Corticosteroids in dentistry / dental implant courses

Corticosteroids and DentistryCorticosteroids and Dentistry
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

 Corticosteroids have been in regular clinical
usage for a range of inflammatory and
immune mediated conditions for over 50
years.

Corticosteroids/MOACorticosteroids/MOA
 reduce the emigration of leukocytes and exudation of
plasma constituents, thereby eliminating the edema;
 maintain the integrity of cell membranes, thus
avoiding excessive swelling of cells;
 Inhibit the release of lysozymes from granulocytes and
phagocytosis;
 Stabilize the membranes of the intracellular
lysosomes, thereby avoiding release of further
hydrolytic enzymes, intracellular digestion, and
spread of the inflammatory process.
 Inhibit fibroblast proliferation, suppressing fibrosis

www.indiandentalacademy.comwww.indiandentalacademy.comwww.indiandentalacademy.comwww.indiandentalacademy.com
Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

Patients on systemic corticosteroidsPatients on systemic corticosteroids
 To replace missing hormonesTo replace missing hormones
 For immunosuppressionFor immunosuppression

General Principles of UseGeneral Principles of Use
 (1) define the specific clinical problem;
 (2) arrive at a diagnosis if possible;
 (3) identify specific clinical goals and
understand the tissue processes that require
alteration to achieve these goals
 (4) is medication likely to be helpful? How will
the medication act? What is the specific
target(s) of the agent?
 (5) what dosage is appropriate and how will
response and compliance be monitored?

Complications of systemic steroidsComplications of systemic steroids
MetabolicMetabolic
 Suppression of ACTH secretion, leading toSuppression of ACTH secretion, leading to
adrenal atrophy and failure to respond to stressadrenal atrophy and failure to respond to stress
 Impaired glucose tolerance, or diabetes mellitusImpaired glucose tolerance, or diabetes mellitus
 Growth retardationGrowth retardation
 Loss of sodium and potassiumLoss of sodium and potassium
 OsteoporosisOsteoporosis
 Fat redistributionFat redistribution

ImmunosuppressiveImmunosuppressive
 Increased susceptibility to infections likeIncreased susceptibility to infections like
oral candidosisoral candidosis

CardiovascularCardiovascular
 HypertensionHypertension
 Myocardial infarctionMyocardial infarction
 Cerebrovascular accidentsCerebrovascular accidents

GastrointestinalGastrointestinal
 Peptic ulcerPeptic ulcer

NeurologicalNeurological
 Mood changesMood changes
 PsychosisPsychosis
 CataractsCataracts

DermatologicalDermatological
 AcneAcne
 StriaeStriae
 BruisingBruising
 NeoplasmsNeoplasms

Considerations for patients onConsiderations for patients on
corticosteroidscorticosteroids
 Adrenocortical function is likely to beAdrenocortical function is likely to be
suppressed if:suppressed if:
1.1. The patient is currently on systemicThe patient is currently on systemic
2.2. Corticosteroids have been taken regularlyCorticosteroids have been taken regularly
during the previous 30 daysduring the previous 30 days
3.3. Corticosteroids have been taken for moreCorticosteroids have been taken for more
than one month in the last yearthan one month in the last year

 Minor operations under local anesthesiaMinor operations under local anesthesia
may be covered either bymay be covered either by
1.1. giving oral steroids 2-4 hours pre- andgiving oral steroids 2-4 hours pre- and
post-operatively (100 mg hydrocortisonepost-operatively (100 mg hydrocortisone
or 20 mg prednisolone or 4 mgor 20 mg prednisolone or 4 mg
dexamethasone)dexamethasone)
2.2. Giving intravenous hydrocortisoneGiving intravenous hydrocortisone
immediately before operationimmediately before operation

 General anesthesia must be given only in hospitalGeneral anesthesia must be given only in hospital
by a specialist anesthetistby a specialist anesthetist
 Aspirin and other NSAID should be avoidedAspirin and other NSAID should be avoided
 Topical steroids for use intraorally are unlikely toTopical steroids for use intraorally are unlikely to
have any systemic complications but predisposehave any systemic complications but predispose
to oral candidosisto oral candidosis
 Prophylactic antibiotics may be indicated as thereProphylactic antibiotics may be indicated as there
may be delayed wound healingmay be delayed wound healing
 On the long term some lesions may develop likeOn the long term some lesions may develop like
Kaposi sarcoma, lymphomas, hairy leukoplakiaKaposi sarcoma, lymphomas, hairy leukoplakia
etc.etc.

