Adrenocorticosteroids

Chapter 16
Alina, Claire, Edith and Phil
Definitions, Mechanism
of release, and
Classification
 Definitions - the following terms are used in
this chapter:
Addison disease: Disease/condition produced by a deficiency of adrenocorticosteroids.

Adrenocorticosteroids/ Steroidal components released from the adrenal cortex, including

corticosteroids/steroids: glucocorticoids and mineralocorticoids.

Adrenocorticotropic Agent secreted by the pituitary that causes the release of hormones
hormone (ACTH): from the adrenal cortex.

Glucocorticoids: Adrenocorticosteroids that primarily affect carbohydrate metabolism.

Mineralocorticoids: Adrenocorticosteroids that affect the body’s sodium and water balance
(fluid levels).
 Mechanism of
release
● The adrenocorticosteroids are naturally occurring compounds
secreted by the adrenal cortex.
● Their release is triggered by a series of event.

I. Initially, a stimulus such as stress causes the

hypothalamus to release corticotropin-releasing
hormone, which acts on the pituitary gland.

II. Under the influence of CRH, the pituitary gland

secretes adrenocorticotropic hormone, which stimulates
the adrenal cortex to release hydrocortisone.

III. hydrocortisone then acts on both the pituitary and

hypothalamus to inhibit the release of CRH and ACTH,
respectively
Mechanism of release

Negative feedback -
● Exogenous steroids acts in the same way as hydrocortisone - as they inhibit
the release of CRH and ACTCH.

➔ With long-term administration of steroids, ACTH release is suppressed and the

adrenal gland degenerate.

➔ However, if the administration of the exogenous steroid is then suddenly

stopped, a relative steroid deficiency occurs. Which may lead to severe
problems, including adrenal crisis.
 Classification

GLUCOCORTICOIDS MINERALOCORTICOIDS

The term adrenocorticosteroids refers to those steroids secreted by the

adrenal cortex and includes both the GLUCOCORTICOIDS +
MINERALOCORTICOIDS.

➔ However, in this chapter we will primarily discuss about the action of

GLUCOCORTICOIDS due to their common use.
 GLUCOCORTICOIDS

➔ Affect intermediate carbohydrate metabolism + the mineralocorticoids - which alter the water and
electrolyte composition of the human body.

➔ Major glucocorticoid in the body is CORTISOL (hydrocortisone).

NOTE: The chemical structures of the synthetic agents and the naturally occurring adrenocorticosteroids
(ex: hydrocortisone), are very similar

➔ Without stress: The normal body secretes abouts about 20 mg of hydrocortisone daily.
➔ Maximal secretion occurs between 4 a.m. + 8 a.m. in individuals with a normal schedule.

★ Many chemical modifications have attempted to produce synthetic glucocorticoids

with less adverse reactions and more specific activity.
Routes, Action, and
Pharmacologic
Effects
 Routes of Administration
● Adrenocorticosteroids are used topically, orally, intramuscularly, and
intravenously.
● The oral, intramuscular, and intraveneus route usually produces systemic
effects, but topical administration rarely causes systemic effects.
○ However, if a large amount of steroid is used topically, especially if the skin is covered
with with an occlusive in addition to plastic wrap, then systemic effects can occur.
 Mechanism of Action
1) Steroid binds to a specific receptor, forming
a steroid-receptor complex.
2) The complex translocates into the nucleus
and alters gene expression either by turning
on or off a specific gene. This results in the
regulation of many cellular processes.
3) Due to this process, there is a lag time for
adrenocorticosteroids to take action.
**Other effects of adrenocorticoids can be mediated
by catecholamines producing vasodilation or
bronchodilation.
● Adrenocorticoids have an antiinflammatory effect because of
their influence on the number, distribution, and function
peripheral leukocytes and from their inhibition of
phospholipase A.
● The use of steroids results in an increase in the concentration
of neutrophils and a decrease in the lymphocytes (T and B
cells),monocytes, eosinophils, and basophils.
● Steroids also induce the synthesis of a protein that inhibits
phospholipase A, decreasing the production of both
prostaglandins and leukotrienes from arachidonic acid.
(Prostaglandins and leukotrienes aid in the inflammatory
process)
● Steroids also inhibit interleukin-2, migration inhibition factor,
and macrophage inhibition factor.
 Pharmacologic
effects
Effects Summary: Antiinflammatory + Suppress Allergic Reactions/Immune

Corticosteroids are for relief and usually not a cure.

