steroids in dentistry

1. DEPARTMENT OF
ORAL MEDICINE
AND RADIOLOGY

2. STEROIDS IN
DENTISTRY
Done By
AMRITHA JAMES
Cri (2012 batch)

3. INTRODUCTION
• Steroids, sometimes referred to as corticosteriods, are substances that are
naturally produced in our body. They are produced by the adrenal glands and
help to regulate many functions in our body.
• Steroids can be manufactured synthetically as drugs, available in the form of
fluid for injections and tablets. There are different types of steroids and they all
have different effects on the body.
• Steroids that are commonly used are hydrocortisone, dexamethasone, methyl
prednisolone, prednisolone etc.

4. • In dentistry, steroids are used as anti-inflammatory drugs to control
pain, relieve anxiety and also for the treatment of some oral diseases.
• Members of steroid family are ubiquitous, occurring in plants,
protozoa, yeast and higher forms of life.
• Steroids exhibit a variety of biological function, from participation
in cell membrane structure to regulation of physiological events and
hence used extensively in medical practice.

5. STRUCTURE OF STEROIDS
• The core steroid is composed of
twenty carbon atoms bonded
together that take the form of four
rings: three cyclohexane rings
(designated as rings A, B and C)
and one cyclopentane ring (D ring).

6. STEROIDS IN THE HUMAN BODY
• The normal secretion rate of the two principal
corticoids in human is:
Hydrocortisone: 10-20 mg daily (nearly half of
this is in the few morning hours).
Aldosterone: 0.125 mg daily.
• Hydrocortisone
• Aldosterone
The two principal
corticosteroids
produced in the body
are:

8. MECHANISM OF ACTION
• They have both direct and permissive actions. Actions of corticosteroids may be
broadly divided into:
Glucocorticoids: Affects carbohydrate, protein, and fat metabolism.
Mineralocorticoids: Affects Na + , K + , and fluid balance.

9. MECHANISM OF ACTION OF GLUCOCORTICOIDS
• Cellular action:
– Activation of receptor: corticosteroids penetrate the cells and bind to
specific receptor protein leads to activation of receptor in the cytoplasm of
the cell called as human glucocorticoid receptor resulting in structural
changes in protein.
– Specific protein synthesis: this receptor moves to the nucleus, interacts with
specific site on chromatin and induces transcription of specific mRNA
results in specific protein synthesis. This process takes atleast 30-60 min.
once appropriate protein is synthesized effect persists for long time.

10. MECHANISMOF ACTION
plasma memb
Corticosteroids
CYTOPLASMIC
RECEPTOR
PROTEIN
GLUCOCORTICOID
RESPONSE
ELEMENT
Nucleus
Transcription of
m - RNA
New protein
synthesis
TOTAL
TIME
30 – 60 mins

11. • Metabolic action:
– Carbohydrate and protein metabolism
• Anti insulin effects: decreases peripheral glucose utilization, increase blood glucose.
• Promotes gluconeogenesis
• Antianabolic effect: Prevent conversion of amino acid to proteins.
• Promote catabolism of protein in cell
– 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
– Mineral metabolism:
• Enhances sodium retention
• Slightly increase potassium excretion
• Decreases blood calcium by inhibiting absorption from intestine.

12. • Anti inflammatory action:
– Increase in neutrophil concentration: increase in neutrophils is due to increased influx of
neutrophils from bone marrow into blood and decreased migration from blood vessel
leading to reduction in no. of cells at site of inflammation.
– T lymphocytes are decreased. Decrease in monocytes, eosinophils, basophils due to their
movement from vascular bed to lymphoid tissue.
– Inhibits macrophage migration factor, tumor necrosis factor, interlukin 1,2,3,6
– Reduces prostaglandin, leucotrine and platelet activating factor due to activation of
phospholipase and decreased expression of cyclooxygenase.
– Produces vasoconstriction when directly applied on to the skin by suppressing mast cell
degranulation.

