1 steroids in omfs by vishnu

steroids in omfs

1. GOOD MORNING

2. STEROIDS IN ORAL AND MAXILLOFACIAL SURGERY GUIDED BY DR KEERTHI R PROFESSOR ORAL AND MAXILLOFACIAL SURGERY PRESENTED BY VISHNU V GOPAL POST GRADUATE STUDENT OMFS

3. According to the National Institute of General Medical Sciences, the term "steroid" is a chemical name for any substance that has a characteristic chemical structure consisting of multiple chemical rings of connected atoms. Some common examples of steroids are: ►Vitamin D ► cholestrol ► estrogen ►cortisone

4. CONTENTS INTRODUCTION HISTORY ANATOMY AND PHYSIOLOGY OF ADRENAL GLAD BIOSYNTHESIS CLASSIFICATION PHARMACOKINETICS PREPARATION AND DOSAGES INDICATIONS USES IN OMFS ADVERSE EFFECTS CONTRAINDICATIONS CONCLUSION

5. INTRODUCTION The adrenal gland is the source of a diverse group of hormones essential for metabolic control, regulation of water and electrolyte balance, and regulation of body’s response to stress. Using cholesterol as a substrate, the adrenal cortex produces a large number of substances collectively known as corticosteroids . These have glucocorticoid, mineralocorticoid, and weakly androgenic activities. Conventionally the term corticosteroid, or corticoid include both natural gluco and mineralocorticoid and their synthetic analogues

6. HISTORY By the middle of 19th century it was demonstrated that adrenal glands were essential for life Later , it was appreciated that the cortex was more important than the medulla A number of steroidal active principles were isolated and their structures were elucidated by K endall and his coworkers in the 1930s.

7. However , the gate to their great therapeutic potential was opened by Hench (1949) who obtained striking improvement in rheumatoid arthritis by using cortisone. The Nobel prize was awarded the very next year to Kendall and Hench. Currently, corticosteroids are drugs with one of the broadest spectrum of clinical utility

8. ANATOMY AND PHYSIOLOGY OF ADRENAL GLANDS An inner medulla, is a source of catecholamine – adrenaline and nor-adrenaline Chromaffin cell is the principal cell type Medulla is richly innervated by sympathetic fibres and is considered as extension of sympathetic nervous system Medulla develops from ectoderm (neural crest) An outer cortex, which secretes several classes of steroid hormones including Glucocorticoids and Mineralocorticoids Three different concentric zones of cells that differ in major steroid hormones they secrete Cortex develops from mesoderm The two adrenal glands are located immediately anterior to the kidneys, encased in a connective tissue capsule and usually partially buried in an island of fat. Their combined weight is about .01-.02% of total body weight in both males and females.

9. BIOSYNTHESIS Adrenal cortex makes and secretes over 30 different steroid hormones(collectively called corticosteroids ).Corticoids are 21 carbon compounds having a cyclopentanoperhydro-phenanthene (steroid) nucleus . Since adrenal cortical cells store only minute quantity of hormone ,rate of release is governed by the rate of biosynthesis.

10. HYPOTHALAMIC PITUITARY AXIS The hypothalamic-pituitary-adrenal (HPA) axis is a feedback loop that includes the hypothalamus, the pituitary and the adrenal glands. The main hormones that activate the HPA axis are corticotropin -releasing factor (CRF ), arginine vasopressin (AVP) and adrenocorticotropin hormone (ACTH). The loop is completed by the negative feedback of cortisol on the hypothalamus and pituitary DIURINAL RHYTHM ACTH is secreted in irregular pulses throughout the day which cause parallel increases in plasma cortisol . Both the frequency and the amplitude of the pulses are the greatest in the early morning. This early morning increase in ACTH release is initiated by the release of CRH ( corticotropin releasing hormone) and starts approximately a couple of hours before waking. The lowest levels of ACTH in blood occur just before or after falling asleep. This results in the characteristic diurnal rhythm in ACTH and cortisol secretion

