chapter 19: adrenocorticosteroids copyright © 2011, 2007 mosby, inc., an affiliate of elsevier. all...

Chapter 19:Chapter 19:

AdrenocorticosteroidsAdrenocorticosteroids

Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

22Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Chapter 19 OutlineChapter 19 Outline

AdrenocorticosteroidsAdrenocorticosteroids Mechanism of releaseMechanism of release ClassificationClassification DefinitionsDefinitions Routes of administrationRoutes of administration Mechanism of actionMechanism of action Pharmacologic effectsPharmacologic effects Adverse reactions Adverse reactions UsesUses Corticosteroid productsCorticosteroid products Dental implicationsDental implications


AdrenocorticosteroidsAdrenocorticosteroids

Haveles (p. 241)Haveles (p. 241) A group of agents secreted by the adrenal A group of agents secreted by the adrenal

cortexcortex Use in dentistry: used topically or systemically for Use in dentistry: used topically or systemically for

treatment of oral lesions associated with treatment of oral lesions associated with inflammatory disordersinflammatory disorders

Long-term therapy: prescribed for patients with Long-term therapy: prescribed for patients with chronic systemic diseases such as asthma or chronic systemic diseases such as asthma or arthritisarthritis


Mechanism of ReleaseMechanism of Release

Haveles (pp. 241-242) (Fig. 19-1)Haveles (pp. 241-242) (Fig. 19-1) Adrenocorticosteroids are naturally occurring Adrenocorticosteroids are naturally occurring

compounds secreted by the adrenal cortex; compounds secreted by the adrenal cortex; release is triggered by a series of eventsrelease is triggered by a series of events A stimulus such as stress causes the hypothalamus A stimulus such as stress causes the hypothalamus

to release corticotropin-releasing hormone (CRH)to release corticotropin-releasing hormone (CRH) CRH acts on the pituitary glandCRH acts on the pituitary gland

cont’d…cont’d…



The pituitary gland releases adrenocorticotropic The pituitary gland releases adrenocorticotropic hormone (ACTH), which stimulates the adrenal hormone (ACTH), which stimulates the adrenal cortex to release hydrocortisonecortex to release hydrocortisone

Hydrocortisone acts on the pituitary and the Hydrocortisone acts on the pituitary and the hypothalamus to inhibit the release of CRH and hypothalamus to inhibit the release of CRH and ACTHACTH• This mechanism is called negative feedbackThis mechanism is called negative feedback




Exogenous steroids act in the same way as Exogenous steroids act in the same way as hydrocortisone; they also inhibit the release hydrocortisone; they also inhibit the release of CRH and ACTHof CRH and ACTH With long-term administration of steroids, ACTH With long-term administration of steroids, ACTH

release is suppressedrelease is suppressed Adrenal crisis may occur if exogenous steroids are Adrenal crisis may occur if exogenous steroids are

abruptly withdrawnabruptly withdrawn


ClassificationClassification

Haveles (pp. 241-242)Haveles (pp. 241-242) Adrenocorticosteroids are divided into two Adrenocorticosteroids are divided into two

major groupsmajor groups Glucocorticoids: affect intermediate carbohydrate Glucocorticoids: affect intermediate carbohydrate

metabolismmetabolism Mineralocorticoids: affect water and electrolyte Mineralocorticoids: affect water and electrolyte

composition of the bodycomposition of the body The major glucocorticoid present in the body The major glucocorticoid present in the body

is cortisol (hydrocortisone)is cortisol (hydrocortisone)


DefinitionsDefinitions Haveles (p. 242)Haveles (p. 242)

Addison disease: disease/condition produced by Addison disease: disease/condition produced by deficiency of adrenocorticosteroidsdeficiency of adrenocorticosteroids

Adrenocorticosteroids/corticosteroids/steroids: Adrenocorticosteroids/corticosteroids/steroids: glucocorticoids and mineralocorticoids released from glucocorticoids and mineralocorticoids released from the adrenal cortexthe adrenal cortex