13. • Miscellaneous effect:
– On CNS
• Essential for normal functioning
• Insufficiency causes personality changes like irritablity and lack of concentration
– Permissive action of glucocorticoids
• The action of some hormones are executed only in the presence of glucocorticoids.
• Eg: Calorigenic effect of glucagon
• Lipolytic effect of catecholamines
• Pressor effects of catecholamines
• Bronchodialation by catecholamines
– Anti allergic action
• Suppression of recruitment of leucocytes at the site of contact with antigen and of
inflammatory response to immunological injury
– Immunosuppresive effects
• Suppress the immune system of the body by decreasing the number of circulating T
lymphocytes
• Prevent release of interleukin-2 by T cells

14. MECHANISM OF ACTION OF MINERALOCORTICOIDS
• On Na+ metabolism
– Increase in the reabsorption of sodium from renal tubules
• On K+ ions
– Increase in the excretion of potassium from renal tubules
• On H+ ion concentration
– Causes tubular secretion of hydrogen ions
– Essential to maintain acid - base balance
• On ECF volume
– Na reabsorption from renal tubules
– Simultaneous water reabsorption
– Increase in ECF volume
• On BP
– Increases ECF volume
– Increases BP

15. CLASSIFICATION OF STEROIDS BASED ON
CHEMISTRY
Class Examples No of C atoms
Cholestanes Cholestrol 27
Cholanes Cholic acid 24
Pregnanes Progesterone 21
Androstanes Testosterone 19
Estranes Estradiol 18

16. CLASSIFICATION OF STEROIDS BASED ON THEIR
RELATIVE ACTIVITY
Glucocorticoids:
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

17. Mineralocorticoids:
Mineralocorticoids
• Desoxycorticosterone
acetate(DOCA)
• Fludrocortisone
• Aldosterone

18. STEROIDS IN ORAL
MEDICINE

19. • Apthous Ulcers
• Bechet’s Disease
• Lichen Planus
• Erythema Multiforme
• Pemphigus
Ulcerative,
Vesiculobullous
diseases
• Central Giant Cell Granuloma
• HemangiomaBenign lesions
• Osteoarthritis
• Rheumatoid ArthritisTMJ Disorders
• Post Herpetic Neuralgia
• Bell’s PalsyNeuralgia Treatment

20. ULCERATIVE AND VESICULOBULOUS
LESIONS
1. Recurrrent apthous ulcers
2. Behcet's disease
3. Oral lichen planus
4. Erythema multiformae
5. Lupus erythematosus
6. Pemphigus
7. Cicatricial pemphigoid

21. RECURRENT APHTHOUS STOMATITIS
• These are superficial ulcers creating severe pain commonly
occurring in the oral cavity.
• Ulcers which are less than one cm are considered to be minor form
having 1-5 ulcers and they persist for one to two weeks and heal
spontaneously without sequelae.
• The ulcers larger than 1 cm are considered as major aphthous
ulcers and persist for months.
• Corticosteroids may act directly on T lymphocytes and alter the
response of effector cells to precipitants of immunopathogenesis
(e.g. food allergies, trauma, and microorganisms), thus reducing
inflammation.

22. Topical Corticosteroids
• The most commonly used steroid for local application orally are
– hydrocortisone hemisuccinate (pellets of 2.5 mg) and
– triamcinolone acetonide (adhesive paste containing 0.1% of the steroid.)
• Ulcerations that are located in the areas which are inaccessible can be controlled by
– Topical dexamethasone elixir, 0.5 mg/5 ml held over the area or applied with a saturated
gauge pad to the ulcers, 4 times/day for 15 min or
– Betamethasone sodium phosphate rinse by dissolving 0.5 mg in 5 ml of water and
asking the patient to rinse for 2-3 min),
– Steroid aerosol (e.G., Beclometasone diproprionate), or
– A high-potency topical corticosteroid, such as clobetasol 0.05% in orabase or
fluocinonide 0.05%, in orabase.

24. Systemic corticosteroids
• Major aphthous ulcers commonly require systemic treatment as the approach initially.
• Intralesional steroids can be employed to treat large indolent major RAS lesions.
Major Aphthous
Ulcer
Prednisolone
Therapy 40mg/Day
For 1 Week
Severe Recurrent
Aphthous Ulcer
Prednisolone
Therapy
1mg/Kg/Day as
single dose, tapered
after 7-14 days.

