CORTICOSTEROIDS IN CORTICOSTEROIDS IN DENTISTRYDENTISTRY

ContentsContents

IntroductionIntroduction

General physiologyGeneral physiology

HormonesHormones

Pharmacological Pharmacological actionsactions

Mechanism of actionMechanism of action

Clinical applicationsClinical applications

Uses in dentistryUses in dentistry

AvailabilityAvailability

ContraindicationsContraindications

Adverse effectsAdverse effects

ConclusionConclusion

referencesreferences

IntroductionIntroductionAdrenal gland is the source of diverse groups Adrenal gland is the source of diverse groups of hormones essential to metabolic of hormones essential to metabolic control ,regulation of body’s response to control ,regulation of body’s response to stress.stress.

The medullary portion secretes epinephrine The medullary portion secretes epinephrine and norepinephrine.and norepinephrine.

Cortex produce a number of Cortex produce a number of substances,collectively called substances,collectively called CORTICOSTEROIDSCORTICOSTEROIDS

General physiologyGeneral physiology

Corticosteroids are not stored to Corticosteroids are not stored to adrenal glands but are adrenal glands but are continuously synthesized and continuously synthesized and secretedsecreted

There is a negative feedback There is a negative feedback mechanismmechanism

Absorption,fate and Absorption,fate and excretionexcretionACTH is destroyd by proteolytic enzymes ACTH is destroyd by proteolytic enzymes in gut, hence given parentrlly.in gut, hence given parentrlly.

Rapidly metabolisedRapidly metabolised

The quantitative response is greater when The quantitative response is greater when given in morning than in evening and given in morning than in evening and when given slowly and for longer periods when given slowly and for longer periods than when given rapidly and for shorter than when given rapidly and for shorter periodsperiods

HORMONESHORMONES

3 distinct groups of steroid 3 distinct groups of steroid hormones:-hormones:-

ZonaZona glomerulosaglomerulosa-aldosterone, -aldosterone, desoxycorticosteronedesoxycorticosterone

ZonaZona fasciculatafasciculata--cortisone,hydrocortisonecortisone,hydrocortisone

ZonaZona reticularisreticularis--dehydroepiandrosteronedehydroepiandrosterone

Pharmacological Pharmacological actionsactions

Metabolic effects:-Metabolic effects:-Carbohydrate and protein metabolismCarbohydrate and protein metabolismFat metabolismFat metabolismCalcium metabolismCalcium metabolismSkeletal musclesSkeletal musclesAction on cardiovascular systemAction on cardiovascular systemAction on central nervous systemAction on central nervous systemOn G.I.TOn G.I.TAntiinflammatory actionAntiinflammatory action

Mechanism of actionMechanism of actionAntiinflammatory action- Antiinflammatory action- suppress clinical features of suppress clinical features of inflammation a local inflammation a local heat,redness,swelling,tendernessheat,redness,swelling,tenderness

MECHANISMMECHANISMInflammationInflammation

Sensitized lymphocytesSensitized lymphocytes

Interaction with Interaction with sensitized antigenssensitized antigens

Production of soluble factors like Production of soluble factors like lymphokines,one being migration lymphokines,one being migration inhibitory factor(MIF)inhibitory factor(MIF)

Local accumulation of macrophages Local accumulation of macrophages at inflammation siteat inflammation site

Effect of MIF blockedEffect of MIF blocked

General clinical General clinical applicationapplication

Emergency therapy-Emergency therapy-anaphylaxis and asthmaanaphylaxis and asthmaReplacemental therapy-in Replacemental therapy-in adrenal insufficiencyadrenal insufficiencyOrgan transplant proceduresOrgan transplant proceduresSuppression of immune Suppression of immune response-immunologically response-immunologically mediated diseasemediated disease