11. Basal secretion Glucocorticoids Cortisol-5 – 30 mg Corticosterone - 2 – 5 mg Mineralocorticoid Aldosterone - 5 – 150 mcg 11- deoxycorticosterone - Trace Sex Hormones Androgen – DHEA - 15 – 30 mg Progestogen – Progesterone - 0.4 – 0.8 mg Oestrogen – Oestradiol - Trace

12. Pharmacological Actions Direct Actions Permissive Actions • Lipolytic effects • Effect on BP • Effect on bronchial muscles (e . g . sympathomimetic amine)

13. Pharmacological Actions 1. Mineralocorticoid actions 2. Glucocorticoid actions  Carbohydrate  Protein  Lipid  calcium metabolism  CVS  Skeletal muscle  CNS  Stomach  Respiratory system  lymphoid tissue and blood cells  Inflammatory responses  Immunological and allergic responses  Growth & Cell Division

14. MINERALOCORTICOID ACTION WATER AND ELECTROLYTE BALANCE

15. CARBOHYDRATE AND PROTEIN METABOLISM

16. Lipid metabolism  Permissive action  Promote adipokinetic agents activity(lipolysis)  Redistribution of Fat  Moon face , fish mouth , buffalo hump Calcium metabolism  ↓ Intestinal absorption  ↑Renal excretion  OSTEOPOROSIS-spongy bones are more sensitive( e.g., vertebrae, ribs etc ) Cardiovascular system  Restrict capillary permeability Maintain tone of arterioles & Myocardial contractility  Na+ sensitize blood vessels to the action of catecholamines & angiotensin-(permissive role in development of hypertension ,should be used cautiously in hypertensives ) CNS  Direct: Mood(mild euphoria), Behaviour,Brain excitability,High doses lower seizure threshold-cautious use in epileptics Indirect: maintain glucose, circulation and electrolyte balance

17. Skeletal muscle Optimum level of corticosteroid is needed for normal muscular activity. Hypocorticisim : ↓ work capacity & weakness(due to hypodyanamic circulation ) Hypercorticism : •excess mineralocorticoid action - hypokalemia – weakness •excess glucocorticoid action - muscle wasting & myopathy -weakness Stomach ↑ section of gastric acid &pepsin&↓ in PG levels in the stomach-- Cytoprotective effect of PG lost--result- -peptic ulcer Misoprostol ( A prostaglandin E1, analogue) may be used to replenish the depleted stomach PGS

18. Lymphoid tissue and Blood cells •Lymphoid tissue: • ↑ rate of destruction of lymphoid cells(T cells are more sensitive than B cells) •Blood cells: ↑ number of RBCs,platlets,neutrophils in circulation. ↓ lymphocytes,eosinophils and basophils blood count come back normal after 24 hours . Inflammatory responses Irrespective of type of injury the attending inflammatory response is ↓ ed.The cardinal signs of inflammation – redness,heat,swelling and pain are suppressed. In early events:↓acute inflammatory response, reduced exudation, ↓ in numbers and activity of leucocytes, ↓ in inflammatory mediators. In late events:↓numbers and activity of mononuclear cells and fibroblasts, ↓ proliferation of blood vessels, less fibrosis-thus ↓ chronic inflammation but also ↓ healing.

19. Growth & Cell division  Delays the process of healing and scar formation .  Retards the growth of children. Respiratory system •Most potent and most effective anti-inflammatory •Effects not seen immediately (delay 6 or more hrs ) •Inhaled corticosteroids are used for long term control in bronchial asthma. Effects on stress ACTH and cortisol secretion are increased by stressful stimuli including surgery , trauma, pain, apprehension, infection, hypoglycaemia and haemorrhage. The increase in cortisol production is necessary for survival, and stresses that are normally tolerated can become fatal in adrenal insufficiency Rapid deterioration resulting in organ damage and shock/coma/death can occur, especially in children

20. MECHANISM OF ACTION This process takes 30-60 min.So effects of corticosteroids are not immediate ,and once the appropriate proteins are synthesized-effects persist much longer than steroid itself

21. p reparations Glucocorticoids Short acting Intermediate acting Long acting Mineralocorticoids Inhalant steroids Topical steroids SYNTHETIC STEROIDS have largely replaced the natural compounds in therapeutic use ,because they are potent,longer acting,more selective,for glucu / mineralo action and have high oral activity.