Adverse Reactions,
Uses,
Corticosteroid
Products
Adverse Reactions
● Adverse reactions of corticosteroids are proportional to the dose, frequency and time of
administration, and duration of treatment

● Metabolic changes
● Infections
● Central nervous system effects
● Peptic ulcer
● Impaired wound healing and osteoporosis
● Ophthalmic effects
● Electrolyte and fluid balance
● Adrenal crisis
● Dental effects
 Adverse Reactions
Central nervous system effects
(when increase dose)

● Changes in behaviour/personality
● Euphoria
● Agitation
● Psychoses Metabolic changes
● Depression
● Moon face (round)
● Buffalo lump
● Truncal obesity
Infections
● Weight gain
● Decrease resistance to infection
● Mask inflammatory symptoms
● Pts taking Long-term glucocorticoid
therapy should be given anti tuberculosis
agent to prevent tuberculosis
 Adverse Reactions

Peptic ulcer
Impaired wound healing and osteoporosis
● Increases production of stomach
● The catabolic effects of the steroid that acid and pepsin
results from impaired synthesis of collagen
interferes with wound healing (same with
osteoporosis and delay growth in children
● Affects alveolar bone, and tooth loss
● Thinning of bone Ophthalmic effects
● Fractures
● Muscle wasting, bruising ● Can increase intraocular pressure , can
exacerbate glaucoma
● Cataracts are associated with steroids
 Adverse Reactions

Electrolyte and fluid balance Adrenal crisis Dental effects

● Glucocorticoids contains ● Adrenal suppression
Is stressful situation arises, ● Oral tissue changes
mineralocorticoid action ●
adrenal gland cannot respond ● Delay healing
causing sodium and water
adequately ● Risk of infection
retention
Weakness, syncope , ● Friable tissue
● Hypertension and CHF ●
cardiovascular collapse, death ● Oral candidiasis
may be worsened
● Hypokalemia can also
result
 Uses: Medical
Replacement:

● Patients with hypofunction of adrenal cortex need replacement of glucocorticoid and

mineralocorticoid.

Emergency:

● Corticosteroids are used in emergency situations for the treatment if chick or adrenal crisis

Inflammation/Allergy:

● Prednisone is the most commonly used. Inflammation of the soft tissues have been treated with
corticosteroids
 Uses: Dental

Oral lesions

● Effective in tx of oral lesions associated with noninfectious inflammatory disease.

Aphthous stomatitis

● The evidence for the benefit of adrenocorticosteroids in the treatment of aphthous stomatitis as shown results.

Temporomandibular joints

● Arthritis of the TMJ a;sp responds to systemic administration of steroids. Can decrease pain and improve movements

Oral surgery

● Adrenocorticosteroids have been used to reduce post-op pain, the magnitude of benefit mus outweigh against the potential risk of infection and decrease
healing. Safety and effectiveness have not been proven

Pulp procedures

● Adrenocorticosteroids have been used in pulp capping in pulpotomy procedures, to control hypersensitive cervical dentin. But still experimental
 Corticosteroid products
The list in compared to equivalent disease in milligrams base on 20mg of hydrocortisone, which
is the amount normally secreted daily by an adult without stress