Therapeutic uses in Therapeutic uses in dentistrydentistry

Oral ulcerationOral ulcerationDenture induced ulcersDenture induced ulcers

Recurrent ulcerative stomatitisRecurrent ulcerative stomatitis

Erosive lichen planusErosive lichen planus

Erythema multiformeErythema multiforme

PemphigusPemphigus

Desquamative gingivitisDesquamative gingivitis

Angular stomatitisAngular stomatitis

aphthous ulcers or recurrent aphthous aphthous ulcers or recurrent aphthous stomatitisstomatitis) are painful mouth ulcer(s) usually ) are painful mouth ulcer(s) usually appear after a gradual burning or tingling sensation. appear after a gradual burning or tingling sensation. usually found on the movable, non-keratinized (less usually found on the movable, non-keratinized (less protected) tissues in the mouth, including the inner protected) tissues in the mouth, including the inner surface of the lips, the cheeks, under the tongue, and surface of the lips, the cheeks, under the tongue, and back of the throat. back of the throat.

For more serious cases prescribe corticosteroids. dexamethasone, used topically as a solution ,rinsed and spit out twice a day for five days. prednisone orally, in tablet form, starting at 40 milligrams per day then tapered for 10 days.

Oral lichen planusOral lichen planus

Topical corticosteroid-clobetasol Topical corticosteroid-clobetasol propionate-0.05%-3-4 times per daypropionate-0.05%-3-4 times per day

Flucocinomide0.05%-3-4 times per dayFlucocinomide0.05%-3-4 times per day

Moderate cases-intralesional injection-Moderate cases-intralesional injection-triamcinolone-10-20mgtriamcinolone-10-20mg

Severe-prednisolone-30-60mg then taper-Severe-prednisolone-30-60mg then taper-20 to 30 mg – 10 to 20mg.20 to 30 mg – 10 to 20mg.

Erosive lichen planusErosive lichen planus

Erythema multiformeErythema multiforme

In moderate to severe caseIn moderate to severe case

Prednisolone initial dose-40 to 80 mg/day Prednisolone initial dose-40 to 80 mg/day then taperthen taper

Recurrent infections-400 mg b.dRecurrent infections-400 mg b.d

Erythema multiformeErythema multiforme

PemphigusPemphigus

Steroids-mainstay of treatmentSteroids-mainstay of treatment

Prednisone-1 to 2 mg/kg/dayPrednisone-1 to 2 mg/kg/day

Only oral involvement-low dose Only oral involvement-low dose prednisolone orprednisolone or

Topical and systemic steroid combination-Topical and systemic steroid combination-betamathasone-0.01%-3 to 4 times/daybetamathasone-0.01%-3 to 4 times/day

PemphigusPemphigus

Desquamative gingivitisDesquamative gingivitis

Topical-triamcinolone-.1%-3 to 4 times/dayTopical-triamcinolone-.1%-3 to 4 times/day

Or flucocinamideOr flucocinamide

Systemic-prednisolone-30 to 40 mg/daySystemic-prednisolone-30 to 40 mg/day

Pulpal hypersensitivity-Pulpal hypersensitivity-Resulting from operative Resulting from operative trauma,bacterial invasion of pulp, trauma,bacterial invasion of pulp, exposure of dentin- glucocorticoids exposure of dentin- glucocorticoids can be used as a component of can be used as a component of endodontic sealer as antiinflammatory endodontic sealer as antiinflammatory agentagent

Temporomandibular Temporomandibular joint disorders-joint disorders-Intraarticular injection of glucocorticoid Intraarticular injection of glucocorticoid such as prednisolone or dexamethasone such as prednisolone or dexamethasone used to relieve temporary or permanent used to relieve temporary or permanent symptomssymptoms..

Post operative sequalaePost operative sequalaeMainly glucocorticoids used – edema, Mainly glucocorticoids used – edema,

trismustrismus

After dental surgical proceduresAfter dental surgical procedures

Anaphylactic and other Anaphylactic and other allergiesallergies

Urticaria,contact dermatitis,allergic Urticaria,contact dermatitis,allergic rhinitis, conjuctivitis,serum rhinitis, conjuctivitis,serum sickness,etcsickness,etc

Oral submucous fibrosisOral submucous fibrosis

Corticosteroids cause a dose dependent Corticosteroids cause a dose dependent enhancement of fibroblast collagen enhancement of fibroblast collagen phagocytosis.phagocytosis.

