Corticosteroids are synthesized by the adrenal cortex and have glucocorticoid and mineralocorticoid actions. They are used for their anti-inflammatory, immunosuppressive, and electrolyte regulating properties. Common corticosteroids used include hydrocortisone, prednisone, and dexamethasone. They are administered topically, orally, intramuscularly or intravenously. Dental procedures on patients taking corticosteroids require stress reduction and adequate pain control to prevent adrenal insufficiency. Management of adrenal insufficiency involves glucocorticoid administration, IV fluids, and hospital transfer if unconscious.

1. DIVISION OF ORAL ANDDIVISION OF ORAL AND
MAXILLOFACIAL SURGERYMAXILLOFACIAL SURGERY
STEROIDSSTEROIDS
Dr V.RAMKUMAR
CONSULTANT DENTAL & FACIOMAXILLARY SURGEON
REG NO .4118 -TAMILNADU -INDIA- (ASIA)

2.  Corticosteroids and theirCorticosteroids and their
biologically synthetic analogsbiologically synthetic analogs
possess glucocorticoid andpossess glucocorticoid and
mineralocorticoid action.mineralocorticoid action.

3. Adrenocortical SteroidsAdrenocortical Steroids
 The adrenal cortex synthesizes two classes ofThe adrenal cortex synthesizes two classes of
steroids-steroids-
• The glucocorticoidsThe glucocorticoids
ex; hydrocortisoneex; hydrocortisone
• The mineralocorticoidThe mineralocorticoid
ex; aldosteroneex; aldosterone

4. GLUCOCORTICOIDSGLUCOCORTICOIDS
Short acting
Compound Equiv. dose (anti-
inflammatory
1. Hydrocortisone (cortisol)
2. Cortisone
20mg
25mg
3. Prednisolone
4. Methylprednisolone
5. Triamcinolone
5mg
4mg Intermediate acting
4mg
6. Paramethasone
7. Dexamethasone
8. Betamethasone
2mg
0.75mg Long acting
0.75 mg

5. MINERALO CORTICOIDSMINERALO CORTICOIDS
9. Desoxycorticosterone
acetate (DOCA)
10. Fludrocortisone
11. Aldosterone
2.5 mg (sublingual)
0.2 mg
Not used clinically

6. ADERNOCORTICAL STERIODSADERNOCORTICAL STERIODS

7. Adernocortical SteriodsAdernocortical Steriods
Adernal cortex
(Synthesizes two classes of steroids)
Androgen
(19 carbon atoms)
Corticosteriods
(21 carbon atoms)
Mineralocorticoids
(Electrolyte balance
regulating)
Glucocorticoids
(Carbohydrate
metabolism regulating)
Hydrocortisone
(cortisol)
Aldosterone

8. Pharmacological actionsPharmacological actions
Increases gluconeogenesisIncreases gluconeogenesis
Increases the peripheralIncreases the peripheral
utilization of glucose.utilization of glucose.

9. Protein metabolismProtein metabolism
 Decreases the conversion of ofDecreases the conversion of of
amino acids to proteinsamino acids to proteins
 Increases muscle wastingIncreases muscle wasting
 Increase in loss of bone matrixIncrease in loss of bone matrix

10. Anti inflammatory and allergyAnti inflammatory and allergy
responseresponse
Steroids decreases the production ofSteroids decreases the production of
inflammatory cells.inflammatory cells.
Steroids interact with antigen antibodySteroids interact with antigen antibody
complex and reduces the allergycomplex and reduces the allergy
response.response.

11. Mineral metabolismMineral metabolism
 Steroids causes sodium and waterSteroids causes sodium and water
retention and produces oedemaretention and produces oedema
 Fat metabolism . It produces moonFat metabolism . It produces moon
face in the head and neck region.face in the head and neck region.
 Mood changes . It causes euphoria.Mood changes . It causes euphoria.

12. Anti vitamin D actionAnti vitamin D action
 Absorption of calcium from the gut isAbsorption of calcium from the gut is
impaired due to steriod action.impaired due to steriod action.

13. Routes of administrationRoutes of administration
 TopicalTopical
 OralOral
 IntramuscularIntramuscular
 Intra venousIntra venous

14. Therapeutic uses in oral andTherapeutic uses in oral and
maxillofacial surgerymaxillofacial surgery
 Minor surgical proceduresMinor surgical procedures
 TraumaTrauma
 TumorsTumors
 Orthognathic surgical proceduresOrthognathic surgical procedures
 Neuro surgical proceduresNeuro surgical procedures

15. Therapeutic Uses in Non-Therapeutic Uses in Non-
endocrine Diseaseendocrine Disease
 Rheumatic Disorders( phempigus)Rheumatic Disorders( phempigus)
 Renal diseasesRenal diseases
 Allergic DiseaseAllergic Disease
 Antiemetic ActionAntiemetic Action
 In AsthmaIn Asthma
 Immunosuppressive ActionImmunosuppressive Action
 Ocular DiseaseOcular Disease
 Skin DiseaseSkin Disease

16. Contd…Contd…
 GIT DiseaseGIT Disease
 Hepatic DiseaseHepatic Disease
 MalignanciesMalignancies
 Cerebral EdemaCerebral Edema
 Apthous stomatitisApthous stomatitis
 Lichen planusLichen planus

