- 5 Medications That May Be Causing Your Teeth to Decay
- Dry Mouth
- Pain Medications That May Cause Tooth Decay
- Antihistamines and Decongestants
- Blood Pressure Medication
- How to Minimize Damage
- Medication Side Effects and Your Oral Health
- Calcium-Channel Blockers (CCBs)
- Calcium-Channel Blockers
- General Pharmacology
- Therapeutic Indications
- Therapeutic Use ofCalcium-Channel Blockers
- Different Classes of Calcium-Channel Blockers
- Side Effects and Contraindications
- Many Common Drugs Promote Tooth Decay
- Prescription Medication: An Agent of Decay
- 5 Ways Opioids Can Affect Teeth and Gums
5 Medications That May Be Causing Your Teeth to Decay
Medications are supposed to make you healthier, but sometimes the side effects have negative impacts on your teeth and oral health.
Nearly 50% of Americans used one or more prescription drugs in the past 30 days.1 Asthma medication, stimulants to treat attention deficit disorder and antidepressants were the most frequently used.2
Though medications rarely have the direct effect of tooth decay, all the medications listed above (and more) have the shared common side effect of xerostomia or dry mouth. Dry mouth is a common factor which can lead to tooth decay and infection.3
Drying irritates the soft tissues in your mouth, which can make them inflamed and heighten your risk for infection. Saliva plays a big role in protecting your teeth from bacteria. So when your mouth is dry, your risk for infection and tooth decay is increased.
Here are the common medications which cause dry mouth and subsequent tooth decay, and what you can do to protect your oral health.
Though the acid from heartburn and acid reflux can lead to tooth erosion, treating these conditions with antacids can also be bad news for your oral health.4
While antacids reduce tooth-damaging acid in your mouth, antacids can weaken your teeth and contribute to tooth decay. This risk is applicable to chewable, dissolvable and liquid antacids.
Antacids also may contain sugar or other tooth-damaging artificial sweeteners. Chewable antacids are especially dangerous to your teeth, as they can get stuck between your teeth and after prolonged exposure, can result in cavities.
Pain Medications That May Cause Tooth Decay
Patients with chronic pain are especially prone to periodontal disease and losing teeth due to dry mouth brought on as a side effect of pain medications. Opioids, which are sometimes prescribed to treat pain, are also guilty of causing dry mouth and the consequent erosion of tooth enamel.5
Antihistamines and Decongestants
Antihistamines block histamine receptors to prevent allergic reactions. However, this same effect happens in other areas of the body, including the mouth and tongue. Antihistamines block the release of saliva, which results in dry mouth.6
Decongestants are another common treatment for allergies and the common cold which can also create dry mouth.
Cough syrups create another level of damage to the teeth in that they’re highly acidic, which, like antihistamines, can lead to tooth decay and discoloration.7
Blood Pressure Medication
Beta blockers, calcium channel blockers, diuretics, heart rhythmic medications and angiotensin-converting enzyme inhibitors are all commonly prescribed to treat high blood pressure. These medications all share the side effect of dry mouth, increasing your chances of developing tooth decay.8
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Antidepressants have been linked to negative effects on bone health9, which can increase a person’s chances of developing rampant tooth decay, bad breath, gum disease, oral yeast infections and implant failure. On top of this, antidepressants also cause dry mouth.10
How to Minimize Damage
If you take regular pain medication, you can help curb dry mouth and consequential tooth decay by following these regiments:
- Increase your daily water intake by drinking at least eight to ten glasses of water a day.
- Brush your teeth twice a day.
- Go for regular dental check-ups and cleanings.
- Use a moisturizing mouth spray.
- Eat hydrating snacks like celery sticks.
- Chew sugarless gum or suck on sugarless candy.
- Don’t use tobacco products.
- Cut back on caffeinated and dehydrating drinks like coffee, tea and alcohol.
- Try a hydrating mouth rinse.
For the bad breath which often accompanies dry mouth, you may want to try chewing on any of the following herbs: parsley, aniseed, fennel or rosemary.
When you do reach for the antacids to treat heartburn or acid reflux, find a sugar-free option. Be sure to brush your teeth after taking an antacid to help reduce any damaging effects.
To minimize the damage of acid reflux on your teeth, try to avoid foods that trigger heartburn and acid reflux, such as the following:
- Spicy foods
- Alcohol (particularly red wine)
- Black pepper
- Raw onions
- Citrus fruits and juices
- Coffee and caffeinated drinks
Add the following foods to your diet to help reduce the occurrence of heartburn and acid reflux:
- Vegetables (green beans, broccoli, asparagus, cauliflower, leafy greens, potatoes and cucumbers)
- Whole-grain bread and whole-grain rice
- Non-citrus fruits (melons, bananas, apples and pears)
- Lean meats (chicken, turkey, fish and seafood grilled, broiled baked or poached — avoid fried meat)
- Egg whites
- Healthy fats (avocados, walnuts, flaxseed, olive oil, sesame oil and sunflower oil)
There are some medications, such as the antibiotics tetracycline, that may result in internal staining of the teeth.
The production and use of methamphetamines, which is a strong stimulant drug, is an increasing problem in the United States.
The common street names for this highly addictive and legal street drug are crystal, quartz, crank, speed, meth, and ice.
It is also known as poor man’s cocaine. Methamphetamine use will result is serious problems to your teeth and mouth.
The mouth of a methamphetamine user is often called meth mouth because of the tooth decay that it represents. The users of this dangerous drug often have decay that is so terrible that the teeth must be extracted because they can’t be saved.
The users of methamphetamines suffer considerable damage to their dental health in many different ways. Methamphetamines dry the protective saliva up from around the teeth.
Methamphetamines users will usually grind and/or clinch their teeth. The acidic contents of methamphetamines sometimes contain ingredients such as over-the-counter cold medicines that contain ephedrine, lye, hydrochloric acidic, drain cleaner, antifreeze, lantern fuel, and battery acid, all of which can damage teeth.
The high from the methamphetamine will last for approximately 12 hours and, during this time, the user probably won’t floss or brush and leave substances of a sugary nature on their teeth for this period of time. During the 12-hour high that the methamphetamine causes, the user will experience a craving for sweet beverages that are carbonated and bed for the teeth.
There isn’t much that a dentist can do for a user of methamphetamines other than pull their teeth. The only other thing that a dentist can do is to try to offer a resource such as a drug counseling service and educate the methamphetamine user on the effects of the drug. But the treatment for methamphetamine addiction is usually an ongoing, long, and slow process.
There are also some medications such a heart drugs and antidepressants that may reduce the flow of saliva in your mouth. Because saliva protects your gums and teeth from infection, a lack of it increases the risk of gum disease.
There are some medications, such as the antibiotics tetracycline, that may result in internal staining of the teeth. Depending on the age of the user, other drugs can also cause staining.
