01/05/2023 CODS Davangere

1

Corticosteroids in oral medicine

PRESENTED BY: G.NAGU NAIKMDS 1ST YEARDEPARTMENT OF ORAL MEDICINE AND RADIOLOGY

3Introduction

History

Functional anatomy and histology of adrenal glands

Synthesis and Fate of steroids

Mineralocorticoids

Glucocorticoids

Contents:

4Classification of steroidsSteroids in oral medicineAdverse effects

Precautions

references

conclusion

5Introduction The adrenal gland is the source of a diverse

group of hormones essential for metabolic control, regulation of water and electrolyte balance, and regulation of body’s response to stress.

Using cholesterol as a substrate, the adrenal cortex produces a large number of substances collectively known as corticosteroids.

6History By the middle of 19th century it was

demonstrated that adrenal glands were essential for life

Later, it was appreciated that the cortex was more important than the medulla

A number of steroidal active principles were isolated and their structures were elucidated by kendall and his coworkers in the 1930s.

7Functional anatomy and histology of adrenal glands

8

9

10

Zones of adrenal cortex Hormones

Zona glomerulosa AldosteroneDesoxycorticosterone

Zona fasciculata CortisoneCortisol

Zona reticularisDehydroepiandrosterone

AndrostenidioneTraces of estrogens

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

01/05/2023 CODS Davangere

11

Fate of corticosteroids

Degraded mainly in liver

Conjugated to form glucuronides and to a lesser extent form sulphates

25% - excreted in bile and feces

75% - excreted in urine

12

MECHANISM OF ACTION plasma memb

CorticosteroidsCYTOPLASMICRECEPTORPROTEIN

GLUCOCORTICOIDRESPONSEELEMENT

Nucleus

Transcription ofm - RNA

New proteinsynthesis

TOTALTIME30 – 60 mins

13

Mineralocorticoids

14

Mineralocorticoids Source : Zona glomerulosa Functions: 90% of mineralocorticoid activity

is provided by aldosterone Aldosterone – life saving hormone

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

15

On Na+ metabolism

• Increase in the reabsorption of sodium from renal tubules

Actions

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

16

On ECF volume

• Na reabsorption from renal tubules• Simultaneous water reabsorption• Increase in ECF volume

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

17

On BP

• Increases ECF volume• Increases BP

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

18

On K+ ions

• Increase in the excretion of potassium from renal tubules

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

19

On H+ ion concentration

• Causes tubular secretion of hydrogen ions• Essential to maintain acid - base balance

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

20

On intestine

• Greatly enhances sodium absorption from the intestine

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

21

Glucocorticoids

22

Glucocorticoids Source : zona fasciculata Functions:

Cortisol – Life protecting hormone

Hormone Glucocorticoid activity

Cortisol 95%Corticosterone 4%Cortisone 1%

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

23

Actions:

On carbohydrate metabolism

• Increases blood glucose level in two ways,• Promotes gluconeogenesis• Inhibits glucose uptake and utilization by peripheral

cells

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

24

On protein metabolism

• Promote catabolism of protein in cell • Increase plasma amino acid and protein content in

the cell.

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

25

On fat metabolism

• Causes mobilization and redistribution of fat• Actions are • - Mobilization of fatty acids from adipose tissue• - Increase the concentration of fatty acids in blood• - Increases the utilization of fat for energy

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

26

On mineral metabolism

• Enhances sodium retention • Slightly increase potassium excretion• Decreases blood calcium by inhibiting absorption

from intestine

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

27

On water metabolism

• Accelerate the excretion of water

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

28

On CNS

• Essential for normal functioning• Insufficiency causes personality changes like

irritablity and lack of concentration

Essentials Of Medical Physiology 3rd Edition,K Sembulingam

29Classification

30

Classification of steroids based on their relative activity

Glucocorticoids:

Short acting(t1/2 < 12 hr)• Hydrocortison

e • Cortisone

Intermediate acting: (t1/2 12 – 36)• Prednisole• Methyl

prednisole• Triamcinolone

Long acting:(t1/2 > 36 hrs)• Paramethasone• Dexamethason

e• Betamethason

e

31

Mineralocorticoids • Desoxycorticosterone acetate(DOCA)• Fludrocortisone • Aldosterone

32Some Commonly

Prescribed Steroids

01/05/2023 CODS Davangere

33

Triamcinolone

01/05/2023 CODS Davangere

34

Dexamethasone

01/05/2023 CODS Davangere

35

Betamethasone

01/05/2023 CODS Davangere

36

Hydrocortisone

01/05/2023 CODS Davangere

37

Cortisone

01/05/2023 CODS Davangere

38

Prednisolone

39Corticosteroid

s in Oral Medicine

40Ulcerative, Vesiculoerosive

diseases•Eg: Erosive LP•RAS

Benign lesions •Eg: CGCG

Salivary gland disorders •Eg: Mucocele

TMJ Disorders •Eg: Osteoarthritis•Rheumatiid arthritis

Neuralgia Treatment •Eg. Post herpatic neuralgia

Miscellanous •OSMF

41

Ulcerative Vesiculoerosive diseases

Immunologically mediated diseases that affect the oral mucosa present with inflammation and loss of epithelial integrity, through cellular and/or humoral immunity-mediated attack on epithelial connective tissue targets.

