CORTICOSTEROIDS IN DENTISTRY

🔷 Introduction:

Steroids are a group of hormones produced naturally in the body.

The adrenal cortex consists of 3 zones:

  1. Zona Glomerulosa synthesizes Aldosterone, the most potent Mineralocorticoid in humans.
  2. Zona Fasciculata – produces hydrocortisone (a glucocorticoid)
  3. Zona Reticularis produces Adrenal Androgens

• Glucocorticoid secretion is regulated by ACTH produced in the anterior pituitary. Cortisol has a -ve feedback on ACTH production.

• In Addison diseases, Glucocorticoid secretion impaired & ACTH is ⬆️

🔷 Corticosteroid Action & its regulation

  • Glucocorticoid – Hepatic Glycogen deposition
  • Mineralocorticoid – Sodium, electrolyte-fluid balance.
  • Glucocorticoid play critical role in body’s response to stress.

Stress

⬇️

Release of cytokines (IL-1)

⬇️

⬆️ cortisol levels

🔷 Classification:

Adrenocortical Hormones & Related Drugs

🔷 Steroid synthesis:

The substrate for steroid production is cholesterol. It is mobilized from the outer to the inner mitochondrial membrane by the steroidogenic acute regulatory (StAR) protein.

🔷 Glucocorticoids:

1) Hydrocortisone

Action: Anti-allergy, anti-inflammatory

Therapeutic Uses:

  • intralesional injection in dose of 20-50 mg/mL
  • Topical application
  • Tablet in dose of 100mg/day can be given systemically to relieve burning sensation.
  • Tab. Cortisol(25mg) combined with dexamethasone(90mg) can be given at biweekly interval.*

Action: Fibrinolytic,Anti-allergic, anti-inflammatory*

It causes ⬇️ fibroblastic production & deposition of collagen*

  • Topical application with orabase
  • Intralesional injection of hydrocortisone acetate (25mg/ml)
  • Topical application (0.25-0.5%) to the affected area
  • Intra-articular injection (25mg/ml)
  • 20-30mg/day in divided doses

Trade Name: CORTEF, ORABASE-HCA

• Preparation:

  1. Oral: 5 – 20 mg tab.
  2. Topical – 1% eye drop solution; 0.025 nasal drops, 0.25-2.5% skin creams

• Hydrocortisone acetate 25-50 mg/mL for soft tissue suspensions

• Hydrocortisone sodium phosphate: 50mg/mL IV, IM, SC

2) Cortisone:

• Uses:

  1. OSMF
  2. Addison disease
  3. Hodgkin lymphoma

3) Prednisolone:

Action: Anti-allergic, anti-inflammatory, immunosuppressive

• Uses:

  1. Rheumatoid arthritis: 10mg/day in divided doses
  2. Collagen disease: 1mg/kg
  3. SLE: IM/IV; Topical application 2-3 times daily
  4. Leukemia: ALL as maintenance dose
  5. Erythema multiforme, pemphigus, bullous pemphigoid, behchet’s syndrome
  6. Bronchial asthma: 40-60 mg
  7. Post-herpetic neuralgia
  8. Amyloidosis, cyclic neutropenia, purpura

Trade name: DELTA-CORTEF, PRELONE

4) Triamcinolone:

• Uses:

  1. Lichen planus: Topical application 3-4 times daily
  2. Erythema multiforme: 40-100 mg/day or inhalation doses
  3. Recurrent aphthae: Oral (2-4 mg/day)
  4. Desquamative gingivitis, OSMF, contact chelitis – intralesional (2-3 mL/day)

Trade name: Kenolog cream

5) Dexamethasone:

Uses:

👉🏻Mainly used for adrenal cortical suppression

  • Allergic diseases, serum sickness, urticaria, hay fever, angioneurotic edema: IV; topically 2-4 times a day
  • Benign migratory glossitis: Topical application
  • Shock, cerebral edema, occular diseases.

