Date post: | 14-Dec-2014 |
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DIVISION OF ORAL AND DIVISION OF ORAL AND MAXILLOFACIAL SURGERYMAXILLOFACIAL SURGERY
STEROIDSSTEROIDSDr V.RAMKUMAR CONSULTANT DENTAL & FACIOMAXILLARY SURGEON REG NO .4118 -TAMILNADU -INDIA- (ASIA)
Corticosteroids and their Corticosteroids and their biologically synthetic analogs biologically synthetic analogs possess glucocorticoid and possess glucocorticoid and mineralocorticoid action.mineralocorticoid action.
Adrenocortical SteroidsAdrenocortical Steroids
The adrenal cortex synthesizes two classes of The adrenal cortex synthesizes two classes of steroids-steroids-
•The glucocorticoidsThe glucocorticoids
ex; hydrocortisoneex; hydrocortisone•The mineralocorticoidThe mineralocorticoid
ex; aldosterone ex; aldosterone
GLUCOCORTICOIDSGLUCOCORTICOIDS
Short acting
Compound Equiv. dose (anti-inflammatory
1. Hydrocortisone (cortisol) 2. Cortisone
20mg 25mg
3. Prednisolone4. Methylprednisolone5. Triamcinolone
5mg4mg Intermediate acting4mg
6. Paramethasone7. Dexamethasone8. Betamethasone
2mg0.75mg Long acting0.75 mg
MINERALO CORTICOIDSMINERALO CORTICOIDS
9. Desoxycorticosterone acetate (DOCA)
10. Fludrocortisone11. Aldosterone
2.5 mg (sublingual)0.2 mg Not used clinically
ADERNOCORTICAL STERIODSADERNOCORTICAL STERIODS
Adernocortical SteriodsAdernocortical SteriodsAdernal cortex
(Synthesizes two classes of steroids)
Androgen(19 carbon atoms)
Corticosteriods (21 carbon atoms)
Mineralocorticoids (Electrolyte balance regulating)
Glucocorticoids (Carbohydrate metabolism regulating)
Hydrocortisone(cortisol)
Aldosterone
Pharmacological actionsPharmacological actions
Increases gluconeogenesis Increases gluconeogenesis
Increases the peripheral Increases the peripheral utilization of glucose. utilization of glucose.
Protein metabolismProtein metabolism
Decreases the conversion of of Decreases the conversion of of amino acids to proteinsamino acids to proteins
Increases muscle wastingIncreases muscle wasting Increase in loss of bone matrixIncrease in loss of bone matrix
Anti inflammatory and allergy Anti inflammatory and allergy responseresponse
Steroids decreases the production of Steroids decreases the production of inflammatory cells.inflammatory cells.
Steroids interact with antigen antibody Steroids interact with antigen antibody complex and reduces the allergy complex and reduces the allergy response.response.
Mineral metabolismMineral metabolism
Steroids causes sodium and water Steroids causes sodium and water retention and produces oedemaretention and produces oedema
Fat metabolism . It produces moon Fat metabolism . It produces moon face in the head and neck region.face in the head and neck region.
Mood changes . It causes euphoria.Mood changes . It causes euphoria.
Anti vitamin D actionAnti vitamin D action
Absorption of calcium from the gut is Absorption of calcium from the gut is impaired due to steriod action.impaired due to steriod action.
Routes of administrationRoutes of administration
TopicalTopical OralOral IntramuscularIntramuscular Intra venousIntra venous
Therapeutic uses in oral and Therapeutic uses in oral and maxillofacial surgerymaxillofacial surgery
Minor surgical proceduresMinor surgical procedures TraumaTrauma TumorsTumors Orthognathic surgical proceduresOrthognathic surgical procedures Neuro surgical proceduresNeuro surgical procedures
Therapeutic Uses in Non-Therapeutic Uses in Non-endocrine Diseaseendocrine Disease
Rheumatic Disorders( phempigus)Rheumatic Disorders( phempigus) Renal diseasesRenal diseases Allergic DiseaseAllergic Disease Antiemetic ActionAntiemetic Action In AsthmaIn Asthma Immunosuppressive Action Immunosuppressive Action Ocular DiseaseOcular Disease Skin Disease Skin Disease
Contd…Contd…
GIT DiseaseGIT Disease Hepatic DiseaseHepatic Disease MalignanciesMalignancies Cerebral EdemaCerebral Edema Apthous stomatitisApthous stomatitis Lichen planusLichen planus
MISCELLANEOUS DISEASE MISCELLANEOUS DISEASE AND CONDITIONSAND CONDITIONS
• SarcoidosisSarcoidosis• ThrombocytopeniaThrombocytopenia• Autoimmune Destruction of Erythrocytes Autoimmune Destruction of Erythrocytes • Organ Transplantation Organ Transplantation • Spinal Cord Injury Spinal Cord Injury
Therapeutic preparation and dosageTherapeutic preparation and dosage
Topical application Topical application Corlan pellet(hydrocortisone Corlan pellet(hydrocortisone
hemisuccinate.2.5mg)hemisuccinate.2.5mg) Triamcinolonepaste(vehicle consist of Triamcinolonepaste(vehicle consist of
gelatin methyl cellulose pectin)gelatin methyl cellulose pectin)
TriamcinoloneTriamcinolone
It is availabe as injectable and water It is availabe as injectable and water formform
Tablets 8-20 mgTablets 8-20 mg Injection 10mg vialInjection 10mg vial
DexamethasoneDexamethasone
Available in oral and injection formsAvailable in oral and injection forms Oral dose .2-10mgOral dose .2-10mg Iv 4-20 mgIv 4-20 mg BethamethasoneBethamethasone available as local drops skin creams available as local drops skin creams
ointment and lotionsointment and lotions Iv 4-20 mg.6-8hrly.Iv 4-20 mg.6-8hrly.
