Chapter 19:Chapter 19:
AdrenocorticosteroidsAdrenocorticosteroids
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Chapter 19 OutlineChapter 19 Outline
AdrenocorticosteroidsAdrenocorticosteroids Mechanism of releaseMechanism of release ClassificationClassification DefinitionsDefinitions Routes of administrationRoutes of administration Mechanism of actionMechanism of action Pharmacologic effectsPharmacologic effects Adverse reactions Adverse reactions UsesUses Corticosteroid productsCorticosteroid products Dental implicationsDental implications
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AdrenocorticosteroidsAdrenocorticosteroids
Haveles (p. 241)Haveles (p. 241) A group of agents secreted by the adrenal A group of agents secreted by the adrenal
cortexcortex Use in dentistry: used topically or systemically for Use in dentistry: used topically or systemically for
treatment of oral lesions associated with treatment of oral lesions associated with inflammatory disordersinflammatory disorders
Long-term therapy: prescribed for patients with Long-term therapy: prescribed for patients with chronic systemic diseases such as asthma or chronic systemic diseases such as asthma or arthritisarthritis
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Mechanism of ReleaseMechanism of Release
Haveles (pp. 241-242) (Fig. 19-1)Haveles (pp. 241-242) (Fig. 19-1) Adrenocorticosteroids are naturally occurring Adrenocorticosteroids are naturally occurring
compounds secreted by the adrenal cortex; compounds secreted by the adrenal cortex; release is triggered by a series of eventsrelease is triggered by a series of events A stimulus such as stress causes the hypothalamus A stimulus such as stress causes the hypothalamus
to release corticotropin-releasing hormone (CRH)to release corticotropin-releasing hormone (CRH) CRH acts on the pituitary glandCRH acts on the pituitary gland
cont’d…cont’d…
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Mechanism of ReleaseMechanism of Release
The pituitary gland releases adrenocorticotropic The pituitary gland releases adrenocorticotropic hormone (ACTH), which stimulates the adrenal hormone (ACTH), which stimulates the adrenal cortex to release hydrocortisonecortex to release hydrocortisone
Hydrocortisone acts on the pituitary and the Hydrocortisone acts on the pituitary and the hypothalamus to inhibit the release of CRH and hypothalamus to inhibit the release of CRH and ACTHACTH• This mechanism is called negative feedbackThis mechanism is called negative feedback
cont’d…cont’d…
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Mechanism of ReleaseMechanism of Release
Exogenous steroids act in the same way as Exogenous steroids act in the same way as hydrocortisone; they also inhibit the release hydrocortisone; they also inhibit the release of CRH and ACTHof CRH and ACTH With long-term administration of steroids, ACTH With long-term administration of steroids, ACTH
release is suppressedrelease is suppressed Adrenal crisis may occur if exogenous steroids are Adrenal crisis may occur if exogenous steroids are
abruptly withdrawnabruptly withdrawn
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ClassificationClassification
Haveles (pp. 241-242)Haveles (pp. 241-242) Adrenocorticosteroids are divided into two Adrenocorticosteroids are divided into two
major groupsmajor groups Glucocorticoids: affect intermediate carbohydrate Glucocorticoids: affect intermediate carbohydrate
metabolismmetabolism Mineralocorticoids: affect water and electrolyte Mineralocorticoids: affect water and electrolyte
composition of the bodycomposition of the body The major glucocorticoid present in the body The major glucocorticoid present in the body
is cortisol (hydrocortisone)is cortisol (hydrocortisone)
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DefinitionsDefinitions Haveles (p. 242)Haveles (p. 242)
Addison disease: disease/condition produced by Addison disease: disease/condition produced by deficiency of adrenocorticosteroidsdeficiency of adrenocorticosteroids
Adrenocorticosteroids/corticosteroids/steroids: Adrenocorticosteroids/corticosteroids/steroids: glucocorticoids and mineralocorticoids released from glucocorticoids and mineralocorticoids released from the adrenal cortexthe adrenal cortex
ACTH: secreted by pituitary, causes release of ACTH: secreted by pituitary, causes release of hormones from the adrenal cortexhormones from the adrenal cortex
Cushing syndrome: disease/condition caused by Cushing syndrome: disease/condition caused by excess of adrenocorticosteroidsexcess of adrenocorticosteroids