25. BEHCET'S DISEASE
• Corticosteroids given locally often controls oro-genital ulcers,
but the mainstay of treatment for Behcet's disease is
immunosuppressive therapy.
• Corticosteroids act by modifying the activity of neutrophils.
Acute phase
Prednisolone
40-60mg/day

26. ORAL LICHEN PLANUS
• Topical corticosteroids widely used in the therapeutics of oral
lichen planus (OLP) to reduce inflammation and pain by
suppressing T cell functions and decreasing IgG synthesis.
0.05% Clobetasol
Proprionate Gel
0.05% Fluocinonide Gel
0.1-0.05% Betamethasone
Valerate Gel
0.1% Triamcinolone
Acetonide Ointment
Topical
Corticosteroids

27. Intralesional corticosteroids
• Subcutaneous injection of 0.2-0.4
ml of a 10 mg/ml solution of
Triamcinolone AcetonideExtensive
Lesions
• Intralesional Triamcinolone
Acetonide in doses of 0.5-1 ml of
a 1 mg/ml suspension in the form
of bi-weekly injections
Erosive
Lesions

28. Systemic corticosteroids
• Systemic corticosteroids are used for recalcitrant erosive or
erythematous lichen planus where topical therapy has not been
effective.
Severe Cases
• Prednisone 10-20 mg/Day

29. ERYTHEMA MULTIFORME
Topical steroid therapy
• Oral topical steroids provide symptomatic relief.
• Clobetasol propionate mouthwashes in aqueous solution is commonly used.

30. Systemic steroid therapy
• Moderate-to-severe oral erythema multiforme can be treated with a
short course of systemic glucocorticosteroid.
Minor EM
Prednisone 20-40
mg/day for 4-6
days
Severe Or Rapidly
Progressing Lesions
Prednisone 60 mg/day
slowly tapered by 10
mg/day over 6 weeks

31. LUPUS ERYTHEMATOSUS
Predisolone – 20 -
30 mg/day for 2- 6
weeks
Tapered gradually

32. PEMPHIGUS
Topical corticosteroids
In patients without progressing oral lesions, moderate to high-potency topical
corticosteroids should be applied twice or thrice a day, such as 0.05%
fluocinolone acetonide or 0.05% clobetasol propionate.

33. Systemic corticosteroid
therapy
In patients with severe
disease and the spread of
lesions is to the dermal
surfaces
100-200 mg
prednisolone is
employed every day until
clinical signs abate.
Intralesional
corticosteroid
therapy
Used to treat
persistent lesions
Intralesional injections
given every 1-2 weeks;
treatment is ceased after
3 injections if there is no
improvement.

34. CICATRICIAL 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

35. SUMMARY OF CORTICOSTEROIDS USED IN TREATMENT OF ORAL LESIONS

36. BENIGN LESIONS
1. Central giant cell granuloma
2. Hemangioma
3. Mucocele

37. CENTRAL GIANT CELL GRANULOMA
• It is a lesion having benign tumor in jaws made up of
loose fibrous connective tissue stroma and is most
often seen among young adults and children.
• A characteristic feature of the tumor is the presence of
interspersed proliferating fibroblasts, aggregations of
multinucleated giant cells and foci of hemorrhage.
• Intracellular corticosteroid injections are generally
given for non surgical treatment. Triamcinolone
acetonide is found to be effective, and may act by
suppressing any angiogenic component of the lesion.

38. HEMANGIOMA
Prednisone at a dose of 20-30
mg/d can be given for 2 weeks to
4 months
Intralesional triamcinolone
acetonide (4 mg/mL)

39. 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.

40. NEURALGIAS
1. Bell’s palsy
2. Ramsay hunt syndrome
3. Post herpetic neuralgia

41. BELL'S PALSY
• Immunocompetent patients are administered prednisone
at 1 mg/kg/day (maximum 80 mg) for the 1 st week and
tapered over the following week.
• Patients with partial palsy should also be managed as
there are chances of around one-fifth of these cases to be
progressive in nature.

