Manfaat Kortikosteroid Pada Lesi Oral

8/10/2019 Manfaat Kortikosteroid Pada Lesi Oral

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Role of Corticosteroids in Oral Lesions

Masoumeh Mehdipour1and Ali Taghavi Zenouz1

[1]Oral and Maxillofacial Medicine Department, Tariz !acult" of Dentistr", Tariz #niversit" of Medical $ciences,

%ran

1. Introduction

&lucocorticoids 'ere first introduced in the 1()*s and have ecome a 'idel" prescried class of drugs+

orticosteroids are a class of chemicals that includes steroid hormones naturall" produced in the adrenal cortex of

verterates and analogues of these hormones that are s"nthesized in laoratories+ orticosteroids are involved in a

'ide range of ph"siologic processes, including stress response, immune response, and regulation of inflammation,caroh"drate metaolism, protein cataolism, lood electrol"te levels, and ehavior+ The" are some of the most

common drugs for management of patients undergoing stressful situations such as surger" and dentstr" -&ison

.**)/+

%t has thus ecome common for standard textoo0s in dentistr" to recommend the administration of oral orintravenous steroids in the management of oral lesions+

$teroids have different effects on different tissues, 'hich are dose dependent+ The reason for varied effect of steroids

lies in its mechanism of action -&rover .**/+

&lucocorticoids have potent anti2inflammator" actions, including the reduction in the numer and function of

various immune cells, such as T and 3 l"mphoc"tes, monoc"tes, neutrophils,and eosinophils, at sites of

inflammation+ &lucocorticoids decrease the production of c"to0ines,chemo0ines, and eicosanoids and enhances theproduction of macrophage migration inhiitor" factor -&ison .**)/+

orticosteroid drugs are 'idel" used in oral medicine such as in vesiculoullous diseases, orofacial granulomatosis,

temporal arteritis and other oral mucosal disorders+ Topical corticosteroids should e considered the treatment of

choice unless the disease is ver" extensive+ $"stemic therap" is reserved for those 'ith severe, refractor" disease+

2. Mucosal ulceration and inflammation

2.1. Recurrent Aphthous Stomatitis

4ecurrent Aphthous $tomatitis -4A$/ are among the most common oral lesions in the general population, 'ith a

fre5uenc" of 67.68 and three month recurrence rates as high as 6*8+ Aphthous ulcers are often 5uite painful9 ma"

lead to difficult" in spea0ing, eating, and s'allo'ing9 and ma" negativel" affect patients: 5ualit" of life -$hip 1((;/+

4A$ is classified as minor, ma


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2.1.1. Topical corticosteroids

Topical corticosteroid use in patients 'ith 4A$ is intended to limit the inflammator" process associated 'ith the

formation of aphthae+

There are t'o doule2lind, placeo2controlled trials have evaluated the efficac" of topical corticosteroids for 4A$

-Merchant 1(@9Thompson 1(@(/+ The patients enrolled in one trial had minor 4A$+ lassification of ulcers 'asnot availale for the other trial+ 3oth trials assessed patients for immuno 2competence through laorator" studies+

One trial excluded other medications used in 4A$ -Thompson 1(@(/+ %n oth trials there 'ere significant reductions,

compared 'ith placeo, in ulcer duration and pain severit" and no changes in the fre5uenc" of 4A$ in patients 'ho

applied etamethasone gel or eclomethasone aerosol spra" to ulcers four times dail" for six da"s to four 'ee0s-?incent 1((.9Thompson 1(@(/+

T'o non2placeo controlled trials found no significant differences et'een triamcinolone ointment or

etamethasone talets and adhesive vehicles and Oraase in the fre5uenc" and duration of severe 4A$+ $u


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atients 'ith 3ehcet:s disease usuall" have repeated exacerations and remission of their clinical s"mptoms,and in

these individuals treatment is essentiall" s"mptomatic+ The choice of therap" depends on 'hether the clinical

manifestations of the disease are local or s"stemic+

Cocal treatment 'ith corticosteroids often controls oral and genital ulcers, and immunosuppressive therap" is

reserved for severe cases of mucocutaneous involvement -Fazici 1((1/+

%mmunosuppressive therap" is the mainsta" of treatment for 3ehcet:s disease+ $uccessful treatment consists of anti2

inflammator" agents that modif" neutrophil activit"+ %n the acute phase, prednisone, at doses of )*2;* mgda", ma"

e helpful, used alone or in comination 'ith other immunosuppressive agents -4eich 1((@/+

$"stemic corticosteroids continue to e used extensivel",and ma" e administered as intravenous pulse therap"+

2.!. Oral Lichen "lanus #OL"$

Cichen lanus -C/ is an uni5ue inflammator" disorder that affects the s0in, mucous memranes,nails and hair 'asfirst descried and named " Grasmus >ilson in 1@;( -Oztas .**=/+ The pathogenesis of C is not entirel"

understood+ %t is a disorder of altered cell mediated immunit" 'ith exogenous antigens targeting the epidermis+

