Steroids in dentistry

Question 1

List the source of steroids and list the three steroid hormones

Answer 1

• Endogenous source: adrenal cortex

3 steroid hormones:

1. Androgens
2. Mineralocorticoids (aldosterone, RAAS system)
3. Glucocorticoids (cortisol)

Question 2

Discuss the metabolism of synthetic glucocorticoids drugs in terms of absorption, transportation, metabolism and excretion

Answer 2

Absorption:
• GIT or application sites

Transportation:
• Plasma proteins

Metabolism:
• Liver

Secretion:
• Kidney (metabolic products 17-hydroxycorticosteroids, 17-ketosteroids)

Question 3

State the two general therapeutic applications of steroids

Answer 3

• Replacement therapy: Insufficient production of natural corticosteroids
• Suppression of inflammation and immune reactions

Question 4

Explain how glucocorticoids work (7)

Answer 4

It works by regulating gene expression and its mode of actions are diverse and complex. The consequences of gene expressions can be:
• Regulate stress associated manner to maintain various metabolic and homeostatic functions that are necessary for life
• Carbohydrate, protein, lipid and purine metabolism
• Electrolyte and water balance
• Functions of multi-organ systems
• Dermatologic effects
• Anti-inflammatory action
• Immune suppression effects

Question 5

Explain glucocorticoid use in replacement therapy, and in suppressing inflammatory/ immune reactions

Answer 5

Replacement therapy:
• Used for those who have insufficient production of natural corticosteroids

Suppression of inflammation and immune reactions:
• Rheumatoid arthritis, lupus
• Psoriasis, dermatitis, pemphigus, lichen planus
• Haematologic malignancies, idiopathic thrombocytopenic purpura
• Asthma, chronic bronchitis acute phase
• Crohn’s disease, Celiac disease, ulcerative colitis

Question 6

State the adverse effects of glucocorticoids (8)

Answer 6

• Increased infections
• Skin atrophy, acne, thinning of the skin and mucosa
• Poor wound healing
• Osteoporosis (reduced calcium absorption), muscle wasting
• Changes in body fat distribution (cushingoid appearance)
• Increase atherosclerotic disease risk
• Glucose intolerance
• Peptic ulcer and related complications

Question 7

Define adrenal crisis, and state its signs and symptoms (8)

Answer 7

Adrenal crisis:
• Prolonged high dosage administration leads to suppression of endogenous corticosteroids production. This causes acuate adrenal insufficiency and thus an adrenal crisis

Signs and symptoms: 
• Nausea, vomiting, diarrhea 
• Dehydration 
• Profound muscle weakness, lethargy
• Hypoglycaemia 
• Hypotension, tachycardia 
• Tachypnea 
• Confusion, loss of consciousness, convulsions
• Systemic effects

Question 8

List the 5 instances in dentistry in which glucocorticoids are used

Answer 8

• Oral ulceration lesions
• Temporomandibular joint pain
• Postoperative sequelae (swelling, pain)
• Allergic reactions
• Endodontic pain management

Question 9

List the 5 issues with applying topical glucocorticoids

Answer 9

• Wet environment (washes away drug)
• Mucosal lining/ bacteria
• Microbial host dynamics (might interact with drug)
• Mastication and speech
• Dental prosthesis, device

Question 10

Explain the:

• Goal of steroid treatment for oral ulcers
• Indications (6)
• Modes of delivery (2)

Answer 10

Goal of steroid treatment:
• Simply to manage symptoms (pain)
• It does NOT alter the underlying pathogenesis

The indications (6)
• Denture-induced ulcers
• Trauma
• Recurrent ulcerative stomatitis
• Erosive lichen planus
• Erythema multiforme
• Angular cheilitis

The modes of delivery
• Can be applied systemically for severe dermatological and mucosal diseases
• Paste or orabase as delivery vehicle to reduce dissolution and displacement

Question 11

State the side effect of steroid injections for TMJ disorders

Answer 11

• Intra-articular injection

* Side effect: Deterioration of the articular surfaces

Question 12

State an example of postoperative sequelae and the 3 ways steroids work

Answer 12

Example of post- operative sequelae:
• Treat paraesthesia caused by tooth extraction due to nerve bruising or stretching
• Symptoms: Change or loss of sensation that controlled by the nerve

Steroids are taken systemically. The 3 ways they work is:
• Reduce oedema (inflammation)
• Reduce trismus
• Reduce pain

Question 13

State how steroids:

• Help with allergic reactions
• Indications for its use
• Sources of oral allergens (3)
• Signs (6)
• Symptoms (3) of an allergy reaction

Answer 13

How steroids help
• Immunosuppressant and anti-inflammatory effects

Indications:
• Contact dermatitis
• Anaphylaxis

Sources of oral allergens:
• Dental materials (amalgam, resins, acrylics)
• Food or flavouring agents in oral hygiene products (peppermint, spearmint)
• Topically applied medications

Signs: 
• Erythema
• Oedema,
• Desquamation
• Ulceration
• Cheilitis
• Perioral dermatitis

Symptoms (3):
• Itchy
• Pain
• Taste alteration

Question 14

Explain the use of steroids in endodontics in terms of:

• Forms
• Active component

Answer 14

Forms:
• Paste: water soluble form, and it placed as an intracanal medicament
• Cement: hard setting lining for pulp capping or pulpotomy

Active components:
• Triamcinolone (steroid to reduce inflammation)
• Demeclocycline (antibiotics to kill bugs infecting root canal)