In 2013, the ADSHG carried out a UK survey of steroid-dependent patients and found that dental procedures were a trigger factor for adrenal crisis reported by 8% of those surveyed.
Although rare, issues with low cortisol, or adrenal crisis, following dental procedures can be distressing and even fatal. Fortunately, they are entirely prevented if individuals with known adrenal insufficiency, e.g., Addison’s disease, are identified, and appropriate steroid cover is provided.
Best practice strategies
For all patients with a diagnosis of adrenal insufficiency, including Addison's disease.
- Ensure that the patient's notes record their steroid-dependent status
- Consider the patient's psychological stress state during dental appointments and treatment, as severe psychological stress will further impact cortisol levels.
- Treat the patient early in the day and early in the week.
- If in doubt, provide steroid cover as there is no known adverse consequence to giving it short-term.
- If unsure, liaise with local endocrine services for advice.
- Please ensure your patient has enough steroid medication available for the pre- and post-operative period.
Dental Guidelines
Please see the table below, clarifying the level of cover required depending on the dental procedure. These guidelines are currently under review (Oct 2026) and will be updated as soon as the new guidelines are available (early 2027).
Download & print Dental Guidelines
Adrenal crisis symptoms
| Adrenal crisis symptoms |
| Severe stomachache Vomiting or severe diarrhoea Feeling very weak Light-headedness/dizziness on sitting or standing Feeling cold or feverish Uncontrollable shaking Pain, which can be anywhere Headache, confusion, feeling sleepy Collapse or loss of conciousness |
For a refresher on the signs and symptoms of adrenal crisis, as well as links to emergency actions in the case of adrenal crisis, visit:
Emergency management of adrenal crisis
- In all cases, if the patient feels unwell or experiences symptoms of low cortisol, the planned return to normal oral dose should be delayed.
- For mild symptoms, where the patient feels unwell, they should take an immediate additional oral dose of 20mg hydrocortisone or 5mg prednisolone, up to twice a day for 24 hours, follow “Sick Day Rules” and seek further advice as required from their GP or endocrine specialist.
- For severe symptoms indicating adrenal crisis, individuals should use their 100mg IM hydrocortisone emergency injection kit and seek urgent medical attention from their local emergency department for monitoring and fluid replacement. In such situations, 999 is appropriate, and the key words “adrenal crisis” and “steroid dependent” should be used.
Pain, anxiety and infection
In the circumstances below, the risk of low cortisol symptoms is increased, and post-operative cover may need to be increased.
- Severe dental anxiety or phobia
- Local infection e.g., swelling
- Systemic infection e.g., high temperature
- Uncontrolled or breakthrough pain during or after a dental procedure
Antibiotic prescription:
If you are prescribing a course of antibiotics, patients must be told to follow the ‘Sick Day Rules’ and increase their steroid dose for the full period that they are on the course of antibiotics. They will then need to taper their steroid dose back down to their normal daily steroid dose.
Tapering
If they are feeling back to their ‘normal self’, they can reduce straight back to their normal replacement dose.
If they have had a more severe illness, they may feel better gradually and therefore can gradually taper down their increased dose of steroids, in line with feeling better, until they are back at their usual steroid replacement dosage.
Everyone is different and they need to listen to their body.
If they start to feel unwell with low cortisol symptoms when they lower their dose, they should “updose" again and seek medical advice from their GP or endocrinology team.