?arious medical therapies are used for the treatment of hototherap" has een used in the treatment of C for man"

"ears+ The therapeutic properties of corticosteroids 'ere first demonstrated " Gd'ard Hendall and hilip Bench in

1()@ -Bench 1()(/+

orticosteroids ma" e applied topicall" as ointments, pastes, lozenges or mouth'ashes or through an inhaler 'ith aspecial adapter+

The est treatment for OC includes the use of high2potenc" topical corticosteroids -$etterfield .***,3ruce .**/+

%t has een reported that topical corticosteroids, 'hich have fe'er side effects, are e5uall" or even more effective

than s"stemic corticosteroids -Codi .**6/+

2.!.1. Topical corticosteroids

Topical corticosteroids are the main sta" in treating mild to moderatel" s"mptomatic lesions+ The" are 'idel" usedin the treatment of OC to reduce pain and inflammation+ Options -presented in terms of decreasing potenc"/

include *+ *68 cloetasol proprionate gel, *+ 12*+ *68 etamethasone valerate gel, *+ *68 fluocinonide gel, *+ *68

cloetasol ointment or cream and *+ 18 triamcinolone acetonide ointment -Cevin .**./+

Triamcinolone acetonide is commonl" used either in oraase or lozenge -Thongprasom 1((.,Zegarelli 1(;(/+ A

numer of investigations have determined the efficac" of triamcinolone acetonide *+ 18 suspension in the treatmentof OC+ This drug is availale over the counter and is useful in the treatment of OC -4ai"i .**=/+

An a5ueous suspension of triamcinolone acetonide *+ 18 'as used as an oral rinse in the treatment of ); patients

'ith s"mptomatic oral lichen planus -?incent 1((*/+ This method proved to e effective, resulting in Icomplete

relief I in . patients+ Although these results most li0el" refer to improvement in patientsJ s"mptoms,no specific

information is provided regarding the clinical improvement 'ith this therap"+

3etamethasone valerate, an even more potent anti2inflammator" agent, produced dramatic results in a numer of

controlled studies in patients 'ith oral lichen planus+ %n a doule2lind stud", a'son treated =* patients 'ith

s"mptomatic oral lichen planus 'ith etamethasone -*+1 mg/ pellets+ %n @ patients, all lesions virtuall" disappeared

'ithin 1 month, and during the same period, .* of =* patients sho'ed sustantial improvement+ Onl" t'o patientsfailed to respond to this therap" -a'son 1(;@/+
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$imilarl", T"ldesle" and Barding sho'ed etamethasone valerate aerosol fitted 'ith a special intraoral adaptor 'as

an excellent treatment in the ma


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Acute pseudomemranous candidiasis is the onl" common side effect from topical corticosteroid therap"

-Thongprasom 1((./+ This can e prevented 'ith antifungal -miconazole gel/ alone or 'ith chlorhexidine

mouth'ashes -arone1(((/+

2.!.2. Intralesional corticosteroids

%ntralesional inu .**1/+

The oral dose of prednisone for a *20g adult ranges from 1*7.* mgda" for moderatel" severe cases to as high as

=6 mgda" -*+ 6 mg0g dail"/ for severe cases -Zegarelli 1(@=/+ rednisone should e ta0en as a single morning dose

to reduce the potential for insomnia and should e ta0en 'ith food to avoid nausea and peptic ulceration+ $ignificantresponse should e oserved 'ithin one to . 'ee0s+

>hen s"stemic corticosteroids are prescried for periods of longer than . 'ee0s, the dosage of steroid must e

graduall" tapered to avoid precipitating an adrenal crisis+ Tapering can e accomplished " decreasing the dail" dose

of prednisone " 6 mg per 'ee0 -Gd'ards .**./+

$ome studies have compared the efficac" of corticosteroids 'ith some other drugs+ !or example %n a doule2lind

randomized controlled stud", compared the efficac" of topical zinc sulfate in comination 'ith *+ *68 fluocinoloneointment in the treatment of OC after . 'ee0s of treatment, 'as founded that topical zinc sulfate in comination

'ith *+ *68 fluocinolone ointment reduced the severit" erosive OC etter than *+ *68 fluocinolone separatel"

-Mehdipour Taghavi .*1*/+

2.%. &rythema Multiforme #&M$

Gr"thema Multiforme is a s0in condition considered to e h"persensitivit" reaction to infections or drugs+ %t consistsof a pol"morphous eruption of macules, papules, and characteristic Ntarget: lesions that are s"mmetricall" distriuted
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'ith a propensit" for the distal extremities+ There is minimal mucosal involvement+ Berpes simplex virus -B$?/ is

the most commonl" identified etiolog" of this h"persensitivit" reaction, accounting for more than 6* percent of

cases+ Although GM 'as first clinicall" recognized in the earl" 1(th centur" and referred to " a variet" of names, it

