Adrenal glands

By Raziyeh Sayadi 

Esfand 1401 
Back ground
The adrenal glands are small (6 to 11 g)
endocrine glands located bilaterally at the
superior pole of each kidney

Each gland contains an outer cortex and

an inner Medulla
The cortex manufactures three classes
:of adrenal steroids
 glucocorticoids

 mineralocorticoids

 androgens
glucocorticoids
Cortisol, the primary glucocorticoid, has
several important physiologic actions
on metabolism, cardiovascular
function, the immune system, and for
maintaining homeostasis during
periods of physical or emotional
stress
Mineralocorticoids

Aldosterone

Aldosterone secretion is regulated by the

renin-angiotensin system, ACTH, and
plasma sodium and potassium level
Adrenal Androgens

Dehydroepiandrosterone (DHEA)
 Excess of glucocorticoid
dexamethasone inhibit test
 The ACTH stimulation test is the most
reliable and most commonly used test
Pathophysiology and Complications

 Hyperadrenalism:
 glucocorticoid excess Cushing’s syndrome
 Mineralocorticoids excess conn’s syndrome
 Hypoadrenalism Addison’s disease :
 Primary
 Secondary
 Tertiary
 pheochromocytoma
Etiology
The most common form of
hyperadrenalism is due to glucocorticoid
excess (endogenous or exogenous),
and it leads to a syndrome known
as Cushing’s syndrome
 Purple striae
 Easy brushing and ecchymoses
 Proximal myopathy
 weight gain
 a broad and round face (“moonfacies”)
 a “buffalo hump” on the upper
 The most common cause of primary
hyperaldosteronism(conn’s syndrome) :
increased production of aldosterone by the Adrenal
glomerulosa
 Increase Hypokalemic blood pressure
 muscle weakness, myopathy, or Severe cases
become hypokalemic or tetany paralysis
 high blood pressure under 40 years old,High blood
pressure resistant to drug treatment, hypokalemia,
The presence of an adrenal mass Screening
The major hormones of the adrenal
cortex are cortisol and aldosterone.
Addison’s disease is caused by the
lack
of these compounds
 Primary adrenocortical insufficiency is
caused by:
 progressive destruction of the adrenal cortex,
usually because of autoimmune disease,
 chronic infectious disease (tuber-culosis, human
immunodeficiency virus [HIV]
infection,cytomegalovirus infection, and fungal
infection)
 or malignancy
Secondary adrenocortical insufficiency is a far
more
common problem and may be caused by structural
,.lesions of the hypothalamus or pituitary gland (e.g
tumor), administration of exogenous corticosteroids,
or
,.less commonly, administration of specific drugs (e.g
desferrioxamine in the treatment of thalassemia) or a
critical illness (burns, trauma, systemic infection)
 MEDICAL MANAGEMENT

Primary Adrenal Insufficiency

Secondary Adrenal Insufficiency

pheochromocytoma
 Tumors that are epinephrine,
norepinephrine or a combination of Both
 it can be part of MEN2B syndrome
(bodyMarfanoid, deep palate, neuromas
tongue, buccal mucosa, lips,Conjunctiva and
eyelid and corneal nerve thickening)
CLINICAL PRESENTATION
Hyperadrenocortism
Cushing's syndrome

 Preliminary appearance of Cushing's syndrome : a

round face in the shape moon Face is due to
muscle weakness and fat accumulation.
 "glow of health“
 Surface capillaries are prone to Hematomas follow
mild trauma.
 Acne and increased hair growth (hirsutism)
 children growth delay
 Hypoadrenalism

 Primary adrenal insufficiency (Addison’s

disease)
The most common complaints are
weakness, fatigue, abdominal pain, and
hyperpigmentation of the skin and
mucous membranes
Oral manifestation
 In primary adrenal insufficiency, diffuse or
focal brown macular pigmentation of the oral
mucous membranes is a common finding

 Pigmentation of sun-exposed skin often

follows the appearance of oral pigmentation
and is accompanied by lethargy
Patients with secondary adrenal
insufficiency may be prone to delayed
healing and may have increased
susceptibility to infection
 DENTAL MANAGEMENT
 the dentist must consider the type and
 degree of adrenal dysfunction and the
dental procedure planned

 Patients with hyperadrenalism or who

take corticosteroids for prolonged
periods have an increased likelihood of
having hypertension, diabetes, delayed
wound healing, osteoporosis, and peptic
ulcer disease
 A past or present history of
tuberculosis, histoplasmosis, or HIV
infection increases the risk for primary
adrenal disease (insufficiency) in that
opportunistic infectious agents may
attack the adrenal glands
 The two major factors influencing the
recommendation for supplemental
corticosteroids are the type of adrenal
insufficiency and the level and type of
stress
 Currently, only patients with primary
adrenal insufficiency are recommended to
receive supplementation, and this
recommendation applies only when
surgery is being performed and/or in the
management of a dental or systemic
infection
 Patients with secondary adrenal
insufficiency and those who take daily or
alternate-day corticosteroids have
enough exogenous and endogenous
cortisol to handle routine dental
procedures and surgery, if their usual
steroid dose (or parenteral dose
equivalent) is taken the morning of the
procedure
Routine dental procedures do not
stimulate cortisol production at levels
comparable with those that occur at the
time of surgery and do not require
supplementation, even in patients
with controlled primary adrenal
insufficiency
Patients undergoing surgery should be
closely monitored for blood and fluid loss
and for hypotension during the
postoperative period. If hypotension
appears during monitoring, intravenous
fluids are to be given and additional doses
of corticosteroid considered if fluid
replacement fails to rectify the blood
pressure. Patients are returned to their
usual glucocorticoid dosage as soon as
their vital signs are stabilized
If a patient with Addison’s disease is
challenged by stress (e.g., illness,
infection, surgery), an adrenal crisis
may be precipitated
 adr
 Sunken eyes
 profuse sweating
 Hypotension
 weak pulse

en
 Cyanosis
 Nausea
 Vomiting
 Weakness

al
 Headache
 Dehydration
 Fever
 Dyspnea
Myalgias

cri


 Arthralgia
 hyponatremia, and eosinophilia

sis
 Treatment Planning
Modifications
Dental treatment of a patient with
undiagnosed and untreated adrenal
insufficiency should be delayed until
the patient has been medically
stabilized. Otherwise,treatment
modifications are not required for
patients with well-controlled adrenal
disorders
Thanks
for
your
attention