Glucocorticoids: adrenocorticosteroids primarily Glucocorticoids: adrenocorticosteroids primarily affecting carbohydrate metabolismaffecting carbohydrate metabolism
Mineralocorticoids: adrenocorticosteroids that affect the Mineralocorticoids: adrenocorticosteroids that affect the body’s sodium and water balancebody’s sodium and water balance
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Routes of AdministrationRoutes of Administration
Haveles (p. 242) (Table 19-1)Haveles (p. 242) (Table 19-1) Glucocorticoids are available a wide variety of Glucocorticoids are available a wide variety of
dose formsdose forms May be used topically, orally, intramuscularly, and May be used topically, orally, intramuscularly, and
intravenouslyintravenously Systemic effects are common when the drug is Systemic effects are common when the drug is
administered orally or parenterally, but topical administered orally or parenterally, but topical administration may rarely cause systemic effectsadministration may rarely cause systemic effects
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Mechanism of ActionMechanism of Action
Haveles (pp. 242-243)Haveles (pp. 242-243) Steroids bind to a specific receptor and form Steroids bind to a specific receptor and form
a steroid-receptor complexa steroid-receptor complex The complex translocates into the nucleus and The complex translocates into the nucleus and
alters gene expression to regulate many cell alters gene expression to regulate many cell processesprocesses
There is a lag time in the action of steroids, and There is a lag time in the action of steroids, and the relationship between their effects and blood the relationship between their effects and blood level is poorlevel is poor
cont’d…cont’d…
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Mechanism of ActionMechanism of Action
Antiinflammatory action of glucocorticoids Antiinflammatory action of glucocorticoids results from profound effects on the number, results from profound effects on the number, distribution, and function of peripheral distribution, and function of peripheral leukocytes and to their inhibition of leukocytes and to their inhibition of phospholipase Aphospholipase A Use of steroids results in an increase in the Use of steroids results in an increase in the
concentration of neutrophils and decrease in concentration of neutrophils and decrease in lymphocytes, monocytes, eosinophils, and basophilslymphocytes, monocytes, eosinophils, and basophils
Inhibition of phospholipase A decreases production Inhibition of phospholipase A decreases production of prostaglandins and leukotrienesof prostaglandins and leukotrienes
Steroids also inhibit interleukin-2, migration inhibition Steroids also inhibit interleukin-2, migration inhibition factor, and macrophage inhibition factorfactor, and macrophage inhibition factor
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Pharmacologic EffectsPharmacologic Effects
Haveles (pp. 243-244) (Box 19-1)Haveles (pp. 243-244) (Box 19-1) Effects for which they are used include Effects for which they are used include
antiinflammatory action and suppression of antiinflammatory action and suppression of allergic reactionsallergic reactions
They suppress the immune responseThey suppress the immune response Corticosteroids are palliative rather than curativeCorticosteroids are palliative rather than curative
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Adverse Reactions of Adverse Reactions of GlucocorticoidsGlucocorticoids
Haveles (pp. 243-244) Haveles (pp. 243-244) Proportional to the dose, frequency, and time of Proportional to the dose, frequency, and time of
administration, and duration of treatmentadministration, and duration of treatment Metabolic changes: moon face, buffalo hump, truncal Metabolic changes: moon face, buffalo hump, truncal
obesity, weight gain, and muscle wasting produce obesity, weight gain, and muscle wasting produce Cushing syndrome appearanceCushing syndrome appearance
Hyperglycemia may be aggravatedHyperglycemia may be aggravated Infections: corticosteroids decrease resistance to Infections: corticosteroids decrease resistance to
infectioninfection Central nervous system effects: changes in behavior Central nervous system effects: changes in behavior
and personality, including euphoria (with increasing and personality, including euphoria (with increasing dose), agitation, psychoses, and depression (with dose), agitation, psychoses, and depression (with decreasing dose) behaviordecreasing dose) behavior
cont’d…cont’d…