17. MISCELLANEOUS DISEASEMISCELLANEOUS DISEASE
AND CONDITIONSAND CONDITIONS
• SarcoidosisSarcoidosis
• ThrombocytopeniaThrombocytopenia
• Autoimmune Destruction of ErythrocytesAutoimmune Destruction of Erythrocytes
• Organ TransplantationOrgan Transplantation
• Spinal Cord InjurySpinal Cord Injury

18. Therapeutic preparation and dosageTherapeutic preparation and dosage
 Topical applicationTopical application
 Corlan pellet(hydrocortisoneCorlan pellet(hydrocortisone
hemisuccinate.2.5mg)hemisuccinate.2.5mg)
 Triamcinolonepaste(vehicle consist ofTriamcinolonepaste(vehicle consist of
gelatin methyl cellulose pectin)gelatin methyl cellulose pectin)

19. TriamcinoloneTriamcinolone
 It is availabe as injectable and waterIt is availabe as injectable and water
formform
 Tablets 8-20 mgTablets 8-20 mg
 Injection 10mg vialInjection 10mg vial

20. DexamethasoneDexamethasone
 Available in oral and injection formsAvailable in oral and injection forms
 Oral dose .2-10mgOral dose .2-10mg
 Iv 4-20 mgIv 4-20 mg
 BethamethasoneBethamethasone
 available as local drops skin creamsavailable as local drops skin creams
ointment and lotionsointment and lotions
 Iv 4-20 mg.6-8hrly.Iv 4-20 mg.6-8hrly.

21. Rule of twoRule of two
 Pt receiving steroids for two yearsPt receiving steroids for two years
twice a week the dose to be doubledtwice a week the dose to be doubled

22. Major complicationsMajor complications
 Suppression of hypothalmohypophysealSuppression of hypothalmohypophyseal
axis.axis.
 Git disturbances.dyspepsiaGit disturbances.dyspepsia
haemorrhage perforationhaemorrhage perforation
 Infection(tb, fungal,candidiasis)Infection(tb, fungal,candidiasis)
 Iatrogenic cushing syndrome(skinIatrogenic cushing syndrome(skin
becomes pale and thin)becomes pale and thin)
 Skeletal osteoporosisSkeletal osteoporosis
 Metabolic odemaMetabolic odema

23.  Mental disturbanceMental disturbance
 Increased intra ocular pressureIncreased intra ocular pressure

24. Minor complicationMinor complication
 AcneAcne
 StriaeStriae
 Weight gainWeight gain
 Increased apetiteIncreased apetite

25. Dental Management GuidlinesDental Management Guidlines
 Define the risk of adrenal insufficiency throughDefine the risk of adrenal insufficiency through
history and clinical examination.history and clinical examination.
 Insure that patient have taken sufficient doses.Insure that patient have taken sufficient doses.
 Schedule surgery in the morning.Schedule surgery in the morning.
 Stress reduction.Stress reduction.
 Use of nitrous oxide-oxygen or IV or oralUse of nitrous oxide-oxygen or IV or oral
benzodiazepine sedation is helpful.benzodiazepine sedation is helpful.

26. Contd.Contd.
 Avoid the use of barbiturates.Avoid the use of barbiturates.
 Avoid GA for out patient procedure.Avoid GA for out patient procedure.
 Discontinue drug therapy that decreasesDiscontinue drug therapy that decreases
cortisol levels at least 24 hours before surgery.cortisol levels at least 24 hours before surgery.
 Adequate pain control.Adequate pain control.
 Methods to reduce blood loss should be used.Methods to reduce blood loss should be used.
 BP below 100/60 mm should receive fluidBP below 100/60 mm should receive fluid
replacement.replacement.
 Take care of hypoglycemia and hypovolemia.Take care of hypoglycemia and hypovolemia.

27. MANAGEMENT OFMANAGEMENT OF
ADRENAL INSUFFICIENCYADRENAL INSUFFICIENCY

28. Conscious patientConscious patient
Terminate dental treatmentTerminate dental treatment
If asymptomatic, supine with feet elevated, IfIf asymptomatic, supine with feet elevated, If
symptomaticsymptomatic
A-B-C provide BLS, as neededA-B-C provide BLS, as needed

29. D- definitive care, monitor vital signs, medicalD- definitive care, monitor vital signs, medical
assistance, obtain emergency kit and O2assistance, obtain emergency kit and O2
Administer glucocorticosteroid, if available and ifAdminister glucocorticosteroid, if available and if
history of insufficiencyhistory of insufficiency

30. Consider additional management; provide BLS,Consider additional management; provide BLS,
O2, glucocorticosteroid, as needed, establishO2, glucocorticosteroid, as needed, establish
IV lineIV line

31. Unconscious patientUnconscious patient
Recognize UnconsciousRecognize Unconscious
supine with feet elevated slightlysupine with feet elevated slightly
A-B-C provide BLS, as neededA-B-C provide BLS, as needed

32. monitor vital signs, medicalmonitor vital signs, medical
assistance, obtain emergency kitassistance, obtain emergency kit
and O2, Administerand O2, Administer
glucocorticosteroidglucocorticosteroid

33. Establish IV line,Establish IV line,
if possible TRANSFER TOif possible TRANSFER TO
HOSPITALHOSPITAL

34. THANK YOUTHANK YOU