Trade name: DECADRON

6) Betamethasone:

Action: Anti-allergy, anti-inflammatory

Uses: Lichen planus, pemphigus, Aphthae ulcer

Dr. Mehnaz Memon🖊


References: Self Notes, Image chart source: Classification of Drugs with DOC by Vikas Seth (Third Edition)

ANALGESICS AND ANTI-INFLAMMATORY DRUGS(NSAID’s) IN DENTISTRY

💊Analgesic is a drug that selectively relieves pain by acting in the CNS or on the peripheral pain mechanisms without significantly altering consciousness.

💊They are divided into 2 groups:

  1. Opiod/Narcotic/Morphine like
  2. Non-opiod/Non-Narcotic/antipyretic (Aspirin like drugs)

The antipyretic analgesics & NSAID’s are more commonly employed for dental pain because tissue injury and inflammation due to abscess, caries, tooth extraction etc. is major cause of acute dental pain.

🔆 CLASSIFICATION:

Image: 1
Image: 2

🔆 ANALGESIC/NSAID’s IN DENTISTRY:

  • The antipyretic analgesics used mainly for dental pain is Paracetemol.
  • Paracetemol (Acetaminophen) is most frequently used to relieve toothache in Pregnancy. It has week anti-inflammtory effect & causes no teratogenesis in the developing fetus.
  • Pain during invasive dental procedures is alloyed by a local anesthesic before & after is treated with NSAID’s.

💊 NSAID’s use during Pregnancy: (The devastating effects to the infant) 👇🏻

Image: 3

🔆Use of OPIOIDS in Dental Pain:

  • Less used than analgesics
  • Mostly codeine is used for dental patients because other opioids cause dullness & short lasting pain.
  • Other alternative Opioid Analgesics used are – Tramadol, Pentazocine.

💊MORPHINE – Depressant actions‼️

🔻Adverse effects:
  1. Sedation, mental clouding, lethargy, nausea, vomitting, diarrhoea.
  2. Respiratory depression, blurring of vision.
  3. Allergic conditions, rashes, urticaria, itching, swelling.
  4. May develop tolerance & dependance.
🔻Contraindications:
  1. Urinary retention – infants & elderly
  2. Asthma patients
  3. Hypotensive states
  4. Hypovolaemic states

💊NSAID’s :

  1. Analgesic, antipyretic, anti-inflammatory effect.
  2. Effectively relieves inflammatory tissue, injury related pain, signs of inflammation like pain, tenderness, swelling are suspected.
  3. Cellular metabolism is increased & due to increased Glucose utilization there is decrease in blood sugar.
  4. Has teratolytic & mild-antiseptic properties
  5. Irritates gastric mucosa
  6. Interferes with platelet aggregation & bleeding time prolonged.
🔻Adverse effects:
  • Nausea, vomiting, diarrhoea, blood loss in stools.
  • Haemolysis in G6PD deficient patients.
  • Nephrotoxicity & hepatotoxicity in long term use.
  • Allergic reactions – rashes, urticaria, photosensitivity.
  • Pregnancy & Infancy – Refer Image 3
🔻Contraindications:
  • Nursing and pregnancy
  • Serious bleeding
  • Allergy/Asthma/Angioedema
  • Impaired renal function
  • Drug (anticoagulant)

Dr. Mehnaz Memon🖊


References:

  1. Flowcharts: Classification of Drugs with DOC by Vikas Seth (Third Edition)
  2. KD TripathiEssentials of Medical Pharmacology 7th Edition; Internet

Drugs of choice in Poisonings/Overdosage/Toxicities

Drug/Poison Antidote
Atropine (Belladona
poisoning)
Physostigmine
Benzodiazepins
(e.g. Diazepam)
Flumazenil
Beta-adrenoceptor antagonistsGlucagon, Adrenaline
Calcium channel blockersCalcium gluconate
CarbamateAtropine
CyanideSodium nitrite/ Amyl nitrite, oxygen, dicobalt edetate, sodium thiosulphate, hydroxocobaamine
Digoxin (Digitalis)Digoxin-specific antibody fragments (Digibind)
Ethylene glycol/ MethanolFomepizole, Ethanol
Fibrinolytics (e.g. Streptokinase)EACA (Epsilon amino caproic acid)
HeparinProtamine
Iron saltsDesferrioxamine
LeadSuccimer (DMSA 2,3-dimercaptosuccinic acid), disodium calcium edetate, Dimercaprol(BAL)
Mercury or ArsenicDimercaprol, d-Penicillamine
Opioids (e.g. Morphine)Naloxone
Oral Anticoagulants (e.g. Warfarin, rodenticides)Vitamin K, fresh frozen plasma
Organophosphorus- insecticides, nerve gasesAtropine, Pralidoxime
Paracetemol (Acetaminophen)N-acetylcysteine, Methionine
Copper (or Wilson’s disease)d-Penicillamine

