STEROIDS IN DENTISTRY

Presented by-Shibani Sarangi

Postgraduate IInd year
(Dept of Oral & Maxillofacial surgery)
 INTRODUCTION

• Corticosteroids, since their introduction in the 1940s, have

become one of the most widely prescribed class of drugs.

• They belong to a class of chemicals that includes steroid

hormones that are produced naturally in the adrenal cortex of
vertebrates and analogous to those that are synthesized in
laboratories.
 HISTORY
• Hench (1949) -improvement in rheumatoid arthritis by using
cortisone.

• In 1950 Nobel Prize -Kendall and Reichstein and Hench, for

developing corticosteroids

• Currently, drugs with one of the broadest spectrum of clinical utility.

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

• The medullary portion secretes epinephrine and epinephrine.

• Cortex produce a number of Cortex produce a number of substances,

collectively called CORTICOSTEROIDS.
• General physiology-

• Corticosteroids are not stored to adrenal glands but are

continuously but are continuously synthesized and secreted .

• There is a negative feedback mechanism.

SOURCE

Mineralocorticoid-
Aldosterone
Desoxycorticosterone

Glucocoticoid-
Cortisone
Hydrocortisone

Androgens-
DHEA,Androstenedione

Catecholamines-
Adrenaline
• NORMAL ADULT DAILY PRODUCTION

•Cortisol 20 mg/ day

•Corticosterone 02 mg / day
•Aldosterone 0.125 mg/day
• Dehydroepiandro sterone 30 mg/day.
BIOSYNTHESIS
 CLASSIFICATION
GLUCOCORTICOIDS

SHORT ACTING INTERMEDIATE ACTING LONG ACTING

•Hydrocortisone •Prednislone
Dexamethasone
(Cortisol) •Methylprednislone
Betamethasone
•Triamicinolone
•Deflazacort

MINERALOCORTICOIDS

•DOCA(Desoxy-corticosterone actete)
•Aldosterone
•Fludrocortisone
Coopman’s classification-Based on chemical structure

• Group A –( Hydrocortisone type)

• Hydrocortisone,
Hydrocortisone acetate,
Cortisone acetate,
Prednisolone, Methylprednisolone.

•Group B- Acetonides (and related substances)

Triamcinolone acetonide
Mometasone,
Amcinonide,
Budesonide,
Flucocortlone
Group C- ( Betamethasone type)
Betamethasone sodium phosphate,
Dexamethasone
Dexamethasone sodium phosphate

Group D – Esters
Group D1 – Halogenated (less labile)
Aclometasone dipropionate
Betamethasone valerate
Betamethasone dipropionate

Group D2 – Labile prodrug esters

Ciclesonide,
Hydrocortisone acetate,
Hydrocortisone butyrate
GLUCOCORTICOIDS
FUNTIONS OF GLUCORTICOIDS
Function sof Glucoroticoids-
1)Permissive action
• Action of some hormones are executed only in presence of
glucocorticoids.

• Examples are :
• Calorigenic effect of glucagon.
• Lypolytic effect of catecholamines.
• Pressor effect of catecholamines.
• Bronchodilation by catecholamines.
Anti- inflammatory Action
 Anti-allergic effect

• Exerted by suppression the nuclear factor functions on T cells

and monocytes / macrophages.

• Suppresion of recruitment of leucocytes at the site of contact

with antigen and inflammatory response to immunological
injury.
 Immunosuppressive action-

• Glucocorticoids (corticosteroids) have inhibitory effects on a

broad range of immune responses.

• Suppresses immune system of body by decreasing number of

circulating T lymphocytes.

• Prevent release of IL-2 IL-6 by T-cells

 Replacement therapy
1.Acute adrenal insufficiency

2.Chronic adrenal insufficiency: (addison’s disease)

Hydrocortisone given orally,Supplemented with –a mineralocorticoid
(fludrocortisone)

3.Congenital adrenal hyperplasia –

Familial disorder due to def.of of 21-hydroxylase &11 - hydroxylase
enzyme. Treatment: hydrocortisone 0.6 mg /kg/day in divided doses
MINERALOCORTICOIDS
• Aldosterone is the naturally produced mineralocorticoid.

• Source- Zona Glomerulosa

• Other two synthetic entities –

-DOCA(Desoxycorticosterone acetate)
-Fludrocortisone
ACTION ON EFFECT

Sodium metabolism Increases sodium reabsorption

from renal tubules

On ECF Stimulates water reabsorption thus

in term increases ECF volume

Blood pressure Increases

Potassium ions Increases ,excretion of potassium
ions from renal tubules

Hydrogen ion Tubular secretion of hydrogen ion ,

essential to maintain acid base
balance.
 Fate of corticosteroids

Degraded chiefly in Liver

Conjugated to form glucouronides &

to a lesser extent sulphates

25% is excreted in Bile & faeces

75% excreted in urine

 ROUTES OF ADMINISTRATION OF
CORTICOSTEROIDS

Topical steroid Beclamethasone,Betamethasone,

Clobetasol,Hydrocortisone,Mometasone

Inhalational steroids Beclomethasone dipropionate,

Budesonide, Fluticasone

Oral forms bethamethasone,prednisone ,prednisolo

ne triamcinolone
methylprednisolone

Systemic form
• General principles for cortico-steroid use:
“The lowest effective dose for the least possible time”