Topical –hydrocortisone(0.05%)Topical –hydrocortisone(0.05%)

Betamethasone(.1%)Betamethasone(.1%)

Intralesional injection-triamcinolone Intralesional injection-triamcinolone suspension-3mg/ml-2-3ml/day. suspension-3mg/ml-2-3ml/day.

CRESOPHENE, Solution for dental use

Composition: Active ingredients: Dexamethasone Acetate 0.111 % and Thymol5.00 % in a solution for dental use

Therapeutic Indications: Root canal antisepsis before filling.Posology and Method of Administration: For local dental use only. After avulsion of the gangrened pulp andthorough reaming, insert a solution – impregnated cotton plug into the canal. Prior to insertion wring out theplug to eliminate excess solution.Temporarily seal the canal with non-compressive impervious cement. Leave in place for 3 to 5 days.If necessary, repeat the procedure after debriding and reaming the root canal using the usual methods.Contraindications: Allergy to any constituent, particularly corticosteroidsand phenols.

Hydrocortisone.Hydrocortisone.Available Available as-as-wycort(2.5%)ointment-wycort(2.5%)ointment-topical 3-4 timestopical 3-4 times

orabase orabase hca(.5%)-topical-3-hca(.5%)-topical-3-4times4times

Cortin-oral-1-2ml a dayCortin-oral-1-2ml a day

Prednisolone.Prednisolone.

Available as-predicort-oral-5-60mg/day in Available as-predicort-oral-5-60mg/day in divided doses,divided doses,

pridprid

wysolonewysolone

Triamcinolone.Triamcinolone.

Kenolog cream(.1%)-Kenolog cream(.1%)-topicaltopicalKenolog spray(.2%)-Kenolog spray(.2%)-inhalationinhalationKenacort(1,4,8 mg)-oralKenacort(1,4,8 mg)-oralTac-3 Tac-3 suspension(3mg/ml)-suspension(3mg/ml)-intralesionalintralesionalLedercort ointment(.1%)Ledercort ointment(.1%)

Betamethasone.Betamethasone.

Diprovate cream(.05%)-Diprovate cream(.05%)-topicaltopicalValisone cream(.1%)-Valisone cream(.1%)-topicaltopicalBetnovate creamBetnovate creamDiprosone(.1%)Diprosone(.1%)

CONTRA INDICATIONSCONTRA INDICATIONS

Peptic ulcerPeptic ulcer - -Corticosteroids, Corticosteroids, which block COX-2 but not COX-1,12 which block COX-2 but not COX-1,12 are not ulcerogenic when used alone,. are not ulcerogenic when used alone,. When corticosteroids are used in When corticosteroids are used in combination with NSAIDs, the risk of combination with NSAIDs, the risk of ulcer formation is much greater.ulcer formation is much greater.

Another mechanismAnother mechanism -decreases synthesis of -decreases synthesis of PGI2 and PGE2.PGI2 and PGE2.

DiabetesDiabetes-- precipitates hyperglycaemia andprecipitates hyperglycaemia and glycosuriaglycosuria

HerpesHerpes - -suppression of host response may suppression of host response may allow disseminatioan of herpes.allow disseminatioan of herpes.

o OsteoporosisOsteoporosis--decreases calcium absorption decreases calcium absorption from intestine, increases renal excretion of from intestine, increases renal excretion of calcium, increased bone resorpion.calcium, increased bone resorpion.

Ocular diseasesOcular diseases - -increases increases intraocular pressure, causes reversible intraocular pressure, causes reversible damage-post subcapsular cataractsdamage-post subcapsular cataracts

Fungal infections –Fungal infections –antiinflammatory-antiinflammatory-decreases body’s reaction to infectious agent is decreases body’s reaction to infectious agent is depressed.depressed.

