Adrenal Cortex

Adrenal Cortex produces two

main groups of corticosteroid
hormones :

Glucocorticoids

Mineralcorticoids

Triggered by the hypothalamus

and pituitary gland

Mediated by the signals triggered

by the kidney
 Glucocorticoids released by the adrenal cortex include:

•Hydrocortisone: Commonly known as cortisol, it regulates how the

body converts fats, proteins, and carbohydrates to energy. It also helps
regulate blood pressure and cardiovascular function.

•Corticosterone: This hormone works with hydrocortisone to regulate

immune response and suppress inflammatory reactions.

The principle mineralcorticoid is aldosterone, which maintains the right balance of salt
and water while helping control blood pressure.
Adenocortical Disorders
1. Glucocorticoids (Cushing Disease)
2. Mineralocorticoids (Conn Syndrome or
hyperaldosteronism)
3. Androgens (congenital adrenal hyperplasia)
1. Cushing SYNDROME

Cushing’s syndrome is a disease caused by an excess of cortisol production

or by excessive use of cortisol or other similar steroid (glucocorticoid)
hormones. Cushing’s disease is the name given to a type of Cushing’s
syndrome caused by too much ACTH production in the pituitary.
Excess levels of the hormone cortisol cause Cushing’s syndrome,
which occurs in the following ways:
• Iatrogenic origin—when cortisol or other glucocorticoid hormones
are taken in excess of the normal daily requirement for a prolonged
period of time
• spontaneous overproduction of cortisol in the adrenals:
• Due to an excess of ACTH
• “ectopic” ACTH production (ACTH produced outside the
pituitary in a benign or malignant tumor in the lung, thymus
gland, pancreas, or other organ)
General physical features, noted on physical examination, include:
1.a tendency to gain weight, especially on the abdomen, face (moon face),
neck and upper back (buffalo hump)
2.thinning and weakness of the muscles of the upper arms and upper legs
3.thinning of the skin, with easy bruising and pink or purple stretch marks
(striae) on the abdomen, thighs, breasts and shoulders
4.Buffalo hump on the upper back
5.increased acne, facial hair growth, and scalp hair loss in women
6.sometimes a ruddy complexion on the face and neck
7.often a skin darkening (acanthosis) on the neck
8.in children, obesity and poor growth in height
 DIAGNOSING CUSHING SYNDROME

Dexamethasone test :
One milligram of dexamethasone is administered in the evening and
the serum cortisol is measured in the morning.

In normal patient, cortisol will not be suppressed, as it should be in a

normal physiologic state, and the morning cortisol will Be < 5 mcg/d

An elevated 24-hour urine cortisol excretion associated with a high

ACTH concentration reluting in Cushing’s disease
 Treatments  Withdraw steroid medicines

 Management of high blood sugar with diet and medications

 Replacement of potassium
 Treatment of high blood pressure
 Early treatment of any infections
 Adequate calcium intake
 Appropriate adjustments in steroid doses at times of acute
illness, surgery or injury
 Dental Management:

Patient with cushing’s syndrome and those on long term

glucocorticoid therapy are considered to be immunocompromised
and more susceptible to infections.

Antibiotics coverage  for dento alveolar infections

2. Hyperaldosteronism

Hyperaldosteronism is a disease in which the adrenal gland(s) make too

much aldosterone which leads to hypertension (high blood pressure) and
low blood potassium levels.

Diagnosis :
Signs and Symtoms:
blood tests to determine that you
Hypertension that is difficult to
have too much aldosterone in
control and low potassium and
your body and that it isn’t
leads to muscle weakness, keram,
secondary to other causes.
fatigue and numbness
Primary hyperaldosteronism is due to the excess production of the
adrenal gland, more specifically the zona glomerulosa. This can present
more commonly as a primary tumor in the gland known as Conn
syndrome or bilateral hyperplasia.

