Corticosteroids in dentistry


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wonder drug for most of the troublesome infections & inflammations.

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Corticosteroids in dentistry

  2. 2. ContentsContents IntroductionIntroduction General physiologyGeneral physiology HormonesHormones PharmacologicalPharmacological actionsactions Mechanism of actionMechanism of action Clinical applicationsClinical applications Uses in dentistryUses in dentistry AvailabilityAvailability ContraindicationsContraindications Adverse effectsAdverse effects ConclusionConclusion referencesreferences
  3. 3. IntroductionIntroduction Adrenal gland is the source of diverse groups ofAdrenal gland is the source of diverse groups of hormones essential to metabolic controlhormones essential to metabolic control ,regulation of body’s response to stress.,regulation of body’s response to stress. The medullary portion secretes epinephrine andThe medullary portion secretes epinephrine and norepinephrine.norepinephrine. Cortex produce a number ofCortex produce a number of substances,collectively calledsubstances,collectively called CORTICOSTEROIDSCORTICOSTEROIDS
  4. 4. General physiologyGeneral physiology Corticosteroids are not stored toCorticosteroids are not stored to adrenal glands but are continuouslyadrenal glands but are continuously synthesized and secretedsynthesized and secreted There is a negative feedbackThere is a negative feedback mechanismmechanism
  5. 5. Absorption,fate andAbsorption,fate and excretionexcretion ACTH is destroyd by proteolytic enzymes in gut,ACTH is destroyd by proteolytic enzymes in gut, hence given parentrlly.hence given parentrlly. Rapidly metabolisedRapidly metabolised The quantitative response is greater when givenThe quantitative response is greater when given in morning than in evening and when givenin morning than in evening and when given slowly and for longer periods than when givenslowly and for longer periods than when given rapidly and for shorter periodsrapidly and for shorter periods
  6. 6. HORMONESHORMONES 3 distinct groups of steroid3 distinct groups of steroid hormones:-hormones:- ZonaZona glomerulosaglomerulosa-aldosterone,-aldosterone, desoxycorticosteronedesoxycorticosterone ZonaZona fasciculatafasciculata-cortisone,hydrocortisone-cortisone,hydrocortisone ZonaZona reticularisreticularis-dehydroepiandrosterone-dehydroepiandrosterone
  7. 7. PharmacologicalPharmacological actionsactions Metabolic effects:-Metabolic effects:- Carbohydrate and protein metabolismCarbohydrate and protein metabolism Fat metabolismFat metabolism Calcium metabolismCalcium metabolism Skeletal musclesSkeletal muscles Action on cardiovascular systemAction on cardiovascular system Action on central nervous systemAction on central nervous system On G.I.TOn G.I.T Antiinflammatory actionAntiinflammatory action
  8. 8. Mechanism of actionMechanism of action Antiinflammatory action- suppressAntiinflammatory action- suppress clinical features of inflammation a localclinical features of inflammation a local heat,redness,swelling,tendernessheat,redness,swelling,tenderness MECHANISMMECHANISM InflammationInflammation Sensitized lymphocytesSensitized lymphocytes Interaction with sensitizedInteraction with sensitized antigensantigens
  9. 9. Production of soluble factors likeProduction of soluble factors like lymphokines,one being migration inhibitorylymphokines,one being migration inhibitory factor(MIF)factor(MIF) Local accumulation of macrophages atLocal accumulation of macrophages at inflammation siteinflammation site Effect of MIF blockedEffect of MIF blocked
  10. 10. General clinicalGeneral clinical applicationapplication Emergency therapy-anaphylaxisEmergency therapy-anaphylaxis and asthmaand asthma Replacemental therapy-inReplacemental therapy-in adrenal insufficiencyadrenal insufficiency Organ transplant proceduresOrgan transplant procedures Suppression of immuneSuppression of immune response-immunologicallyresponse-immunologically mediated diseasemediated disease
  11. 11. Therapeutic uses inTherapeutic uses in dentistrydentistry Oral ulcerationOral ulceration Denture induced ulcersDenture induced ulcers Recurrent ulcerative stomatitisRecurrent ulcerative stomatitis Erosive lichen planusErosive lichen planus Erythema multiformeErythema multiforme PemphigusPemphigus Desquamative gingivitisDesquamative gingivitis Angular stomatitisAngular stomatitis
  12. 12. aphthous ulcers or recurrent aphthousaphthous 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 (lessusually found on the movable, non-keratinized (less protected) tissues in the mouth, including the innerprotected) tissues in the mouth, including the inner surface of the lips, the cheeks, under the tongue, andsurface 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.
  13. 13. Oral lichen planusOral lichen planus Topical corticosteroid-clobetasolTopical 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.
