2. History
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.
2
3. However, the gate to their
great therapeutic potential was
opened by Hench (1949) who
obtained striking improvement
in rheumatoid arthritis by using
cortisone.
The nobel prize was awarded
the very next year to kendall
and Hench.
Currently, corticosteroids are
drugs with one of the broadest
spectrum of clinical utility.
3
7. 7
Zones of adrenal cortex Hormones
Zona glomerulosa Aldosterone
Desoxycorticosterone
Zona fasciculata
Cortisone
Cortisol
Zona reticularis
Dehydroepiandrosterone
Androstenidione
Traces of estrogens
Essentials Of Medical Physiology 3rd Edition,
K Sembulingam
8. 8
MECHANISM OF ACTION
plasma memb
Corticosteroids
CYTOPLASMIC
RECEPTOR
PROTEIN
GLUCOCORTICOID
RESPONSE
ELEMENT
Nucleus
Transcription of
m - RNA
New protein
synthesis
TOTAL
TIME
30 – 60 mins
9. On resistance to stress 9
Physical or mental stress
Increases ACTH
Increase in glucocorticoid secretion
High resistance to body against stress
GOODMAN & GILMAN'S THE PHARMACOLOGICAL BASIS OF
THERAPEUTICS - 11th Ed. (2006)
10. Steroids in Dentistry
Used primarily to decrease postoperative edema and
manage oral inflammatory diseases
10
11. Classification of steroids based on their
relative activity
11
Mineralocorticoids
• Desoxycorticosterone acetate(DOCA)
• Fludrocortisone
• Aldosterone
12. Classification of steroids based on their
relative activity
12
Short acting
(t1/2 < 12 hr)
• Hydrocortisone
• Cortisone
Intermediate
acting:
(t1/2 12 – 36)
• Prednisole
• Methyl prednisole
• Triamcinolone
Long acting:
(t1/2 > 36 hrs)
• Paramethasone
• Dexamethasone
• Betamethasone
20. Protocols for use -(TC)
POTENCY
RELIEF
20
JDR April 2005 vol. 84 no. 4 294-301
21. 21
short course of
TCs
Accelerate
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)
Scully et al., 1999; Chan et al., 2002
Criteria for use topical and systemic
22. 22
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
Laskaris and Angelopoulos, 1981;
Nisengard and Neiders, 1981; Fine et al., 1984;
Domloge-Hultsch et al., 1994; Dayan et al., 1999
23. The key factors 23
JDR April 2005 vol. 84 no. 4 294-301
The specific diagnosis
The severity of the oral disease
The presence or absence of extra-oral lesions
The medical history of the patient
24. Factors that influence the
effectiveness of TCs:
24
JDR April 2005 vol. 84 no. 4 294-301
The intrinsic potency of the drug
25. Factors that influence the
effectiveness of TCs:
25
JDR April 2005 vol. 84 no. 4 294-301
The contact time between the
drug and lesion and the vehicle
used to apply it;
26. Factors that influence the
effectiveness of TCs:
26
JDR April 2005 vol. 84 no. 4 294-301
Concentration
27. Success of a topical medicine
27
Two main factors
Number of applications per day
High-potency
(2-3 times)
Low potency
(5-10 times)
The vehicle
used
Various vehicles
JDR April 2005 vol. 84 no. 4 294-301
28. Various vehicles. 28
JDR April 2005 vol. 84 no. 4 294-301
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).
29. Steroids as anti- inflammatory 29
Prevention of postoperative pain,
edema, trismus after 3rd molar surgery
Prevention of postoperative edema
after orthognathic surgery
TREATING alveolar osteitis
34. 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 after
1 to 2 weeks.
34
35. 35
Minor EM 20 – 40 mg/day for 4 – 6
days / PREDNISOLONE
Severe or rapidly
progressing
lesions
60 mg/day slowly
tapered by 10 mg/day
over 6 weeks
Erythema multiforme
36. Pemphigus Vulgaris
Mainstay 1-2mg/kg/d.
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.
36
Burkit’s Oral Medicine, 11th edition
37. 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
37
38. 39Cicatricial pemphigoid
Predisolone – 30
to 60 mg/day
2-3 weeks to
stop new bullae
formation
Tapered by 20%
every 2-3 weeks
until the dose of
10 mg is reached
Dose maintained on
alternate days and
reduced by 5 mg
every 2 weeks, then
stopped
42. Steroids in the treatment of benign
lesions
43
CENTRAL GIANT CELL GRANULOMA
HEMANGIOMA
43. 44CGCG
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.
44. Hemangioma 46
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)
48. 52Post 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)
53. 58
Injections of triamcinolone 10mg/ml diluted
in 1 ml of 2% lidocaine with hyaluronidase 1500
IU, biweekly for 4 weeks.
(Borle et al)
dexamethasone (4mg/ml) and
two parts of hyaluronidase,
diluted in 1.0 ml of 2%
xylocaine.
54. 59Adverse effects
Due to extention of pharmacological action occuring
with prolonged therapy
Mineralocorticoids:
Sodium and water retention
Edema
Hypokalemic alkalosis
Progressive rise in B.P
Fluid and electrolyte disturbance
56. 61
Cushing’s Habitus:
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
57. 62
CVS and renal system:
Hypertension
Salt and water retention
Hypokalemic alkalosis
CNS:
Influence mood, sleep pattern
Insomnia
Acute psychotic reactions
Benign intracranial hypertension
Epilepsy
58. 63
Suppression of inflammation and immune response:
Latent infection may flare
Oppurtunistic infection with low grade pathogens
Retardation of linear growth:
Occurs in children who receive more than 50 mg
of cortisone per day.
61. Rule of 2
Adrenocortical suppression should be suspected if a patient
has received Glucocoticoid therapy through two of the
following methods
In a dose of 20 mg or more of cortisone or its equivalent
Via oral or parenteral route or a continuous period of 2
weeks or longer
Within 6 months -2 years of therapy
66
Medical emergencies in dental office, Stanley F.Malamed
Complications in Anesthesia - John L. Atlee; Page-132
the key factors that determine the selection of a topical or systemic treatment
It also depends upon the concentration
Logically, the success of a topical medicine depends mainly on the contact time of the drug with the lesion.
TCs have been applied in various vehicles.
2.1 Lotion
2.2 Shake lotion
2.3 Cream
2.4 Ointment
2.5 Gel
2.6 Foam
2.7 Transdermal patch
2.8 Powder
2.9 Solid
2.10 Sponge
2.11 Tape
2.12 Vapor
2.13 Paste
2.14 Tincture
The applications in the field of oral surgery would include,
Prevention of postoperative pain, edema, trismus after 3rd molar surgery
Prevention of postoperative edema after orthognathic surgery
Prevention of alveolar osteitis
Doses of each pulse are not
standardized but are usually 500 to 1000 mg methylprednisolone
or 100 to 200 mg dexamethasone.
Doses of each pulse are not
standardized but are usually 500 to 1000 mg methylprednisolone
or 100 to 200 mg dexamethasone.
1 mg /kg/day for 7 days
Followed by reduction of 10mg each subsequent day
Burkits 11th edition
Normal HPA suppression recovery may take time to 30 days to 12 month
But according to the guideline given by John L. Atlee it is considered normal to return in 6 months