Indications for topical corticosteroidsIndications for topical corticosteroids
in Oral Medicinein Oral Medicine
• Recurrent aphthous ulcers
• Oral manifestations of Behçet's disease, Reiter's
syndrome, ulcerative colitis, Crohn's disease,
Melkersson-Rosenthal syndrome
• Drug-induced ulcerations mediated by an immune
mechanism
• Lichen planus
• Cicatricial pemphigoid
• Mucous membrane pemphigoid
• Bullous pemphigoid
• Erythema multiforme
• Linear IgA dermatosis
• Pemphigus vulgaris www.indiandentalacademy.comwww.indiandentalacademy.com

Topical corticosteroidsTopical corticosteroids
 HydrocortisoneHydrocortisone
 Triamcinolone acetonide in OrobaseTriamcinolone acetonide in Orobase
 Prednisolone m/wPrednisolone m/w
 Betamethasone m/wBetamethasone m/w
 Fluticasone spray/inhalerFluticasone spray/inhaler
 Flucinonide cream(s)Flucinonide cream(s)
 Beclomethasone inhaler(s)Beclomethasone inhaler(s)
 Clobetasol preparationsClobetasol preparations
 DexamethasoneDexamethasone

TYPES OF TCS USED IN ORAL
MEDICINE
 TCs known to be used in oral medicine can
be classified broadly as having mild,
moderate, high, or very high potency.

Mild-potency steroids
 Hydrocortisone hemisuccinate find favor in
some patients with minor aphthae,

Moderate-potency Steroids
 triamcinolone acetonide,
 oral lichen planus.

High-potency Steroids
Clobetasol,
Fluocinonide
 Clobetasol 17-propionate is currently the most
widely used potent topical corticosteroid.
 Severe erosive oral lesions
 Clobetasol and flucinonide are safe and
effective in the treatment of OLP

Very Highly Potent Steroids
 fluticasone propionate,
 betamethasone sodium phosphate
 momethasone furoate

Adverse reactions of TCS
 secondary candidosis
 nausea;
 oral use not tolerated;
 Refractory response;
 mucosal atrophy;
 delayed healing;
 systemic absorption.

some patients will develop a
secondary erythematous candidosis
or pseudomembranous candidosis
 This results in:
 Immediate interruption to treatment;
 prolonged and amplified morbidity;
 additional treatment for the infection;
 delayed management of the original
condition;

ManagementManagement
 Denture hygiene management and correct
use of asthma medications are usually all
that is required.
 The xerostomic patient is more complex
and consideration should be given to
concurrent antifungal treatment and
strategies to enhance salivary function, at
least in the short-term.

Refractory ResponseRefractory Response
 poor patient compliance;
 inappropriate instruction and patient use;
 inappropriate application,
 agent of insufficient potency;
 incorrect diagnosis;
 failure to remove any local cause

Systemic absorptionSystemic absorption
 There is always absorption of small
amounts through the oral mucosa but
clinical experience and laboratory studies
have shown this not to be of clinical
significance in almost all cases.

Mucosal AtrophyMucosal Atrophy
 Mucosal atrophy is a
very real consideration
both with prolonged
use and for patients
who have mucosal
atrophy as an intrinsic
component of their
condition, for example
in LP

General guidelines for topical CS
 Ensure there are no medical contra-indications;
 ensure there is no likely infectious component;
 be confident about the clinical diagnosis;
 select a midrange CS for the oral mucosa;
 do not use on the facial skin or lips;
 provide detailed instructions, written if possible;
 monitor the amount used carefully;
 Monitor the clinical response;
 monitor the development of adverse reactions;
 ensure full resolution
 taper withdrawal to ensure recurrence is minimized;
 encourage short-term, intermittent use rather than prolonged
use www.indiandentalacademy.comwww.indiandentalacademy.com

 Co-prescribingCo-prescribing
 AntifungalsAntifungals
 AntibioticsAntibiotics

Other topical preparations for oralOther topical preparations for oral
lesionslesions

Topical Analgesic agentsTopical Analgesic agents
 Benzydamine hydrochloride - 0.15%Benzydamine hydrochloride - 0.15%

Topical immunosuppressivesTopical immunosuppressives
 Cyclosporin mouthrinse (100mg/ml)Cyclosporin mouthrinse (100mg/ml)
 RetinoidsRetinoids

Topical agentsTopical agents
Chlorhexidine gluconate - 0.2%Chlorhexidine gluconate - 0.2%
Benzydamine hydrochloride - 0.15%Benzydamine hydrochloride - 0.15%

 New promising topical agents like
tacrolimus could obviate the need for
systemic corticosteroid therapy for
recalcitrant cases of OLP

Intralesional CorticosteroidsIntralesional Corticosteroids
 Intralesional injections of a solution ,
triamcinolone aqueous suspension and
either Lidocaine 2% with epinephrine
1:200,000, or Bupivacaine, 50% mixture by
volume.
 The solution is administered with a 5-cm
disposable syringe with a 22G needle

Systemic immunosuppressantsSystemic immunosuppressants
PrednisolonePrednisolone
AzathioprineAzathioprine
DapsoneDapsone
ColchicineColchicine
ThalidomideThalidomide

Corticosteroids in dentistry / dental implant courses

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