4. INTRODUCTION
There are two adrenal glands or suprarenal gland situated on the upper
pole of each kidney.
Made of two distinct parts, the and
.
Adrenal cortex releases group of hormones called as
, which are essential to metabolic control, regulation
of water and electrolyte balance ,and regulation of body’s response to
stress.
Adrenal cortex has got three different layers :
Zona glomerulosa [15%] Zona fasciculate Zona reticularis [7%]
Mineralocorticoids [50%] release releasers sex hormones
glucocorticoids
5.
6.
7. MECHANISM FOR ITS PHARMACOLOGICAL
ROLE IN DENTISTRY
CORTICOSTEROIDS
AND THEIR SYNTHETIC
ANALOGUES ARE
COMMONLY USED
FOR THEIR POTENT
ANTI-INFLAMMATORY
AND
IMMUNOSUPPRESSIVE
PROPERTIES.
BECAUSE OF THESE
PROPERTIES, THESE
ARE USED IN
INFLAMMATORY
CONDITION AND
AUTOIMMUNE
DISEASE.
9. ANTI -INFLAMMATORY
MAINTAINANCE OF CELLULAR MEMBRANE INTEGRITY AND DECREASE
THE PERMEABILITY OF CAPILLARIES SO DECREASED EXUDATION.
REDUCTION OF EXUDATION OF LEUCOCYTE AND PLASMA
CONSTITUENTS ,THEREBY LESSING OEDEMA.
INHIBIT THE MIGRATION OF LEUCOCYTES
10. DECREASE THE PRODUCTION OF ENDOTHELIAL LEUCOCYTE ADHESION MOLECULE
[ELAM] AND INTERACELLULAR ADHESSION MOLECULE [ICAM] IN ENDOTHELIAL CELL SO THE
ADHESION AND LOCALIZATION IS DECREASED.
DECREASED THE CHEMOTAXIS
INHIBITION OF PHAGOCYTOSIS
STABILIZATION OF MEMBRANES OF THE INTERACELLULAR LYSOZYME, WHICH CONTAINS
HYDROLYTIC ENZYME SO INHIBITION OF LYSOZYME RELEASE FROM GRANULOCYTE
INHIBITION OF PROLIFERATION OF FIBRBLAST TO DECREASE FIBROSIS
11. RELEASE OF ANTI-INFLAMMATORY MOLECULES SUCH AS
LIPOCORTIN-1, INTERLEUKINS IL-10,IL-1 RA,AND NUCLEAR FACTOR
–B,BY MACROPHAGES, EOSINOPHILS AND EPITHELIAL CELLS.
DECREASE THE PRODUCTION OF IL-1,2,3,6 GM-CSF ,INTERFERON.
SUPRESST-T CELLS
12.
13.
14.
15. IMMUNOSUPPRESIVE ACTION
GLUCOCORTICOIDS
SUPPRESS THE IMMUNE
SYSTEM OF THE BODY BY
DE CREASING THE
NUMBER OF CIRCULATING
T LYMPHOCYTES.
THIS IS DONE BY
SUPPRESING LYMPHOID
TISSUE ,eg- LYMPH NODES
AND THYMUS AND
PROLIFERATION OF T-
CELLS.
GLUCOCORTICOIDS ALSO
PREVENT RELEASE OF
INTERLUKIN-2 BY T-CELLS.
CORTICOSTEROID INHIBIT
ANTIBODY REACTION AND
ANTIBODY FORMATION
AND ANTIBODY REACTION.
THEY PRESENT THE
CONCEQUENCES OF CELL
MEDIATED IMMUNE
REACTION SUCH AS GRAFT
REJECTION REACTION.
GLUCOCORTICOID
SUPPRESS THE SYNTHESIS
OF DNA AND DNA-
DEPENDENT RNA
POLYMERASE IN
LYMPHOCYTES.
16. THEY ALSO CAUSE DURATION
OF T-LYMPHOCYTES BY
SUPPRESSING LYMPHOID
TISSUE ,i.e LYMPHNODE
THYMUS AND PROLIFERATE T-
CELLS PRESENT RELEASE OF
INTERLEUKIN -2 BY T- CELLS
THE ANTI-INFLAMMATORY
ACTIVITIES OF THESE
STEROIDS ALSO APPEAR TO
PLAY AN IMPORTANT ROLE IN
IMMUNO-SUPPRESSION.
17.