22. ► Corticosteroids are generally grouped into four classes , based on chemical structure. ►Allergic reactions to one member of a class typically indicate an intolerance of all members of the class. " Coopman classification“ Given after S. Coopman who gave the classification in 1989 CLASSSIFICATION OF STEROIDS

23. ► Group A Hydrocortisone, Hydrocortisone acetate, Cortisone acetate, Tixocortol pivalate , Prednisolone, Methylprednisolone, and Prednisone. ► Group B Triamcinolone acetonide , , Mometasone , Amcinonide , Budesonide , Desonide , Fluocinonide , Fluocinolone acetonide , and Halcinonide .

24. ► Group C Betamethasone , Betamethasone sodium phosphate, Dexamethasone, Dexamethasone sodium phosphate, and Fluocortolone . ► Group D Hydrocortisone-17-butyrate , Betamethasone valerate , Betamethasone dipropionate , Prednicarbate and Fluprednidene acetate

25. Routes of adm : of Corticosteroids ►1. Topical steroid for use topically on the skin, eye, and mucous membranes. ►2. Inhaled steroids for use to treat the nasal mucosa, sinuses , bronchi, and lungs. ►3. Oral forms - such as prednisone and prednisolone. ►4. Systemic forms - available in injectable for use intravenously and parenteral routes

26. Potency Examples Highest 0.05% Clobetasol propionate 0.05%Betamethasone dipropionate High 0.1% Halcinonide 0.25% Desoximethasone 0.05% Fluocinonide 0.5% Triamcinolone acetinode 0.05% Betamethasone dipropionate 0.05% Diflorasone diacetate cream Intermediate 0.2% Fluo-cinolone acetonide 0.05% Desoxymethasone 0.025% Betamethasone benzoate 0.2% Hydrocortisone valerate Low 0.025% Fluo-metholone 0.025% Triamcinolone acetonide 0.03% Fluocinolone pivalate 0.01% Betamethasone valerate Lowest 0.25-2.5% Hydrocortisone 0.5% Prednisolone

27. Agent Antiinflammatory Topical Equivalent oral dose (mg) Forms Available Hydrocortisone 1 1 20 O,I,T Cortisone 0.8 25 O Prednisolone 5 4 5 O,I Triamcinolone 5 5 4 O,I,T Flu-prednisolone 15 7 1.5 O Betamethasone 25-40 10 .6 O,I,T Dexamethasone 30 10 .75 O,I,T

28. Injectable: Betamethasone Dexamethasone Prednisolone Methylprednisolone Hydrocortisone Triamcinolone Oral: Betamethasone Fludricortisone Prednisolone Prednisone Methylprednisolone Topical: Betamethasone Clobetasol Flucinolone Mometasone Inhalation : Beclomethasone Budesonide Flunisolode

29. Commonly prescribed and dosages Triamcinolone Kenacort , Tricort , kenalog , Tess buccalpaste Oral :1,4,8mg syrup Topical:0.1% eye drops,ointment Parentral : 3,10,40 mg/ml for I.M, intraarticular , Intralesional injections

30. Dexamethasone Decadron , Dexasone , Wymesone Oral :0.25,0.5,0.75,1,2,4,6mg tablets Topical :0.1% eye drops, ear drops, skin ointment Parenteral : 4,8,10,20 mg/ml for IV, IM, intralesional and intraarticular

31. Betamethasone Betnesol , Betnovate , Betnesol forte, Betawin forte, Walacort , Stemin Oral : oral drops – 0.5 mg/ ml, tablets – 0.5 to 1 mg. Topical – 0.1% eye drops, ointment,0.05% nasal drops, 0.12% skin creams Parenteral :4 mg/ml for IM, IV, intralesional , intraarticular

32. Hydrocortisone Wycort , Hycort , Unicort , Cipcorlin , Efcorlin Oral :5mg,10mg,20mgtab Topical : 1%eye drops 0.025%nasal drops 0.25-2.5%skin cream Parenteral :25, 50 mg/ml for IV,IM,SC Injections