'as not until 1@;* that !erdin and von Bera termed the disease Gr"thema Multiforme -!orman .**./+

Gr"thema multiforme -GM/ 'as once thought to e the earl" presentation of a continuum of diseases related to

$tevens2Pohnson s"ndrome -$P$/, 'ith toxic epidermal necrol"sis -TGE/ elieved to e a distinct entit"+ %t is no'generall" accepted that a separation exists et'een GM and $P$+ urrentl", t'o different classifications existK first,

an er"thema multiforme spectrum -minor and ma


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enefit is seen 'hen treatment is administered as earl" as possile in the progression of the cutaneous insult

-Martinez .***/+

Hardaun and Pon0man recentl" proposed dexamethasone pulse therap" -1+ 6mg0g %? over =* to ;* minutes on =

consecutive da"s/ to avoid long2term use of s"stemic corticosteroids -Hardaun .**/+ The authors descried the

pleomorphic effects of dexamethasone on the immune s"stem, including inhiition of epidermal apoptosis "

several mechanisms+ These mechanisms include suppression of various c"to0ines, such as TE!2alpha9 inhiition ofinterferon2gamma2induced apoptosis9 and inhiition of !as2mediated 0eratinoc"te apoptosis -Feung .**6/+

>hen treating TGE, it is generall" agreed that after 'idespread sloughing occurs, an" ris0 of infection out'eighs

the potential enefits of s"stemic corticosteroid therap" ->olverton .**/+

4ecurrent Gr"thema Multiforme often is secondar" to B$?21 and 2. reactivation, although the B$? ma" eclinicall" silent -Buff 1((./+

2.'. "emphi(us

emphigus refers to a group of rare chronic mucocutaneous diseases characterized " painful lesions caused "

intraepidermal anthol"tic structures in the s0in and mucous memrane -$irois .***/+

Oral mucosal lesions in emphigus are common -6*82*8/ and predominantl" appear as uccal erosions in the

occlusal line, 'hich is most exposed to trauma and also on the palate, gingival and tongue -$irois .***/+

The exact nature of the disease remains un0no'n+ emphigus is characterized " intra2epithelial ulla formation,due to autoantiodies directed against proteins of the desmosome2tonofilament complex et'een 0eratinoc"tes

-$irois .***/+

emphigus vulgaris -?/ has a high moridit" and mortalit" rate 'ithout treatment+ 3ecause of the rarit" of the

disease, there is not "et a standard treatment regimen -otell .***/+

The aim of treatment in pemphigus vulgaris is the same as in other autoimmune ullous diseases, 'hich is to

decrease lister formation, promote healing of listers and erosions, and determine the minimal dose of medicationnecessar" to control the disease process -Hnudson .*1*/+

#ntil no', treatment consists mostl" of the use of corticosteroid and immunosuppressive drugs+ The use of

corticosteroids in the 1(6*s had reduced mortalit" from ;*8 to (*8 to aout =*8+ The current mortalit" 'as aout

;+ .8 -range * to 1*8/ and did not sho' further significant reduction -3"str"n 1((;/+

The treatment depends on the prognostic elements of the condition, such as the extent of the lesions and antiod"

levels+ Treatment is administered in . phasesK a loading phase, to control the disease, and a maintenance phase,

'hich is further divided into consolidation and treatment tapering+ The asic treatment for pemphigus consists of

either local or s"stemic corticosteroid therap" -!ellner .**1/+

2.'.1. Topical corticosteroids

Cocal corticosteroid therap" is used in cases 'here the ? is not extensive and lesions are limited to the oral cavit"+orticosteroids can e prescried in the form of a paste, an ointment or a mouth'ash administered as monotherap"

or as ad


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Dumas et al+ descried pemphigus patients, = of 'hom 'ere treated 'ith cloetasol propionate *+ *68 cream as

monotherap" for their mild ?+ ? 'as defined as mildQ if fe'er than 1* ne' ullae appeared per 'ee0 and if the

circulating pemphigus antiod" titer 'as 1K=.*+ The cream 'as applied t'ice a da" for at least 16 da"s, and then

tapered+ Cesions 'ere controlled in onl" 1 of the = ? patients -Dumas 1(((/+

2.'.2. Systemic corticosteroid therapy

%n patients 'ith severe disease and spreading of the lesions to s0in surfaces, s"stemic corticosteroids are the

treatment of choice -Hnudson .*1*/+

The dosing schedule of s"stemic corticosteroids in pemphigus is largel" empirical -4atnam 1((*/+ rednisolone 'as

the first drug used to treat this disease and almost in all situations, is the first line of treatment -amisa 1((@/+

The starting dose is high9 a total oral dose of 1**7.** mg rednison is administered dail" until susidence of

clinical signs+ This dose can graduall" e decreased to a maintenance level of )* to 6* mg dail"+ Topical applicationof corticoids is effective if small, isolated areas of the oral mucosa are involved+ The acute phase of pemphigus is

associated 'ith changes in gastric mucosa and this condition is further aggravated " ingestion of corticosteroids

