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Dr. Smijal PG Its Year Department of Periodontics
Dr. Smijal PG Its Year Department of Periodontics
Smijal
PG Its year
Department of Periodontics
INTRODUCTION
• Adrenal corticosteroids are necessary regulators of
homeostatic life processes.
• Natural hormones include
Glucocorticoid
Mineralocorticoid
Sex hormones
HISTORY
• Hench (1949) -improvement in
rheumatoid arthritis by using
cortisone
• In 1950 Nobel Prize -Kendall and
Reichstein and Hench, for developing
corticosteroids
• Currently, drugs with one of the
broadest spectrum of clinical utility.
CHEMICAL STRUCTURE
• 4 cycloalkane rings
• 3 cyclohexane rings
• 1 cyclopentane ring .
• Gonane is the simplest steroid
• Vary by the configuration of the side
chain, the number of additional methyl
groups, and the functional groups
attached to the rings
ADRENAL GLAND
Corticosteroid Hormones
• Epinephrine
• Norepinephrine
• Dopamine
Regulating salt and
water
• Suppress inflammation
and immunity
• Breakdown
of fats, carbohydrates,
and proteins,
• Resistance to stress
•Mineralocorticoids Aldosterone
•Glucocorticoids Cortisol
Corticosterone Testosterone
11 Desoxyhydro
cortisone
Aldosterone
Hydrocortisone
24-30mg of cortisol
300mg of cortisol
• Most potent
Corticosterone • Provides 95% of glucocorticoid
activity
Hypothalamus
Feedback inhibition
Corticotropin releasing factor
Anterior pituitary
ACTH
Adrenal cortex
Cortisol
MINERALOCORTICOIDS
Source : Zona glomerulosa
Juxtaglomerular Excretion of K+
angiotensinogen Renin
apparatus Retention of Na+
Retention of water
28
• Group A
• (short to medium acting glucocorticoids)
Hydrocortisone, Hydrocortisone acetate, Cortisone
acetate, Tixocortol pivalate, Prednisolone,
Methylprednisolone, and Prednisone.
• Group B
• Triamcinolone acetonide, , Mometasone, Amcinonide,
Budesonide, Desonide, Fluocinonide, Fluocinolone
acetonide, and Halcinonide.
29
•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
30
Classification of steroids based on their
relative activity:
GLUCOCORTICOIDS
ADRENAL INSUFFICIENCY
• Endocrine disorder
• Inadequate production of adrenal androgens,
mineralocorticoids and glucocorticoids by the
adrenal cortex
• Primary AI
• Secondary AI
PRIMARY ADRENAL INSUFFICEINCY
• Addison disease
• Progressive destruction of the adrenal cortex
• Idiopathic nature (most commonly autoimmune)
• Weakness, fatigue, loss of appetite, weight loss and
patchy hyperpigmentation of the skin and oral mucosa.
SECONDARY ADRENAL INSUFFICEINCY
Inhibition of
Hypothalamic/ feedback loop-
Pituitary disease pituitary and adrenal
glands
Failure to
Chronic produce cortisol
administration Failure of production
of exogenous of
corticosteroids adrenocorticotropin
•2-3 Times more common
•Selectively causes glucocorticoid
deficiency
•Mineralocorticoid function is better
maintained than in primary AI and the
condition is less likely to cause acute
adrenal crisis
ADRENAL CRISIS
• Rare, potentially lethal event
• Precipitated by stress
• In patients with chronic AI.
• Primary AI > Secondary AI
• Susceptible patients have diminished adrenal
reserve and are unable to secrete sufficient amounts
of the steroid the body requires during a stressful
event.
• Fever, gastrointestinal complaints, hypotension,
tachycardia and electrolyte disturbances.
• Hypovolemic shock and cardiovascular failure can
ensue.
• Few cases have been reported during dental care
RISK FACTORS OF ADRENAL CRISIS
• Significant and unrecognized AI
• Poor health status and stability at the time of dental
treatment (acute illness, fever)
• Pain
• Infection
• Extractions or invasive procedures that caused
bleeding and discomfort
• Use of general anesthetic containing a barbiturate.
Management Of 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.
• Changed to an oral formulation whenever the patient is stable.
• The dose 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.
• The condition that precipitated the crisis should be treated.
• Patients will not need mineralocorticoid replacement because
the renin angiotensin-aldosterone axis is intact.
It is best not to rub the TC in, because this can produce
irritation.
JDR April 2005 vol. 84 no. 4 294-301
Prolonged topical therapy
•Can cause atrophy of epidermis, dermis
•Subcutis
•Disturbed wound healing
•Hypertrichosis
•Perioral dermatitis
Heike Scha¨cke, Wolf-Dietrich Do¨cke, Khusru Asadullah; Mechanisms involved in
the side effects of glucocorticoids; Pharmacology & Therapeutics 96 (2002) 23 – 43
Major aphthae or severe multiple minor
aphthae
• Prednisone therapy 1.0 mg/kg/day in
patients with severe RAU and tapered
after 1 to 2 weeks.
• Predisone therapy 1- 2mg /kg/day after
breakfast until the disease is controlled
and then maintenance dose of 2.5 to
15mg daily ( Burket 11th edition )
ERYTHEMA MULTIFORME
• Minor EM – 20 to 40
mg/day for 4 to 6 days
• Severe or rapidly progressing lesions – 60
mg/day slowly tapered by 10mg/day over 6
weeks Indian J Ophthalmol Jan-Feb 2010;58(1):64-66
PEMPHIGUS VULGARIS
• Mainstay 1-2mg/kg/d.
• Clobetasol propionate
• 20 -40 mg/day is most effective for the
treatment.
• Lets keep it mind that these drugs do not cure the disease but rather
control or relieve the symptoms.
References
• Risk of adrenal crisis in dental patients Results of a systematic search; May/June 2014
• Steroids in Dentistry - A Review Sambandam V, Int. J. Pharm. Sci. Rev. Res., 22(2), Sep – Oct
2013; nᵒ 44, 240-245
• Steroids Application In Oral Diseases, Int J Pharm Bio Sci 2013 Apr; 4(2): (P) 829 – 834
• Murthy, J. M. K., and Amrit B. Saxena. “Bell’s Palsy: Treatment Guidelines.” Annals of Indian
Academy of Neurology 14.Suppl1 (2011): S70–S72. PMC. Web. 23 Jan. 2017.
Thank You