ACTH: secreted by pituitary, causes release of ACTH: secreted by pituitary, causes release of hormones from the adrenal cortexhormones from the adrenal cortex

Cushing syndrome: disease/condition caused by Cushing syndrome: disease/condition caused by excess of adrenocorticosteroidsexcess of adrenocorticosteroids

Glucocorticoids: adrenocorticosteroids primarily Glucocorticoids: adrenocorticosteroids primarily affecting carbohydrate metabolismaffecting carbohydrate metabolism

Mineralocorticoids: adrenocorticosteroids that affect the Mineralocorticoids: adrenocorticosteroids that affect the body’s sodium and water balancebody’s sodium and water balance


Routes of AdministrationRoutes of Administration

Haveles (p. 242) (Table 19-1)Haveles (p. 242) (Table 19-1) Glucocorticoids are available a wide variety of Glucocorticoids are available a wide variety of

dose formsdose forms May be used topically, orally, intramuscularly, and May be used topically, orally, intramuscularly, and

intravenouslyintravenously Systemic effects are common when the drug is Systemic effects are common when the drug is

administered orally or parenterally, but topical administered orally or parenterally, but topical administration may rarely cause systemic effectsadministration may rarely cause systemic effects


Mechanism of ActionMechanism of Action

Haveles (pp. 242-243)Haveles (pp. 242-243) Steroids bind to a specific receptor and form Steroids bind to a specific receptor and form

a steroid-receptor complexa steroid-receptor complex The complex translocates into the nucleus and The complex translocates into the nucleus and

alters gene expression to regulate many cell alters gene expression to regulate many cell processesprocesses

There is a lag time in the action of steroids, and There is a lag time in the action of steroids, and the relationship between their effects and blood the relationship between their effects and blood level is poorlevel is poor



Mechanism of ActionMechanism of Action

Antiinflammatory action of glucocorticoids Antiinflammatory action of glucocorticoids results from profound effects on the number, results from profound effects on the number, distribution, and function of peripheral distribution, and function of peripheral leukocytes and to their inhibition of leukocytes and to their inhibition of phospholipase Aphospholipase A Use of steroids results in an increase in the Use of steroids results in an increase in the

concentration of neutrophils and decrease in concentration of neutrophils and decrease in lymphocytes, monocytes, eosinophils, and basophilslymphocytes, monocytes, eosinophils, and basophils

Inhibition of phospholipase A decreases production Inhibition of phospholipase A decreases production of prostaglandins and leukotrienesof prostaglandins and leukotrienes

Steroids also inhibit interleukin-2, migration inhibition Steroids also inhibit interleukin-2, migration inhibition factor, and macrophage inhibition factorfactor, and macrophage inhibition factor


Pharmacologic EffectsPharmacologic Effects

Haveles (pp. 243-244) (Box 19-1)Haveles (pp. 243-244) (Box 19-1) Effects for which they are used include Effects for which they are used include

antiinflammatory action and suppression of antiinflammatory action and suppression of allergic reactionsallergic reactions

They suppress the immune responseThey suppress the immune response Corticosteroids are palliative rather than curativeCorticosteroids are palliative rather than curative


Adverse Reactions of Adverse Reactions of GlucocorticoidsGlucocorticoids

Haveles (pp. 243-244) Haveles (pp. 243-244) Proportional to the dose, frequency, and time of Proportional to the dose, frequency, and time of

administration, and duration of treatmentadministration, and duration of treatment Metabolic changes: moon face, buffalo hump, truncal Metabolic changes: moon face, buffalo hump, truncal

obesity, weight gain, and muscle wasting produce obesity, weight gain, and muscle wasting produce Cushing syndrome appearanceCushing syndrome appearance

Hyperglycemia may be aggravatedHyperglycemia may be aggravated Infections: corticosteroids decrease resistance to Infections: corticosteroids decrease resistance to

infectioninfection Central nervous system effects: changes in behavior Central nervous system effects: changes in behavior

and personality, including euphoria (with increasing and personality, including euphoria (with increasing dose), agitation, psychoses, and depression (with dose), agitation, psychoses, and depression (with decreasing dose) behaviordecreasing dose) behavior




