Addison’s disease is a disorder that was first discovered by Thomas Addison in 1885. It is defined as an endocrine disease that targets the adrenal glands that are found on top of the kidneys. This disease causes a decrease in the production of the aldosterone and cortisol hormones.1
Cortisol is known as the “stress hormone” and is responsible for increasing the production of glucose in the bloodstream. It helps enable the brain to utilize this glucose so that it can function properly. It also helps aid the body when it is in a “fight or flight” situation, a necessary function for all of our bodies.2
Aldosterone is responsible for regulating sodium absorption and potassium excretion in the body. It also plays a role in blood pressure regulation since it aids in regulating the amount of volume that is found in the extracellular fluid.3
Primary and Secondary Addison’s Disease and Acute Adrenal Insufficiency
There are two types of Addison’s disease: primary and secondary. Primary Addison’s disease develops when the adrenal glands are damaged and cannot produce enough cortisol and aldosterone. Secondary Addison’s disease is a result of another systemic disease or disorder, but the adrenal glands are not damaged.
Seventy-five percent of cases of Addison’s disease are considered primary and are caused by an autoimmune response. Tuberculosis, certain fungal infections, and bleeding inside of the adrenal gland are some other uncommon causes for primary Addison’s disease.4 Many cases of secondary Addison’s disease stem from some sort of disruption of the pituitary gland.5
If a patient suffers from an injury, high-stress event, or sickness, symptoms of Addison’s disease can come on fast and furious and can lead to a potentially fatal episode known as acute adrenal insufficiency (also referred to as an adrenal crisis). Acute adrenal insufficiency is a medical emergency and, if left untreated, can lead to shock and ultimately death.1
Addison’s Disease Signs and Symptoms
Addison’s disease is considered a rare disease that affects approximately 1 in 100,000 people in the United States and targets both males and females of all ages equally. This disease typically progresses slowly and can include the following symptoms: fatigue and weakness, hypotension, nausea, diarrhea, weight loss, abnormal menstrual periods, sensitivity to cold, and mood disruptions.1,6
Hyperkalemia and hyponatremia are also common symptoms for these patients and they will often complain of a craving for salt.7 Since the earlier symptoms of Addison’s can overlap those of countless other conditions and diseases, have the ability to wax and wane, and be nonspecific, patients may not seek prompt medical treatment. This is why a complete health history that not only focuses on new medications, surgeries, and diagnoses but also any “new” symptoms patients may have recently developed is extremely important.
Even though this disease is considered rare, it is vital that dental hygienists familiarize themselves with it because it almost always manifests itself in the oral cavity before anywhere else in the body. Oral signs and symptoms are present in 92% of all patients with the disease.
Clinically, it can appear as a diffuse intraoral pigmentation, or melanotic patches that are commonly found on the tongue, gingiva, buccal mucosa, and hard palate.6-8 The extraoral hyperpigmentation in patients with Addison’s disease can occur anywhere on the body but is most commonly seen where there are creases and folds in the skin and near scars.
Patients may also develop white patches of skin which can be found on single areas of the body or in multiple locations.4
In the life-threatening situation of an acute adrenal insufficiency, patients can show any of the following signs and symptoms: confusion, extreme weakness, loss of consciousness, paleness, and severe pain in the back, legs, and stomach. 911 should be called immediately if an adrenal crisis is suspected in a patient so that they can receive immediate medical attention.1
Addison’s Disease Treatment
Blood tests are needed to confirm this disease, but different types of imaging like MRIs and CT scans may be used in conjunction. An ACTH test may also be used to help diagnose the disease. This involves injecting a synthetic version of ACTH and then measuring the blood levels of cortisol in response to it. Blood sugar tests may also be performed.9
Treatment for Addison’s disease whether it is considered primary or secondary always involves medication to help balance the hormone levels appropriately.2,8
In the case of acute adrenal insufficiency, fast and emergent treatment is needed. The treatment includes the use of glucocorticoids, usually hydrocortisone given either intravenously or intramuscularly. Intravenous fluids are also needed because dehydration is usually present. Due to the severity of the adrenal crisis, these patients always require critical monitoring in an ICU setting of a hospital.5
Hygienists should feel comfortable in identifying the signs and symptoms of Addison’s disease. They should also be able to communicate their findings to other health-care professionals that may be involved in treating the patient such as their primary care physician and endocrinologist. Intraoral cameras can be especially useful in these cases if intraoral signs are present.