33. Cortisone Corlin , Cortone Oral : 5, 10, 25 mg tablets Parentral :22,25 mg/ml of solution

34. Prednisolone Wysolone , Prelone , Nucort , Cecort , Oral :5,10, 20 mg tablets, 15mg/5 ml syrup, 5mg/ml suspension as pediatric drops Parenteral :25,50 mg/ml IM,IV,Intralesional

35. Uses of steroids

36. Replacement therapy Acute adrenal insufficiency • Hydrocortisone or dexamethasone are given i.v , first as a bolus injection and then as infusion along with istonic saline and glucose solutions. Chronic adrenal insufficiency • Hydrocortisone given orally is the most commonly used drug with adequate salt and water allowance. Congenital adrenal hypoplasia : • 0.6 mg/kg daily in divided doses round the clock

37. pharmacotherapy • Single dose (even excessive) is not harmful can be used to tide over mortal crisis even when benefit is not certain. • Short courses (even high doses) are not likely to be harmful in the absence of contraindications. Starting Long term use is potentially hazardous: keep the dose to minimum which is found by trial and error, even partial relief may have to be tolerated. • No abrupt withdrawal after a corticoid has been given for > 2 to 3 weeks: may precipitate adrenal insufficiency doses can be high in severe illness

38. Arthritis Rheumatoid arthritis Osteoarthritis Rheumatic fever Gout Collagen diseases SLE Polyarteritis nodosa Dermatomyositis Nephrotic syndrome Glomerulonephritis Severe allergic reactions Used for short periods in anaphylaxis Angioneurotic edema Utricaria Serum sickness Autoimmune disorders Autoimmune hemolytic anemia Thrombocytopenia Active chronic hepatitis Myasthenia gravis

39. Bronchial asthma Status asthmaticus Severe chronic asthma Infective diseases Severe forms of tuberculosis Severe lepra reaction Certain form of bacterial meningitis Pneumocystitis carini pneumonia with hypoxia in AIDS patients Eye diseases Effective in diseases of anterior chamber Allergic conjuctivitis Iritis Keratitis Skin diseases Eczematous skin diseases Pemphigus vulgaris Exfoliative dermatitis Steven johnsons syndrome

40. Intestinal diseases Ulcerative colitis Chron’s disease Others Cerebral edema Malignancies Organ transplantation and skin allograft Shock To test the adrenal pituitary axis

41. USES OF STEROIDS IN ORAL AND MAXILLOFACIAL SURGERY

42. Steroids are used in : Impactions Extractions To control post operative pain and swelling In maxillofacial trauma In malignancies and other disorders

43. Prevention of postoperative pain, edema , trismus after 3rd molar surgery. Prevention of postoperative edema after orthognathic, and reconstructive surgery after trauma. Prevention of alveolar osteitis . Other than this steroids are used in many other conditions which are encountered as an oral and maxillofacial surgeon.

44. Abducent nerve palsy from trauma or edema systemic steroids are used for treatment. Orbital apex syndrome is treated by corticosteroids and decompression. Steroids are also used in treatment of traumatic superior orbital fissure syndrome. Used In traumatic facial nerve palsy in temporal bone fractures. Steroids eye drops are used to reduce swelling and pain in eye after transconjuctival approach For orbital floor repair etc. Steroids in maxillofacial trauma

45. Ulcerative,Vesiculoerosive diseases Erosive lichenplannus , RAS Benign lesions • Eg : CGCG Salivary gland disorders • Eg : Mucocele TMJ Disorders • Eg : Osteoarthritis • Rheumatiid arthritis Neuralgia Treatment • Eg . Post herpatic neuralgia Miscellanous • OSMF Steroids used in other conditions

46. Ulcerative Vesiculoerosive diseases Immunologically mediated diseases that affect the oral mucosa present with inflammation and loss of epithelial integrity, through cellular and/or humoral immunity-mediated attack on epithelial connective tissue targets. The main clinical features are ulceration and reddening , with pain that can be severe and debilitating . Corticosteroids play a central role in the treatment of vesiculoerosive lesions . However, the frequency and severity of the adverse effects associated with the use of systemic corticosteroids have led to the increased use of topical corticosteroids (TCs ).