The main clinical features are ulceration and reddening, with pain that can be severe and debilitating.

42

Corticosteroids play a central role in the treatment of vesiculoerosive lesions.

However, the frequency and severity of the adverse effects associated with the use of systemic corticosteroids have led to the increased use of topical corticosteroids (TCs)

01/05/2023

43short course of

TCsAccelerate remission

without adverse effects

Recurrent aphthous stomatitis (RAS), some cases of

erythema multiforme (EM), and Drug-

induced ulceration.

TCs must be used for longer, less predictable

periods

Severe RAS, Erosive oral lichen planus

(OLP), specific forms of EM, and mucous

membrane pemphigoid (MMP)

Criteria for use

01/05/2023 CODS Davangere

44

very severe cases of

ulceration

Short course of systemic

corticosteroids followed by

maintenance regimen of TCs and or can also

be started simultaneously with the systemic therapy

Pemphigus vulgaris ,10-

30% of Pemphigoid

patients, Erosive lichen

planus

Inevitably be treated with systemic

corticosteroids and/or other

immunosuppressant therapies

45

Protocols for use When a TC is prescribed, and especially when a

prolonged course is predicted, the basic rule is that a TC of a potency appropriate to the severity of the clinical symptoms should be used, at the lowest possible concentration and frequency, with maintaining the effectiveness of the treatment.

It should always be taken into account that these drugs do not cure the disease but rather control or relieve the symptoms.

46

The key factors The specific diagnosis

The severity of the oral disease

The presence or absence of extra-oral lesions

The medical history of the patient

47

Factors that influence the effectiveness of TCs:

The contact time between the drug and lesion and the vehicle used to apply it;

48

Factors that influence the effectiveness of TCs:

Concentration

(Regezi and Sciubba, 1999).

49

Success of a topical medicine

Two main factors

Number of applications per day

High-potency(2-3 times)

Low potency(5-10 times)

The vehicle usedVarious vehicles

50

Various vehicles.Orabase (Stoy, 1966),

Cyanoacrylate (Jasmin et al., 1993),

Bioadhesive patches made of cellulose derivatives (Mahdi et al., 1996),

Gels (Regezi and Sciubba, 1999), and

Denture adhesive paste (Lo Muzio et al., 2001).

51

Patients prescribed TC in an adherent vehicle .

Apply a small amount to the target area after meals.

Not to eat or drink for at least 30 min. It is best not to rub the TC in, because this

can produce irritation.

53

Systemic steroids for ulcerative vesiculobullous diseases

54

major aphthae or severe multiple minor aphthae

Prednisone therapy should be started at 1.0 mg/kg/day

in patients with severe RAU and should be tapered after1 to 2 weeks.

55

Minor EM 20 – 40 mg/day for 4 – 6 days

Severe or rapidly

progressing lesions

60 mg/day slowly tapered by 10 mg/day

over 6 weeks

Erythema multiforme

56Pemphigus Vulgaris

Initial dose of treatment – 0.5 mg/kg/day to 3 mg/kg/d

Dose that achieves clinical control is maintained for 2-3 weeks and then gradually tapered.

Burkit’s Oral Medicine, 11th edition

57

Pulse therapy Also called short term therapy High dose therapy involves a 48-72 hrs course of

intensive steroid administration Single i.v injection of a supra-physiological dose

of steroid Dose of 0.5-2g of prednisolone or equivalent

58

Benefits

Avoids complications & side effects of long term

steroid therapy

To achieve immunosuppressive effects similar to

those with higher doses of steroids

59

Lichen planusPrednisolone 1mg/kg/d for

<7 days

Tapered to 10-20mg per

day for 2 weeks

Burkit’s Oral Medicine, 11th editionJIAOMR, April-June 2011;23(2):128-131

60

Lupus erythematosusPredisolone –

20 - 30 mg/day for 2- 6

weeks

Tapered gradually

61

Steroids in the treatment of benign lesions

CGCGHEMANGIOMA

62CGCG

Intralesional injection of triamcinolone can be given in a dose of 1 to 2 mg/kg/d (maximum of 60

mg).

The treatment interval at 4 to 6 weeks.

66

Prednisone at a dose of 20-30 mg/d can be given for 2

weeks to 4 months( Fost and Esterly)

Intralesional triamcinolone acetonide (4 mg/mL)

(Hawkins et al)

Hemangioma

67

Steroids in salivary gland disorders

MUCOCELE

68

Mucocele

0.05% clobetasol propionate 3 times a day for 4 weeks in a mucosal adhesive base.

Intralesional injections have also been tried with success.