These drugs include antihistamines, antidepressants, and oral contraceptives. The chronic use of blood thinners, such as an anticoagulant like warfarin or heparin or an antiplatelet drug like aspirin can result in bleeding gums.
Other things that can cause bleeding gums include the interaction between some medicines, such as herbal preparations, over-the-counter medications, and prescriptions, radiotherapy or chemotherapy, arsenic, lead, and mercury.
In addition, there are several drugs that may damage the teeth of children younger than seven and in fetuses. These drugs include tetracyclines, such as oxytetracylin, minocycline, and doxycycline.
These reactions happen since tetracyclines bind to calcium phosphate and allow the drug to be absorbed by the teeth. This damages the tooth’s dental enamel and causes brown/yellow discoloration, pitting, and can result in the susceptibility to dental cavities.
Medication Side Effects and Your Oral Health
Many medications can affect your oral health. In addition to prescribed and over-the-counter drugs, vitamins, minerals, and herbal supplements can also cause oral health issues that range from dry mouth to inflamed gums to taste alterations and bone loss.
Oral Health: Medication Side Effects
Some of the most common side effects from medications that affect oral health include:
- Dry mouth
- Abnormal bleeding
- Altered taste
- Inflammation, mouth sores, or discoloration of the soft tissues in your mouth
- Enlarged gums
- Teeth and gum color changes
- Bone loss
- Thrush, or an oral yeast infection
Medications That Can Cause Dry Mouth
More than 400 medications have the potential to cause dry mouth. Saliva cleans your mouth but if it’s not flowing normally and dry mouth develops, you’ll be more prone to gum infections and tooth decay.
The most common types of medications that cause dry mouth include:
- High blood pressure medications (including diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors)
- Pain medications
- Parkinson’s disease medications
What to do about dry mouth: If dry mouth is severe as a result of your medication, you can ask your doctor to switch your medication to something else. If that isn’t recommended, here are some tips to help alleviate dry mouth symptoms:
- Ask your doctor or dentist about using an artificial saliva product.
- Sip water or any type of sugarless drink throughout the day.
- Skip or cut down on caffeinated beverages, alcohol, and tobacco because they contribute to a dry mouth.
- Drink water or a sugarless drink while eating to make swallowing and chewing easier.
- Suck on sugarless candy or gum to promote saliva production.
- Avoid salty and spicy foods, which can cause pain to an already dry mouth.
- Use a humidifier at night.
Medications That Can Cause Abnormal Bleeding
Aspirin and anticoagulants, also known as blood thinners, lessen the ability for blood to clot. While they’re helpful in preventing heart attacks and stroke, they can cause your gums to bleed, especially during oral surgery.
What to do about abnormal bleeding: Be sure to let your dentist know that you are taking these drugs so that precautions can be taken to minimize bleeding. Also, be sure to use a soft tooth brush and gentle motions when brushing and flossing your teeth to lessen the bleeding.
Medications That Can Alter Taste
Certain drugs can leave a metallic or bitter taste in your mouth. And some medications may simply change the taste of the things you eat. Such medications include:
- Cardiovascular drugs (some beta blockers and calcium channel blockers)
- Central nervous system stimulants
- Flagyl (metronidazole), an antibiotic drug
- Nicotine skin patches for smoking cessation
- Some respiratory inhalants
What to do about taste changes: If this side effect is intolerable, ask your doctor if your medication can be changed.
Medications That Can Cause Soft Tissue Reactions
You can develop inflammation, mouth sores, or discoloration of the soft tissues in your mouth when taking the following prescribed drugs:
- Blood pressure medications
- Immunosuppressive agents
- Oral contraceptives
- Certain chemotherapy medications
What to do about soft tissue reactions: Let your dentist know if you are taking any of these medications so he or she can recommend a special dental care regimen to reduce the discomfort.
Medications That Can Cause Gums to Enlarge
Enlarged gums, also known as gingival overgrowth, can occur when you take:
- Antiseizure medications (such as those for epilepsy)
- Immunosuppressant drugs (typically used after organ transplantations)
- Calcium channel blockers (for cardiovascular conditions)
What to do about enlarged gums: While taking these medications, you’ll need to take extra care when brushing and flossing. Ask your dentist for specific dental care instructions.
Medications That Can Increase the Risk of Cavities
Many medications, especially those given to children, contain sugar. Sugar is also found in antacid tablets, antifungal agents, cough drops, and many chewable tablets, such as vitamins. Too much sugar can lead to cavities.
What to do about sugar in medications:
- If possible, take the medication in tablet form.
- Take the medications at mealtimes.
- Avoid taking the medication right before bed.
- Make sure you or your children brush with a fluoride toothpaste or chew sugarless gum after taking the medication.
- Seek regular preventive dental care.
Medications That Can Change Teeth and Gum Color
Certain drugs can change the color of your teeth or gums. For example, minocycline (which is used to treat acne) can cause an area of black pigmentation on your gums and a black or gray discoloration of your teeth. Chlorhexidine, a mouth rinse used to treat gum disease, can also stain your teeth.
What to do about gum or teeth discoloration: If a medication has discolored your teeth, ask your dentist about tooth-whitening procedures that may help.
Medications That Can Cause Bone Loss
Use of corticosteroids, such as prednisone, and antiepileptic drugs, can lead to the loss of bone that supports your teeth. Bisphosphonates, drugs used to treat osteoporosis, can sometimes cause a rare condition called osteonecrosis of the jawbone, which results in destruction of the jawbone. Symptoms include painful, swollen gums or jaw, loose teeth, jaw numbness, a heavy feeling in the jaw, fluid in the gums and jaw, and exposed bone.
What to do about osteonecrosis: Be sure to tell your dentist if you are taking a drug for osteoporosis. Your dentist may prescribe an antibiotic or nonsteroidal anti-inflammatory drug to slow your bone loss.
Medications That Can Cause Thrush
Thrush, also known as an oral yeast infection, is caused by a fungus (Candida) and appears as white lesions on the mouth and tongue. Taking antibiotics, steroids, or chemotherapy can cause thrush.
What to do about thrush: Your dentist may prescribe an antifungal mouthwash or lozenges to treat the infection. If these don’t work, stronger antifungal medications can be prescribed.
Behavior-Altering Drugs and Oral Health
Behavior-altering drugs, such as psychotropic drugs, can cause lethargy, fatigue, or memory impairment. If you are taking any of these type of medications, take steps to help you remember to brush and floss your teeth regularly — whether that means setting an alarm, leaving yourself a note, or some other reminder method.
Never stop taking a psychotropic medication without first consulting your doctor. If a drug is causing bothersome oral health side effects, let your doctor know. In many cases, you may be able to take a different type of medication or make lifestyle changes that minimize the side effects. And, as always, take care of your mouth by regularly brushing and flossing your teeth, getting regular dental checkups, and treating any problems that arise.