• Have a clear indication / objective and consider all alternatives before

starting.
• Consider prior steroid use, effectiveness and side effects.
• Clarify the individual risk-benefit ratio
• Ensure specified indications/ doses reflect current evidence base/ best
practice.
• Discuss risk factors/incidence of adverse effects with the patient to ‘gain
consent’.
• Dexamethasone is the corticosteroid of choice . Other steroids can be
converted using the dose equivalent table below: Corticosteroid
Equivalent Dose
CLINICAL IMPLICATIONS
 STEROIDS IN ORAL SURGERY

Chiefly used in –

• Post operative pain, edema and trismus after 3rd molar

surgery.
• Post operative edema after orthognathic surgery
• Prevention of alveolar osteitis
Hydrocortisone-
• Primarily glucocorticoid
• Acts rapidly
• Short duration of action
• But has significant mineralcorticoid activity also

purpose route dose

Replacement orally 20mg in morning

therapy 10mg in afternoon
Shock iv 100mg bolus &
Status asthmaticus 100mg 8 hrly
Acute adrenal infusion
insufficiency
Cortisone-
• Inactive
• Hydroxylated in liver – hydrocortisone
• Primarily glucocorticoid
• Occasionally being used now

Route dose

orally 20- 100 mg

im 20- 100mg
Prednisolone-
• More selective glucocorticoid
• 4 times more potent than hydrocortisone
• Fluid retention with high doses
• Less pituitary adrenal axis suppresion

Purpose Route Dose

Allergic Orally 5-60mg /day
Inflammatory Im 10-40mg /day
Autoimmune Intra articular
Malignant disease topically
Methylprednisolone-

• Slightly more selective and more potent than prednisolone

• Less pituitary adrenal axis suppression

Purpose Route Dose

Retention enema in orally 4-32mg/day
ulcerative colitis
Nonsuppressive Iv 1 gm infused every
active rheumatoid 6-8 weeks
arthritis,
Renal transplant,
pemphigus
• TMJ arthritis-

• Single intra-articular injection of corticosteroid (methylprednisolone)

diluted with 0.5ml of lidocaine or Triamicinolone acetonide significantly
reduced joint pain and other symptoms for 4-6 weeks.

• The pharmacologic effect - 3-4 weeks

 Orthognathic surgery
• Glucocorticoids are given to patients to relieve postoperative pain,
swelling, trismus, and nausea and vomiting after a wide variety of surgical
procedures including orthognathic surgery.

• Glucocorticoids reduce PONV by depleting 5-HT3 in neural tissue

• Also prevent its release in the gut, and they have a synergistic action with
5-HT3 antagonists.
• Temporomandibular joint (TMJ) disorder

• They are the main cause of chronic facial pain and a major cause of
disability (Horten 1953).

• Intra-articular injection of steroids - often diluted with a local anesthetic

prior to injection into the TMJ (Kopp 1981; Alstergren 1996).

• Triamcinolone acetonide : 2 to 40 mg, depending upon the size of the

joint injected (Hollander 1951; Silbermann1978). & 10 mg (Gray 1994).
• Guidelines for Management of Dental
patients under Corticosteroid therapy
 Preoperative considerations
Adrenocortical function may be suppressed if –

• The patient is currently on daily systemic corticosteroids at doses above

7.5 mg prednisolone(or equivalent).

• Cortisteroids has been taken regularly during the past 30 days.

• Corticosteroids have been taken for more than one month during past one
year
 CORTICOSTEROIDS IN ORTHODONTIC
TOOTH MOVEMENT
•Orthodontic tooth movement is by sequential reactions of the periodontal
tissue in response to biomechanical forces.

• The arachidonic acid metabolites also play an important role in the process
of bone remodeling during tooth movement

• The acute activity of neutrophils

macrophages is targeted.
 STEROIDS IN ENDODONTICS

• Steroid-antibiotic combinations are often used for eg:-

Ledermix

• Steroids like hydrocortisone are

also mixed with zinc oxide eugenol
as root canal sealers.
STEROID IN ORAL MEDICINE
 Recurrent aphthous stomatitis

• Topical-
Hydrocortisone hemisuccinate (pellets of 2.5 mg)
Triamcinolone acetonide (adhesive paste containing 0.1% of the steroid).

- Inaccessible areas controlled by-

• Topical dexamethasone.(0.5 mg/5 ml held over the area or applied with a

saturated gauge pad to the ulcers, 4 times/day for 15 min )

• Betamethasone sodium phosphate rinse

Major aphthous ulcers-

• Systemic treatment -
-Prednisone therapy 40 mg/day for 1 week
-1.0 mg/kg a day as a single dose in severe RAS patients and
gradually tapered after 7-14 days.
 BEHCET’S DISEASE

• The main stay of treatment for Behcet’s disease is

immunosuppressive therapy.

