What is the function of corticosteroids?
Corticosteroids have both anti-inflammatory and immunosuppressive effects. Their mechanism of action involves inhibiting the function of white blood cells (WBCs) and reducing the synthesis of inflammatory mediators.
What are the indications for topical corticosteroids?
Topical corticosteroids are used to manage symptoms of immune-mediated oral mucosal diseases, such as inflammatory, autoimmune, and hypersensitivity conditions, as well as oral ulceration. These indications include diseases like pemphigus vulgaris, mucous membrane pemphigoid, lichen planus, erythema multiforme, recurrent aphthous ulcers, and discoid lupus erythematosus. Only mild or moderate potency topical corticosteroids should be prescribed without a specialist consultation, with hydrocortisone being an example of a mild option and triamcinolone as a moderate one.
What are the indications for systemic steroids?
Corticosteroids at used as replacement doses for adrenal insufficiency disorders. They are also used at therapeutic doses in the management of inflammatory and immune disorders (e.g. rheumatoid arthritis, severe dermatological conditions, asthma) - at therapeutic doses. They can cause immunosupression in immune comcompromised patients.
Are there intradental indications of corticosteroids?
Intradental use of corticosteroids involves applying them within the tooth to manage pulpal and periapical disease caused by inflammation. Corticosteroid and antibiotic pastes, such as OdontoPaste and Ledermix paste, are indicated for reducing periapical inflammation and pain associated with irreversible pulpitis or necrotic pulp, preventing inflammatory root resorption, and reducing external replacement resorption following tooth avulsion or intrusion. Additionally, corticosteroid and antibiotic cement, like OdontoCem and Ledermix cement, are used for indirect pulp capping, direct pulp capping, and as a pulpotomy agent.
Systemic corticosteroids are prescribed only by dental specialists due to their significant adverse effects. Indications for systemic use include severe postoperative swelling, severe trauma, periapical nerve sprouting, and acute apical periodontitis following the removal of inflamed pulp, as well as immune-mediated mucosal diseases.
What are the consequences of long term use?
Adverse effects of corticosteroids include delayed wound healing, candidiasis, and mucosal atrophy. Long term use of corticosteroids can mean adrenocortical suppression and subsequent dependence on exogenous corticosteroid therapy. The dose and duration of treatment likely not to cause clinically relevant adrenocortical suppression is not clear and varies significantly between patients. oral prednisolone at a dose of 10mg or more daily (or the equivalent dose of another corticosteroid) for more than 3 weeks could be expected to cause adrenocortical suppression. A high dose of an inhaled, topical or intra-articular corticosteroid can also cause adrenocortical suppression.
Patients with adrenocortical suppression or adrenal insufficiency are at risk of glucocorticoid deficiency during periods of physiological stress (e.g. significant systemic illness or surgery), since the usual response of increased adrenal cortisol production will not occur. This can precipitate adrenal crisis (also known as acute adrenal insufficiency or Addisonian crisis(. The primary manifestations of adrenal crisis are gastrointestinal symptoms and symptoms of acute circulatory failure (e.g. hypotension, confusion).
Patients udnegoing a dental procedure may require an increased dose of corticosteroid for the. Perform dental treatm in the morning so that if an adrenal crisis occurs, symptoms present while the patient is awake. After dental treatment, ensure the patient remains in the care of a responsible adult for the rest of the day , and the carer remains in contact with the patient for the following 2 - 3 days. Advice the patient and the caerer to seek urgent medical attention if the patient experiences symptoms of adrenal insufficiency.
What are the corticosteroid dose adjustment for oral and dental procedures?
There is limited evidence to inform the approach to corticosteroid dose adjustment for dental procedures for patients at risk of adrenocortical suppression.
For non-invasive dental procedures (e.g. dental check, impressions, X rays), the dose of corticosteroid dose not need to be increased in patients at risk of adrenocortical suppression. Advice patients to take their usual dose of the day of treatment.
For invasive dental procedures of less than 1 hour in an outpatient setting (e.g. professional teeth cleaning, restorative treatment, tooth extraction, periodontal treatment, implant placement), patients at risk of adrenocortical suppression require an increased dose of corticosteroid. These patients may have a dosing strategy (action plan) for periods of stress. If the patient does not have a dosing strategy in place already, consult their medical practitioner. The increased dose is usually started in the morning of the procedure.
For invasive procedures that are longer than 1 hour or dental procedures requiring sedation, general anaesthesia or fasting in patients at risk of adrenocortical suppression, seek specialist advice.
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