18. THESE DRUGS DO NOT CURE ANY, BUT THEY REDUCE INFLAMMATION AND PROVIDE SYMPTOMATIC
RELIEF.
THEY DO NOT DESTROY MICRORGANISMS OR NEUTRALIZE TOXINS ,ALLERGENS OR ANY TOXIOUS
AGENTS.
THEIR EFFECTS , WHETHER BENEFECIAL OR DELETERIOUS,ARE USUALLY TEMPORARY.
STEROID THERAPY IS PARTICULARLY USEFUL IN DISEASE PROCESS THAT OCCUR EPISODICALLY AS
THESE DO NOT REQUIRE AN EXTENDED TREATMENT.
EVERY EFFORT SHOULD BE MADE TO USE OTHER DRUG OR PROCEDURE BEFORE STEROID
TREATMENT IS UNDERTAKEN. SUDDEN CESSATION OF TREATMENT WITH THESE DRUGS MAY
ACCUTELY EXACERBATE VARIOUS DISEASES.
19. DESPITE THEIR MANY DISADVANTAGES THESE STEROIDS PROVIDE GREAT BERNEFIT IN SELF-
LIMITING DISEASES AND IN CHRONIC DISABLING PROCESS THAT FAIL TO RESPOND TO ANY
OTHER TREATMENT. THE SYSTEMIC USE OF STEROID IS ALWAYS A CALCULAATED RISK.
ACCURATE DIAGNOSIS SHOULD BE MADE , AND CONFIRMED THAT THE CONDITION IS STEROID
RESPONSIVE.
STEROID THERAPY IS STARTED ONLY AFTER ALTERNATIVE THERAPIES HAVE BEEN FAILED .
THE DOSAGE SHOULD BE DETERMINED BASED ON THE SEVERITY OF DISEASE AND SMALLEST DOSE
THAT CONTROLS SHOULD BE USED.
SYSTEMIC ADMINISTRATION OF A SINGLE LARGE DOSE NOT RESULT IN ANY ADVESRSE EFFECT
BUT WITH PROLONGED USE , THE RISK OF ADVERSE RECTION RISES.
WHEN INDICATED CORTICOSTEROIDS ARE ADMINISTERED LOCALLY IN ORDER TO INCREASE THE
CONCENTRATION OF DRUG AT THE LESION,WHICH IN TURN INCREASES THE THERAPEUTIC EFFECT.
20. ROUTES ,DOSE,ADVERSE EFFECTS AND CONTRAINDICATION
• QR
TOPICAL
TOPICAL STEROIDS [SEE ABOVE] APPLY
2-3TIMES/DAY FOR 3 WEEKS
FOLLOWED BY TAPERING
DURING THE FOLLOWING 9 WEEKS
INDICATED IN MILD /MODERATE
CASES OF :
o -ORAL LICHEN PLANUS
o -APTHOUS STOMATITIS
o -PEMPHIGUS ,PEMPHIGOID
o -OSMF, ERYTHEMA
MULTIFORME
• PSEUDOMEMBRANOUS
CANDIDIASIS
• THINNING OF MUCOSA
• HYPOPIGMENTATION
• BURNING MOUTH
• SYSTEMIC SIDE EFFECT OF
TOPICAL STEROIDS
CONTRAINDICATION-
NOT SPECIFIC
ROUTES
USUAL DOSE AND
INDICATION ADVERSE EFFECT
21. INTRALESIONAL IT INCLUDES THE DIRECT
INJECTION OF THE DRUG TO
THE LESION PROPER TO
ENSURE MAXIMUM DRUG
CONCENTRATION.
10-20 mg OF TRIAMCINOLON
ACETONIDE OR
DEXAMETHASONE[4mg/mL] IS
DILUTED WITH 0.5mL SALINE AND
2% LIDOCAINE INJECTED DIRECTLY
INTO THE LESION 3-4
TIMES/WEEK OR 2 TIMES/WEEK.
INDICATED:
-TO MANAGE PERSISTENT ,
LOCALIZED LESION
-LESIONS UNRESPONSIVE TO
TOPICAL THERAPY: OSMF , LICHEN
PLANUS, MUCOCELE, MAJOR
APTHOUS.