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Adverse Reactions of Adverse Reactions of GlucocorticoidsGlucocorticoids
Peptic ulcer: corticosteroids stimulate an increase Peptic ulcer: corticosteroids stimulate an increase in production of stomach acid and pepsinin production of stomach acid and pepsin
Impaired wound healing and osteoporosis: Impaired wound healing and osteoporosis: catabolic effects resulting from impaired synthesis catabolic effects resulting from impaired synthesis of collagen can impair wound healingof collagen can impair wound healing
Ophthalmic effects: corticosteroids can increase Ophthalmic effects: corticosteroids can increase intraocular pressure, may exacerbate glaucomaintraocular pressure, may exacerbate glaucoma• Cataracts are associated with steroidsCataracts are associated with steroids
cont’d…cont’d…
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Adverse Reactions of Adverse Reactions of GlucocorticoidsGlucocorticoids
Electrolyte and fluid balance glucocorticoids with some Electrolyte and fluid balance glucocorticoids with some mineralocorticoid action can produce sodium and water mineralocorticoid action can produce sodium and water retentionretention• Hypertension or congestive heart failure may be exacerbated; Hypertension or congestive heart failure may be exacerbated;
hypokalemia may resulthypokalemia may result
Adrenal crisis: adrenal suppression with prolonged useAdrenal crisis: adrenal suppression with prolonged use• The adrenal gland cannot respond adequately if a stressful The adrenal gland cannot respond adequately if a stressful
situation arisessituation arises
Dental effects: delayed healing of mucosal surfaces, Dental effects: delayed healing of mucosal surfaces, more likely to have an infection, and are more friablemore likely to have an infection, and are more friable• Oral candidiasis may result with use of oral steroid inhalersOral candidiasis may result with use of oral steroid inhalers
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Uses of CorticosteroidsUses of Corticosteroids
Haveles (p. 245) (Box 19-2)Haveles (p. 245) (Box 19-2) Medical usesMedical uses
Replacement: patients with hypofunction of the Replacement: patients with hypofunction of the adrenal cortex (Addison disease) need adrenal cortex (Addison disease) need replacementreplacement• Patients with a hyperfunctioning adrenal cortex (Cushing Patients with a hyperfunctioning adrenal cortex (Cushing
syndrome) may have a majority of the gland removed syndrome) may have a majority of the gland removed and need replacement therapyand need replacement therapy
cont’d…cont’d…
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Uses of CorticosteroidsUses of Corticosteroids
Medical usesMedical uses Emergencies: used for treatment of shock or Emergencies: used for treatment of shock or
adrenal crisisadrenal crisis Inflammatory/allergic: treatment of a wide variety Inflammatory/allergic: treatment of a wide variety
of inflammatory and allergic conditionsof inflammatory and allergic conditions• Not curative, ameliorate symptoms Not curative, ameliorate symptoms
• Topical steroids are used for skin conditions which Topical steroids are used for skin conditions which involve dermatoses or “irritations”involve dermatoses or “irritations”
cont’d…cont’d…
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Uses of CorticosteroidsUses of Corticosteroids
Haveles (p. 245) (Box 19-2)Haveles (p. 245) (Box 19-2) Dental usesDental uses
Oral lesions: systemically administered steroids may Oral lesions: systemically administered steroids may be effective in treatment of oral lesions be effective in treatment of oral lesions
Aphthous stomatitis: triamcinolone acetonide Aphthous stomatitis: triamcinolone acetonide (Kenalog in Orabase) has been advocated(Kenalog in Orabase) has been advocated
Temporomandibular joint: if only the joint is affected, Temporomandibular joint: if only the joint is affected, intraarticular injection can often decrease pain and intraarticular injection can often decrease pain and improve joint movementimprove joint movement
Uses in oral surgery: to reduce edema, trismus, and Uses in oral surgery: to reduce edema, trismus, and painpain
Pulp procedures: used in pulp capping, pulpotomies, Pulp procedures: used in pulp capping, pulpotomies, and control of hypersensitive cervical dentinand control of hypersensitive cervical dentin
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Corticosteroid ProductsCorticosteroid Products
Haveles (p. 246) (Table 19-2)Haveles (p. 246) (Table 19-2) May be arranged according to duration of May be arranged according to duration of