Calcium-Channel Blockers (CCBs)
- Decrease contractility
- Decrease heart rate
- Decrease conduction velocity
- Smooth muscle relaxation
Currently approved calcium-channel blockers (CCBs) bind to L-type calcium channels located on the vascular smooth muscle, cardiac myocytes, and cardiac nodal tissue (sinoatrial and atrioventricular nodes). These channels are responsible for regulating the influx of calcium into muscle cells, which in turn stimulates smooth muscle contraction and cardiac myocyte contraction. In cardiac nodal tissue, L-type calcium channels play an important role in pacemaker currents and in phase 0 of the action potentials. Therefore, by blocking calcium entry into the cell, CCBs cause vascular smooth muscle relaxation (vasodilation), decreased myocardial force generation (negative inotropy), decreased heart rate (negative chronotropy), and decreased conduction velocity within the heart (negative dromotropy), particularly at the atrioventricular node.
CCBs are used to treat hypertension, angina and arrhythmias.
Therapeutic Use of
(systemic & pulmonary)
By causing vascular smooth muscle relaxation, CCBs decrease systemic vascular resistance, which lowers arterial blood pressure. These drugs primarily affect arterial resistance vessels, with only minimal effects on venous capacitance vessels.
The anti-anginal effects of CCBs are derived from their vasodilator and cardiodepressant actions. Systemic vasodilation reduces arterial pressure, which reduces ventricular afterload (wall stress) thereby decreasing oxygen demand. The more cardioselective CCBs (verapamil and diltiazem) decrease heart rate and contractility, which leads to a reduction in myocardial oxygen demand, which makes them excellent antianginal drugs. CCBs can also dilate coronary arteries and prevent or reverse coronary vasospasm (as occurs in Printzmetal’s variant angina), thereby increasing oxygen supply to the myocardium.
The antiarrhythmic properties (Class IV antiarrhythmics) of CCBs are related to their ability to decrease the firing rate of aberrant pacemaker sites within the heart, but more importantly are related to their ability to decrease conduction velocity and prolong repolarization, especially at the atrioventricular node. This latter action at the atrioventricular node helps to block reentry mechanisms, which can cause supraventricular tachycardia.
Different Classes of Calcium-Channel Blockers
There are three chemical classes of CCBs. They differ not only in their basic chemical structure, but also in their relative selectivity toward cardiac versus vascular L-type calcium channels. The most smooth muscle selective class of CCBs are the dihydropyridines. Because of their high vascular selectivity, these drugs are primarily used to reduce systemic vascular resistance and arterial pressure, and therefore are used to treat hypertension. Extended release formulations or long-acting compounds are used to treat angina and are particularly effecting for vasospastic angina; however, their powerful systemic vasodilator and pressure lowering effects can lead to reflex cardiac stimulation (tachycardia and increased inotropy), which can offset the beneficial effects of afterload reduction on myocardial oxygen demand. Note that dihydropyridines are easy to recognize because the drug name ends in “pine.”
Dihydropyridines include the following specific drugs: (Go to www.rxlist.com for specific drug information)
Non-dihydropyridines, of which there are only two currently used clinically, comprise the other two classes of CCBs. Verapamil (phenylalkylamine class), is relatively selective for the myocardium, and is less effective as a systemic vasodilator drug. This drug has a very important role in treating angina (by reducing myocardial oxygen demand and reversing coronary vasospasm) and arrhythmias. Diltiazem (benzothiazepine class) is intermediate between verapamil and dihydropyridines in its selectivity for vascular calcium channels. By having both cardiac depressant and vasodilator actions, diltiazem is able to reduce arterial pressure without producing the same degree of reflex cardiac stimulation caused by dihydropyridines.
Side Effects and Contraindications
Dihydropyridine CCBs can cause flushing, headache, excessive hypotension, edema and reflex tachycardia. Baroreceptor reflex activation of sympathetic nerves and lack of direct negative cardiac effects can make dihydropyridines a less desirable choice for stable angina than diltiazem, verapamil or beta-blockers. Long-acting dihydropyridines (e.g., extended release nifedipine, amlodipine) have been shown to be safer anti-hypertensive drugs, in part, because of reduced reflex responses. This characteristic also makes them more suitable for angina than short-acting dihydropyridines. The cardiac selective, non-dihydropyridine CCBs can cause excessive bradycardia, impaired electrical conduction (e.g., atrioventricular nodal block), and depressed contractility. Therefore, patients having preexistent bradycardia, conduction defects, or heart failure caused by systolic dysfunction should not be given CCBs, especially the cardiac selective, non-dihydropyridines. CCBs, especially non-dihydropyridines, should not be administered to patients being treated with a beta-blocker because beta-blockers also depress cardiac electrical and mechanical activity and therefore the addition of a CCB augments the effects of beta-blockade.
Year : 2016 | Volume : 8 | Issue : 4 | Page : 252-254
Corticosteroids in dentistry
Rishu Bhanot1, Jyoti Mago2
1 Department of Medicine, DMC and Hospital, Ludhiana, Punjab, India
2 Department of Oral Medicine and Radiology, SKSS Dental College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||27-Dec-2016|
Department of Medicine, DMC and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
Steroids are one of the widely used drugs in dentistry. These are immunosuppressive agents. The reason for its use is its anti-inflammatory as well as immunosuppressive properties. Corticosteroids have revolutionized the management of several disabling conditions, but its use in term of dosage is inappropriate. The current review highlights its uses, contraindications, side-effects as well as a guideline for its use in dentistry.
Keywords: Adrenal insufficiency, anti-inflammatory, corticosteroid, immunosuppressive
How to cite this article:
Bhanot R, Mago J. Corticosteroids in dentistry. Indian J Dent Sci 2016;8:252-4
Steroids are the substances that are naturally produced in our body. These are one of the widely prescribed drugs in both medical and dental sciences. Commonly used steroids are hydrocortisone, dexamethasone, methyl prednisolone, prednisolone, etc. Dental patients with a history of corticosteroid use may require special consideration before receiving any dental treatment. Currently, the misuse of steroids is its overdosage as it is prescribed even before minor dental procedures. The risks associated with excess glucocorticoid administration are relatively small. These includes impaired electrolyte balance and hypertension. The current review emphasizes on the uses and guidelines of use of corticosteroid in dentistry.
|Uses and Effects of Steroid in Dentistry|
Steroids have shown its effects on root resorption. In intracanal medicaments such as ledermix paste which reduces pulpal inflammation as well as root resorption. Further, zinc oxide eugenol along with steroids is also used as root canal sealer. In cavity liners, when steroid is mixed with chloramphenicol and gum caphor to reduce mainly postoperative thermal sensitivity.