ReferencesKD TripathiEssentials of Medical Pharmacology 7th Edition

Drugs of choice in respiratory diseases

🔗Refer Asthma First Aid & Prevention tips on Page 2‼️

ASTHMA

Mild intermittent

💊 Short acting β2-agonists (e.g. Salbutamol, Terbutaline) inhalations when needed.

💊 Anticholinergics (e.g. Ipratropium, Tiotropium) inhalations when needed, alone or in addition to beta-2 agonists

💬 Patient is asymptomatic between the dyspnoea episodes, so no daily medication required!

ASTHMA

Mild persistent

💊 Short acting β2-agonists (e.g. Salbutamol, Terbutaline) inhalations ➕ Corticosteroid inhalation (low dose)

💊 Short acting β2-agonists ➕ Mast cell stabilizer or Leukotriene antagonist or Theophylline sustained release

💬 Beta-2 agonist inhalation is needed every day, so once daily corticosteroid inhalation if given for asthma control.

ASTHMA

Moderate persistent

💊 Long acting beta-2 agonists (e.g. Salmeterol, Formeterol) inhalations ➕ Corticosteroid inhalation (low to high dose)

💊 Long acting beta-2 agonist tablets or Theophylline sustained release ➕ Corticosteroid inhalation (medium dose)

💬 The dose of corticosteroid inhalations depends on the severity of symptoms.

ASTHMA

Severe persistent

💊 Long acting beta-2 agonists (e.g. Salmeterol, Formeterol) inhalations ➕ Corticosteroid inhalation (high dose) ➕ Corticosteroid tablets/syrup

💊 Long acting beta-2 agonist tablets or Theophylline sustained release ➕ Corticosteroid inhalation (high dose) ➕ Corticosteroid tablets/syrup

💬 Systemic corticosteroids have significant adverse effects, so after adequate asthma control, are gradually withdrawn.*

ASTHMA

Acute severe asthma

💊 Oxygen 60% ➕ Nebulized beta-2 agonists (e.g. Salbutamol) in high dose ➕ Systemic corticosteroids

💬 An emergency condition, earlier called as status asthmatics. Aminophylline is no longer recommended.

* After adequate control of severe persistent asthma, systemic corticosteroids are withdrawn, and the patient then would be managed as moderate persistent type. This is called "step down" approach of management. In this approach, it is considered better to manage patients assuming in the next higher type and then, after reviewing in 1-6 months, to step-down, instead of "step-up" after failure in asthma control.

Aspirin induced

asthma

💊 Leukotriene antagonists (e.g. Montelukast, Zafirlukast)

Exercise induced

asthma

For Prophylaxis: Mast cell stabilizers or beta-2 agonists or Leukotriene antagonists💊

COPD

  • For smoking cessation: I line: Behaviour therapy; II line: Nicotine replacement therapy; III line: Antidepressants e.g. Bupropion
  • For respiratory infections: Antibiotics
  • For bronchodilatation: I line: Anticholinergics; II line: beta-2 agonists; III line: Theophyline
  • For hypoxemia: I line: Ambulatory oxygen; II line: Long term oxygen therapy

Dry cough

💊 Cough suppressants (e.g. Dextromethorphan) + Treat the cause e.g. post nasal drip by antihistaminics and decongestants.

Productive cough

💊 Expectorants (e.g. Pot iodide) &/or Mucolytics (e.g. Acetylcysteine) ➕ Treat the cause e.g. allergy by antihistaminics and bacterial infection by antibiotics

References: CLASSIFICATION OF DRUGS WITH DRUGS OF CHOICE 3RD EDITION BY VIKAS SETH


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