-!assmann .**=/+

orticosteroids ta0en " mouth have man" long2term harmful effects, including adrenal atroph", anormalsensitivit" to infection, high lood pressure, h"pertrigl"ceridemia, h"pergl"cemia, cortisone m"opath", erosive

duodenitis and stress fracture, as in the case presented here+ To minimize iatrogenic effects, Cever and $chaumurg

recommended a treatment called the high Cever schemeQ 'ith ver" high loading doses -1**716 mg ta0en t'ice

dail" for 671* 'ee0s/, follo'ed " the lo' Cever scheme,Q 'hich includes a rapid reduction in dosage over a fe''ee0s, 'ith a maintenance dose of )* mg ever" . da"s accompanied " local ad


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ulse corticosteroid usuall" seems to result onl" in short2term relief from the disease and most li0el" needs

continued administration of oral corticosteroids -!unauchi 1((/+

>erth has compared these t'o therapeutic protocols+ %t 'as onl" a retrospective stud" that included t'o

heterogeneous groups of patients 'ith completel" different therapeutic regimens for each patient+ %t included nine

patients 'ho had received pulse therap" and six patients 'ho had received conventional treatment+ $ome received

onl" one course of pulse therap", 'hile others received t'o courses+ This stud" sho'ed the superiorit" of pulsetherap" over conventional treatment ->erth 1((;/+

2.'.!. Intralesional corticosteroid therapy

%ntralesional corticosteroid therap" accelerates the scarring process of a lesion or is used to treat persistent lesions+

This treatment, 'hich gives inconsistent results, involves sulesional in


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%n lo' ris0 patients 'ith lesions confined to the oral mucosa andor s0in, topical corticosteroids are advised, such as

*+ 18 triamcinolone acetonide, *+ *68 fluocinoloneacetonide, or *+ *68 cloetasol propionate in oraase, applied =2

) times a da" during (2.) 'ee0s+ %n patients 'ith isolated erosions, intralesional corticosteroid inesterhof 1(@(/+

T'ent" patients 'ith 3 -involvement of less than ;*8 od" surface/ in a second stud" 'ere treated 'ith ver"

potent topical corticosteroidsK in seven patients 3 'as completel" suppressed and the same numer otained

remission 'ith an 112month follo'2up+ There 'ere mild side2effects of cutaneous infection and s0in atroph"+ Theuse of topical corticosteroids has also een reported in a large numer of case reports and smaller series of fe'erthan five patients -Zimmermann 1(((/+

otent topical corticosteroids should e considered in patients 'ith limited or moderate disease -Mutasim .**)/+

%n a large randomized controlled trial, initial disease control and 12"ear survival 'ere significantl" etter 'hen

treating extensive 3 'ith cloetasol propionate cream )* mg dail" compared 'ith oral prednisolone 1mg0gda"
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'hile in moderate 3 - 1* listersda"/ outcomes using cloetasol cream and prednisolone *+ 6mg0g 'ere similar

-Pol" .**./+

4ecentl", lo'er doses of topical cloetasol propionate -1*2=*g dail"/ 'ere sho'n to have similar short2term efficac"

ut reduced side2effects compared to the high dose topical regimen -)*g dail" cloetasol propionate/ -Pol" .**(/+

2.+.2. Systemic steroid therapy

Bigh2doses of s"stemic corticosteroids are the standard for initial treatment of 3 to gain control over the eruptions,and prolonged high2doses are often used in severe cases+ Adverse side effects from s"stemic corticosteroids seem to

e the main cause of mortalit" in 3 -Mamela0 .**/+

4ecommended initial doses of prednisolone are .* mgda" or *+ = mg0gda" in localised or mild disease, )* mgda"

or *+ ; mg0gda" in moderate disease, and 6*2* mg or *+ 621 mg0gda" in severe disease ->o


12/22

occurrence of clinicall" significant steroid toxicities -Ad Boc >or0ing &roup on $teroid2$paring riteria in Cupus

.**)/+

%n the localized variet" of Discoid Cupus the lesions tend to e confined to the head and nec0 and in the generalized

variet" the" occur oth aove and elo' the nec0+ The disease ma" occur at an" age9 'ith higher incidence et'een

.* to )* "ears of age+ %t has a prolonged course and can have a considerale effect on 5ualit" of life+ otent topical

steroids and antimalarials are the mainsta" of treatment -Hhare .*11/+

Topical steroids are the mainsta" of treatment of DCG+ atients usuall" start 'ith a potent topical steroid -e+ g+,

etamethasone or cloetasol/ applied t'ice a da", then s'itch to a lo'er2potenc" steroid as soon as possile+ The

minimal use of steroids reduces the recognized side effects li0e atroph", telengiaectasiae, striae, and purpura+

