CORTICOSTEROIDS AND ITS USES • Bleaching may be defined as the lightening of the color of the tooth through the application of chemical agent to oxidise the organic pigmentation in the tooth.

• Definition
• Bleaching agents
• Mechanism of bleaching
• Factors affecting bleaching
• Classification of bleaching procedures
• Instructions to the patient
• Management of tetracycline-stained teeth
• Microabrasion and macroabrasion

1. CORTICOSTEROIDS AND ITS USES Presented by: Hannah Thomas

2. CONTENTS Introduction Corticosteroid action Classification Pharmacological action Uses Precaution Types Adverse effects of glucocorticoids Contraindications Newer drugs Mineralocorticoids

3. INTRODUCTION Steroids are the name given to a group of hormones,which are produced naturally in the body. They are essential for normal functioning of the body.

4. CORTICOSTEROID ACTION Glucocorticoids action is mainly for hepatic glycogen deposition. Mineralocorticoid action is for sodium, electrolyte-fluid balance.

5. CLASSIFICATION Glucocorticoids Short acting (biological half life less than 12 hours) Hydrocortisone (cortisol) Cortisone Intermediate acting (biological half life in 12–36 hours) Prednisolone Methyl prednisolone Triamcinolone Long acting (biological half life more than 36 hours) Paramethasone Dexamethasone Betamethasone Mineralocorticoids Deoxycorticosteroneacetate (DOCA) Fludrocortisone Aldosterone

6. PHARMACOLOGICAL ACTION Glucocorticoids Cellular Action Activation of receptor Specific protein synthesis Metabolic action Carbohydrate and protein metabolism Fat metabolism Calcium metabolism and bone Electrolyte and water metabolism Anti inflammatory action

7. USES Substitution therapy: It is used as substitution therapy in Addison’s disease and hypopituitarism Intensive short term therapy: It can save life and reduce morbidity in certain potentially lethal conditions in which inflammatory response of the body itself threatens life. For example, allergic emergencies such as anaphylactic shock, status asthmaticus , acute necrotizing vasculitis, etc. Prolonged high dose suppressive therapy: It is indicated in acute rheumatic fever, ulcerative colitis, subacute hepatitis, autoimmune hemolytic anemia, pemphigus, ITP, Hodgkin’s disease, etc.

8. Low dose chronic palliative therapy: Use of small doses of glucocorticoids as an adjunct to some other drugs like salicylates in rheumatic arthritis. Topical application: Topical application is found invaluable in many dermatological, oral, ocular and external ear conditions Diagnostic test: Dexamethasone suppression of adrenal function, cortisone test in hypocalcemia and prednisolone test to distinguish intra- and extrahepatic obstructive jaundice Dental use: Corticosteroids because of their anti- inflammatory action are used in many oral diseases. Corticosteroids are used in the management of aphthous stomatitis, pemphigus, erythema multiforme , lichen planus, oral submucus fibrosis and sinusitis Miscellaneous: It is used in a variety of conditions like Bell’s palsy, infective hepatitis and encephalitis.

9. Precaution History : Before starting the therapy, enquire about history suggestive of peptic ulceration. Glucose estimation : Examine urine Weight and blood pressure : Keep record of weight and blood pressure. Do not stop abruptly Increase dose : If the patient develops an acute infection or has to undergo therapy, increase the dose of steroids. Restrict use : Not be used in the presence of infection unless they can be simultaneously treated with antibiotics.

10. Hydrocortisone ( cortisol ) Naturally occuring steroid It acts rapidly, short duration of action Action : Anti allergic, anti inflammatory Therapeutic uses : OSMF Aphthous ulcer Desquamative gingivitis Osteoarthritis Addison disease Lichen planus , pemphigus Ulcerative colitis

11. Shock, status asthmaticus Trade name: CORTEF, EFCORLIN, WYCORT, ORABASE- HCA CORTISONE Next potent drug than hydrocortisone Action : Anti allergic , Anti inflammatory Therapeutic uses : OSMF Addison disease Hodgkin lymphoma Trade name: CORLIN, CORTONE

12. PREDNISOLONE OR PREDNISONE 4 times more potent than hydrocortisone Most selective glucocorticoid Action : Anti inflammatory, Anti allergic and immunosuppresive Therapeutic uses : Rheumatoid arthritis Collagen disease Systemic lupus erythematous Leukemia Erythema multiforme Pemphigus

13. Bullous pemphigoid Behcet’s syndrome Rheumatic arthritis Bronchial asthma Malignancies Post-herpetic neuralgia Trade name: DELTA-CORTEF, PRELONE, WYSOLONE, METICORTEN METHYL PREDNISOLONE Slightly more potent and more selective than prednisone. Action: Anti-inflammatory, antiallergic and immunosuppressive.

