Addison's Disease and Orthodontics UK

What is Addison's disease and why does it matter for dental treatment?

Addison's disease (primary adrenal insufficiency) is a rare condition in which the adrenal glands — located above the kidneys — fail to produce sufficient cortisol and, in most cases, aldosterone. In the UK it affects approximately 1 in 10,000 people and is most commonly caused by autoimmune destruction of the adrenal cortex. The deficit of cortisol means the body cannot mount an adequate stress response to physiological challenges — including surgical procedures and sedation. This is the central concern for dentists and orthodontists: procedures that the normal cortisol-producing body manages without difficulty can precipitate an adrenal crisis in unmanaged Addison's disease. Patients with Addison's disease must therefore carry a steroid replacement medication and a steroid emergency injection kit (hydrocortisone for injection), and their dental team must know about their diagnosis and current medication regimen.

What is steroid cover and when is it needed in orthodontic treatment?

Steroid cover refers to the additional oral or injectable hydrocortisone given to a patient with adrenal insufficiency before a stressful dental procedure to supplement their baseline cortisol replacement. In routine orthodontic appointments — wire changes, aligner fittings, impressions, bonding of brackets — the stress level is relatively low and many patients on stable replacement therapy do not require additional steroid cover beyond their normal daily dose. However, for dental extractions (including those planned as part of orthodontic treatment to create space), minor oral surgery, and procedures under sedation or general anaesthesia, steroid cover is standard practice. The specific protocol — whether to double the morning hydrocortisone dose, take an additional dose before the procedure, or require injectable cover — should be agreed with the patient's endocrinologist or GP before any extraction or invasive procedure is scheduled.

How does Addison's disease affect wound healing after extractions?

Cortisol plays an important role in the inflammatory response and tissue repair. Patients with adrenal insufficiency on replacement therapy generally heal normally from routine extractions, provided their steroid replacement is adequate and the procedure-specific cover protocol has been followed. However, if steroid replacement is subtherapeutic — due to missed doses, intercurrent illness, or inadequate cover for the procedure — wound healing may be impaired and the risk of post-operative infection may be increased. Patients should be reminded to take their normal morning hydrocortisone before any dental appointment, and to carry their emergency hydrocortisone injection kit. Prolonged bleeding, excessive pain, failure of the socket to begin closing normally, or signs of infection in the days following extraction should prompt earlier dental review and consideration of whether the stress of the procedure caused a relative cortisol deficiency.

What is hyperpigmentation of the gingiva in Addison's disease?

One of the oral signs of Addison's disease is hyperpigmentation — a darkening of the skin and mucous membranes caused by elevated levels of adrenocorticotropic hormone (ACTH) and related peptides, which stimulate melanin production. In the mouth, this presents as brown or bluish-brown discolouration of the gingiva (gums), buccal mucosa (inner cheeks), lips, and palate. Gingival hyperpigmentation due to Addison's disease may be the first clinical sign that leads to diagnosis in some patients. For orthodontists, awareness of this sign is important: if a patient presents with unexplained gingival pigmentation not explained by racial or medication-related causes, Addison's disease should be considered and the patient referred to their GP. In patients with known Addison's disease, the hyperpigmentation does not usually require treatment and does not affect orthodontic appliance placement.

What are the risks of sedation and electrolyte imbalance in Addison's disease?

Aldosterone deficiency in Addison's disease (primary adrenal insufficiency) leads to reduced sodium retention and increased potassium levels in the blood (hyponatraemia and hyperkalaemia). Under normal replacement conditions these are corrected by fludrocortisone supplementation, but electrolyte levels can fluctuate — particularly during illness, dehydration, or physiological stress. Electrolyte disturbances of clinical significance can cause arrhythmias, hypotension, and cardiovascular instability during sedation or general anaesthesia. For any orthodontic procedure planned under conscious sedation or general anaesthesia (for example, surgical exposure of impacted teeth), pre-procedure electrolyte checking is appropriate, the endocrinologist or GP should be consulted regarding medication management, and the anaesthetic team must be informed of the Addison's diagnosis and current medications including fludrocortisone and hydrocortisone. Patients with Addison's disease should not be sedated in primary care without appropriate medical assessment.

How do medication interactions affect orthodontic care for Addison's disease patients?

The primary medications used in Addison's disease are hydrocortisone (for cortisol replacement), fludrocortisone (for aldosterone replacement), and in some cases dehydroepiandrosterone (DHEA). Hydrocortisone is a corticosteroid with known interactions relevant to dental practice: it can affect wound healing at very high doses, interact with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen by potentially increasing the risk of peptic ulceration, and in very high doses may affect bone metabolism. For the doses used in Addison's replacement therapy, these interactions are of minimal clinical significance in routine orthodontic care. However, when NSAIDs are prescribed for orthodontic pain management — for example after extractions — patients with Addison's disease should be advised to take them with food and for the shortest necessary duration. Paracetamol is a safer first-line analgesic choice for pain management following dental procedures in this patient group.

What should patients with Addison's disease tell their orthodontist?

Patients with Addison's disease should disclose their diagnosis at the initial consultation and provide their full medications list including current hydrocortisone and fludrocortisone doses. They should inform the team of the name and contact details of their endocrinologist or supervising GP. They should bring their emergency hydrocortisone injection kit to every appointment and confirm that it is in date. They should advise the orthodontic team of any recent changes to their replacement therapy, any recent adrenal crises, and any planned or recent illness that may have affected their steroid balance. If extractions are planned as part of orthodontic treatment, the patient should request guidance from their endocrinologist on the appropriate steroid cover protocol before the procedure is booked, and provide this information to the dental team in advance.

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This guide is for general information only. It is not a diagnosis, treatment plan, or substitute for advice from a registered dentist or orthodontist.