Adrenal insufficiency

Overview

Board takeaway: Establish the child’s replacement and stress-dose plan before care. Illness, pain, fasting, and procedures can precipitate crisis.

Inadequate cortisol production may follow adrenal disease or suppression of the hypothalamic–pituitary–adrenal axis.

How does Adrenal insufficiency affect dental management?

• Routine care: Morning appointments after the usual dose; minimize stress and pain
• Established adrenal insufficiency: confirm the written dental stress-dose plan.
• Fillings or extractions without GA: BSPED advises the prescribed oral sick-day dose beforehand, continuing for up to 24 hours if painful or unwell.
• General anesthesia: obtain a separate perioperative plan. BSPED guidance.
• Adrenal crisis: activate EMS promptly, support airway and breathing, give the prescribed emergency hydrocortisone without delaying for testing, and arrange IV fluids and glucose management through trained emergency personnel
• Preparedness: Have a written crisis plan; ask the family to bring a prescribed emergency hydrocortisone kit.

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Suspected crisis requires EMS and emergency hydrocortisone without delaying for tests. Stable patients with established adrenal insufficiency use their written sick-day or general-anesthesia plan.

Exam pearl

What is Adrenal insufficiency?

A condition in which the adrenal glands do not produce enough cortisol, sometimes with aldosterone deficiency. It can result from adrenal damage or inadequate stimulation by the pituitary or hypothalamus.

What are the main systemic features of Adrenal insufficiency?

• Primary: autoimmune adrenal disease or congenital adrenal hyperplasia; mineralocorticoid deficiency depends on the cause
• Primary clues: high ACTH; may cause hyperpigmentation and salt craving
• Secondary: HPA-axis suppression from glucocorticoid therapy; more common; usually spares aldosterone and lacks pigmentation
• Symptoms: fatigue, weight loss, salt craving, hypotension, hypoglycemia; hyperpigmentation in primary only
• Crisis: hypotension, shock, vomiting, abdominal pain, confusion

What oral findings occur in Adrenal insufficiency?

• Brown hyperpigmentation of gingiva, buccal mucosa, palate and lips (primary)
• Immunosuppressive steroid treatment can impair healing and increase infection risk; physiologic replacement for adrenal insufficiency is a different exposure

A teen with Crohn disease took prednisone for 3 months, stopping 6 months ago. Does that matter for an extraction under GA?

Yes. Three months of prednisone is relevant even six months after stopping.

• Review: dose, duration, and any testing of hypothalamic–pituitary–adrenal (HPA) axis recovery.
• Plan: ask endocrinology and anesthesia for an individualized perioperative plan.
• Why it matters: pediatric guidance identifies systemic exposure beyond two weeks as a risk factor and advises considering stress coverage after recent discontinuation unless recovery is established. Canadian Paediatric Society.

During treatment the child becomes pale, confused, hypotensive and vomits. What is happening and what do you do?

Suspect adrenal crisis.

1. Stop treatment, lay the patient supine with legs raised, give oxygen, and activate EMS.
2. Give IM or IV hydrocortisone at the emergency dose in the child’s written plan; do not delay treatment while seeking IV access. Trained personnel provide IV fluids and treat hypoglycemia.
3. Check glucose for hypoglycemia.

Sources

• Supplemental study guide: Pediatric Dental Study Guide: Adrenal Insufficiency
• Management of Medical Emergencies
• Supplemental clinical source: BSPED: Adrenal insufficiency — dental and perioperative guidance
• Supplemental clinical source: Canadian Paediatric Society: Adrenal suppression from exogenous glucocorticoids
• AAPD best practice: AAPD: Management of Dental Patients with Special Health Care Needs (2026)