Secondary hyperaldosteronism occurs due to excess activation of the

renin-angiotensin-aldosterone system (RAAS). This activation can take the
form of a renin-producing tumor, renal artery stenosis, or edematous
disorders like left ventricular heart failure, cor pulmonale, or cirrhosis with
ascites.
 Dental Treatment

Local analgesia is used for pain control. Conscious sedation

may be helpful, especially if there is hypertension. GA must
as always be carried out in hospital. In the untreated patient,
hypertension and muscle weakness are the main complications.
Competitive muscle relaxants may be dangerous, as they can
cause profound paralysis.
3. Primary hypoadrenocortison/Addison disease

Addison's disease, also called adrenal insufficiency, is an

uncommon disorder that occurs when your body doesn't
produce enough of certain hormones. In Addison's
disease, your adrenal glands, located just above your
kidneys, produce too little cortisol and, often, too little
aldosterone.
Lack of adrenocortical makes patients vulnerable to infection, trauma, surgery or
anesthesia. Acute adrenal crisis characterized by collapse, bradycardia,
hypotension, profound weakness, hypoglycaemia, vomiting and dehydration
Diagnosis of hypoadrenocorticism is confirmed by hypotension, low plasma
sodium, raised potasium, plasma glucose assay and low plasma cortisol
level and depressed cortisol reponses to ACTH stimulation.

Health plasma level normally 200nmol/L to 500 nmol/L 

Hypoadrenocorticism plasma is lower than 200 nmol/L

Brown or black pigmentation of the mucosa is seen in

over 75% of patients with Addison disease
 In a patient with addison disease, the adrenal is anadequate to produce
much cortisol in response to stress to dental treatment. Patient may
experience severe hypotension, nausea, cardiovascular events, stroke, coma
and death.

Require premedication with oral or IM glucocorticoids

before an invasive procedures. Dosage must be agreed
with patient’s physician
4. Congenital Adrenal hyperplasia
Congenital adrenal hyperplasia (CAH) is a group of
inherited genetic disorders that affect the adrenal
glands

CAH affects the production of one or more of three steroid

hormones: cortisol, which regulates your body's response to illness
or stress; mineralocorticoids, such as aldosterone, which regulate
sodium and potassium levels; or androgens, such as testosterone,
which are sex hormones.

Lack of cortisol and overproduction of androgen.

 Two Major type of CAH

CLASSIC CAH NON CLASSIC CAH

Normal Appearing genitals but

• A lack in the production of later signs and symptoms
cortisol in both the salt-losing include absent of menstrual
and simple virilizing form periods, masculine
• A lack in the production of characteristics and severe acne
aldosterone in the salt-losing
form
• Excess procution of the male
sex hormones
 Causes Enzym 21-hydroxylase deficiency

CAH is passed along in an inheritance

pattern called autosomal recessive.
Children who have the condition have
two parents who either have CAH
themselves or who are both carriers of
the genetic mutation that causes the
condition.

Dental Consideration:

Use additional hydrocortison therapy for any surgical procedures

5. Systemic corticosteroids therapy

Corticosteroids are used to suppress inflammation,

graft rejection and replace missing hormon. And
essential to the body’s response to stress such as
trauma, infection, or operation.

When the adrenal cortex is unable to produce the

necessary steroid response to stress, acute adrenal
insufficiency (adrenal crisis) can result, with rapidly
developing hypotension, collapse and possibly
death
The patient with steroid treatment is for longer periods, adrenal
function may be suppressed for at least 30 days and perhaps for
2–24 months after the cessation of treatment and the patients
may be at risk from adrenal crisis.
General management
In order to minimize the effects above, patients on systemic steroids are usually
monitored and given drugs prophylactically as below:

- There should be no contraindications such as hypertension, diabetes or TBC

- The smallest effective steroid dose should be given, best in the morning on alternate
days
• Systemic corticosteroids cause the greatest risk of adrenocortical suppression, so
topical steroids should always be used in preference, provided that the desired
therapeutic effect is achievable.
• The patient must be given a warning card and told of the dangers of withdrawal, and
side-effects
• Weight, chest radiography, bone mineral density, blood pressure and blood glucose
baseline measures should be taken
• Ranitidine and calcitriol or didronel are often given
The blood pressure on patient given exogenous steroids must
be watched during surgery and especially during recovery.
Dental aspects
And steroids supplementation is needed if the blood pressure
started to fall.

Dental treatment that may result in stress:

Dentoalveolar or maxillofacial surgery

 Before minor operations patients given usual oral steroid dose in the morning and
giving oral steroids 2-4h (25-50 mg hydrocortisone or 20 mg prednisolone or 4 mg
dexamethasone)

 Before major operations can be provided by giving at least 25-50 mg

hydrocortisone sodium succinate