Peptic ulcer: corticosteroids stimulate an increase Peptic ulcer: corticosteroids stimulate an increase in production of stomach acid and pepsinin production of stomach acid and pepsin

Impaired wound healing and osteoporosis: Impaired wound healing and osteoporosis: catabolic effects resulting from impaired synthesis catabolic effects resulting from impaired synthesis of collagen can impair wound healingof collagen can impair wound healing

Ophthalmic effects: corticosteroids can increase Ophthalmic effects: corticosteroids can increase intraocular pressure, may exacerbate glaucomaintraocular pressure, may exacerbate glaucoma• Cataracts are associated with steroidsCataracts are associated with steroids




Electrolyte and fluid balance glucocorticoids with some Electrolyte and fluid balance glucocorticoids with some mineralocorticoid action can produce sodium and water mineralocorticoid action can produce sodium and water retentionretention• Hypertension or congestive heart failure may be exacerbated; Hypertension or congestive heart failure may be exacerbated;

hypokalemia may resulthypokalemia may result

Adrenal crisis: adrenal suppression with prolonged useAdrenal crisis: adrenal suppression with prolonged use• The adrenal gland cannot respond adequately if a stressful The adrenal gland cannot respond adequately if a stressful

situation arisessituation arises

Dental effects: delayed healing of mucosal surfaces, Dental effects: delayed healing of mucosal surfaces, more likely to have an infection, and are more friablemore likely to have an infection, and are more friable• Oral candidiasis may result with use of oral steroid inhalersOral candidiasis may result with use of oral steroid inhalers


Uses of CorticosteroidsUses of Corticosteroids

Haveles (p. 245) (Box 19-2)Haveles (p. 245) (Box 19-2) Medical usesMedical uses

Replacement: patients with hypofunction of the Replacement: patients with hypofunction of the adrenal cortex (Addison disease) need adrenal cortex (Addison disease) need replacementreplacement• Patients with a hyperfunctioning adrenal cortex (Cushing Patients with a hyperfunctioning adrenal cortex (Cushing

syndrome) may have a majority of the gland removed syndrome) may have a majority of the gland removed and need replacement therapyand need replacement therapy




Medical usesMedical uses Emergencies: used for treatment of shock or Emergencies: used for treatment of shock or

adrenal crisisadrenal crisis Inflammatory/allergic: treatment of a wide variety Inflammatory/allergic: treatment of a wide variety

of inflammatory and allergic conditionsof inflammatory and allergic conditions• Not curative, ameliorate symptoms Not curative, ameliorate symptoms

• Topical steroids are used for skin conditions which Topical steroids are used for skin conditions which involve dermatoses or “irritations”involve dermatoses or “irritations”




Haveles (p. 245) (Box 19-2)Haveles (p. 245) (Box 19-2) Dental usesDental uses

Oral lesions: systemically administered steroids may Oral lesions: systemically administered steroids may be effective in treatment of oral lesions be effective in treatment of oral lesions

Aphthous stomatitis: triamcinolone acetonide Aphthous stomatitis: triamcinolone acetonide (Kenalog in Orabase) has been advocated(Kenalog in Orabase) has been advocated

Temporomandibular joint: if only the joint is affected, Temporomandibular joint: if only the joint is affected, intraarticular injection can often decrease pain and intraarticular injection can often decrease pain and improve joint movementimprove joint movement

Uses in oral surgery: to reduce edema, trismus, and Uses in oral surgery: to reduce edema, trismus, and painpain

Pulp procedures: used in pulp capping, pulpotomies, Pulp procedures: used in pulp capping, pulpotomies, and control of hypersensitive cervical dentinand control of hypersensitive cervical dentin


Corticosteroid ProductsCorticosteroid Products

Haveles (p. 246) (Table 19-2)Haveles (p. 246) (Table 19-2) May be arranged according to duration of May be arranged according to duration of

action into short-, intermediate-, and long-action into short-, intermediate-, and long-acting groupsacting groups