47. S hort course of Topical Corticosteroids accelerate remission without adverse effects in conditions like : Recurrent aphthous stomatitis (RAS), some cases of erythema multiforme (EM), and Drug-induced ulceration. Topical Corticosteroids must be used for longer, less predictable periods in conditions like : Severe RAS, Erosive oral lichen planus (OLP ), specific forms of EM , and mucous membrane pemphigoid (MMP) In very severe cases of ulcerations the treatment can be started by short courses of systemic corticosteroids followed by maintainance regimen of topical steroids or can be started simultaneously.

48. When a TC is prescribed, and especially when a prolonged course is predicted, the basic rule is that a TC of a potency appropriate to the severity of the clinical symptoms should be used, at the lowest possible concentration and frequency, with maintaining the effectiveness of the treatment. It should always be taken into account that these drugs do not cure the disease but rather control or relieve the symptoms .

49. Factors that influence the effectiveness of Topical Corticosteroids: The intrinsic potency of the drug which can be significantly increased by the halogenation of the steroid; esterification , which makes the drug more lipophilic and gives it greater Penetrability which is explained in article by ( Regezi and Sciubba , 1999 ). The contact time between the drug and lesion and the vehicle used to apply it. Concentration which can increase its clinical effectiveness , although no additional advantage is obtained beyond certain limits . Patients prescribed TC in an adherent vehicle should be instructed to Apply a small amount to the target area after meals , and Not to eat or drink for at least 30 min. It is best not to rub the TC in, because this can produce irritation .

50. Systemic steroids for ulcerative vesiculobullous diseases: major aphthae or severe multiple minor aphthae • Prednisone therapy should be started at 1.0 mg/kg/day in patients with severe RAU and should be tapered after 1 to 2 weeks . Pemphigus Vulgaris • Mainstay 1-2mg/kg/day Initial dose of treatment – 0.5 mg/kg/day to 3 mg/kg/day Dose that achieves clinical control is maintained for 2-3 weeks and then gradually tapered . Erythema multiforme : minor : treted by steroid 20-40mg /day for 4-6 days major: 60mg/day slowly tapered to 10/mg day for 6 weeks

51. Cicatrical phemphigoid Prednisolone 20-60mg/day to stop new bullae formation , then tapered by 20% every 2-3 week until it resches dose of 10mg and the dose is maintained on alternate days and reduced by 5mg every 2 weeks and the stopped . Bullous pemphigoid Clobetasol propionate 20 -40 mg/day is more effective for the treatment. Lichen planus Prednisolone 1mg/kg/d for < 7 Days Tapered to 10-20mg per day for 2 weeks. Lupus erythematosus Predisolone – 20 - 30 mg/day for 2- 6 weeks Tapered gradually.

52. Steroids uesd in benign lesions CGCG Intralesional injection of triamcinolone can be given in a dose of 1 to 2 mg/kg/day (maximum of 60 mg ). The treatment interval at 4 to 6 weeks . Hemangioma Prednisone at a dose of 20-30 mg/d can be given for 2 weeksto 4 months ( Fost and Esterly ) Intralesional triamcinolone acetonide (4 mg/mL ) ( Hawkins et al)

53. Steroids In salivary gland disorders Mucocele 0.05 % clobetasol propionate 3 times a day for 4 weeks in a mucosal adhesive base . Intralesional injections have also been tried with success .

54. Steroids in neuralgia Post herpetic neuralgia To reduce incidence of post herpetic neuralgia:  Prednisolone 20 to 30 mg/day for 7 – 10 days tapered to 10 mg/day for 1 week (Treatment of oral diseases, George Lascaris )

55. Steroids for TMJ disorders Rheumatoid arthritis Intraarticular injection – 10 to 40 mg/ml O steoarthritis Intraarticular injection – 20 mg/ml(2 injections 14 days apart)

56. Miscellaneous Bell’s palsy Significant improvement can be achieved when Prednisolone is started within 72 hours of symptom onset 1 mg/kg body weight (maximum 70 mg ) in divided doses with meals for six days, and the dose can be reduced gradually over the next four days . OSMF Prednisolone – 20 - 30 mg/day for 2 – 4 weeks Gradually taper Discontinue in 1- 2 months Injections of triamcinolone 10mg/ml diluted in 1 ml of 2% lidocaine with hyaluronidase 1500 IU, biweekly for 4 weeks . ( Borle et al ) Biweekly submucosal injections of a combination of dexamethasone (4mg/ml) and two parts of hyaluronidase , diluted in 1.0 ml of 2% xylocaine by means of a 27 gauge needle, not more than 0.2ml solution per site, for a period of 20 weeks. Significant relief of burning sensation (88%) and improvement of trismus (83%) can be seen in most patients .