action into short-, intermediate-, and long-action into short-, intermediate-, and long-acting groupsacting groups
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Selected Corticosteroids, OralSelected Corticosteroids, Oral
Haveles (p. 246) (Table 19-2)Haveles (p. 246) (Table 19-2) Short actingShort acting
hydrocortisone (Cortisol)hydrocortisone (Cortisol) prednisone (Deltasone) prednisone (Deltasone) methylprednisolone (Medrol)methylprednisolone (Medrol)
Intermediate actingIntermediate acting triamcinolone triamcinolone prednisoloneprednisolone
Long actingLong acting dexamethasone dexamethasone betamethasone betamethasone
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Dental ImplicationsDental Implications
Haveles (pp. 246-248)Haveles (pp. 246-248) Adverse reactionsAdverse reactions Steroid supplementationSteroid supplementation Topical useTopical use
cont’d…cont’d…
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Dental ImplicationsDental Implications
Haveles (p. 246) (Box 19-3)Haveles (p. 246) (Box 19-3) Steroids suppress the immune reactionSteroids suppress the immune reaction
Infections are more likely to occur and healing is Infections are more likely to occur and healing is delayed with chronic administrationdelayed with chronic administration
Symptoms of infections may be maskedSymptoms of infections may be masked
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Adverse Reactions of Adverse Reactions of CorticosteroidsCorticosteroids
Haveles (pp. 246-247)Haveles (pp. 246-247) Gastrointestinal effects: adrenocorticosteroids Gastrointestinal effects: adrenocorticosteroids
stimulate acid secretionstimulate acid secretion Blood pressure: mineralocorticoid action can Blood pressure: mineralocorticoid action can
exacerbate hypertensionexacerbate hypertension Glaucoma: other agents that induce or exacerbate Glaucoma: other agents that induce or exacerbate
glaucoma should be used with cautionglaucoma should be used with caution Behavioral changes: bizarre behavior may be Behavioral changes: bizarre behavior may be
explained by presence or withdrawal from explained by presence or withdrawal from adrenocorticosteroidsadrenocorticosteroids
Osteoporosis: may be seen in patients taking long-Osteoporosis: may be seen in patients taking long-term adrenocorticosteroidsterm adrenocorticosteroids
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Adverse Reactions of Adverse Reactions of AdrenocorticosteroidsAdrenocorticosteroids
Haveles (p. 247)Haveles (p. 247) Infection: antiinflammatory activity may mask symptoms Infection: antiinflammatory activity may mask symptoms
of infectionof infection Delayed wound healingDelayed wound healing Adrenal crisis: with prolonged administration of steroids, Adrenal crisis: with prolonged administration of steroids,
suppression of the hypothalamic-pituitary-adrenal axis suppression of the hypothalamic-pituitary-adrenal axis occursoccurs The body does not respond quickly to stress with release of The body does not respond quickly to stress with release of
hydrocortisonehydrocortisone Periodontal disease: steroids interfere with the body’s Periodontal disease: steroids interfere with the body’s
response to infection and can produce osteoporosis, response to infection and can produce osteoporosis, which may reduce bony support for teethwhich may reduce bony support for teeth
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Steroid SupplementationSteroid Supplementation
Haveles (pp. 247-248) (Fig. 19-4)Haveles (pp. 247-248) (Fig. 19-4) With both low and very high doses of steroid, With both low and very high doses of steroid,
supplementation is not needed for patients who supplementation is not needed for patients who use chronic steroids and are to undergo a use chronic steroids and are to undergo a stressful dental procedurestressful dental procedure With some intermediate doses of steroids, additional With some intermediate doses of steroids, additional
steroids may be indicated if the procedure will steroids may be indicated if the procedure will produce severe stressproduce severe stress
Consult with the patients physicianConsult with the patients physician
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Topical UseTopical Use
Haveles (p. 248)Haveles (p. 248) Steroids are used in dentistry to manage oral Steroids are used in dentistry to manage oral
conditions such as aphthous stomatitis, conditions such as aphthous stomatitis, related to inflammatory or immune conditionsrelated to inflammatory or immune conditions