Tuberculosis- Tuberculosis- latent tuberculosis latent tuberculosis reactivated after initiation of glucocorticoid reactivated after initiation of glucocorticoid therapy.therapy.

ADVERSE EFFECTSADVERSE EFFECTS

Neurologic –Neurologic –insomnia,agitation,maniainsomnia,agitation,mania

InfectiousInfectious-opportunistic,increased -opportunistic,increased infectionsinfections

VasculaurVasculaur-hypertention,increased -hypertention,increased atherosclerotic risk.atherosclerotic risk.

Skin and mucosa-Skin and mucosa-atrophyatrophy

Skeletal-Skeletal-osteoporosis, impaired growthosteoporosis, impaired growth

MuscularMuscular--myopathy, wastingmyopathy, wasting

Metabolic-Metabolic-glucose glucose intolerance,hyperlipaedemiaintolerance,hyperlipaedemia

G.I.TG.I.T--ulcersulcers

OcularOcular--cataractscataracts

MiscellaneousMiscellaneous-acne,thinning of -acne,thinning of skin,hirsutism,weight skin,hirsutism,weight gain,pancreatitis.gain,pancreatitis.

Primary adrenocortical Primary adrenocortical insufficiency, also known as insufficiency, also known as

Addison’s diseaseAddison’s disease

idiopathic nature (most commonly idiopathic nature (most commonly autoimmune), but also results from autoimmune), but also results from hemorrhage, sepsis, infectious diseases hemorrhage, sepsis, infectious diseases (such as tuberculosis, human (such as tuberculosis, human immunodeficiency virus, cytomegalovirus immunodeficiency virus, cytomegalovirus and fungal infection), malignancy, and fungal infection), malignancy, adrenalectomy, amyloidosis or drugs adrenalectomy, amyloidosis or drugs

ADRENAL CRISISADRENAL CRISIS The most significant acute adverse outcome of AI The most significant acute adverse outcome of AI is adrenal crisis. This event can occur when a is adrenal crisis. This event can occur when a patient with AI, most commonly in the form of patient with AI, most commonly in the form of Addison’s disease, is challenged by stress (for Addison’s disease, is challenged by stress (for example, illness, infection or surgery), and, in example, illness, infection or surgery), and, in response, is unable to synthesize adequate response, is unable to synthesize adequate amounts of cortisol and aldosterone. This amounts of cortisol and aldosterone. This potentially life-threatening emergency usually potentially life-threatening emergency usually evolves slowly during a few hours and then is evolves slowly during a few hours and then is manifested by severe exacerbation of the manifested by severe exacerbation of the condition, including profuse sweating, condition, including profuse sweating, hypotension, weak pulse, cyanosis, nausea, hypotension, weak pulse, cyanosis, nausea, vomiting, weakness, headache, dehydration, vomiting, weakness, headache, dehydration, fever, sunken eyes, dyspnea, myalgias, fever, sunken eyes, dyspnea, myalgias, arthralgia, hyponatremia and eosinophilia. arthralgia, hyponatremia and eosinophilia.

CONCLUSIONCONCLUSION

Corticosteroids form the mainstay of Corticosteroids form the mainstay of treatment in allergic and inflammatory treatment in allergic and inflammatory diseases and oral inflammationsdiseases and oral inflammationsDose of corticosteroids should always be Dose of corticosteroids should always be tapered.tapered.Corticosteroid therapy should not be Corticosteroid therapy should not be discontinued abruptly because abrupt discontinued abruptly because abrupt withdrawl will lead to signs of withdrawl will lead to signs of adrenocortical insufficiency.adrenocortical insufficiency.

References.References.

Burket’s- oral medicineBurket’s- oral medicine

Arvindo ghomes-oral medicineArvindo ghomes-oral medicine

Carranza-periodonticsCarranza-periodontics

Neelima anil malik-oral surgery Neelima anil malik-oral surgery

Yagella,dowd-pharmacologyYagella,dowd-pharmacology

K.d. tripathi-pharmacologyK.d. tripathi-pharmacology

www.google.comwww.google.com

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