42. RAMSAY HUNT SYNDROME
• Definitive treatment consists of antiviral therapy.
• Adjunctive steroid therapy may help in the
treatment of the facial paralysis of Ramsay Hunt
syndrome.
• A large prospective study showed that
combination therapy with both acyclovir and
steroids leads to a better recovery of facial nerve
function in comparison to steroids administered
alone.

43. POST HERPETIC NEURALGIA
• Corticosteroids are used, which help to treat pain, swelling, and also reduce
the risk of recurrence of post herpetic neuralgia (PHN) significantly.
• Prednisolone is the drug most commonly prescribed in heavy doses to
herpes patients. A moderate dose of prednisone 40 mg daily for 10 days,
which is gradually tapered off over the following 3 weeks is a very effective
and safe routine in reducing the incidence of PHN.

44. TMJ DISORDERS

45. TEMPOROMANDIBULAR DISORDERS
• Tempero Mandibular Disorders (TMDs) are clinical problems involving
temperomandibular joints (TMJs), the masticatory muscles or both. It is a
common musculoskeletal disorder causing orofacial pain.
• The most common signs and symptoms of TMDs are pain, altered mandibular
movements and the elicitation of joint noise.
• Intra-articular corticosteroid injections are useful in adult patients with
temperomandibular joint (TMJ) disorders; a single intra-articular injection
resulted in resolution of TMJ pain and other symptoms in 62% of adult
patients.
• Disadvantage: Intra articular injections of corticosteroids (like triamcinolone
acetonide) cause damage to fibrous layer, cartilage and bone of TMJ.

46. ARTHRITIS
Rheumatoid
arthritis
Intraarticular injection – 10
to 40 mg/ml
osteoarthritis
Intraarticular injection – 20
mg/ml(2 injections 14 days
apart)

47. TEMPORAL ARTERITIS
• Oral prednisone is the first-line acute
therapy for temporal arteritis. Majority of
patients respond to an initial dose of 1
mg/kg/day, or between 40 and 60
mg/day of prednisone. The dose is
lowered after 2-4 weeks and slowly
tapered over 9 months to 1 year.
• Higher doses of 80-100 mg/day are
suggested for patients of GCA with
visual or neurological symptoms.

48. Steroids in management of temporomandibular disorders

49. OTHER USES
1. Oral submucous fibrosis
2. Keloid and hypertrophic scar

50. ORAL SUBMUCOUS FIBROSIS
• Oral submucous fibrosis is an insidious, chronic, resistant disease involving the
mucosa, submucosa or any part of the oral cavity including the pharynx and
esophagus.
• The disease produces excessive salivation, burning sensation, difficulty in
chewing, swallowing and restricted mouth opening in severe cases.
• Application of steroid ointment topically helps in cases with ulcers and painful
oral mucosa.
• Intralesional injection of Dexamethasone is most commonly used treatment.

51. KELOID AND HYPERTROPHIC SCARS
• These generally represent pathologic over-healing conditions
that are caused due to excess production of fibrous tissue
following healing of skin injuries.
• Triamcinolone acetonide is the most commonly used steroid
for the treatment of HS and keloid. It is used at a concentration
of 10-20 mg/ml and can go upto 40 mg/ml for a tough and
bulky lesion.
• Side effects of steroid injection include hypopigmentation,
telangiectasia, dermal atrophy and cushingoid effect due to
systemic absorption.

52. STEROIDS IN ORAL SURGERY
• Prevention of postoperative pain, edema, trismus after 3rd molar surgery
• Prevention of postoperative edema after orthognathic surgery
• Prevention of alveolar osteitis
• topical use on the lips and corners of the mouth to prevent ulceration and
excoriation as a consequence of retraction during surgery
• They are also used in the prophylaxis of adrenal crisis in patients with
secondary adrenal insufficiency

53. STEROIDS IN ENDODONTICS
• Steroids are used in intracanal medicaments such as Ledermix to reduce
pulpal inflammation and prevent root resorption.
• Ledermix is also used for the control of postoperative pain associated
with acute apical periodontitis.
• Steroids like hydrocortisone are also mixed with zinc oxide eugenol to be
used as root canal sealers.

