Steroid cover & adrenal crisis

Most routine dental care needs no extra steroid. Know the exception — and the emergency.

Scaffold · unverifiedSCAFFOLD — clinical content NOT yet verified. Every threshold, dose and indication below is drafted from general consensus as a starting point and must be confirmed against current Therapeutic Guidelines (and reconciled the way the rest of this site is) before any clinical use.

Two questions, often confused. (1) Cover — does a patient on long-term steroids need an EXTRA dose before a dental procedure? Usually no: the modern evidence is that routine dental treatment under local anaesthetic rarely precipitates an adrenal crisis. (2) Crisis — if one does occur it is a life-threatening emergency: recognise it and give hydrocortisone.

Steroid cover — does this patient need an extra dose?

Decide whether a steroid-dependent patient needs supplementation before a procedure — and avoid the reflex of covering everyone.

Cover is considered only when BOTH a suppressed HPA axis AND a higher-stress procedure are present. Routine care under local anaesthetic, in a patient who has taken their usual dose, generally needs none.

Is the HPA axis likely suppressed?

Assume suppression — at risk

[UNVERIFIED] Prednis(ol)one >=5 mg/day (or equivalent) for >=2 weeks within the past 12 months
Currently on long-term systemic corticosteroid (oral, or regular IM/IV)
Stopped a long course within the last few months — HPA recovery is gradual
Known primary adrenal insufficiency (Addison's) or hypopituitarism — always at risk
Long-term high-dose inhaled corticosteroid

Suppression unlikely

Short courses (<2 weeks), even if occasionally repeated
Low-dose or alternate-day therapy below the threshold
Topical skin steroids; standard-dose inhaled corticosteroid
A single / intra-articular injection in the distant past

[UNVERIFIED] The threshold for 'significant suppression' varies between sources — confirm the exact dose, duration and look-back window against your reconciled guideline. Steroid equivalence (approx): hydrocortisone 20 mg = prednisolone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg.

UNVERIFIED scaffold — confirm against TG / adrenal-insufficiency guidance.

Procedure stress

Higher stress — consider cover (with the patient's doctor)

Multiple or surgical extractions; extensive oral surgery
Procedures under general anaesthesia or deep sedation
Long, difficult procedures with significant intra-operative stress
Significant acute infection — which itself raises steroid requirement

Routine — usual dose, no extra

Examination, radiographs, impressions
Simple restorations; supragingival scaling
A single simple extraction under LA
Most routine treatment under local anaesthetic

[UNVERIFIED] The stress threshold for supplementation is debated and trending higher (fewer patients covered). Confirm against your reconciled guideline; when in doubt, consult the patient's physician rather than reflexively covering.

UNVERIFIED scaffold — confirm against TG / peri-operative steroid guidance.

↓In practice (to verify): for most routine dental treatment the patient takes their normal steroid dose, you book a morning appointment and control pain and anxiety well — and give NO supplementary steroid. Reserve supplementation for major/surgical procedures, GA, or significant infection, decided WITH the treating doctor.

If supplementation is judged necessary (verify first)

Take the usual doseEnsure the patient has taken their normal morning corticosteroid dose before the appointment; schedule early in the day. [UNVERIFIED]

Moderate stress (if indicated)Some guidance suggests the usual dose suffices; other sources allow a modest extra oral dose on the day. Confirm whether your guideline recommends any increase at all. [UNVERIFIED]

Major / surgical / GAPerioperative IV hydrocortisone (e.g. 100 mg at induction, then per protocol) is used for major surgery — but this is decided and given by the surgical / anaesthetic / medical team, not improvised chairside. [UNVERIFIED]

Decide supplementation WITH the patient's physician or endocrinologist — not unilaterally.
Never STOP a patient's regular steroid for a procedure.
Morning appointments; minimise pain, fasting and anxiety — all raise cortisol demand.
Have hydrocortisone and an emergency plan available for any at-risk patient.

UNVERIFIED scaffold — confirm regimens against TG / peri-operative steroid guidance.

Inhaled / topical steroids[UNVERIFIED] Standard doses are not usually a concern; very-high-dose long-term inhaled steroid can suppress the axis — confirm thresholds.

'Just double everyone'[UNVERIFIED] The old reflex to cover all steroid patients for any dental work is no longer supported; routine care under LA generally needs none.

Missed dose + procedure[UNVERIFIED] A patient who has not taken their usual steroid, or is acutely unwell, is the higher-risk scenario — ensure the dose is taken and stay alert for crisis.

Adrenal crisis — recognise & treat

A steroid-dependent or Addison's patient who collapses or becomes shocked may be in adrenal crisis. It is rapidly fatal untreated — and reversible with hydrocortisone.

Suspect adrenal crisis if —

Known Addison's / long-term steroid / recently-stopped steroid, now acutely unwell
Hypotension — especially postural; collapse or shock not otherwise explained
Profound weakness, pallor, sweating
Nausea, vomiting, abdominal pain
Drowsiness or confusion, progressing to loss of consciousness
Often precipitated by stress, infection, trauma or a missed steroid dose

UNVERIFIED scaffold — confirm features against TG O&D — Medical emergencies.

If adrenal crisis is suspected

1 · Stop & assessStop treatment. ABCDE. Lay the patient flat and elevate the legs.
2 · Call 000Call an ambulance immediately — state suspected adrenal (Addisonian) crisis.
3 · HydrocortisoneHydrocortisone 100 mg IM (or IV) without delay if available. [UNVERIFIED — confirm dose, route, and whether the dental-chair flowchart has the dentist give it or defer to the ambulance.]
4 · OxygenHigh-flow oxygen.
5 · SupportTreat hypoglycaemia if present; IV fluids (normal saline) — usually ambulance / hospital. Monitor; be ready for basic life support.

Emergency dose (to verify)

Adult: hydrocortisone 100 mg IM / IV.
[UNVERIFIED] Child: lower dose by age / weight (e.g. ~50 mg) — confirm.
Hydrocortisone (sodium succinate) is not yet a drug record on this site — add it to the emergency-kit list.

When in doubt in a collapsed at-risk patient, treat for adrenal crisis — the downside of a single hydrocortisone dose is low, and the cost of missing a crisis is high. [UNVERIFIED — confirm this framing against your guideline.]

UNVERIFIED scaffold — confirm the algorithm against TG O&D — Medical emergencies (Sept 2025) / ARC.

Walk the steroid-cover decision step by stepMedical emergency in the chair

Scaffold for review only — clinical content is NOT yet verified. Do not use for patient care until every threshold, dose and indication below has been reconciled to current Australian Therapeutic Guidelines. You confirm the diagnosis, the patient's medication history, and every dose before prescribing.

SCAFFOLD — NOT yet reconciled. Confirm against Therapeutic Guidelines: Oral & Dental — Medical emergencies in dental practice (Sept 2025), plus current adrenal-insufficiency / peri-operative corticosteroid guidance, before clinical use.

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