Corticosteroids in dentistry
Transcript of Corticosteroids in dentistry
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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
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Zones of adrenal cortex Hormones
Zona glomerulosa AldosteroneDesoxycorticosterone
Zona fasciculata CortisoneCortisol
Zona reticularisDehydroepiandrosterone
AndrostenidioneTraces of estrogens
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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
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MECHANISM OF ACTION plasma memb
CorticosteroidsCYTOPLASMICRECEPTORPROTEIN
GLUCOCORTICOIDRESPONSEELEMENT
Nucleus
Transcription ofm - RNA
New proteinsynthesis
TOTALTIME30 – 60 mins
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Mineralocorticoids
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Mineralocorticoids Source : Zona glomerulosa Functions: 90% of mineralocorticoid activity
is provided by aldosterone Aldosterone – life saving hormone
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On Na+ metabolism
• Increase in the reabsorption of sodium from renal tubules
Actions
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On ECF volume
• Na reabsorption from renal tubules• Simultaneous water reabsorption• Increase in ECF volume
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On BP
• Increases ECF volume• Increases BP
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On K+ ions
• Increase in the excretion of potassium from renal tubules
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On H+ ion concentration
• Causes tubular secretion of hydrogen ions• Essential to maintain acid - base balance
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On intestine
• Greatly enhances sodium absorption from the intestine
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Glucocorticoids
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Glucocorticoids Source : zona fasciculata Functions:
Cortisol – Life protecting hormone
Hormone Glucocorticoid activity
Cortisol 95%Corticosterone 4%Cortisone 1%
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Actions:
On carbohydrate metabolism
• Increases blood glucose level in two ways,• Promotes gluconeogenesis• Inhibits glucose uptake and utilization by peripheral
cells
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On protein metabolism
• Promote catabolism of protein in cell • Increase plasma amino acid and protein content in
the cell.
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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
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On mineral metabolism
• Enhances sodium retention • Slightly increase potassium excretion• Decreases blood calcium by inhibiting absorption
from intestine
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On water metabolism
• Accelerate the excretion of water
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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
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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
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Mineralocorticoids • Desoxycorticosterone acetate(DOCA)• Fludrocortisone • Aldosterone
32Some Commonly
Prescribed Steroids
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Triamcinolone
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Dexamethasone
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Betamethasone
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Hydrocortisone
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Cortisone
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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
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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.
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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)
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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
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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
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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.
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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
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Factors that influence the effectiveness of TCs:
The contact time between the drug and lesion and the vehicle used to apply it;
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Factors that influence the effectiveness of TCs:
Concentration
(Regezi and Sciubba, 1999).
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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
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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).
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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.
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Systemic steroids for ulcerative vesiculobullous diseases
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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.
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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
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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
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Benefits
Avoids complications & side effects of long term
steroid therapy
To achieve immunosuppressive effects similar to
those with higher doses of steroids
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Lichen planusPrednisolone 1mg/kg/d for
<7 days
Tapered to 10-20mg per
day for 2 weeks
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Lupus erythematosusPredisolone –
20 - 30 mg/day for 2- 6
weeks
Tapered gradually
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Steroids in the treatment of benign lesions
CGCGHEMANGIOMA
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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.
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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
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Steroids in salivary gland disorders
MUCOCELE
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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.
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Steriods in neuralgia
POST HERPETIC NEURALGIA
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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)
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Steroids for TMJ disorders
OSTEOARTHRITISRHEUMATOID ARTHRITIS
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Rheumatoid arthritis
Intraarticular injection – 10 to 40 mg/ml
osteoarthritisIntraarticular injection
– 20 mg/ml(2 injections 14 days
apart)
Arthritis
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Miscellaneous
OSMFBELL’S PALSY
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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.
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OSMFPredisolone –
20 - 30 mg/day for 2 –
4 weeks
Gradually taper
Discontinue in 1- 2 months
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Injections of triamcinolone 10mg/ml
diluted in 1 ml of 2% lidocaine with hyaluronidase 1500 IU, biweekly for 4 weeks.
(Borle et al)
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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.
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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
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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
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Musculoskeletal effects: Proximal myopathy and osteoporosis with
compression fractures of vertebrae Acute aseptic necrosis of boneEyes: Glaucoma
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Relative Contraindications:
Peptic ulcer Diabetes mellitus Hypertension Pregnancy Tuberculosis Osteoporosis
Psychosis Epilepsy Renal failure
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Precautions during therapyBefore starting therapy: Enquire and check for hypertension,
diabetes mellitus, peptic ulcer, any infection
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During therapy: Prescribe drug with food Diet low in calories and sodium and rich in
potassium Check periodically for weight gain,
hypertension, hyperglycemia
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Increase dose in case of stress Instruct patient not to stop abruptly
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Protocol for Supplementation of Patients on Glucocorticoid Therapy Who Are Undergoing Dental Care (Burket’s 10th ed)
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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
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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
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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.
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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...