● Ex: Prednisone has an anti inflammatory activity of 4, which means it has anti inflammatory action as hydrocortisone.
● Ex: triamcinolone does not increase salt retention whereas hydrocortisone does
● Ex: 0.75 mg on dexamethasone = 20 mg of hydrocortisone
Dental Implications,
Management, DH
Considerations, and
Clinical Case Study
 Dental implications
● The use of steroids in dentistry has had mixed success
● Oral Lesions
● Aphthous Stomatitis (Canker sores)
● Arthritis of the temporomandibular joint (TMJ)
● Adrenocorticosteroids have been used in oral surgery to reduce postoperative edema,
trismus, and pain.
● Pulp capping, in pulpotomy procedures, and for the control of hypersensitive cervical
dentin. Their use in these situations is currently empirical or experimental.
● Benefits must be weighed against potential risk of infection and decreased healing.
The safety and effectiveness of these agents have not been proved in double-blind
controlled studies.
 Dental management and negative
implications
● MANAGEMENT
○ Most dental patients taking steroids who are having NORMAL dental treatment
DO NOT need additional corticosteroids. Supplemental steroids may be
required if a patient has severe dental fears or for major surgical procedures.
● NEGATIVE IMPLICATIONS
○ Steroids have actions that can contribute to periodontal disease
○ First, they interfere with the body's’ response to infection (inflammatory
mediators are inhibited)
○ Second, steroids can cause osteoporosis which may reduce the bony support for
the teeth
 Dental management continued
● No supplementation needed, depending on risk category
○ Steroid therapy stopped > 1 year ago
○ Dose < 20 mg/day hydrocortisone (HC) or 5 mg/day prednisone
○ Dose > 40 mg/day HC or 10 mg/day prednisone
○ Duration of therapy < 1 month
○ Every-other-day therapy
● Supplementation may be needed depending on risk category
○ Dose 20-40 mg HC or 5-10 mg prednisone/day
○ Duration of therapy > 1 month
● Supplemental steroid doses
○ Minor risk – 25 mg HC or 5mg prednisone on day of surgery
○ Moderate risk – 50-75 mg HC on day of surgery and for at least 1 post-op day
○ Major risk – 100-150 mg HC on day of surgery and for at least 1 post-op day
 Dental hygiene considerations
● Obtain a detailed medication history in order to avoid drug interactions
● Obtain a detailed health history because corticosteroids can interfere with or
exacerbate several medical illnesses
● Encourage the patient to avoid the use of NSAIDs and aspirin, which can cause GI
upset and ulcer
● Antibiotics may be necessary for patients using corticosteroids on a long-term basis
● Check for symptoms of osteoporosis of the jaw and bone
● Corticosteroids
○ Elevate blood pressure and pulse
○ Increase risk for GI upset and ulcer
○ Can cause behavioral changes which could interfere with the patient’s ability to
sit through an appointment (may need to reschedule)
○ Can mask the symptoms of infection and delay wound healing
Case studies
CLINICAL CASE STUDIES

1. Your patient has been taking 5mg of prednisone daily for 5 years. She is very
calm and relaxed. You are to perform an oral prophylaxis. What should be
given to your patient on the day of her dental appointment?

2. You are reviewing the chart of a patient you will treat tomorrow. She has
been taking 60mg of prednisone for 12 years for systemic lupus
erythematosus. What problems might occur if the patient experiences oral
mucosa trauma? What is the recommended supplemental steroid does for
this patient?
CLINICAL CASE STUDIES: ANSWERS

1. Most dental patients taking steroids who are having normal dental treatment DO
NOT NEED additional corticosteroids. No supplementation is needed, especially
since the patient is calm and not experiencing anxiety about the dental appointment.

2. Because steroids suppress immune reaction, infections are more likely to occur and
healing is delayed. The most likely steroid supplementation would be to administer
2-3 times the patient’s usual daily dose the day of the procedure and 1 hour before.
If pain is expected to persist into the next day, then 2 times the usual daily dose
should also be given the following day.
The End
References

● Haveles, E. B. (2019). Applied Pharmacology for the Dental Hygienist. Mosby.