14. Therapeutic uses: Same as that of Prednisolone . Trade name: MEDROL, DEPOMEDROL TRIAMCINOLONE Slightly more potent than prednisolone but highly selective glucocorticoids . Action: Immunosuppressive, anti inflammatory, hematopoietic action Therapeutic uses: Lichen planus Bronchial asthma Ocular disease

15. Purpura Contact cheilitis , exfoliative cheilitis , plasma cell cheilitis , granulomatous cheilitis Benign mucous membrane pemphigoid Hemangioma Trade name : KENACORT, KENALOG DEXAMETHASONE Very potent and highly selective glucocorticosteroids Used for adrenal cortical supression Action: Immunoinflammatory , anti allergic Therapeutic uses: Allergic diseases, serum sickness, hay fever, contact dermatitis

16. Benign migratory glossitis Ocular diseases Shock, cerebral edema Trade name: DECADRON, DECADRON-L, WYMESONE BETAMETHASONE Action: Similar action that of dexamethasone Therpeutic uses: Same as dexamethasone . Mainly preferred in cerebral edema and shock Trade name: Celestone , Betnovate , Betnesol , Betnelan

17. Adverse effects ( On long term use) Fat distribution: “ Cushingoid appearance”, which is characterized by moon-like face, accumulation of fat in back of neck (buffalo hump), upper abdomen and in supraclavicular region. Edema, hypokalemia and hypertension Osteoporosis and osteonecrosis Hyperglycemia and glycosuria Supression of HPA axis: Prolonged administration results in suppression of ACTH and adrenal corticosteroid production.

18. Peptic ulcers Ocular effects: Subcapsular cataract and glaucoma are common adverse effects Myopathy and muscle wasting: Prolonged therapy especially of fluorinated synthetic analogues (e.g. betamethasone and triamcinolone) can cause muscle wasting particularly of limbs. Infections: The body’s reaction to infective pathogens (fungal, bacterial and viral) is decreased due to immuno -suppressive effects. Wound healing is also delayed. Miscellaneous: Acne, thinning of skin, weight gain, hepatomegaly can occur over prolonged glucocorticoid therapy. In AIDS patients Kaposi’s sarcoma can also be activated over long time usage.

19. Contraindications Cushing syndrome (absolute contraindication) : 100 mg of hydrocortisone for longer than 2 weeks. Diabetes mellitus Hypertension Pregnancy and lactation: First trimester of pregnancy due to risk of cleft palate and intrauterine growth retardation in the fetus. Peptic ulcer Osteoporosis Glaucoma Heart diseases like CHF Herpes simplex infection

20. Caution Cautiously used in pregnancy, tuberculosis, epilepsy, in debilitating and other patients Newer drugs Budesonide Clobetasol Fluocinolone Fluticasone Halocinonide Mometasone

21. Mineralocorticoids Mechanism of action They have main effect on electrolyte (Na, K) and fluid balance. They have Na retaining and K depleting action this is how it influences the salt and fluid water equilibrium in the body Mineralocorticoids bind to the receptors present in the cytoplasm. It increases reabsorption of Na and secretion of K by electrolyte and water metabolism.

22. Desoxycortisone Acetate (DOCA) It has mineralocorticoid activity. Serves as a precursor of aldosterone . Action: Sodium and potassium balance retaining action Therapeutic uses: Hypoaldosteronism Severe postural hypotension Addison’s disease Trade name: Percorten

23. Fludrocortisone More potent mineralocorticoid having some glucocorticoids action. Action : Sodium retention action. Anti- inflammatory action only at high doses. Therapeutic uses : Addison’s disease Autonomic neuropathy Hypotension Congenital adrenal hypoplasia Trade name : Florinef

24. Adverse effects of mineralocorticoids Edema Hypokalemia Progressive rise in blood pressure Fluid and electrolyte balance disturbance Systemic hypotension Weight gain

25. Contraindications Hypertension Systemic heart diseases Osteoporosis Cushing syndrome

26. Dental consideration Physician consideration Osteoporotic changes Stressful condition Minimum stress dental treatment Doubling the dose Major dental surgery

27. References Textbook of Oral Medicine, Anil Govindrao Ghom , 2 nd Edition. Essentials of Medical Pharmacology, KD Tripathi , 6 th Edition Burket’s Oral Medicine , 11 th Edition

28. THANK YOU