Selected Corticosteroids, OralSelected Corticosteroids, Oral

Haveles (p. 246) (Table 19-2)Haveles (p. 246) (Table 19-2) Short actingShort acting

hydrocortisone (Cortisol)hydrocortisone (Cortisol) prednisone (Deltasone) prednisone (Deltasone) methylprednisolone (Medrol)methylprednisolone (Medrol)

Intermediate actingIntermediate acting triamcinolone triamcinolone prednisoloneprednisolone

Long actingLong acting dexamethasone dexamethasone betamethasone betamethasone


Dental ImplicationsDental Implications

Haveles (pp. 246-248)Haveles (pp. 246-248) Adverse reactionsAdverse reactions Steroid supplementationSteroid supplementation Topical useTopical use



Dental ImplicationsDental Implications

Haveles (p. 246) (Box 19-3)Haveles (p. 246) (Box 19-3) Steroids suppress the immune reactionSteroids suppress the immune reaction

Infections are more likely to occur and healing is Infections are more likely to occur and healing is delayed with chronic administrationdelayed with chronic administration

Symptoms of infections may be maskedSymptoms of infections may be masked


Adverse Reactions of Adverse Reactions of CorticosteroidsCorticosteroids

Haveles (pp. 246-247)Haveles (pp. 246-247) Gastrointestinal effects: adrenocorticosteroids Gastrointestinal effects: adrenocorticosteroids

stimulate acid secretionstimulate acid secretion Blood pressure: mineralocorticoid action can Blood pressure: mineralocorticoid action can

exacerbate hypertensionexacerbate hypertension Glaucoma: other agents that induce or exacerbate Glaucoma: other agents that induce or exacerbate

glaucoma should be used with cautionglaucoma should be used with caution Behavioral changes: bizarre behavior may be Behavioral changes: bizarre behavior may be

explained by presence or withdrawal from explained by presence or withdrawal from adrenocorticosteroidsadrenocorticosteroids

Osteoporosis: may be seen in patients taking long-Osteoporosis: may be seen in patients taking long-term adrenocorticosteroidsterm adrenocorticosteroids


Adverse Reactions of Adverse Reactions of AdrenocorticosteroidsAdrenocorticosteroids

Haveles (p. 247)Haveles (p. 247) Infection: antiinflammatory activity may mask symptoms Infection: antiinflammatory activity may mask symptoms

of infectionof infection Delayed wound healingDelayed wound healing Adrenal crisis: with prolonged administration of steroids, Adrenal crisis: with prolonged administration of steroids,

suppression of the hypothalamic-pituitary-adrenal axis suppression of the hypothalamic-pituitary-adrenal axis occursoccurs The body does not respond quickly to stress with release of The body does not respond quickly to stress with release of

hydrocortisonehydrocortisone Periodontal disease: steroids interfere with the body’s Periodontal disease: steroids interfere with the body’s

response to infection and can produce osteoporosis, response to infection and can produce osteoporosis, which may reduce bony support for teethwhich may reduce bony support for teeth


Steroid SupplementationSteroid Supplementation

Haveles (pp. 247-248) (Fig. 19-4)Haveles (pp. 247-248) (Fig. 19-4) With both low and very high doses of steroid, With both low and very high doses of steroid,

supplementation is not needed for patients who supplementation is not needed for patients who use chronic steroids and are to undergo a use chronic steroids and are to undergo a stressful dental procedurestressful dental procedure With some intermediate doses of steroids, additional With some intermediate doses of steroids, additional

steroids may be indicated if the procedure will steroids may be indicated if the procedure will produce severe stressproduce severe stress

Consult with the patients physicianConsult with the patients physician


Topical UseTopical Use

Haveles (p. 248)Haveles (p. 248) Steroids are used in dentistry to manage oral Steroids are used in dentistry to manage oral

conditions such as aphthous stomatitis, conditions such as aphthous stomatitis, related to inflammatory or immune conditionsrelated to inflammatory or immune conditions

chapter 19: adrenocorticosteroids copyright © 2011, 2007 mosby, inc., an affiliate of elsevier. all...

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