70

Steriods in neuralgia

POST HERPETIC NEURALGIA

71

Post herpetic neuralgia

To reduce incidence of post herpetic neuralgia:

Prednisolone 20 to 30 mg/day for 7 – 10 days tapered to 10 mg/day for 1 week

(Treatment of oral diseases, George Lascaris)

74

Steroids for TMJ disorders

OSTEOARTHRITISRHEUMATOID ARTHRITIS

75

Rheumatoid arthritis

Intraarticular injection – 10 to 40 mg/ml

osteoarthritisIntraarticular injection

– 20 mg/ml(2 injections 14 days

apart)

Arthritis

76

Miscellaneous

OSMFBELL’S PALSY

77

Bell’s palsy Significant improvement can be

achived when Prednisolone is started within 72 hours of symptom onset

1 mg/kg body weight (maximum 70 mg) in divided doses with meals for six days, and the dose can be reduced gradually over the next four days.

78

OSMFPredisolone –

20 - 30 mg/day for 2 –

4 weeks

Gradually taper

Discontinue in 1- 2 months

79

Injections of triamcinolone 10mg/ml

diluted in 1 ml of 2% lidocaine with hyaluronidase 1500 IU, biweekly for 4 weeks.

(Borle et al)

80

Bi weekly submucosal injections of a combination of dexamethasone (4mg/ml) and two parts of hyaluronidase, diluted in 1.0 ml of 2% xylocaine by means of a 27 gauge needle, not more than 0.2ml solution per site, for a period of 20 weeks.

Significant relief of burning sensation (88%) and improvement of trismus (83%) can be seen in most patients.

81

Adverse effectsDue to extention of pharmacological action occuring with

prolonged therapyMineralocorticoids: Sodium and water retention Edema Hypokalemic alkalosis Progressive rise in B.P Weight gain Fluid and electrolyte disturbance

82Glucocorticoid:

GIT: Acute erosive gastritis with hemorrhage Peptic ulcer Intestitial perfortion Pancreatitis Metabolic effects: Hyperglycemia Ketoacidosis Hyperosmolar coma Hypophosphatemia

83

Cushingoidism:Prolonged therapy causes Central obesity with moon face Buffalo hump Pink florid striae are liable to appear on

the abdomen, hips and pectoral region and skin may become friable

84CVS and renal system:

Hypertension Salt and water retention Hypokalemic alkalosisCNS: Influence mood, sleep pattern Insomnia Acute psychotic reactions Benign intracranial hypertension Epilepsy

85

Musculoskeletal effects: Proximal myopathy and osteoporosis with

compression fractures of vertebrae Acute aseptic necrosis of boneEyes: Glaucoma

86

Relative Contraindications:

Peptic ulcer Diabetes mellitus Hypertension Pregnancy Tuberculosis Osteoporosis

Psychosis Epilepsy Renal failure

87

Precautions during therapyBefore starting therapy: Enquire and check for hypertension,

diabetes mellitus, peptic ulcer, any infection

88

During therapy: Prescribe drug with food Diet low in calories and sodium and rich in

potassium Check periodically for weight gain,

hypertension, hyperglycemia

89

Increase dose in case of stress Instruct patient not to stop abruptly

90

Protocol for Supplementation of Patients on Glucocorticoid Therapy Who Are Undergoing Dental Care (Burket’s 10th ed)

01/05/2023 CODS Davangere

91

Dental Procedure

Previous Systemic Steroid Use

Current Systemic Steroid Use

Daily alternating Systemic Steroid Use

Current topical Systemic Steroid Use

Extractions, surgery, or extensive procedures

If prior usage lasted > 2 weeks and ceased < 14–30 days ago, give previous maintenance dose

If prior usage ceased > 14–30 days ago, no supplementation needed

Double daily dose on day of procedure

Double daily dose on first postoperative day when pain is anticipated

Treat on steroid dosage day, and give double daily dose on day of procedure

Give normal daily dose on first postoperative day when pain is anticipated

No supplementation needed

92

Dental Procedure

Previous Systemic Steroid Use

Current Systemic Steroid Use

Daily alternating Systemic Steroid Use

Current topical Systemic Steroid Use

Routine procedures

If prior usage lasted for > 2 weeks and ceased < 14–30 days ago, give previous maintenance dose

If prior usage ceased > 14–30 daysago, no supplementation needed

No supplementation needed

Treat on steroid dosage day; no further supplementation needed

No supplementation needed

93

Conclusion Corticosteroids play an important role in

control of pain & inflammation associated with numerous disease states of oral cavity.

Currently corticosteroids are drugs with one of the broadest spectrum of clinical utility.

But it should never be used as a substitute to other treatments

Lets keep it mind that these drugs do not cure the disease but rather control or relieve the symptoms.

94

References:1)Essentials OfMedical Physiology 3rd Edition,K Sembulingam 2)GOODMAN&GILMAN Pharmocological basis of therapeutics/11th ed.(2006)3)Natah SS, Konttinen YT. IJOMS 2004;33:221-34.4)JDR April 2005 vol. 84 no. 4 294-301 5)IndianJOphthalmol Jan-Feb 2010;58(1):64-666)Basic and Clinical Pharmacology LANGE-11th Edition7)Oral Surgery Volume 1 Issue 2, Pages 88 8)-Burkit’s Oral Medicine, 11th edition9)Satyanarayana-Essentialsof biochemistry

95Thank You...