If hygienists notice anything abnormal during their exam or hygiene treatment appointment, they should discuss their findings with the patient and recommend follow-up with their doctor.
Dental Considerations of Addison’s Disease
Because the signs and symptoms of Addison’s disease can be vague and overlap those of many other conditions, patients are not always aware they have the disease. If they are, they may not be aware that their disease is escalating and approaching the dangerous and potentially life-threatening acute adrenal insufficiency.
Taking blood pressure on every dental patient is ideal, but taking blood pressure for patients suffering from Addison’s disease has the potential to save their life. If a patient with Addison’s is suffering an adrenal crisis, they will have low blood pressure and an elevated heart rate. A radial pulse (pulse taken at the wrist) may not be able to be found or maybe weak and/or thready. Because we are in such close proximity to our patients, hygienists are in the perfect position to recognize some of the initial signs and symptoms of a sudden adrenal crisis.
Cortisol production increases dramatically in response to invasive procedures, surgeries, as well as stress, all of which we as dental professionals can be responsible for inducing. This upset of the delicate balance of hormones can induce an acute adrenal insufficiency in our patients suffering from Addison’s disease.
Another consideration for dental professionals is the type of anesthetic that is used for a procedure. Anesthetics that contain barbiturates, which are commonly used in IV sedation, can increase the metabolism of cortisol and will also cause a drop in blood pressure, which in turn can exacerbate an adrenal crisis.10,11 Dental professionals should consider completing a medical consult for these patients before they have any invasive treatment completed because their medications may need to be temporarily adjusted.2
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References
- Addison’s Disease. Cleveland Clinic. 2019. Retrieved from https://my.clevelandclinic.org/health/diseases/15095-addisons-disease
- Stress Management: Chronic Stress Puts Your Health at Risk. Mayo Clinic. 2019. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037#:~:text=Cortisol%2C%20the%20primary%20stress%20hormone,fight%2Dor%2Dflight%20situation
- Scott, J.H., Menouar, M.A., Dunn, R.J. Physiology, Aldosterone. Statpearls Publishing, LLC. Treasure Island, FL. 2020. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470339/.
- Addison’s Disease. National Organization for Rare Disorders. 2018. Retrieved from https://rarediseases.org/rare-diseases/addisons-disease/
- Ghada E., Faysal A., Jordan M.J. Adrenal Crisis. Statpearls Publishing, LLC. Treasure Island, FL. 2020. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499968/
- Briody, A.N., Cordell, K.G., Rosebush, M.S. Black and Brown: Non-neoplastic Pigmentation of the Oral Mucosa. Head Neck Pathol. 2020; (1): 47–55. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405786/
- Sarkar, S.B., Sarkar, S., Ghosh, S., Bandyopadhyay, S. Addison’s Disease. Contemp Clin Dent. 2012; 3(4): 484–486. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636818/
- Sreeja, C., Ramakrishnan, K., Vijayalakshmi, D., et al. Oral Pigmentation: A Review. J Pharm Bioallied Sci. 2012; (Suppl 2): S403–S408. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606629/
- Adrenal Insufficiency & Addison’s Disease. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease.
- Khalaf, M.W., Khader, R., Cobetto, G., et al. Risk of Adrenal Crisis in Dental Patients: Results of a Systematic Search of the Literature. JADA. 2013; 144(2): 152-160. Retrieved from https://jada.ada.org/article/S0002-8177(14)60616-4/pdf
- Skibiski, J., Abdijadid, S. Barbiturates. StatPearls Publishing, LLC. Treasure Island, FL. 2020. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539731/