%ntralesional inilliamson 1((;/+
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%mmunocompetent patients 'ithout specific contraindications are prescried prednisone at 1 mg0gd -maximum @*

mg/ for the first 'ee0, 'hich is tapered over the second 'ee0+ Around a fifth of patients 'ill progress from partial

pals", so these patients should also e treated -4amse" .***/+

Bo'ever the $ullivan stud" 'ith )(; participants compared different cominations of prednisolone, ac"clovir and

placeo+ The" found significant enefit from prednisolone ut not ac"clovir -$ullivan .**/+

Bato assessed the efficac" of valac"clovir 'ith .(; participants divided into t'o groups -valac"clovir 'ith

prednisolone,and placeo'ith prednisolone/ and found significant enefit from valac"clovir -Bato .**/+

!.2. Ramsay unt syndrome

4amsa" Bunt s"ndrome -4B$/ is caused " the reactivation of a previous ?aricella zoster virus -?Z?/ infection+

4B$ is a potentiall" serious viral infection that accounts for approximatel" 1.8 of all facial nerve palsies -4oillard

1(@;9#ri .**=/+

?Z? is also the cause of shingles,Q 'hich fre5uentl" presents 'ith a classic painful dermatomal distriution of

vesicles and crusted s0in ulcerations+ %n addition to the alarming facial pals", 4B$ ma" also e characterized "

severe otalgia, sensorineural hearing loss, vertigo, painful s0in vesicles and aguesia in the ipsilateral anterior tongue

-Biroshige .**./+

The treatment of 4amsa" Bunt s"ndrome is not entirel" agreed upon+ Definitive treatment consists of antiviraltherap" and sometimes includes steroids+ Ad


14/22

sensitization of the nociceptive s"stem, the most important mechanism underl"ing long2lasting chronic pain+

%nterventions that decrease the repetitive painful stimuli and inflammation during the acute phase of BZ ma"

attenuate central sensitization and sustantiall" reduce the incidence of chronic pain -Hell" .**19Pohnson .**./+

Treatment includes corticosteroids, 'hich are used to treat pain, s'elling and effectivel" reduces the ris0 of

recurrence of post2herpetic neuralgia+ $teroids 'ere found to accelerate the resolution of acute neuritis and provide a

clear improvement in 5ualit"2of2life measures in comparison to those patients treated 'ith antivirals alone+ The useof oral steroids had no effect on the development or duration of postherpetic neuralgia -D'or0in .**/+

Bistoricall", epidural, intrathecal, and s"mpathetic nerve loc0s have all een used in the treatment of pain caused

" BZ and BE+ %t 'as accepted " some investigators that nerve loc0s do not provide lasting relief in estalishedBE, ut inood1(()9Bollander 1(61/+
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A variet" of methods are currentl" used for intra2articular corticosteroid inise .**69&er'in.**;9Cavelle .**/+

Triamcinolone acetonide 'hich has een used for intra2articular ine"and

.**=/+ The dose of prednisone is lo'ered after .7) 'ee0s, and slo'l" tapered over (71. months -han .**1/+

Bigher doses of @* to 1** mgd are suggested for patients 'ith visual or neurological s"mptoms of &A+ %? pulse

meth"lprednisolone has een proposed as an induction therap", particularl" in cases 'here vision is at ris0-4ahman 9 4ahman .**6/+

%. Medical emer(encies in dental practice

%.1. Adrenal crisis prophylais

atients 'ith a histor" compatile 'ith adrenal suppression and presenting 'ith features of adrenal crisis should e

treated urgentl"+
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te-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B14http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B122http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B4http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B61http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B53http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B114http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B111http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B20http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B114


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Acute adrenal crisis, 'ith insufficienc" of mineralocorticoids and glucocorticoids,is a medical emergenc"+ The

patient presents 'ith adominal pain, 'ea0ness, h"potension, deh"dration, nausea and vomiting+ Caorator"

findings ma" include decreased sodium -h"ponatraemia/, elevated potassium -h"per0alaemia/, decreased lood

glucose -h"pogl"cemia/, acidosis and uraemia+ !e' patients have all these findings, 'ith h"potension and nauseaeing most common+

atients 'ith secondar" AddisonJs most t"pical presentation is of h"potension,and h"ponatraemia 'ithout volumedepletion+ Additional s"mptoms ma" include fatigue, 'ea0ness, arthralgia, nausea, and orthostatic dizziness

associated 'ith h"potension+

atients ta0ing exogenous glucocorticoids+ Gxogenous glucocorticoids can cause adrenal gland suppression andresultant atroph"+ >ith atroph" of the adrenal glands there is a decreased glucocorticoid response to stress, and this

ma" precipitate an adrenal crisis -Gd'ards 1((6/+

%.1.1. Mana(ement

i+ %ntravenous fluids, in the form of 68 dextrose in normal saline, should e given to address the volume

depletion that is often present+

ii+ rimar" adrenal insufficienc"K start on .*7.6 mg h"drocortisone per .) h

iii+ $econdar" adrenal insufficienc"K 167.* mg h"drocortisone per .) h9 if orderline fail in cos"ntropin test

consider 1* mg or stress dose cover onl"

iv+ B"drocortisone should e given intravenousl" initiall"+ %f improvement has occurred 'ithin .) hours,