57. Adverse effects of steroids Mineralocorticoids :  Sodium and water retention  Edema  Hypokalemic alkalosis  Progressive rise in B.P  Weight gain  Fluid and electrolyte disturbance Glucocorticoid: GIT:  Acute erosive gastritis with hemorrhage  Peptic ulcer  Intestitial perfortion  Pancreatitis Metabolic effects:  Hyperglycemia  Ketoacidosis  Hyperosmolar coma  Hypophosphatemia

58. CVS and renal system:  Hypertension  Salt and water retention  Hypokalemic alkalosis CNS:  Influence mood, sleep pattern  Insomnia  Acute psychotic reactions  Benign intracranial hypertension  Epilepsy Musculoskeletal effects:  Proximal myopathy and osteoporosis with compression fractures of vertebrae  Acute aseptic necrosis of bone Eyes:  Glaucoma

59. Suppression of inflammation and immune response :  Latent infection may flare  Oppurtunistic infection with low grade pathogens Retardation of linear growth:  Occurs in children who receive more than 50 mg of cortisone per m2 of body surface per day . Relative Contraindications:  Peptic ulcer  Diabetes mellitus  Hypertension  Pregnancy  Herpes simplex  Tuberculosis  Osteoporosis  Psycosis  Epilepsy  Renal failure

60. Rule of 2 Adrenocortical suppression should be suspected if a patient has received Glucocorticoid therapy through two of the following methods In a dose of 20 mg or more of cortisone or its equivalent Via oral or parenteral route or a continuous period of 2 weeks or longer Within 6 months -2 years of therapy

61. SURGICAL MANAGEMENT OF A PATIENT IN STEROIDS Barely three years later after the discovery of steroids , Fraser and co-workers reported the death of a34-year-old man after routine orthopaedic surgery due to shock , adrenal insufficiency , and circulatory collapse. The patient had been on corticosteroids for rheumatoid arthritis, but the treatment had been stopped prior to surgery. Surgery-activation of HPA axis Surgery is one of the most potent stressors that can cause activation of the HPA axis. The degree of activation depends on the type and duration of surgery and anesthesia , with many other variables, including analgesics, antihypertensive medications , infections, and age. The maximum stimulation of the HPA axis is occur during reversal of anesthesia and in the immediate postoperative period.

62. Significant hypotension Significant hypotension which cannot be explained by acute blood loss, myocardial infarction , anesthesia , drugs, or electrolyte imbalance should suggest the possibility of an acute adrenal insufficiency. This is especially true if the blood pressure does not respond promptly to blood transfusions or vasopressors . It is suggested that an increase in capillary resistance and potentiation of the effect of vasoconstrictors on blood vessels may be factors in the blood pressure response to adrenal corticosteroids

63. Lack of increase in cortisol production during stress would cause the host to succumb to it. On the other hand, too much cortisol would be detrimental, causing increased tissue breakdown, poor wound healing, and immunosuppression . Given this background, it is clear that any patient who has inadequate cortisol production in response to surgical stress will fare poorly in such a situation . This patient will need to be recognized , and his acute steroid requirement will have to be estimated and supplemented

64. Preoperative considerations Adrenocortical function may be suppressed if : The patient is currently on daily systemic corticosteroids at doses above 7.5 mg prednisolone(or equivalent ).  Cortisteroids has been taken regularly during the past 30 days.  Corticosteroids have been taken for more than one month during past one year.  Although the evidence for the need of steroid cover may be questionable , medico legal and other considerations suggest that one should act on the side of caution and fully inform and discuss with patient, take medical advice in case of doubt, give a steroid cover unless confident that collapse is unlikely .