PAINFUL
MUCOSAL ATROPHY
NO SPECIFIC
CONTRAINDICATIONS ,BUT
TAKE CARE THAT
INJECTION SHOULD NOT BE IN
VESSELS
22. SYSTEMIC IT INVOLVES SYSTEMIC
ADMINISTRATION OF DRUG VIA
ORAL ROUTES
PREDNISOLONE -1mg/kg/day[40-
60mg/day}
INDICATED IN :
FOR PATIENTS WITH DIFFUSE LESION
MULTISIDE INVOLVEMENT FOR
ACUTE EXACRABATIOS
IN CASES UNRESPONSIVE TO
TOPICAL AND INTRALESIONAL
AGENTS
ONLY IN RECALCITRANT LESIONS
INDICATED IN SEVERE CASE OF:
ORAL LICHEN PLANUS,APTHOUS
STOMATITIS ,PEMPHIGUS
,PEMPHIGOID ,ERYTHEMA
MULTIFORME
• CUSHIND SYNDROME
• OSTEOPOROSIS
• PEPETIC ULCER
• CATRACT
• OPTIC GLAUCOMA
• INFECTION
• DIABETIES
• HYPERTENSION
• CONTRAIDICATION:
PEPETIC ULCER
DIABETIES MELITUS
HYPERTENSION
PREGNANCY
IMMUNOCOMPROSIED CONDITIONS
LIKE TB,HIV
HERPES SIMPLEX VIRUS
PSYCHOSIS
EPILEPSY
RENAL FALIURE
23. PULSED
THERAPY
PULSED INTRAVNOUS THERAPY INCLUDES HIGH
DOSE OF CORTICOSTEROID TO ACIEVE IN LONG
TERM MAINTAINANCE DOSES AND SIDE EFFECTS
AND IS USUALLY APPLIED TO YOUNG, HEALTHY
PATIENTS.
PULSED INTRAVENOUS THERAPY WITH 1g OF AND
WATER , ADMIMNISTERED OVER A PERIOD OF 90
min ONCE DAILY , ON 1-5 CONSECUTIVE DAYS
,MAY BE COSIDERED .
USED IN SEVERE CASES,
UNRESPONSIVE TO OTHER
MEASURES OF :
a) -PEMPHIGUS
b) -PEMPHIGOID
c) -ERYTHEMA MULTIFORME
d) -EPIDERMOLYSIS BULLOSA
WORSENING OF HYPERTENSION
INFECTIONS
HYPERGLYCAEMIA , HYPOKAlAEMIA
BEHAVIOUR EFFECTS INCLUDING MO
,OD ALTERATION, HYPERACTIVITY
PSHCHOSIS, DISORIENTATION ,SLEEP
DISTURBANCE
SYSTEMIC FUNGAL INFECTION
UNCONTROLLED HYPERTENSION
24. INTRAARTICULAR IT INCLUDES INJECTION OF DRUG INTO THE
JOINT
INJECTION CONTAINS 0.5 mL OF
TRIAMCINOLONE ACETONIDE [40 mg /mL]
OR DEXAMETHASONE (4mg/mL) AND 1 mL
2% LIDOCAINE ON TO THE JOINT SPACE
INDICATED IN(IN TMJ INFLAMMATORY
CONDITIONS):
-CAPSULITIS
-SYNOVITIS
-RETRODISCITIS
-RHEUMATOID ARTHRITIS
-OSTEOARTHRITIS
INJECTION IN WRONG
POSITION MIGHT LEAD TO
LIGAMENT
RUPTURE/PERFORATION
SEPTIC ARTHRITIS
BLEEDING DISORDER
25. COMPLEMENT
COMPONENTS
HISTAMINE-MEDIATED
REACTION
LYMPHOCYTE AND
MONOCYTE FUNCTIONS
LYMPHOCYTOPENIA
MONOCYTOPENIA
COMPLEMENT LEVELS
COMMON MECHANISM SHARED BY ANTI-INFLAMMATORY AND
IMMUNOSUPPRESSIVE ACTION
LUKOCYTE
ACCUMULATION
COMMON MECHANISM SHARED BY ANTI-INFLAMMATORY AND
IMMUNOSUPPRESSIVE ACTION
LUKOCYTE
ACCUMULATION
HISTAMINE-MEDIATED
REACTION
LYMPHOCYTOPENIA
MONOCYTOPENIA
MONOCYTOPENIA
EOSINOPENIA
COMMON MECHANISM SHARED BY ANTI-INFLAMMATORY AND
IMMUNOSUPPRESSIVE ACTION
LUKOCYTE
FUNCTIONS
ANTI-
INFLAMMATORY
EFFECTS
IMMUNOSUPRR
ESSIVE EFFECTS
26. IT SHOULD ALWAYS BE TAKEN INTO ACCOUNT THAT THESE DRUGS DO NOT CURE THE DISEASE ,BUT RATHER
CONTROL OR RELIEVE THE SYMPTOMS.