It is reported that the upon treatment with hydrocortisone at a dose of 10 mg/kg/day for 7 days on rats followed by observed for 20 h; the teeth showed a lower amount of tooth movement. Hence, it is essential that the patients are reviewed of their prior history of corticosteroids use.
Steroids are used after oral surgical procedures to limit postoperative inflammation. In 1974, Hooley and Hohl elaborated the use of steroid in the prevention of postoperative edema. He further concluded that topical use of steroid helps to prevent ulceration and excoriation which results during retraction during surgery over the lips and corners of the mouth.
In the treatment of various diseases as summarized.
Oral submucous fibrosis
Topical application of steroid applied over ulcerative or painful mucosa. The anti-inflammatory property of steroid shows a direct healing action on the mucosal patch.
Oral lichen planus
A gingival tray can also be used to deliver 0.05% clobetasol propionate with 100,000 IU/ml of nystatin in orabase. Around 3–5 min application of this mixture daily appears to be effective in controlling erosive lichen planus.
Early therapy begins with systemic prednisone (0.5–1.0 mg/kg/day) or pulse methylprednisolone (1 mg/kg/day for 3 days). Intravenous pulsed dose methylprednisolone (3 consecutive daily infusions of 20–30 mg/kg to a maximum of 500 mg given over 2–3 h) is reported, with the suggestion that this approach is superior to oral prednisone because it imparts the benefit when treatment is administered as early as possible in the progression of the cutaneous insult.
Systemic steroids with other immunosuppressive agents are used. Pulse therapy is most commonly used. Each pulse is not standardized. 500–1000 mg prednisolone or 100–200 dexamethasone is given for each pulse.
Bullous and mucous membrane pemphigoid
The mainstay of the treatment of pemphigoid is a moderate dose of corticosteroid. However, in severe cases, steroid-sparing agents are used. This includes clobetasol propionate 20–40 mg daily dose.
Prednisolone 60–80 mg daily during 1st 5 days and taper over next 5 days.
Central giant cell granuloma
Intracellular corticosteroid injections are used for nonsurgical treatment. Topically, triamcinolone acetonide can also be given as it suppresses an angiogenic component of the lesion.
Post herpetic neuralgia
The systemic steroid is used to reduce the pain in these patients.
Melkersson Rosenthal Syndrome
Due to anti-inflammatory action of steroid, it is used to reduce swelling and persistent edema. Short courses are preferred. Prednisolone in dose 1–1.5 mg/kg/day is given mainly. Tapering can be done further over 3–6 weeks depending on the severity as well as response.
|Guideline for Dental Use|
Current evidence reveals that the majority of patients with adrenal insufficiency can undergo routine, nonsurgical dental treatment without the need for supplemental glucocorticoids., This conclusion is supported by the fact that these dental procedures do not stimulate cortisol production at levels comparable to those oral surgical procedures, and local anesthetic blocks neural stress pathways required for adrenocorticotropic hormone secretion.
For patients undergoing general anesthesia for minor surgery 100 mg hydrocortisone intramuscularly should be administered and the usual glucocorticoid medications maintained. For major surgery 100 mg hydrocortisone delivered as a bolus preoperatively followed by 50 mg 8-hourly for 48 h is adequate.
The major controversy resides for the patients who are undergoing any oral surgical procedures and had discontinued steroids recently. These are prescribed with supplemental steroid therapy. A conservative approach remains to wait 2 weeks for the normal adrenal function to return before performing elective oral surgical procedures.,, However, this conservative waiting period is not required for patients who are receiving 30 mg of hydrocortisone (that is, 5 mg of prednisone) or less per day.
|Contraindications of Steroids|
Steroids may exacerbate the response in the following conditions. Therefore, these are contraindicated. In patients with:
- Primary bacterial infection
- Peptic ulcer
- Diabetes mellitus
- Herpes simplex infections
- Congestive heart failure
- Renal failure.
Sideeffects depend on duration for which steroids are given, dosage of the drug as well as approach it is used.
In patients, suffering from primary hyperaldosteronism secondary to an adrenal adenoma and in patients treated with potent mineralocorticoids, it may cause hypokalemic alkalosis, edema as well as hypertension.
Other side effects includes Cushing’s habitus, skin atrophy, precipitation of diabetic myopathy, susceptibility to infection, delayed healing of wounds, peptic ulcers, osteoporosis, osteonecrosis, ophthalmic complications, growth retardation, fetal abnormalities, central nervous system complications, suppression of hypothalamic-pituitary-adrenal axis, effects on reproductive system, hyperlipidemia, weight gain, atherosclerosis, hypertension, malignancy.
This approach causes adverse effects, such as skin atrophy, hypopigmentation contact dermatitis, oral thrush, subcutaneous fat wasting, and cushingoid effect.
These include oropharyngeal candidiasis, dysphonia, reflex cough, bronchospasm, pharyngitis.
This may lead to mucosal atrophy.
|Minimize the Effects of Steroid Therapy|
Probiotics play a crucial role in minimizing the effects of candidiasis when the patient is under steroid therapy. Probiotics act in three-ways. First, it inhibits pathogenic enteric bacteria. Second, it improves epithelial and mucosal barrier function by enhancing mucus production, increasing barrier integrity and by producing short chain fatty acids. Third, it alters immune regulation by stimulating secretory immunoglobulin a production, decreasing tumor necrosis factor expression, by inducing interleukin-10.
Corticosteroids are regarded as double-edged sword to the patients. Despite its various advantages, they also have severe side-effects. These drugs are one of the most misused drugs in the form of dosage. The current article highlights its various uses, side-effects, and contraindications in the oral and maxillofacial region as well as a guideline for its use in dentistry.
Dr. Rajesh Bhanot, Principal and HOD, Department of Prosthodontics, SKSS Dental College and Hospital, Sarabha, Ludhiana, Punjab, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Many Common Drugs Promote Tooth Decay
A visit to dentist Gene Watson, D.D.S., Ph.D., is often the last stop for such patients. Watson, director of the Salivary Dysfunction Center at the University of Rochester Medical Center, gave up a thriving dental practice to devote his career to discovering new knowledge about our oral health. His latest discovery appears in the March-April issue of Caries Research. In a recent experiment with clonidine, a medicine for treating high blood pressure in adults and often used to treat attention deficit hyperactivity disorder in children, Watson’s dental research team showed that rats receiving clonidine developed 84 percent more cavities on the smooth surfaces of their teeth than rats not on the medicine.
Watson’s group is one of just a handful in the world to study the effects of drugs on cavities. In previous studies he has shown that the drugs atropine and propranolol also boost the cavity rate in rats. The researchers found that propranolol, commonly used to treat heart patients, alters the composition of saliva and makes it less effective, while atropine lessens saliva flow. Drugs that behave like atropine include antihistamines like Benadryl, anti-depressants such as Elavil and Aventyl, and Detrol, which is used to treat incontinence.
