DIVISION OF ORAL AND DIVISION OF ORAL AND MAXILLOFACIAL SURGERYMAXILLOFACIAL SURGERY

STEROIDSSTEROIDSDr V.RAMKUMAR CONSULTANT DENTAL & FACIOMAXILLARY SURGEON REG NO .4118 -TAMILNADU -INDIA- (ASIA)

Corticosteroids and their Corticosteroids and their biologically synthetic analogs biologically synthetic analogs possess glucocorticoid and possess glucocorticoid and mineralocorticoid action.mineralocorticoid action.

Adrenocortical SteroidsAdrenocortical Steroids

The adrenal cortex synthesizes two classes of The adrenal cortex synthesizes two classes of steroids-steroids-

•The glucocorticoidsThe glucocorticoids

ex; hydrocortisoneex; hydrocortisone•The mineralocorticoidThe mineralocorticoid

ex; aldosterone ex; aldosterone

GLUCOCORTICOIDSGLUCOCORTICOIDS

Short acting

Compound Equiv. dose (anti-inflammatory

1. Hydrocortisone (cortisol) 2. Cortisone

20mg 25mg

3. Prednisolone4. Methylprednisolone5. Triamcinolone

5mg4mg Intermediate acting4mg

6. Paramethasone7. Dexamethasone8. Betamethasone

2mg0.75mg Long acting0.75 mg

MINERALO CORTICOIDSMINERALO CORTICOIDS

9. Desoxycorticosterone acetate (DOCA)

10. Fludrocortisone11. Aldosterone

2.5 mg (sublingual)0.2 mg Not used clinically

ADERNOCORTICAL STERIODSADERNOCORTICAL STERIODS

Adernocortical SteriodsAdernocortical SteriodsAdernal cortex

(Synthesizes two classes of steroids)

Androgen(19 carbon atoms)

Corticosteriods (21 carbon atoms)

Mineralocorticoids (Electrolyte balance regulating)

Glucocorticoids (Carbohydrate metabolism regulating)

Hydrocortisone(cortisol)

Aldosterone

Pharmacological actionsPharmacological actions

Increases gluconeogenesis Increases gluconeogenesis

Increases the peripheral Increases the peripheral utilization of glucose. utilization of glucose.

Protein metabolismProtein metabolism

Decreases the conversion of of Decreases the conversion of of amino acids to proteinsamino acids to proteins

Increases muscle wastingIncreases muscle wasting Increase in loss of bone matrixIncrease in loss of bone matrix

Anti inflammatory and allergy Anti inflammatory and allergy responseresponse

Steroids decreases the production of Steroids decreases the production of inflammatory cells.inflammatory cells.

Steroids interact with antigen antibody Steroids interact with antigen antibody complex and reduces the allergy complex and reduces the allergy response.response.

Mineral metabolismMineral metabolism

Steroids causes sodium and water Steroids causes sodium and water retention and produces oedemaretention and produces oedema

Fat metabolism . It produces moon Fat metabolism . It produces moon face in the head and neck region.face in the head and neck region.

Mood changes . It causes euphoria.Mood changes . It causes euphoria.

Anti vitamin D actionAnti vitamin D action

Absorption of calcium from the gut is Absorption of calcium from the gut is impaired due to steriod action.impaired due to steriod action.

Routes of administrationRoutes of administration

TopicalTopical OralOral IntramuscularIntramuscular Intra venousIntra venous

Therapeutic uses in oral and Therapeutic uses in oral and maxillofacial surgerymaxillofacial surgery

Minor surgical proceduresMinor surgical procedures TraumaTrauma TumorsTumors Orthognathic surgical proceduresOrthognathic surgical procedures Neuro surgical proceduresNeuro surgical procedures

Therapeutic Uses in Non-Therapeutic Uses in Non-endocrine Diseaseendocrine Disease

Rheumatic Disorders( phempigus)Rheumatic Disorders( phempigus) Renal diseasesRenal diseases Allergic DiseaseAllergic Disease Antiemetic ActionAntiemetic Action In AsthmaIn Asthma Immunosuppressive Action Immunosuppressive Action Ocular DiseaseOcular Disease Skin Disease Skin Disease

Contd…Contd…

GIT DiseaseGIT Disease Hepatic DiseaseHepatic Disease MalignanciesMalignancies Cerebral EdemaCerebral Edema Apthous stomatitisApthous stomatitis Lichen planusLichen planus

MISCELLANEOUS DISEASE MISCELLANEOUS DISEASE AND CONDITIONSAND CONDITIONS

• SarcoidosisSarcoidosis• ThrombocytopeniaThrombocytopenia• Autoimmune Destruction of Erythrocytes Autoimmune Destruction of Erythrocytes • Organ Transplantation Organ Transplantation • Spinal Cord Injury Spinal Cord Injury

