Risk of adrenal crisis in dental patients: results of a systematic search of the literature

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

Systemic Diseases with Oral Manifestations and Their Impact on Health-Related Quality of Life

Health-related quality of life is a multidimensional concept established to evaluate the physical, psychological, and social impacts of health conditions on individuals’ well-being. Various tools for measuring health-related quality of life can be categorized into two subsets: generic and disease–specific instruments. The oral cavity can be stricken by a broad range of local and systemic diseases and their systemic treatment modalities. The most common systemic illnesses associated with oral lesions are hematologic disorders, endocrinopathies, neurological disorders, gastrointestinal conditions, mucocutaneous and rheumatic diseases, and neoplastic processes. Their manifestations in the oral cavity are, in most cases, rather nonspecific but should not be overlooked. Oral health is one of the most important parts of overall health, thus it has been proposed that poor oral health may affect health–related quality of life. The presence of oral manifestations of systemic diseases has a negative impact on the daily functioning of patients, decreasing their overall well-being. This article will review the most common systemic diseases with oral manifestations and their impact on the health–related quality of life. Oral health researchers should put a stronger emphasis on the patient-reported quality of life as a primary outcome in future clinical trials. The significance of this area has still not been widely understood in the current dental literature even though it could help improve patients’ health-related quality of life.

New Approach to Addison Disease: Oral Manifestations Due to Endocrine Dysfunction and Comorbidity Burden

This review highlights oral anomalies with major clinical impact in Addison disease (AD), including dental health and dermatologic features, through a dual perspective: pigmentation issues and AD comorbidities with oral manifestations. Affecting 92% of AD patients, cutaneomucosal hyperpigmentation is synchronous with or precedes general manifestations by up to a decade, underlying melanocytic infiltration of the basal epidermal layer; melanophages in the superficial dermis; and, rarely, acanthosis, perivascular lymphocytic infiltrate, and hyperkeratosis. Intraoral pigmentation might be the only sign of AD; thus, early recognition is mandatory, and biopsy is helpful in selected cases. The buccal area is the most affected location; other sites are palatine arches, lips, gums, and tongue. Pigmented oral lesions are patchy or diffuse; mostly asymptomatic; and occasionally accompanied by pain, itchiness, and burn-like lesions. Pigmented lingual patches are isolated or multiple, located on dorsal and lateral areas; fungiform pigmented papillae are also reported in AD individuals. Dermoscopy examination is particularly indicated for fungal etiology; yet, it is not routinely performed. AD’s comorbidity burden includes the cluster of autoimmune polyglandular syndrome (APS) type 1 underlying AIRE gene malfunction. Chronic cutaneomucosal candidiasis (CMC), including oral CMC, represents the first sign of APS1 in 70–80% of cases, displaying autoantibodies against interleukin (IL)-17A, IL-17F ± IL-22, and probably a high mucosal concentration of interferon (IFN)-γ. CMC is prone to systemic candidiasis, representing a procarcinogenic status due to Th17 cell anomalies. In APS1, the first cause of mortality is infections (24%), followed by oral and esophageal cancers (15%). Autoimmune hypoparathyroidism (HyP) is the earliest endocrine element in APS1; a combination of CMC by the age of 5 years and dental enamel hypoplasia (the most frequent dental complication of pediatric HyP) by the age of 15 is an indication for HyP assessment. Children with HyP might experience short dental roots, enamel opacities, hypodontia, and eruption dysfunctions. Copresence of APS-related type 1 diabetes mellitus (DM) enhances the risk of CMC, as well as periodontal disease (PD). Anemia-related mucosal pallor is related to DM, hypothyroidism, hypogonadism, corresponding gastroenterological diseases (Crohn’s disease also presents oral ulceration (OU), mucogingivitis, and a 2–3 times higher risk of PD; Biermer anemia might cause hyperpigmentation by itself), and rheumatologic diseases (lupus induces OU, honeycomb plaques, keratotic plaques, angular cheilitis, buccal petechial lesions, and PD). In more than half of the patients, associated vitiligo involves depigmentation of oral mucosa at different levels (palatal, gingival, alveolar, buccal mucosa, and lips). Celiac disease may manifest xerostomia, dry lips, OU, sialadenitis, recurrent aphthous stomatitis and dental enamel defects in children, a higher prevalence of caries and dentin sensitivity, and gingival bleeding. Oral pigmented lesions might provide a useful index of suspicion for AD in apparently healthy individuals, and thus an adrenocorticotropic hormone (ACTH) stimulation is useful. The spectrum of autoimmune AD comorbidities massively complicates the overall picture of oral manifestations.

The Impacts of Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dysplasia (APECED) on the Oral Health of Children and Young People: A Review and Case Report

Aim:

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare, highly variable disease with significant oral health impacts. The aim of the study is to examine the existing evidence base surrounding the oral health impacts of APECED and consider the wider clinical significance of the condition relevant to the provision of pediatric dental care.