Anything that stems the flow of saliva is a concern to dentists, many of whom regard the substance with a kind of wonder. “Our saliva washes away sugars and other substances that help promote cavities. It neutralizes the acids in our mouths,” says Watson. “And it’s concentrated with minerals like calcium and phosphate. When you eat sugar, bacteria on your teeth produce acid that demineralizes the teeth a little bit, but then the saliva flows in and replaces the layer that has been removed.”
The effect of a dry mouth on tooth decay is not as well known as it should be, Watson says. “Most patients and doctors are not aware of the problem.” Dental researchers say millions of people are at heightened risk for tooth decay because of the medicines they take. Watson says the problem is particularly common among the elderly, many of whom take several medications that stem the flow of saliva.
“A dry mouth can start an unfortunate cycle. To make his mouth feel better, the person starts drinking liquids constantly, oftentimes juices or colas that contain sugar and are acidic. That just promotes tooth decay. If you start sipping those all day, you end up in trouble.”
In addition to medication, an autoimmune disease known as Sjögren’s syndrome as well as radiation treatment for cancers of the head or neck can also knock out saliva flow by damaging the salivary glands. Watson says that doctors who treat patients who have Sjögren’s or cancer, as well as physicians who treat the elderly, are among the health-care professionals who should be especially aware of the dental effects of dry mouth.
Dentists like Watson take a variety of steps when they encounter patients whose medications cause dry mouth. Oftentimes Watson speaks with the patient’s physician about switching to another medicine, reducing the dose, or changing the timing of the dose. Other suggestions can include more vigilant brushing, a change in diet, and less frequent snacking. Or he might recommend a mouthwash with fluoride, or even a prescription fluoride gel.
Watson urges patients on medications to be vigilant in brushing their teeth and having their teeth checked and cleaned every six months. “If there is evidence that there’s a problem, then the medication might be playing a role, and they should speak to their dentist or physician.”
For its latest research, the team chose to study clonidine because half of adults who take the medicine for high blood pressure complain of dry mouth. The medicine is also being used more and more by doctors to treat children who have attention deficit hyperactivity disorder. The drug tricks the body into releasing less of the neurotransmitters acetylcholine and norepinephrine, which stimulate the salivary glands.
Watson’s group compared cavities in 56 rats, including some on the medication and some that weren’t. The control rats had an average of 30 cavities on their smooth tooth surfaces, while their counterparts on clonidine had an average of more than 55 cavities, an 84-percent jump. The discrepancy was less but still notable on the teeth’s chewing surfaces.
Since rodents develop cavities similar to humans, researchers often turn to rats to understand the tooth decay in human patients. “What promotes cavities in rats promotes cavities in humans, and what prevents or controls cavities in rats controls them in humans,” says Watson, who is also assistant professor in the Eastman Department of Dentistry. Watson was joined in the research, funded by the National Institutes of Health, by technical associate Sylvia Pearson and William Bowen, B.D.S., Ph.D., Welcher Professor of Dentistry.
Prescription Medication: An Agent of Decay
At Bash Dental, we offer comprehensive 24-hour dental services for the Philadelphia region. We also believe it is important to educate our patients about different topics regarding their oral health.
When discussing tooth decay, the perils of sugary foods and drinks tend to take center stage. Although sugar is a culprit, another agent of decay is often glanced over. Your prescription medication could be causing far more damage than you realized. Here are some things you should know about the harm your prescriptions can cause.
Benefits of Saliva
Saliva acts as a buffer to keep teeth healthy as it fends off harmful bacteria, regulates PH and aids tooth remineralization. Without proper salivary function, your teeth will almost certainly suffer some degree of damage. The overwhelming cause of prescription drugs damaging teeth comes down to decreased salivary flow. When saliva production is lessened, teeth are more vulnerable to acid attack- mitigating the effects of bacteria.
What prescription drugs can damage my teeth?
There are hundreds of prescription medications that can pose a threat to your oral health. Below is a brief list of those which most commonly prescribed which can cause tooth decay because of dry mouth
Although dry mouth is a common cause, commonly prescribed antibiotics such as Doxycycline can also adversely affect dentin development in the teeth of unborn babies and children up to the seven years old.
The risks that prescription medications pose to your teeth are not always communicated or known by doctors. Furthermore, the risks and warning pamphlets included with your medication at the pharmacy aren’t always complete. Always be sure to ask your doctor about your medication and do not quit until you get the data.
In addition to your prescription drugs, lifestyle choices, habits and side effects of the drug can cause tooth damage to progress at an accelerated rate.
For example, to combat dry mouth, it’s natural to experience the urge to take in more fluids. All too often, those fluids are filled with sugar and acid that only weakened enamel more susceptible to damage.
Stimulants commonly prescribed for ADHD (Adderall, Ritalin) are notorious for causing lack of appetite. Not only is this bad for your overall health, but going without eating also denies the body of increased saliva production that aids digestion. This further impacts the salivary buffer time teeth should experience on a daily basis. Overuse and abuse of your medication can also exacerbate the damaging effect of certain prescription meds.
Some more compounding factors include:
- Failure to visit your dentist regularly
- Unaddressed grinding or clenching issues
- Caffeine intake
- Poor home care
- Poor diet
- Use of recreational drugs such as cocaine and crystal meth
Ways to Mitigate Damage
If your medication is necessary, there are some ways to lessen the damaging effect that medications can have on teeth and gums. Here are just a few
- Chew sugar-free gum to encourage the production of saliva
- Make sure you know the risks of your medication by asking your doctor or pharmacist if it can be damaging to your teeth. Ask your doctor about lower dosages and if less harmful alternatives exist for your condition.
- Make an effort to avoid exacerbating factors like smoking, consuming soda and energy drinks, high-stress lifestyle
- Be proactive and methodical about regular dental checkups and maintaining an excellent home care regimen
What can I do now?
Fortunately, we can help repair damaged teeth if the decay is caught early enough. However, tooth damage from medications and dry mouth can occur rather quickly and tend to affect many teeth simultaneously, so it’s up to you to ensure that potential issues are detected in a timely manner.
Remember, to be honest about all prescription and recreational drug use with your dentist and doctor. Also, never stop taking your prescribed drug without the direct supervision of your doctor.
If your medication is causing consistent dry mouth, then you are at a higher risk for tooth damage than others. Make an appointment at Bash Dental, the leading 24-hour emergency dentist serving Philadelphia, to regain control of your oral health.
5 Ways Opioids Can Affect Teeth and Gums
Posted November 26, 2018
Drug abuse is considered one of the most devastating health problems worldwide. In recent years, medical professionals have focused on the harmful effects of opioids, an addictive pain reliever. Long-term opioid use can cause a range of medical conditions and oral health problems. Consider five ways opioids can affect teeth and gums.