Therapeutic preparation and dosageTherapeutic preparation and dosage

Topical application Topical application Corlan pellet(hydrocortisone Corlan pellet(hydrocortisone

hemisuccinate.2.5mg)hemisuccinate.2.5mg) Triamcinolonepaste(vehicle consist of Triamcinolonepaste(vehicle consist of

gelatin methyl cellulose pectin)gelatin methyl cellulose pectin)

TriamcinoloneTriamcinolone

It is availabe as injectable and water It is availabe as injectable and water formform

Tablets 8-20 mgTablets 8-20 mg Injection 10mg vialInjection 10mg vial

DexamethasoneDexamethasone

Available in oral and injection formsAvailable in oral and injection forms Oral dose .2-10mgOral dose .2-10mg Iv 4-20 mgIv 4-20 mg BethamethasoneBethamethasone available as local drops skin creams available as local drops skin creams

ointment and lotionsointment and lotions Iv 4-20 mg.6-8hrly.Iv 4-20 mg.6-8hrly.

Rule of two Rule of two

Pt receiving steroids for two years Pt receiving steroids for two years twice a week the dose to be doubledtwice a week the dose to be doubled

Major complicationsMajor complications

Suppression of hypothalmohypophyseal Suppression of hypothalmohypophyseal axis.axis.

Git disturbances.dyspepsia Git disturbances.dyspepsia haemorrhage perforationhaemorrhage perforation

Infection(tb, fungal,candidiasis)Infection(tb, fungal,candidiasis) Iatrogenic cushing syndrome(skin Iatrogenic cushing syndrome(skin

becomes pale and thin)becomes pale and thin) Skeletal osteoporosisSkeletal osteoporosis Metabolic odema Metabolic odema

Mental disturbanceMental disturbance Increased intra ocular pressureIncreased intra ocular pressure

Minor complicationMinor complication

AcneAcne

StriaeStriae

Weight gainWeight gain

Increased apetiteIncreased apetite

Dental Management GuidlinesDental Management Guidlines

Define the risk of adrenal insufficiency Define the risk of adrenal insufficiency through history and clinical examination.through history and clinical examination.

Insure that patient have taken sufficient Insure that patient have taken sufficient doses.doses.

Schedule surgery in the morning.Schedule surgery in the morning. Stress reduction.Stress reduction. Use of nitrous oxide-oxygen or IV or oral Use of nitrous oxide-oxygen or IV or oral

benzodiazepine sedation is helpful.benzodiazepine sedation is helpful.

Contd.Contd. Avoid the use of barbiturates.Avoid the use of barbiturates. Avoid GA for out patient procedure.Avoid GA for out patient procedure. Discontinue drug therapy that decreases Discontinue drug therapy that decreases

cortisol levels at least 24 hours before cortisol levels at least 24 hours before surgery.surgery.

Adequate pain control.Adequate pain control. Methods to reduce blood loss should be used.Methods to reduce blood loss should be used. BP below 100/60 mm should receive fluid BP below 100/60 mm should receive fluid

replacement.replacement. Take care of hypoglycemia and hypovolemia.Take care of hypoglycemia and hypovolemia.

MANAGEMENT OF ADRENAL MANAGEMENT OF ADRENAL INSUFFICIENCY INSUFFICIENCY

Conscious patientConscious patient

Terminate dental treatmentTerminate dental treatment

If asymptomatic, supine with feet elevated, If If asymptomatic, supine with feet elevated, If symptomaticsymptomatic

A-B-C provide BLS, as neededA-B-C provide BLS, as needed

D- definitive care, monitor vital signs, medical D- definitive care, monitor vital signs, medical assistance, obtain emergency kit and O2assistance, obtain emergency kit and O2

Administer glucocorticosteroid, if available and Administer glucocorticosteroid, if available and if history of insufficiencyif history of insufficiency

Consider additional management; provide BLS, Consider additional management; provide BLS, O2, glucocorticosteroid, as needed, establish O2, glucocorticosteroid, as needed, establish

IV lineIV line

Unconscious patientUnconscious patient

Recognize UnconsciousRecognize Unconscious

supine with feet elevated slightlysupine with feet elevated slightly

A-B-C provide BLS, as neededA-B-C provide BLS, as needed

monitor vital signs, medical monitor vital signs, medical assistance, obtain emergency kit assistance, obtain emergency kit

and O2, Administer and O2, Administer glucocorticosteroidglucocorticosteroid

Establish IV line, Establish IV line,

if possible TRANSFER TO if possible TRANSFER TO HOSPITALHOSPITAL

THANK YOUTHANK YOU