FACTORS THAT INFLUENCE THE EFFECTIVENESS OF TCs IN ORAL MEDICINE INCLUDE:-
THE POTENCY OF THE DRUG
NUMBER OF APPLICATION
DURATION OF CONTACT OF THE DRUG TO LESION
WHEN HIGH POTENCY CORTICOSTEROIDS ARE USED, TWO OR THREE DAILY APPLICATIONS ARE GENERALLY
PRESCRIBED.
DURATION OF CONTACT OF THE DRUG TO LESION –INCREASED BY :
a) ADHERENT VEHICLE
b) ORABASE
c) BIOADHESIVE PATCHES MADE OF CELLULOSE DERIVATIVES
d) GELS
e) CUSTOM DENTURE TRAY
f) AQUEOUS SOLUTION
g) CHEW AND SPIT METHOD
POINTS TO REMEMBER FOR TOPICAL
CORTICOSTEROIDS
27. THE SPECIFIC DIAGNOSIS
THE SEVERITY OF ORAL DISEASE
THE PRESENCE OR ABSENCE OF EXTRA-ORAL LESION
MEDICAL HISTORY OF THE PATIENT
28. POINTS TO REMEMBER FOR SYSTEMIC
ADMINISTRATION
• THE PATIENT SHOULD BE INSTRUCTED TO TAKE IN EACH MORNING WITH A MEAL
UNTIL THE SYMPTOMS ARE RESOLVED.
• MORNING DOSING MIMICS THE BODY’S DIURNAL RELEASE OF ENDOGENOUS
CORTISOL AND MINIMIZES THE SIDE EFFECTS.
• NO TAPERING DOSE OF THE MEDICATION IS REQUIRED,IF TREATMENT IS
EXPECTED TO BE LESS THAN 2 WEEKS.
• SHORT –TERM USE OF SYSTEMIC CORTICOSTEROIDS IS GENERALLY WELL
TOLERATED ,BUT THE RISK OF ADVERSE EVENTS INCREASE WITH DURATION OF
USE.
34. Inhaled corticosteroids are appropriate in patients with
severe and very severe COPD staging.
Although they have not been shown to alter the decline
in lung function in COPD patients, inhaled
corticosteroids result in fewer exacerbations,
a decrease in pulmonary symptoms, and improved
sensitivity of the lungs to external stimuli.
Long-term treatment with oral corticosteroids is not
recommended.
35. Asthma management include the patient having little or no chronic symptoms, few or no
exacerbations, no hospitalizations, and minimal or no activity limitation.
Patients with mild-persistent asthma usually require routine therapy for control of underlying
airway inflammation. Inhaled corticosteroids are the most widely used and most effective
asthma anti-inflammatory agents.
Strong evidence establishes that inhaled corticosteroids improve long term outcomes for
children of all ages with mild
or moderate persistent asthma, compared with as-needed b2-agonists, as measured by
prebronchodilator,
reduced hyperresponsiveness, improvements in symptom scores, fewer courses of oral
corticosteroids,
and fewer urgent care visits or hospitalizations.
36. The principal treatment for pemphigus vulgaris is systemic corticosteroids at doses
of 1 to 2 mg/kg/d .
Injectable Corticosteroids for Ulcerative and
Vescul obullous Oral Mucosal Diseases
Topical Corticosteroids for the Treatment of
Ulcerative and Vesiculobullous Oral Mucosal
Diseases
Systemic Corticosteroids for Ulcerative and
Vesiculobullous Oral Mucosal Diseases
37. • The mainstay of treatment remains high doses of systemic cortico-
steroids, usually given in dosages of 1 to 2 mg/kg/d. When substantial
doses of steroids must be used for long periods of time, adjuvant
therapy is recommended to reduce the steroid dose and their
potential serious complications. The most commonly used adjuvants
are immunosuppressive drugs such as mycophenolate mofetil,
azathioprine, or cyclophosphamide. Prednisone is used initially to
bring the disease under control, and once this is achieved, the dose of
prednisone is decreased to the lowest possible maintenance levels.
Pemphigus Vulgaris (PV)