Rule of two Rule of two
Pt receiving steroids for two years Pt receiving steroids for two years twice a week the dose to be doubledtwice a week the dose to be doubled
Major complicationsMajor complications
Suppression of hypothalmohypophyseal Suppression of hypothalmohypophyseal axis.axis.
Git disturbances.dyspepsia Git disturbances.dyspepsia haemorrhage perforationhaemorrhage perforation
Infection(tb, fungal,candidiasis)Infection(tb, fungal,candidiasis) Iatrogenic cushing syndrome(skin Iatrogenic cushing syndrome(skin
becomes pale and thin)becomes pale and thin) Skeletal osteoporosisSkeletal osteoporosis Metabolic odema Metabolic odema
Mental disturbanceMental disturbance Increased intra ocular pressureIncreased intra ocular pressure
Minor complicationMinor complication
AcneAcne
StriaeStriae
Weight gainWeight gain
Increased apetiteIncreased apetite
Dental Management GuidlinesDental Management Guidlines
Define the risk of adrenal insufficiency Define the risk of adrenal insufficiency through history and clinical examination.through history and clinical examination.
Insure that patient have taken sufficient Insure that patient have taken sufficient doses.doses.
Schedule surgery in the morning.Schedule surgery in the morning. Stress reduction.Stress reduction. Use of nitrous oxide-oxygen or IV or oral Use of nitrous oxide-oxygen or IV or oral
benzodiazepine sedation is helpful.benzodiazepine sedation is helpful.
Contd.Contd. Avoid the use of barbiturates.Avoid the use of barbiturates. Avoid GA for out patient procedure.Avoid GA for out patient procedure. Discontinue drug therapy that decreases Discontinue drug therapy that decreases
cortisol levels at least 24 hours before cortisol levels at least 24 hours before surgery.surgery.
Adequate pain control.Adequate pain control. Methods to reduce blood loss should be used.Methods to reduce blood loss should be used. BP below 100/60 mm should receive fluid BP below 100/60 mm should receive fluid
replacement.replacement. Take care of hypoglycemia and hypovolemia.Take care of hypoglycemia and hypovolemia.
MANAGEMENT OF ADRENAL MANAGEMENT OF ADRENAL INSUFFICIENCY INSUFFICIENCY
Conscious patientConscious patient
Terminate dental treatmentTerminate dental treatment
If asymptomatic, supine with feet elevated, If If asymptomatic, supine with feet elevated, If symptomaticsymptomatic
A-B-C provide BLS, as neededA-B-C provide BLS, as needed
D- definitive care, monitor vital signs, medical D- definitive care, monitor vital signs, medical assistance, obtain emergency kit and O2assistance, obtain emergency kit and O2
Administer glucocorticosteroid, if available and Administer glucocorticosteroid, if available and if history of insufficiencyif history of insufficiency
Consider additional management; provide BLS, Consider additional management; provide BLS, O2, glucocorticosteroid, as needed, establish O2, glucocorticosteroid, as needed, establish
IV lineIV line
Unconscious patientUnconscious patient
Recognize UnconsciousRecognize Unconscious
supine with feet elevated slightlysupine with feet elevated slightly
A-B-C provide BLS, as neededA-B-C provide BLS, as needed
monitor vital signs, medical monitor vital signs, medical assistance, obtain emergency kit assistance, obtain emergency kit
and O2, Administer and O2, Administer glucocorticosteroidglucocorticosteroid
Establish IV line, Establish IV line,
if possible TRANSFER TO if possible TRANSFER TO HOSPITALHOSPITAL
THANK YOUTHANK YOU