'hich is common, the h"drocortisone dose can e decreased+ This can e changed to an oral formulation

'henever the patient is stale+ The dose can e decreased " one third to one half the dose dail" until amaintenance dose of .* mg in the morning and 1* mg in the afternoon or at night is attained+ $ome patients

ma" need onl" a dose of .* mgda" total -i+e+, .* mg ever" morning, or 16 mg in the morning and 6 mg in

the afternoon or at night/+

v+ A search for the condition that precipitated the crisis, such as infection, should e underta0en+ Treatment of

the underl"ing cause should e instituted+

vi. atients 'ill not need mineralocorticoid replacement, ecause the renin2angiotensin2aldosterone axis is

intact -Arlt .**(/+

%.2. Anaphylais shoc

Anaph"laxis is the 5uintessential disease of emergenc" medicine+ The term anaph"laxis literall" meaning againstprotectionQ 'as introduced " 4ichet and ortier in 1(*. -3ro'n 1((6/+

%t is a potentiall" fatal illness 'ith rapid onset that can affect "oung, health" people+ %t must e diagnosed clinicall",

and is potentiall" curale if treated immediatel" -&olden .**/+

A s"stematic revie' of the literature has failed to demonstrate the effectiveness of an" of these medications in the

treatment of anaph"laxis -G'an .*1*/+

$teroids are unli0el" to e helpful in the treatment of acute anaph"laxis+ The" have a dela"ed onset of ) to ; hours+$teroids are thought to pla" a role in preventing reound anaph"laxis9 ho'ever, this has never een proven -4evie'

Anaph"laxis in the emergenc" department .**@/+

As 'ith the antihistamines, despite their man" theoretical enefits on mediator release and tissue responsiveness,

there are no placeo2controlled trials to confirm the effectiveness of steroids in anaph"laxis+
http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B25http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B6http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B11http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B42http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B29http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B119http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B119http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B25http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B6http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B11http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B42http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B29http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B119http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B119


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Most clinicians ho'ever give prednisone 1 mg0g up to 6* mg orall" or h"drocortisone 1+ 62= mg0g %? particularl"

in patients 'ith air'a" involvement and ronchospasm, ased empiricall" on their important role in asthma -$oar

.**@/+

%t is unclear if steroids prevent a iphasic reaction 'ith recrudescence of s"mptoms follo'ing recover", as

supporting data are unconvincing -Cieerman .**6/+

$teroids are of course fundamental to the management of recurrent idiopathic anaph"laxis -4ing .**.9&reenerger

.**/+

'. &mer(ency dru(s in (eneral dental practice

'.1. Intracanal corticosteroid in root canal therapy

The application of antiinflammator" agents on exposed pulp tissue in an attempt to prevent or minimize

inflammator" reaction and to favor healing has een investigated for a long time+ orticosteroid can e used as adressing agent for deep cavities and exposed pulp tissue in order to control the inflammator" pulp response and

reduce postoperative pain+ The therapeutic effect of a corticosteroid agent seems to depend upon its potenc",

concentration and ailit" to diffuse into connective tissue -Bolland 1((19&ordon Marshall .**./+

The results of studies that emplo" corticosteroids as a cavit" liner support that these medications are effective in

reducing or preventing postoperative thermal sensitivit"+ 4esearchers have sho'n that application of corticosteroidantiiotic association for short period of time 'as effective to control inflammation in the pulp tissue 'ithout

determining changes in the healing process -$antini 1(@=/+

Triamcinolone acetonide is a potent corticosteroid that could e used effectivel" to eliminate or at least reduce the

severe inflammation that might occur secondar" to endodontic treatment -Eegm .**1/+

'.2. "erioperati3e corticosteroid use in dentoal3eolar sur(ery

$everal authors have examined the effects of corticosteroids for prevention of pain and edema associated 'ith oral

surger"+ Dental surgeons are often advised to use corticosteroids during and after third molar removal and otherdentoalveolar surger" to reduce postsurgical edema+ The most commonl" used forms of corticosteroids in

dentoalveolar surger" include dexamethasone -oral/, dexamethasone sodium phosphate and dexamethasone acetate,

and meth"lprednisolone acetate and meth"l prednisolone sodium succinate+ Dexamethasone has a longer duration ofaction than methl"prednisolone and is considered more potent -Alexander .***/+

Meth"lprednisolone has een used in a numer of studies+ Meth"lprednisolone is usuall" administered via the

intramuscular or intravenous route though the possiilit" of topical -intraalveolar/ application has een descried,

'ith a reduction in moridit" and possile side effects+ This drug is five times more potent than cortisol, 'ith scant

associated saline retention and an intermediate duration of action -1.2=; hours/ -MicW2Clorens .**;9Ceone .**9?egas23ustamante .**@/+