  14. 14. Erosive lichen planusErosive lichen planus
  15. 15. erythema multifOrmeerythema multifOrme In moderate to severe caseIn moderate to severe case Prednisolone initial dose-40 to 80 mg/dayPrednisolone initial dose-40 to 80 mg/day then taperthen taper Recurrent infections-400 mg b.dRecurrent infections-400 mg b.d
  16. 16. Erythema multiformeErythema multiforme
  17. 17. 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 doseOnly 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
  18. 18. PemphigusPemphigus
  19. 19. DesquamativeDesquamative gingivitisgingivitis Topical-triamcinolone-.1%-3 to 4Topical-triamcinolone-.1%-3 to 4 times/daytimes/day Or flucocinamideOr flucocinamide Systemic-prednisolone-30 to 40 mg/daySystemic-prednisolone-30 to 40 mg/day
  20. 20. Pulpal hypersensitivity-Pulpal hypersensitivity- Resulting from operativeResulting from operative trauma,bacterial invasion of pulp,trauma,bacterial invasion of pulp, exposure of dentin- glucocorticoids canexposure of dentin- glucocorticoids can be used as a component of endodonticbe used as a component of endodontic sealer as antiinflammatory agentsealer as antiinflammatory agent tempOrOmanDibulartempOrOmanDibular jOint DisOrDers-jOint DisOrDers- Intraarticular injection of glucocorticoidIntraarticular injection of glucocorticoid such as prednisolone or dexamethasonesuch as prednisolone or dexamethasone used to relieve temporary or permanentused to relieve temporary or permanent symptomssymptoms..
  21. 21. Post operative sequalaePost operative sequalae Mainly glucocorticoids used – edema,Mainly glucocorticoids used – edema, trismustrismus After dental surgical proceduresAfter dental surgical procedures AnAphylActic And otherAnAphylActic And other AllergiesAllergies Urticaria,contact dermatitis,allergicUrticaria,contact dermatitis,allergic rhinitis, conjuctivitis,serum sickness,etcrhinitis, conjuctivitis,serum sickness,etc
  22. 22. Oral submucous fibrosisOral submucous fibrosis Corticosteroids cause a dose dependentCorticosteroids cause a dose dependent enhancement of fibroblast collagenenhancement of fibroblast collagen phagocytosis.phagocytosis. Topical –hydrocortisone(0.05%)Topical –hydrocortisone(0.05%) Betamethasone(.1%)Betamethasone(.1%) Intralesional injection-triamcinoloneIntralesional injection-triamcinolone suspension-3mg/ml-2-3ml/day.suspension-3mg/ml-2-3ml/day.
  23. 23. CRESOPHENE, Solution for dental use Composition: Active ingredients: Dexamethasone Acetate 0.111 % and Thymol 5.00 % 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 and thorough reaming, insert a solution – impregnated cotton plug into the canal. Prior to insertion wring out the plug 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 corticosteroids and phenols.
  24. 24. Hydrocortisone.Hydrocortisone. AvailableAvailable as-as- wycort(2.5%)ointment-wycort(2.5%)ointment- topical 3-4 timestopical 3-4 times orabaseorabase hca(.5%)-topical-3-4timeshca(.5%)-topical-3-4times Cortin-oral-1-2ml a dayCortin-oral-1-2ml a day
  25. 25. Prednisolone.Prednisolone. Available as-predicort-oral-5-60mg/day in dividedAvailable as-predicort-oral-5-60mg/day in divided doses,doses, pridprid wysolonewysolone
  26. 26. Triamcinolone.Triamcinolone. Kenolog cream(.1%)-Kenolog cream(.1%)- topicaltopical Kenolog spray(.2%)-Kenolog spray(.2%)- inhalationinhalation Kenacort(1,4,8 mg)-oralKenacort(1,4,8 mg)-oral Tac-3 suspension(3mg/ml)-Tac-3 suspension(3mg/ml)- intralesionalintralesional Ledercort ointment(.1%)Ledercort ointment(.1%)
  27. 27. Betamethasone.Betamethasone. Diprovate cream(.05%)-Diprovate cream(.05%)- topicaltopical Valisone cream(.1%)-Valisone cream(.1%)- topicaltopical Betnovate creamBetnovate cream Diprosone(.1%)Diprosone(.1%)
  28. 28. CONTRA INDICATIONSCONTRA INDICATIONS Peptic ulcerPeptic ulcer--Corticosteroids, whichCorticosteroids, which block COX-2 but not COX-1,12 are notblock COX-2 but not COX-1,12 are not ulcerogenic when used alone,. Whenulcerogenic when used alone,. When corticosteroids are used in combinationcorticosteroids are used in combination with NSAIDs, the risk of ulcer formationwith NSAIDs, the risk of ulcer formation is much much greater. Another mechanismAnother mechanism -decreases synthesis of-decreases synthesis of PGI2 and PGE2.PGI2 and PGE2.
