a group of endocrinologists with an interest in adrenal medicine. They advise the ADSHG on its clinical guidelines, write medical commentaries and review our publications for us. They are led by Professor John Wass of the Churchill Hospital, Oxford.

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Addison's & Adrenal Insufficiency: Advice for Dentists

The ADSHG guidelines offer illustrative guidance for major and minor dental procedures. It is important to recognise the physical stress of any invasive dental procedure and to ensure that adequate glucocorticoid cover is provided for steroid-dependent patients.
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The ADSHG surgical guidelines are intended for the information of your medical team or your dentist and have been developed by our Clinical Advisory Panel.

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