Materials and Methods:

The evidence surrounding APECED and the oral health impacts obtained from a review of multiple databases was qualitatively summarized in the form of a literature review. A case study was used to illustrate the relevance of literature in caring patients with APECED.

Results:

The literature describes a broad range of impacts from APECED, although it is characterized by chronic candidal infection, autoimmune hypoparathyroidism, and Addison’s disease. Oral manifestations of APECED appear frequently and can present early. Developmental defects of the teeth affect a large proportion of patients with APECED and together with candidiasis, characterize the key oral manifestations of the disease. An enhanced preventive and minimally invasive approach to oral health care is recommended for these patients in light of the complexities of their medical condition.

Conclusion:

Patients with APECED require careful multidisciplinary care to ensure that the optimal oral health outcomes are achieved.

Clinical Unmet Needs in the Treatment of Adrenal Crisis: Importance of the Patient's Perspective

Adrenal crisis is the most severe manifestation of adrenal insufficiency (AI), but AI can present with variable signs and symptoms of gradual severity. Despite current hormone replacement strategies, adrenal crisis is still one of the leading causes of mortality in AI patients. Although underlying factors explaining differences in interindividual susceptibility are not completely understood, several subgroups are particularly vulnerable to adrenal crises, such as patients with primary AI, and patients treated for Cushing's syndrome. Currently, the health care professional faces several challenges in the care for AI patients, including the lack of reliable biomarkers measuring tissue cortisol concentrations, absence of a universally used definition for adrenal crisis, and lack of clinical tools to identify individual patients at increased risk. Also from the patient's perspective, there are a number of steps to be taken in order to increase and evaluate self-management skills and, finally, improve health-related quality of life (HR-QoL). In this respect, the fact that inadequate handling of AI patients during stressful situations is a direct consequence of not remembering how to act due to severe weakness and cognitive dysfunction in the context of the adrenal crisis is quite underexposed. In this narrative review, we give an overview of different clinical aspects of adrenal crisis, and discuss challenges and unmet needs in the management of AI and the adrenal crisis from both the doctor's and patient's perspective. For the latter, we use original focus group data. Integration of doctor's and patient's perspectives is key for successful improvement of HR-QoL in patients with AI.

Death related to dental treatment: a systematic review

OBJECTIVE

The aim of this study was to identify factors associated with death in relation to dental care.

STUDY DESIGN

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Dental and Oral Sciences Source, Web of Science, and the Cochrane database were searched, and the references of all retrieved articles were analyzed. Studies were included if death had occurred within 90 days of the dental appointment, and if the patient's age, procedure, and information regarding cause or time of death were provided. Factors associated with death were assessed by multivariate analyses and logistic regression.

RESULTS

Fifty-six publications, including retrospective studies and case reports/series that reported 148 fatalities, were analyzed. On average, 2.6 deaths were reported per year. The leading cause of deaths was anesthesia/sedation/medication-related complications (n = 70). Other causes were cardiovascular events (n = 31), infection (n = 19), airway-respiratory complications (n = 18), bleeding (n = 5), and others (n = 5). Age (P < .0001), disease severity (P < .02), disease stability (P < .006), dental provider characteristics (P < .05), level of consciousness/sedation (P < .02), and drug effects (P < .03) had significant associations with death.

CONCLUSIONS

Reports of death were rare; however, specific risk factors associated with dentistry were identified. A better understanding of these factors is important for the development of guidelines that help prevent fatalities in dentistry.

Incidence of adrenal crisis in patients with adrenal insufficiency

BACKGROUND

An adrenal crisis (AC) is a potential life-threatening event in patients with adrenal insufficiency (AI). This study aims to determine the incidence, causes, and risk factors of AC in AI.

METHODS

Patients with AI diagnosed and treated at the University Medical Center Utrecht for the past 30 years were identified, and all medical records were assessed by two independent investigators. The observed frequency of AC was determined as incidence rate, calculated as the number of AC divided by person-years (PY). In addition, precipitating factors and risk factors were assessed.

RESULTS

We observed an incidence rate of 5·2 AC (95% CI 4·3-6·3) per 100 PY in primary adrenal insufficiency (PAI, a total of 111 patients), and 3·6 AC (95% CI 3·1-4·1) per 100 PY in secondary adrenal insufficiency (SAI a total of 319 patients). Patients with an established diagnosis of tertiary (glucocorticoid-induced) adrenal insufficiency (a total of 28 patients) had 15·1 AC (95% CI 11·0-19·9) per 100 PY. The most important risk factor was the existence of comorbidity. Gastro-enteritis and other infections were the most common precipitating factors for AC.

CONCLUSION

AC still occurs relatively frequent in patients with AI, mostly precipitated by infections and particularly in patients with high comorbidity. This should be taken into account in the education and follow-up of patients with AI.