1. Tooth decay – Studies show that people addicted to opioids often stop taking care of themselves, including daily brushing and flossing their teeth, and seeing the dentist for checkups and cleanings. Neglected oral care can increase tooth decay and cause tooth loss.
2. Dry mouth – Regular use of opioids can dry out oral tissues and reduce the amount of saliva the mouth produces. Saliva naturally lubricates the mouth and keeps tissues moist. It also removes food particles stuck between teeth and along the gumline. It controls oral acids and bacteria that attack tooth surfaces and causes decay and bad breath.
3. Acid reflux – Opioid users tend to have increased amounts of acid reflux, which can damage tooth enamel and gum tissues.
4. Weakened teeth and gum tissues – Opioid users who neglect their oral health may experience several other problems, such as:
- Bruxism – Users are more prone to grind their teeth, which can crack and break enamel and weaken the jaw.
- Reduced blood flow to oral tissues – Blood contains oxygen that helps keep tissues healthy. Decreased blood flow to oral tissues can cause them to die and weaken tooth structures including the jaw.
- Mouth sores and ulcers – Diminished blood flow and reduced saliva can increase the development of painful mouth sores and ulcers.
5. Masked pain – Since opioids reduce pain, people may not detect changes in their teeth and gums, such as decay and periodontal disease. Studies show that some opioid users apply the drug directly into the teeth and gums to dull dental pain. They put off seeing a dentist until experiencing significant oral health problems.
American Addiction Centers
National Institutes of Health
Dental Products Report
Year : 2015 | Volume : 4 | Issue : 1 | Page : 19-24
Applications of Corticosteroids in Dentistry
Jatan Sanghavi1, Amita Aditya2
1 Department of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||19-Oct-2015|
Reader, Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Corticosteroids, since their introduction in the 1940s, have become one of the most widely prescribed class of drugs. They belong to a class of chemicals that includes steroid hormones that are produced naturally in the adrenal cortex of vertebrates and analogous to those that are synthesized in laboratories. They have been used extensively in managing many oral diseases, due to their excellent anti-inflammatory and immuno-modulatory effects. However, considering their potential and significant side-effects, they are sometimes termed as the “double-edged sword” in the field of medicine. Their successful use depends upon the comprehension of the disease process. This includes an appropriate diagnosis, a clear view of the desirable treatment outcome and understanding of whether the treatment is aimed at the management of a chronic disease or enhanced resolution of a short-term condition. The possible beneficial effects of systemic corticosteroids must be weighed against probable risks. This article is aimed at reviewing the use of corticosteroids in the treatment of various oral conditions and lesions, and deriving a certain protocol for the same.
Keywords: Corticosteroids, dentistry, oral lesions
How to cite this article:
Sanghavi J, Aditya A. Applications of Corticosteroids in Dentistry. J Dent Allied Sci 2015;4:19-24
Corticosteroids have been in regular clinical usage for a range of inflammatory and immune-mediated conditions for over half a century. Their initial recognition and subsequent development from clinical observations about 80 years ago lead to the Nobel Prize award in Medicine to Kendall, Reichstein and Hench in 1950. This certifies to their extreme importance in physiological homeostasis and in clinical medicine. An extract of animal adrenocortical tissue could counteract human adrenal failure, which was the first clinical evidence, was demonstrated in 1930. By 1940, it became evident that there are two categories: Those that cause retention of sodium and fluid and those that counteract shock and inflammation. Intra-articular and oral administration of cortisone and hydrocortisone began in 1950-51. Several attempts in research to produce cortisone semi-synthetically showed some success by 1952. Between 1954 and 1958, six synthetic steroids were introduced for systemic anti-inflammatory therapy. By 1960, all of the toxic effects of long-term corticosteroid administration had been reported. In addition, protocols to withdraw such drugs while reducing the symptoms of cortical insufficiency were made. To be able to use lower corticosteroid doses, companion use of nonsteroidal anti-inflammatory drugs began in the late 1950s (phenylbutazone was the first). In the 1970s, methotrexate and other anti-metabolites were introduced which lead to a reduction in dosages and limited use of corticosteroids in rheumatic diseases. Wide applications of corticosteroids in Dentistry can be mainly owed to their excellent anti-inflammatory and immuno-modulatory properties. Glucocorticosteroids exhibit intervention at several points in the immune response and appear to affect many aspects of inflammation. In fact, corticosteroids have evolved and emerged as the mainstay of therapy for numerous oral lesions and conditions.
Corticosteroids are chemically similar to endogenous cortisol which is vital in protein, carbohydrate, and fat metabolism, maintenance of vascular reactivity, and body adaption to stress. , Every day, the adrenal gland normally produces about 24-30 mg of cortisol, but may produce up to 300 mg of cortisol in times of great stress. The secretion of cortisol is regulated by circadian rhythm, a stress-related response, and a negative feedback mechanism between the adrenals, hypothalamus, and pituitary. When supraphysiologic doses of corticosteroids (>30 mg cortisol equivalent) are given for over 14 days, the hypothalamic-pituitary-adrenal axis may become suppressed and may even take up to 12 months to recover. A functional ability to respond to stress, however, has been shown to return within 2 weeks to 1 month. ,
The normal secretion rate of the two principal corticoids in human is:
- Hydrocortisone: 10-20 mg daily (nearly half of this is in the few morning hours).
- Aldosterone: 0.125 mg daily.
|Mechanism of Action|
The corticosteroids have wide spread of actions. These include maintenance of fluid electrolytes, cardiovascular and energy substrate homeostasis as well as functional status of skeletal muscles and nervous system. They basically prepare the body to withstand any type of stress. They have both direct and permissive actions. Actions of corticosteroids may be broadly divided into :
- Glucocorticoids: Affects carbohydrate, protein, and fat metabolism.
- Mineralocorticoids: Affects Na + , K + , and fluid balance.
|Applications in Management of Oral Lesions and Conditions|
Recurrent aphthous stomatitis
The drugs that are most commonly adopted for local application orally in recurrent aphthous stomatitis (RAS) are hydrocortisone hemisuccinate (pellets of 2.5 mg) and triamcinolone acetonide (adhesive paste containing 0.1% of the steroid). Gel, pellets, and pastes can be applied directly to the lesion post meals and at bedtime twice or thrice a day or mixed with an adhesive such as orabase before application.
Ulcerations that are located in the areas which are inaccessible can be controlled by topical dexamethasone elixir, 0.5 mg/5 ml held over the area or applied with a saturated gauge pad to the ulcers, 4 times/day for 15 min or betamethasone sodium phosphate rinse by dissolving 0.5 mg in 5 ml of water and asking the patient to rinse for 2-3 min), steroid aerosol (e.g., beclometasone diproprionate), or a high-potency topical corticosteroid, such as clobetasol 0.05% in orabase or fluocinonide 0.05%, in orabase.
