Please ensure that both the ADSHG surgical and dental guidelines, plus the ADSHG crisis guidelines, are scanned into the patient's notes, along with a list of their regular steroid medications. Both these publications can downloaded for free via the links above.
If in any doubt, it is best to consult with the patient's endocrinologist when planning for a major or invasive dental procedure. Where this is not possible, it is best to err on the side of caution and ensure the patient receives 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.
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
Responding to adrenal crisis
Providing the patient has been well-medicated, this consideration should not arise. Most dental practices no longer carry injectable hydrocortisone, as detailed in the BNF guidance for medical emergencies.
Within the Real life emergencies section of the website, you can read one man's experience of adrenal crisis following uncomplicated dental treatment, when his steroid-dependence meant he was unable to mount a normal physiological response to a vasavagal faint. In this instance, his wife was able to fetch his emergency injection kit from home. He then required ambulance transportation to hospital for further treatment and monitoring. This personal story was first reported in the June 2011 ADSHG newsletter to members.