54. CORTICOSTEROIDS IN ORTHODONTIC TOOTH
MOVEMENT
• It is reported that the upon treatment with hydrocortisone at a dose of 10
mg/kg/day for 7 days on rats followed by observation for 20 hours the teeth
showed lower amount of tooth movement.
• Hence, it is essential that the patients are reviewed of their prior history of
corticosteroids use.

55. MEDICAL EMERGENCIES IN DENTAL
PRACTICE

56. ADRENAL CRISIS PROPHYLAXIS
• Acute adrenal crisis, with the lack of mineralocorticoids and glucocorticoids,
is a medical emergency.
• Symptoms include abdominal pain, weakness, hypotension, dehydration,
nausea, and vomiting.
• Laboratory findings may include hyperkalemia, hyponatremia,
hypoglycemia, uremia, and acidosis.
• Exogenous glucocorticoids can lead to suppression of adrenal gland and
resultant atrophy. This may cause a decreased glucocorticoid response to
stress, and precipitate an adrenal crisis.

57. Management
• Intravenous fluids (in the form of 5% dextrose in normal saline).
• Primary adrenal insufficiency: Start on 20-25 mg hydrocortisone
per 24 h.
• Secondary adrenal insufficiency: 15-20 mg hydrocortisone per 24
h; if borderline fails in cosyntropin test considers 10 mg or stress
dose cover only.
• Hydrocortisone should initially be given intravenously. If there is
an improvement within 24 h, the hydrocortisone dose can be
reduced. This can be changed to an oral formulation whenever the
patient is stable.
• The condition that precipitated the crisis, such as infection, should
be searched. The underlying cause should be treated.

58. ANAPHYLACTIC SHOCK
• Steroids are unlikely to be beneficial in the management of
acute anaphylaxis. One of the reasons is their delayed onset of
4-6 h.
• Most clinicians, however, give prednisone 1 mg/kg up to 50
mg orally or hydrocortisone 1.5-3 mg/kg intravenously
specific in patients with airway involvement and
bronchospasm, based empirically on their crucial role in
asthma.
• Steroids are fundamental in the management of recurrent
idiopathic anaphylaxis.

59. CONTRAINDICATIONS OF STEROIDS
• Topical corticosteroids are contraindicated in the treatment of
– Primary bacterial infections
– Patients with hypersensitivity

60. RELATIVE CONTRAINDICATION
Peptic ulcer
Diabetes mellitus
Hypertension
Pregnancy
Tuberculosis and other infections
Osteoporosis
Herpes simplex infections
Psychosis
Epilepsy
Congestive heart failure
Renal failure.

61. SIDE EFFECTS
• Weight gain
• Impaired growth
• Adrenal insufficiency
• Increased susceptibility to infection
• Myopathy
• Osteoporosis
• Osteronecrosis
• Cataract
• Glaucoma
• Fractures
• Hypertension
• Insomnia, diabetes, peptic ulcer.
• Topical treatments cause adverse effects such as
– Skin atrophy
– Hypo-pigmentation
– Contact dermatitis
– Oral thrush
– Sub cutaneous fat wasting
– Cushingoid effect from systemic absorption.
• Inhaled corticosteroids cause side effects including
oropharygneal candidiasis, dysphonia, reflex cough,
bronchospasm and pharyngitis

63. 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
days
ago, no
supplementation
needed
No
supplementation
needed
Treat on steroid
dosage day; no
further
supplementatio
n needed
No
supplementatio
n needed
DENTAL CONSIDERATION

64. 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
supplementatio
n needed

65. CONCLUSION
• Corticosteroids have proven to be the archetypal and double-edged sword of
medicine. The risks associated with corticosteroids are parallel to the benefits of
their therapeutic power.
• Corticosteroids have wide range of uses in dentistry. Corticosteroids are used for
treatment of various diseases affecting oral and maxillofacial area to control pain,
edema especially after surgery. They have widest applications in chronic and
acute conditions of allergy, inflammation, etc. It also carries the potential side
effects, sometimes very severe. Non steroidal drugs are prescribed to minimize
dosage of steroids to lesser side effects. The use of steroids should be viewed
carefully in dentistry.

66. THANK YOU