Major aphthous ulcers commonly require systemic treatment as the approach initially. Prednisone therapy 40 mg/day for 1 week is usually adequate to manage the outbreak. Oral prednisone systemically is prescribed most commonly. Systemic prednisone therapy should begin at 1.0 mg/kg a day as a single dose in severe RAS patients and should be tapered after 7-14 days. Intralesional steroids can be employed to treat large indolent major RAS lesions.
Corticosteroids given locally often controls oro-genital ulcers, and immunosuppressive therapy is reserved for extreme mucocutaneous cases. The mainstay of treatment for Behcet’s disease is immunosuppressive therapy. Successful treatment includes anti-inflammatory agents that modify the activity of neutrophils. In the acute phase, prednisone, at doses of 40-60 mg/day, may be beneficial. It may be used alone or in combination therapy with other immunosuppressive agents.
Oral lichen planus
In treating mild to moderate symptomatic lesions, topical corticosteroids are the chief treatment agents. They are widely used in the therapeutics of oral lichen planus (OLP) to reduce inflammation and pain. Options (in order of decreasing potency) include 0.05% clobetasol proprionate gel, 0.1-0.05% betamethasone valerate gel, 0.05% fluocinonide gel, 0.05% clobetasol ointment or cream, and 0.1% triamcinolone acetonide ointment. Triamcinolone acetonide is used either in orabase or lozenge form.
In widespread OLP, high-potency steroid mouthwashes such as disodium betamethasone phosphate, or clobetasol propionate can be used.
Intralesional corticosteroid injection for recalcitrant or extensive lesions involves the subcutaneous injection of 0.2-0.4 ml of a 10 mg/ml solution of triamcinolone acetonide via a 1.0 ml 23- or a 25-gauge tuberculin syringe.
Intralesional triamcinolone acetonide in doses of 0.5-1 ml of a 1 mg/ml suspension in the form of bi-weekly injections, or even 3-4 times a week in more severe cases can be used for the treatment of erosions.
Systemic corticosteroids are used for recalcitrant erosive or erythematous lichen planus where topical therapy has not been effective. Systemic prednisolone is the drug of choice, but should be employed at the lowest possible dose for the least duration (40-80 mg for 5-7 days). It can be used to control the erythema and ulcers in OLP. The oral dose of prednisone is in the range of 10-20 mg/day for moderately severe cases to as high as 35 mg/day (0.5 mg/kg daily) for extreme cases.
Topical steroid therapy
Oral topical steroids provide symptomatic relief. Clobetasol propionate mouthwashes in aqueous solution may offer another topical approach to this patient population. The mouthwash-solution provides ready accessibility to all lesional areas, and there is good control over the contact time between the lesion and the drug.
Systemic steroid therapy
Moderate-to-severe oral erythema multiforme can be treated with a short course of systemic glucocorticosteroid in patients without severe contraindications to their usage.
Prednisone may be used in patients with severe lesions at a dose of 40-80 mg/day for 1-2 weeks then tapered rapidly. Initial therapy with systemic prednisone (0.5-1.0 mg/kg/day) or pulse methylprednisolone (1 mg/kg/day for 3 days) has shown effective results.
Corticosteroids may be employed in the following forms: A paste, an ointment, or a mouthwash administered as monotherapy or as adjunctive therapy with systemic treatment. In patients without progressing oral lesions, moderate to high-potency topical corticosteroids should be applied twice or thrice a day, such as 0.05% fluocinolone acetonide or 0.05% clobetasol propionate.
Systemic corticosteroid therapy
In patients with severe disease and the spread of lesions is to the dermal surfaces, the systemic corticosteroid is the drug of choice. The first drug used to treat this disease is prednisolone and, almost, all situations, is the first line of treatment. The starting dose is more; a total oral dose of 100-200 mg prednisolone is employed every day until clinical signs abate. The dose can be gradually reduced to a maintenance level of 40-50 mg daily.
Intralesional corticosteroid therapy
This accelerates the scarring process of a lesion. It may be used to treat persistent lesions. This treatment, which does not give consistent results, involves intralesional injections given every 1-2 weeks; treatment is ceased after 3 injections if there is no improvement. Scarring is often seen along with cutaneous or mucosal atrophy, which is the main drawback of this treatment.
Mucous membrane pemphigoid
Topical steroid therapy
Lesions that are mild and localized usually respond to topical steroids, including triamcinolone, fluocinonide, and clobetasol propionate. Mild oral lesions should be managed with topical and intralesional steroids. Desquamative gingivitis can often be managed with topical steroids in soft dental splint covering the gingiva, although the clinician must closely monitor the patient for side effects such as candidiasis and effects of systemic absorption.
Systemic steroid therapy
In patients with high risk, such as with multiple oral lesions, the administration of prednisone 1-2 mg/kg/day, with gradual dose reduction, and immune-suppressors such as cyclophosphamide (0.5-2 mg/kg/day), azathioprine 1-2 mg/kg/day, or mycophenolate mofetil 2-2.5 g/day have shown good results.
Topical steroid therapy
In patients with the limited or moderate disease, potent topical corticosteroids should be considered. In recent times, low dose topical clobetasol propionate (10-30 g daily) was shown to have similar short-term efficacy but reduced side-effects compared to the high-dose topical regimen (40 g daily clobetasol propionate).
Systemic steroid therapy
High-dose systemic corticosteroids are the standard initial treatment of bullous pemphigoid to manage the eruptions, and prolonged high-doses are commonly used in severe cases.
Initial doses of prednisolone are 20 mg/day or 0.3 mg/kg/day in localized or mild disease, 40 mg/day or 0.6 mg/kg/day in moderate disease, and 50-70 mg or 0.75-1 mg/kg/day in severe disease are recommended. In patients with limited disease, clobetasol propionate cream alone is used; in patients with moderate disease, clobetasol propionate cream may be combined with dapsone (1.0-1.5 mg/kg/day) and in severe cases, oral prednisolone (0.5 mg/kg/day) may be added.
Intralesional corticosteroid therapy
Triamcinolone acetonide 3-10 mg/ml can be administered to resistant lesions intralesionally. Experience benefits in injecting correctly, thereby maximizing efficacy and minimizing atrophy. When pemphigoid is not responsive to steroids, or large maintenance doses are required, other “steroid-sparing” agents can be administered.
Systemic lupus erythematosus
Lesions that are symptomatic can be managed with high-potency topical corticoids or injections of intralesional steroids. Systemically low dose prednisone 10-20 mg/day or a dose of 20-40 mg every alternate day may be required in some cases.
Potent topical steroids and antimalarials are the prime drugs to treat systemic lupus erythematosus. Patients commonly begin with a topical steroid (e.g., betamethasone or clobetasol) applied 2 times a day, and then shift to a lower-potency steroid as soon as possible. Intralesional corticosteroid injection is useful as a supportive therapy for individual lesions.
