Adrenocorticosteriodsnrc1320-f2.jpg


What are Corticisteroids used for?
Adrenal insufficiency(acute or chronic, primary or caused by anterior pituitary insufficiency
Cerebral edema and icreased intracranial pressure(brain tumors, meningitis, trauma, cererovascular accidents)
Collagen vascular diseases
Lupus erythematosus

Polymyositis
Polyarteritis nodosa
Chronic granulomatous disorders
Temporal ( giant cell) arteritis
Mixed connective tissue disease syndrome
Dermatologoc disturbances
Psoriasis
Dermatitis (atopic, allergic, irritant)
Pemphigus
Lichen planus
Gastrointestinal diseases
Ulcerative colitis
Crohns disease
Celiac disease
Hematologic disease
Malignancies (acute and chronic lymphocyte leukemia, lymphoma,multiple myeloma)
Hemolytic anemia (autoimmune or drug induced)
Idiopathic thrombocytopenic purpura
Hepatic diseases
Chronic active hepatitis
Alcoholic hepatitis (severe forms with hepatic encephalopathy
Hypercalcemia ( sarcoid, malignancies,vitamin D intoxication)
Multiple sclerosis (acute episodes)
Nephrotic syndrome
Ocular diseases with inflammatory or allergic components
Pulmonary disorders
Asthma
Chronic bronchitis(acute episodes)
Aspiration pneumonia
Rheumatic diseases
Rheumatic diseases and joint ailments
Rheumatic arthritis

Rheumatic carditis
Osteoarthritis (intraarticular administation)
Bursitis (intracapsular administration)
Shock
Solid tumors (breast)
Tissue grafts and organ transplants

Natural adrenocortical hormones:
  • steroid molecules synthesized in released by the adrenal cortex
    • Clinical Uses:
      1. diagnosis of adrenal function
      2. treatment of adrenal function disorders
      3. treatment of inflammatory/immunological disorders (at higher doses)
    • Control over adrenocorticosteroid secretion:
      • pituitary corticotropin (ACTH) release
      • Angiotensin modulation of aldosterone secretion
      • Corticosteroids with:
        1. androgenic activity
        2. estrogenic activity
      • quantitatively -- DHEA
      • DHEA and androstenedione }very weak androgens
      • small amount of testosterone, secreted by the adrenals, maybe more important
      • adrenal androgens: testosterone and androstenedione may be converted to estrone by non-endocrine tissue:
        • Major endogenous estrogen source in women after menopause

Administration routes for Adrenocorticosteroids:



  1. IM
  2. IV
  3. Oral
  4. Topical

Adrenocorticosteroids for the uses of Dentistry include:

  • Treatment for oral inflammatory lesions, such as Apthous stomatitis
  • Apthous stomatitis
  • Temporomandibular disorders
  • Oral surgery or endodontic procedures
  • Control adrenal insufficiency

Implications in Dentistry include:

  • Delayed wound healing
  • Susceptibility to periodontal disease- bone loss
  • Increased risks for infections
  • May affect density of alveolar bone
  • Oral fungal infections
  • Adrenal crisis may occur with severe stress
  • Medical consultation in regards to glucocorticosteroid therapy- Rules of Two
  • Patient may require premedication prior to dental treatment




Adrenocorticosteroids
Agents secreted by the adrenal cortex
IMPORTANCE IN DENTISTRY
nThey are used topically or systemically for the treatment of oral lesions associated with inflammatory diseases
nThey are often prescribed for patients with chronic systemic diseases such as asthma or arthritis and long-term therapy can cause adverse reactions on patients’ dental treaments
Mechanism of release
nStress → hypothalamus → CRF pituitary → ACTH adrenal cortex → hydrocortisone → pituitary → hypothalamus inhibits release of CRF and ACTH = negative feedback
nLong-term therapy → ↓ ACTH → atrophy of adrenal cortex
nFor these patients, if exogenous steroid is abruptly stopped, steroid deficiency and adrenal crisis can result
Classification
nGlucocorticoids
qAffect immediate carbohydrate metabolism
qMajor one = cortisol
qStress increases its release
nMineralocorticoids
qAffect the water and electrolyte composition of the body
Definitions
nAddison’s disease
nAdrenocorticosteroids/corticosteroids/steroids
nAdrenocoticotropic hormone (ACTH)
nCushing’s syndrome
nGlucocorticoids
nMineralocorticoids

Routes of administration
nTopical
nOral
nIntramuscular
nIntravenous


Mechanism of action
nBinding to a receptor and forming a steroid-receptor complex → alterations in gene expression
nOther effects mediated by catecholaminesvasodilation or bronchodilation
nAntiinflammatory action results from their effects on the number, distribution, and function of PMNs and their inhibition of phospholipase A
nThese effects serve therapeutic uses but also produce many severe adverse effects
Pharmacologic effects – palliative not curative
nGlucocorticoid effects
qBroad
nCarbohydrate metabolism
nAntiinflammatory
nAnti-allergenic
nEnzyme action
nMembrane function
nNucleic acid synthesis
qSpecific
nCatabolic
nIncrease glucogenesis
nDecrease glucose use
nInhibit protein synthesis
nIncrease protein catabolism
nDecrease growth
nDecrease bone density
nDecrease resistance to infection


nMineralcorticoid effects
qIncrease sodium
qIncrease potassium loss
qEdema and hypertension
Adverse reactions
nMetabolic changes
qMoon face, buffalo hump, truncal obesity, increase weight, muscle wasting → Cushing’s syndrome appearance
qAggravated or initiated hyperglycemia
nInfections
qDecrease resistance
qMask symptoms
nCNS effects
qEuphoria
qAgitation
qPsychoses
qdepression

nPeptic ulcer
qStimulate production of stomach acid and pepsin
qExacerbate peptic ulcers
qImpair healing
nImpaired wound healing and osteoporosis
qCan impair growth in children
qCould affect alveolar bone
qCan lead to fractures
qOther
nOpthalmic effects
qIncreased ocular pressure
qcataracts

nElectrolyte and fluid balance
qCan produce sodium and water retention
qExacerbate hypertension or CHF
qHyperkalemia may also occur
nAdrenal crisis
qAdrenal suppression with long term use
qIf stressful situation occurs – weakness, syncope, cardiovascular collapse, death
nDental effects
qOral mucosa heals more slowly
qMore likely to have infection
qMore friable
qWith steroid inhalers, candidiasis may occur
Uses
nMedical
qBox 19-1
qAddison’s disease
qCushing’s disease
qInfammatory/allergic diseases
nPrednisone is most commonly used
nPotency = triamcinolone is least, bethamethasone is most
Uses
nDental
qOral lesions
qAphthous stomatitis
qTMD
qOral surgery
qPulp procedures

Dental implications
nAdverse reactions in patients taking them
qGI
qBP
qGlaucoma
qBehavioral changes
qOsteoporosis
qInfection
qDelayed would healing
qAdrenal crisis
qPeriodontal disease
Steroid supplementation
nFor patients who use chronic steroids and are about to undergo a very stressful dental procedure
qRule of twos – not reccommended
qOne-time increase
Topical use
nIn dentistry, used to manage oral inflammatory conditions