3ased on the literature revie', interim recommendations for the use of corticosteroids are proposed, including

dosages and regimens that appear rational for oral, intramuscular, or intravenous corticosteroid administration eforeand after extractions and other dentoalveolar surger"+ These largel" empiric recommendations might re5uiread


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the" are the onl" possile drug to use in dail" medical practice+ Despite their clinical efficac", the" can induce

multiple severe adverse effects+

Adverse effects of corticosteroids ma" e due to local effects on the s0in or mucosa at the site of or to s"stemic

effects follo'ing asorption of the oral drugs+ $"stemic side effects are rarer than local side effects+

).1. Systemic ad3erse effects

$"stemic side effects occur ecause the steroids contained in the corticosteroid ecome asored into the loodstream and egin to affect other parts of the od", such as the adrenal gland -a gland that produces man" of the

od":s natural steroids/+

$"stemic side effects can include -Cozada2Eur 1((193ircher 1((;/K

B"pothalamic2ituitar"adrenal Axis and $econdar" Adrenal

%nsufficienc"

>eight gain

Osteoporosis

Diaetes

Bigh 3lood ressure -h"pertension/

s"chological Gffects

%ndigestion or Bearturn

ushing:s $"ndrome

Moon !ace

3one Damage

Decreased &ro'th in hildren

$0in can ecome thin, easil" ruised and slo' to heal

Avascular Eecrosis -a painful one condition/

&laucoma

).2. Local ad3erse effects

>hile topical steroids have tremendous enefit in reducing inflammation, the" also have significant side effects+

Most of these side effects are seen 'ith long2term use, ut some ma" e noticed 'ithin da"s of starting therap"+ Theris0 of side effects from topical corticosteroids is related to drug potenc", duration of therap", fre5uenc" of

application and anatomical area+ Cocal side effects can include -He".**=93aid .**;/K

Tach"ph"laxis

3urning Mouth

B"pogeusia
http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B92http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B92http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B9http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B9http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B76http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B8http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B8http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B92http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B9http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B76http://www.intechopen.com/books/state-of-the-art-of-therapeutic-endocrinology/role-of-corticosteroids-in-oral-lesions#B8


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Oral Bair" Ceu0opla0ia

B"persensitive 4eactions to the Drug

Topical $teroid Allerg"

$0in Atroph"

$triae 2 $tretch Mar0s

Acne form4osacea li0e eruptions

andidosis

Dela"ed Bealing

!ine Bair &ro'th

).2.1. Special Considerations

3ecause corticosteroids cause the adrenal glands to slo' or stop the production of cortisol, the" cannot e

discontinued aruptl"+ %t ta0es some time for the adrenal glands to egin producing cortisol again+ &raduall"tapering the dose of corticosteroids allo's the od" to egin producing its o'n suppl" of cortisol again+

#nderta0e 'eight earing exercise -such as ris0 'al0ing/

$top smo0ing

Avoid excess alcohol inta0e

ontraindications for acute B$? %nfection

reams are less effective in the mouth than ointments, and the ointment form is preferred+

+. 4uidelines on the mana(ement of dental patients on corticosteroid therapy in community dental clinics

&eneral dental procedures for patients receiving long2term steroid medication do not 'arrant supplementation 'ith

additional glucocorticoids+

The aims of these guidelines are to assist and support Dentists and Dental therapists 'hen providing dental treatmentto patients 'ho are currentl" receiving, or 'ho have received orticosteroid therap" in the past t'elve months+

+.1. -or routine conser3ati3e dentistry or minor oral sur(ery #to include one simple etraction$ under local

anaesthesia

Although Opinions onflict On >hether An" $ignificant $uppression Of Adrenal !unction Occurs %n atientsTa0ing Co' Doses Of $teroids -#nder + 6 Mg rednisolone/ Availale Gvidence $uggests That $upplementation %s#nnecessar" !or Cocal Anaesthetic rocedures+

+.2. -or minor sur(ery under (eneral anesthesia for patients under(oin( (eneral anesthesia for minor sur(ery

1** Mg B"drocortisone %ntramuscularl" $hould 3e Administered And The #sual &lucocorticoid Medications

Maintained+


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+.!. -or ma0or sur(ery

1** Mg B"drocortisone Delivered As A 3olus re2Operativel" !ollo'ed 3" 6* Mg @2Bourl" !or )@ Bours %s

Ade5uate+

+.%. American Society Of Anaesthesiolo(ists #ASA$ "hysical Classification Status

1+ A normal health" patient

.+ A patient 'ith mild s"stemic disease

=+ A patient 'ith severe s"stemic disease

)+ A moriund patient 'ho is not expected to survive 'ithout surger"

6+ A declared rain2dead patient 'hose organs are eing removed for donor purposes+

atients 'ith A$A score 1 and . 'ho are currentl" on or 'ho have een on corticosteroids in the last "ear+

atients 'ith A$A score = and ) 'ho are currentl" on or 'ho have een on corticosteroids in the last "ear+