• In the acute phase, prednisone, at doses of 40-60 mg/day.

• It may be used alone or in combination therapy with other

immunosuppressive agents.
 ULCERATIVE VESICULOEROSIVE
DISEASES
• Immunologically mediated diseases affecting oral mucosa

• Inflammation and loss of epithelial integrity

• Corticosteroids central role in the treatment

 ERYTHEMA MULTIFORME

• Minor EM –
20 to 40 mg/day of Triamicinolone
acetonide for 4 to 6 days

• Severe or rapidly progressing

lesions –
• 60 mg/day slowly tapered by
10mg/day over 6 weeks
 Lichen planus
• Prednisolone - 1mg/kg/d for <7 days

• Triamicinolone acetonide 10mg/ml

(Burkit’s Oral Medicine, 11th edition

• Tapered to 10-20mg per day for 2 weeks.

• Combination of [Prednisolone + Levamisole)-

orally 50mg for first three days
Indications for use

• Short course of TC –
• Accelerates remission without producing adverse effects
• Ulcerative disease that have tendency to remit spontaneously
•Eg RAS, some cases of EM, drug induced ulceration

• In severe cases of ulceration-

• After a short course of systemic corticosteroids, maintenance
regimen of TC
• Prevent recurrence, and avoids adverse effects associated
with long course of systemic corticosteroids
STEROIDS IN THE TREATMENT OF
BENIGN LESIONS
 CENTRAL GIANT CELL GRANULOMA

• 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.

 Hemangioma

• Prednisone at a dose of 20-30 mg/d

can be given for 2 weeks to 4
months

• Intralesional triamcinolone
acetonide (4 mg/mL)
• STEROIDS IN SALIVARY GLAND
DISORDERS
• 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

STERIODS IN NEURALGIA

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
 ORAL SUBMUCOUS FIBROSIS

•The initial symptomatic relief the anti- inflammatory action of the steroid
• Biweekly submucosal injections combination of –

Dexamethasone (4mg/ml) + hyaluronidase + diluted in 1.0 ml of 2%

Lignocaine For a period of 20 weeks

Systemic-
• Therapy with Hydrocortisone 25 mg orally QID
• Triamicinolone or 90mg of Dexamethasone supplemented with biweekly
intraleisonal injections.
• Medical emergencies in Dental
Practice
 Adrenal crisis prophylaxis
• Hydrocortisone i.v. initially.

• If improvement within 24 hours – changed to an oral formulation.

• The dose can be decreased by one third to one half the dose daily until a
maintenance dose of 20 mg in the morning and 10 mg in the afternoon or
at night is attained.

• Some patients may need only a dose of 20 mg/day total (i.e., 20 mg every
morning, or 15 mg in the morning and 5 mg in the afternoon or at night).
 Anaphylatic shock
• They have a delayed onset of 4 to 6 hours.

• Are unlikely to be helpful in the treatment of acute anaphylaxis. Play a

role in preventing rebound anaphylaxis.

• Prednisone 1 mg/kg up to 50 mg orally,.

• Hydrocortisone 1. 5- 3 mg/kg IV particularly in patients with airway

involvement and bronchospasm, based empirically on their important role
in asthma
 Scheme for Steroid withdrawal

• Any patient taking > 20 -25 mg /day hydrocortisone or equivalent dose for
longer than 2-3 week.
• 20mg hydrocortisone/day reduction every week

• Such patients need protection with steroids if a stressful condition

develop up to 1 year after withdrawal.

• If a patient on steroid therapy develops infection –

• Never steroid discontinuation
increase the dose
Adverse effects

• Seen in long term use

• Depends on drug potency, duration of therapy, frequency

of application
 Local adverse effects
• Tachyphylaxis
• Burning Mouth
• Hypogeusia
• Oral Hairy Leukoplakia
• Hypersensitive Reactions to the Drug
• Topical Steroid Allergy
• Skin Atrophy
• Striae - Stretch Marks
• Acne form/Rosacea like eruptions
• Candidiasis
• Delayed Healing of application and anatomical area.
 Systemic adverse effects
• Mineralocorticoid :
-Sodium & water retention,
-oedema,
-hypokalemic
- alkalosis & a progressive raise in BP.

Glucocorticoid :
1. Cushing’s habitus: round face,
narrow mouth,
supraclavicular hump,
obesity of trunk with relatively thin limbs.
• Fragile skin & purple striae :
-typically on thighs & lower abdomen
-easy bruising
-telengiactasis
-hirstuism,
-cutaneous atrophy due to topical use
telengiactasis
Psychiatric disturbances : mild euphoria
nervousness
decreased sleep
mood changes
depressive illness
Suppression of hypothalamo-pitutary axis (HPA) :

adrenal atrophy + stoppage of exogenous steroid = withdrawal syndrome

 References

• Essential of Pharmaclogy:K D Tripathi

• Textboot of Oral Medicine: Burkitt
• The Journal of Anesthesia :Britain society of anesthesiologist
• Textbbook of oral medicine: Anil Govindrao Ghom
• Internet