Treatment should be conservative, depending upon the severity and probable prognosis in each case. If there are no specific contraindications, immunocompetent patients are administered prednisone at 1 mg/kg/day (maximum 80 mg) for the 1 st week and tapered over the following week. Patients with partial palsy should also be managed as there are chances of around one-fifth of these cases to be progressive in nature.
Ramsay Hunt syndrome
Definitive treatment consists of antiviral therapy. Often, it includes steroids. Adjunctive steroid therapy may help in the treatment of the facial paralysis of Ramsay Hunt syndrome. However, steroid therapy should be employed with proper caution, especially with periocular lesions, because of the fear of dissemination of the VZV infection.
A large prospective study showed that combination therapy with both acyclovir and steroids leads to a better recovery of facial nerve function in comparison to steroids administered alone.
Post herpetic neuralgia
Corticosteroids are used, which help to treat pain, swelling, and also reduce the risk of recurrence of post herpetic neuralgia (PHN) significantly.
Prednisolone is the drug most commonly prescribed in heavy doses to herpes patients. A moderate dose of prednisone 40 mg daily for 10 days, which is gradually tapered off over the following 3 weeks is a very effective and safe routine in reducing the incidence of PHN.
The use of steroids in combination with an antiviral for uncomplicated herpes zoster is controversial. Steroids increase the resolution of acute neuritis as well as provide a definite improvement in the quality of life in comparison to those patients treated with antivirals alone. The use of oral steroids did not affect the development or duration of PHN though it seems reasonable for steroids to be used adjunctive to antiviral therapy.
The use of oral or epidural corticosteroids concurrently with antiviral therapy has been effective in treating moderate-to-severe acute zoster, but has no effect on the development or duration of PHN. ,
Temporomandibular joint disorders
Toller suggested that intra-articular corticosteroid injections were only useful in adult patients with temporomandibular joint (TMJ) disorders; a single intra-articular injection resulted in resolution of TMJ pain and other symptoms in 62% of adult patients, compared to only 17% of pediatric patients.
Triamcinolone acetonide which has been used for this purpose is absorbed from the injection sites very slowly. The dose ranges between 2 and 40 mg, depending upon the size of the joint to be injected. The dose is usually 10 mg in cases of TMJ.
Oral prednisone is the first-line acute therapy for temporal arteritis. Vast majority of patients respond to an initial dose of 1 mg/kg/day, or between 40 and 60 mg/day of prednisone. The dose is lowered after 2-4 weeks and slowly tapered over 9 months to 1 year.
Higher doses of 80-100 mg/day are suggested for patients of GCA with visual or neurological symptoms. Intravenous pulse methylprednisolone has been proposed as an induction therapy, especially when vision is at risk.
Medical emergencies in dental practice
Adrenal crisis prophylaxis
Acute adrenal crisis, with the lack of mineralocorticoids and glucocorticoids, is a medical emergency. Symptoms include abdominal pain, weakness, hypotension, dehydration, nausea, and vomiting. Laboratory findings may include hyperkalemia, hyponatremia, hypoglycemia, uremia, and acidosis.
Exogenous glucocorticoids can lead to suppression of adrenal gland and resultant atrophy. This may cause a decreased glucocorticoid response to stress, and precipitate an adrenal crisis.
- Intravenous fluids (in the form of 5% dextrose in normal saline).
- Primary adrenal insufficiency: Start on 20-25 mg hydrocortisone per 24 h.
- Secondary adrenal insufficiency: 15-20 mg hydrocortisone per 24 h; if borderline fails in cosyntropin test considers 10 mg or stress dose cover only.
- Hydrocortisone should initially be given intravenously. If there is an improvement within 24 h, the hydrocortisone dose can be reduced. This can be changed to an oral formulation whenever the patient is stable. The dose can be declined by one-third to one-half the doses daily until a maintenance dose of 20 mg in the morning and 10 mg in the afternoon or at night is attained. Some patients may need only a dose of 20 mg/day total (i.e., 20 mg every morning, or 15 mg in the morning and 5 mg in the afternoon or at night).
- The condition that precipitated the crisis, such as infection, should be searched. The underlying cause should be treated.
- Patients will not need mineralocorticoid replacement because the renin angiotensin-aldosterone axis is intact.
Anaphylaxis is the quintessential disease of emergency medicine. Steroids are unlikely to be beneficial in the management of acute anaphylaxis. One of the reasons is their delayed onset of 4-6 h.
With the antihistamines, despite their many theoretical benefits on mediator release and tissue responsiveness, there are no placebo-controlled trials that can confirm how much steroids are effective in the treatment of anaphylaxis. Most clinicians, however, give prednisone 1 mg/kg up to 50 mg orally or hydrocortisone 1.5-3 mg/kg intravenously specific in patients with airway involvement and bronchospasm, based empirically on their crucial role in asthma.
Steroids are fundamental in the management of recurrent idiopathic anaphylaxis.
Applications in restorative dentistry
Corticosteroid can be used as a dressing agent for deep cavities and exposed pulp tissue so as to control the inflammatory pulp response and decrease postoperative pain. The therapeutic effect of a corticosteroid depends upon its concentration, potency, and ability to diffuse into the connective tissue.
The results of studies that use corticosteroids as a cavity liner support that these medications are effective in decreasing or preventing postoperative thermal sensitivity.
The intracanal use of corticosteroid-antibiotic combination has been reported to effectively control the post treatment endodontic pain.
Perioperative corticosteroid use in dentoalveolar surgery
Dentists are often advised to use corticosteroids during and after third molar removal and other dentoalveolar surgery for reducing the postsurgical edema.
Dexamethasone has a longer duration of action and is more potent than methyl prednisolone. Methylprednisolone is usually administered via the intramuscular or intravenous route, though the possibility of the topical (intra-alveolar) application has been described, showing a reduction in morbidity and possible side-effects. It is 5 times more potent than cortisol.
Corticosteroids cause the adrenal glands to slow or stop the production of cortisol. Hence, they cannot be discontinued abruptly. The adrenal glands take some time to start producing cortisol again. Tapering the dose of corticosteroids gradually allows the body to start producing its own supply of cortisol again.
The usage of corticosteroids is vast, yet crucial. No wonder, cortisol (hydrocortisone) is called the “life-protecting hormone” and aldosterone, the “life-saving hormone.”
Corticosteroids used in different forms can be given intralesionally, topically, and even systemically. Sometimes it may be given to control edema, whereas, in some situations, it is given because of its immunosuppressive properties. Even though corticosteroids have adverse effects, their anti-inflammatory and immuno-modulatory properties are very beneficiary and supersede them.
It can be said in conclusion that corticosteroids play an important role in the management of lesions affecting the oral mucosa and skin. In addition, its importance in medical emergencies cannot be neglected.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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