An" patient that does not fit the aove criteria or if the clinician is in an" dout then the patient should not e treatedin the primar" care setting and should e referred -&ison .**)/+

Aphthous 5lcers Treatment 6 Mana(ement

AuthorK rispian $cull", MD, hD, MD$, MD$, 3G, M4$, !D$4$, !D$4$, !!D4$%,!D$4$G, !4ath, !Med$ci, !BGA, !#C, !$3, D$c, DhD, DMed-B/, Dr-B/ 9 hief GditorK

Arlen D Me"ers, MD, M3A more+++

%dentif" and correct predisposing factors for recurrent aphthous stomatitis -4A$/+ Gnsure that patients rush

atraumaticall" -eg, 'ith a small2headed, soft toothrush/ and avoid eating particularl" hard or sharp foods -eg, toast,potato crisps/ and avoid other trauma to the oral mucosa+

$C$ should e avoided if implicated as a predisposing factor+ An" iron or vitamin deficienc" should e corrected

once the cause of that deficienc" has een estalished+ %f an ovious relationship to certain foods is estalished,

these should e excluded from the diet+ atch testing ma" e indicated to reveal allergies+ The occasional patient

'ho relates ulcers to her menstrual c"cle or to use of an oral contraceptive ma" enefit from suppression ofovulation 'ith a progestogen or a change in the oral contraceptive+

%n most cases, the natural histor" of 4A$ is one of eventual remission+ Bo'ever, for some patients, remission occurs

spontaneousl" several "ears later9 thus, treatment is indicated in these patients if discomfort is significant+ 4elief of

pain and reduction of ulcer duration are the main goals of therap"+ There is a huge range of supposed or possileremedies availale, ut o


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?itamin 31. used orall" ma" have some effect

Topical corticosteroids -Ts/ remain the mainsta"s of treatment+ A spectrum of different Ts can e used+

At est, Ts reduce painful s"mptoms ut not the rate of ulcer recurrence+ The commonl" used

preparations are as follo'sK

o B"drocortisone hemisuccinate pellets -orlan/, .+6 mg used ) times dail"

o Triamcinolone acetonide in carox"meth"l cellulose paste -Adcort"l in oraase ['ithdra'n in

some countries], Henalog/, administered ) times dail"

o 3etamethasone sodium phosphate as a *+62mg talet dissolved in 16 mC of 'ater to ma0e a mouth

rinse, used ) times dail" for ) minutes each time

B"drocortisone and triamcinolone preparations are popular ecause neither causes significant adrenal

suppression9 ho'ever, ulcers still recur+

3etamethasone, fluocinonide, fluocinolone, fluticasone, and cloetasol are more potent and effective than

h"drocortisone and triamcinolone, ut the" carr" the possiilit" of some adrenocortical suppression and a

predisposition to candidiasis+

Topical tetrac"clines ma" reduce the severit" of ulceration, ut the" do not alter the recurrence rate+ Adox"c"cline capsule of 1** mg in 1* mC of 'ater administered as a mouth rinse for = minutes or

tetrac"cline 6** mg plus nicotinamide 6** mg administered ) times dail" ma" provide relief and reduceulcer duration+ Avoid tetrac"clines in children "ounger than 1. "ears 'ho might ingest them and develop

tooth staining+

hlorhexidine gluconate and ioadhesive -&elclair/ mouth rinses reduce the severit" and pain of ulceration

ut not the fre5uenc"+

Anti2inflammator" agents can help9 a spectrum of topical agents such as enz"damine and amlexanox ma"

help+ 3enz"damine h"drochloride mouth'ash, though no more eneficial than a placeo, can produce

transient pain relief+

%f 4A$ fails to respond to local measures, s"stemic immunomodulators ma" e re5uired+ A 'ide spectrumof agents has een suggested as eneficial, ut fe' studies have een performed to assess their efficac" -or

their adverse effects are significant/+ Thalidomide 6*21** mg dail" is effective againstsevere 4A$,

although ulcers tend to recur 'ithin = 'ee0s+ Teratogenicit", neuropath", and other adverse effects dissuade

most ph"sicians from its use+

!e', if an", of the other medications used for 4A$ have undergone serious scientific evaluation+ These

include iologics, transfer factor, gamma2gloulin therap", sodium cromogl"cate lozenges, dapsone,colchicine, pentoxif"lline, levamisole, colchicine, azathioprine, prednisolone, azelastine, alpha .2interferon,

ciclosporin, degl"cerinated li5uorice, 62aminosalic"lic acid -62A$A/, prostaglandin G. -&G./, sucralfate,

diclofenac, and aspirin+
http://www.medscape.com/viewarticle/532727http://www.medscape.com/viewarticle/532727http://www.medscape.com/viewarticle/532727


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Documents

Manfaat Kortikosteroid Pada Lesi Oral