65. INTRAOPERATIVE CONSIDERATIONS B.P. must be carefully watched during surgery and especially during recovery and steroid supplementation must be given if B.P. starts to fall.  Drugs especially sedative and GA ,are a hazard and it is extremely important to avoid hypoxia , hypotension and haemorrhage  Patient may also require special management as a result of diabetes, hypertension ,poor wound healing and infections .

66. Procedure No steroids for previous 12 months Steroids taken during previous 12 months Steroids currently taken Conservative dentistry or dentoalveolar surgery ↓LA No cover required Give usual oral steroids dose in morning or hydrocortisone 25- 50mg I.V. preop Double oral steroids dose in morning or hydrocortisone 25- 50 mg I.V preop , continue normal steroid medication postop Intermediate surgery(multiple extractions,or surgery ↓GA) Consider cover if large doses of steroids were given Give usual steroids dose in morning +hydrocortisone 25- 50 mg i,.v. preop + i.m . 6 hourly for 24 h Double oral steroid dose in morning +hydrocortisone 25- 50mg I.Vpreop + i.m.6 hourly for 24h,then continue normal med. Maxillofacial surgery or trauma Consider cover if large doses were given Same+i ,.m 6 houly for 72 h Same +I. M 6 hourly for 72 h+normal thereafter

67. CARE TO BE TAKEN IN ROUTINE DENTAL PROCEDURE Conducting treatment in the morning. Control of anxiety and emotional stress. Use long-acting anaesthetics. Treatment of postoperative pain. Minimum use of NSAIDs Asepsis surgery ,Antibiotic prophylaxis Prevention of iatrogenic fracture during surgery . T opical steroids for use in mouth predispose to oral candidiosis .

68. Pathologies of adrenal gland Hyperactivity can cause: Cushings syndrome Hyperaldosteronism Adreno genital syndrome

69. Cushings syndrome Due to hyper secretion of glucocorticoids particularly cortisol. Due to pituitary origin its cushings disease. Due to adrenal origin its cushings syndrome.

70. Disproportionate body fat distribution Moon face Buffalo hump Pot belly Purple striae Thinning of skin Pigmentation Facial redness Hirsutism Muscle weakness Bone resorption Hyperglycemia Hypertension Susceptiblity to infections Poor wound healing

71. Hyper aldosteronism Can be due to adrenal cause (primary) Can be due to extra adrenal cause ( secondary) Increase in ECF volume and blood volume Hypertension Severe depletion of potassium Muscle weakness Metabolic alkalosis

72. Hypo activity Addison's disease Adrenal crisis Chronic adrenal hyperplasia Addison’s disease Failure of adrenal cortex to secrete all the corticosteroids Primary : due to adrenal cause Secondary : failure of anterior pituitary to secrete ACTH. Tertiary: failure of hypothalamus to secrete CRF.

73. Pigmentation of skin and mucous membrane Muscle weakness Dehydration Hypotension Decreased cardiac output Hypoglycemia Nausea, vomiting, diarrhoea Inability to withstand stress Addison's disease

74. Adrenal crisis Common symptom of Addison's disease characterized by sudden collapse associated with an increase in need for large quantities of glucocorticoids . Fatal if not treated in time Causes Exposure to even mild stress Hypoglycaemia due to fasting surgical operation Sudden withdrawal of glucocorticoid treatment

75. Congenital adrenal hyperplasia Congenital disorder characterized by increase in size of adrenal cortex. Even though the size of the gland increases the cortisol secretion decreases. Congenital enzymes necessary for synthesis of cortisol , particularly 21- hydroxylase . cortisol , particularly 21- hydroxylase . In boys: Precocious body growth, causing stocky appearance called infant Hercules Precocious sexual development with enlarged penis even at age of 4 years. In girls: Produces Masculinization Female child born with external genitalia of male type.

76. Conclusion • Corticosteroids play an important role in control of pain & inflammation associated with numerous disease states of oral cavity. • Currently corticosteroids are drugs with one of the broadest spectrum of clinical utility. • But it should never be used as a substitute to other treatments. • Lets keep it mind that these drugs do not cure the disease but rather control or relieve the symptoms. • It should be used cautiously as it is two edged sword.

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