  29. 29. DiabetesDiabetes-- precipitates hyperglycaemiaprecipitates hyperglycaemia andand glycosuriaglycosuria HerpesHerpes --suppression of host response maysuppression of host response may allow disseminatioan of herpes.allow disseminatioan of herpes. o OsteoporosisOsteoporosis--decreases calciumdecreases calcium absorption from intestine, increases renalabsorption from intestine, increases renal excretion of calcium, increased boneexcretion of calcium, increased bone resorpion.resorpion.
  30. 30. Ocular diseasesOcular diseases --increasesincreases intraocular pressure, causes reversibleintraocular pressure, causes reversible damage-post subcapsular cataractsdamage-post subcapsular cataracts Fungal infections –Fungal infections –antiinflammatory-antiinflammatory- decreases body’s reaction to infectious agent isdecreases body’s reaction to infectious agent is depressed.depressed. Tuberculosis-Tuberculosis- latent tuberculosis reactivatedlatent tuberculosis reactivated after initiation of glucocorticoid therapy.after initiation of glucocorticoid therapy.
  31. 31. ADVERSE EFFECTSADVERSE EFFECTS neurologic –neurologic – insomnia,agitation,maniainsomnia,agitation,mania infectiousinfectious-- opportunistic,increased infectionsopportunistic,increased infections VAsculAurVAsculAur-- hypertention,increasedhypertention,increased atherosclerotic risk.atherosclerotic risk.
  32. 32. Skin and mucoSa-Skin and mucoSa-atrophyatrophy Skeletal-Skeletal-osteoporosis, impairedosteoporosis, impaired growthgrowth muScularmuScular--myopathy, wastingmyopathy, wasting metabolic-metabolic-glucoseglucose intolerance,hyperlipaedemiaintolerance,hyperlipaedemia
  33. 33. G.i.tG.i.t--ulcersulcers ocularocular--cataractscataracts miScellaneouSmiScellaneouS-acne,thinning of-acne,thinning of skin,hirsutism,weightskin,hirsutism,weight gain,pancreatitis.gain,pancreatitis.
  34. 34. Primary adrenocorticalPrimary adrenocortical inSufficiency, alSo knowninSufficiency, alSo known aS addiSon’S diSeaSeaS addiSon’S diSeaSe idiopathic nature (most commonlyidiopathic nature (most commonly autoimmune), but also results fromautoimmune), but also results from hemorrhage, sepsis, infectious diseaseshemorrhage, sepsis, infectious diseases (such as tuberculosis, human(such as tuberculosis, human immunodeficiency virus, cytomegalovirusimmunodeficiency virus, cytomegalovirus and fungal infection), malignancy,and fungal infection), malignancy, adrenalectomy, amyloidosis or drugsadrenalectomy, amyloidosis or drugs
  35. 35. ADRENAL CRISISADRENAL CRISIS The most significant acute adverse outcome of AIThe most significant acute adverse outcome of AI is adrenal crisis. This event can occur when ais adrenal crisis. This event can occur when a patient with AI, most commonly in the form ofpatient with AI, most commonly in the form of Addison’s disease, is challenged by stress (forAddison’s disease, is challenged by stress (for example, illness, infection or surgery), and, inexample, illness, infection or surgery), and, in response, is unable to synthesize adequateresponse, is unable to synthesize adequate amounts of cortisol and aldosterone. Thisamounts of cortisol and aldosterone. This potentially life-threatening emergency usuallypotentially life-threatening emergency usually evolves slowly during a few hours and then isevolves slowly during a few hours and then is manifested by severe exacerbation of themanifested 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.
  36. 36. CONCLUSIONCONCLUSION Corticosteroids form the mainstay ofCorticosteroids form the mainstay of treatment in allergic and inflammatorytreatment in allergic and inflammatory diseases and oral inflammationsdiseases and oral inflammations Dose of corticosteroids should always beDose of corticosteroids should always be tapered.tapered. Corticosteroid therapy should not beCorticosteroid therapy should not be discontinued abruptly because abruptdiscontinued abruptly because abrupt withdrawl will lead to signs ofwithdrawl will lead to signs of adrenocortical insufficiency.adrenocortical insufficiency.
  37. 37. References.References. Burket’s- oral medicineBurket’s- oral medicine Arvindo ghomes-oral medicineArvindo ghomes-oral medicine Carranza-periodonticsCarranza-periodontics Neelima anil malik-oral surgeryNeelima anil malik-oral surgery Yagella,dowd-pharmacologyYagella,dowd-pharmacology K.d. tripathi-pharmacologyK.d. tripathi-pharmacology