1. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 19 Adrenocorticosteroids

2. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Adrenocorticosteroids  Adrenocorticosteroids are naturally occurring compounds that are released by the adrenal gland.  Stress, anxiety, and the time of day cause the hypothalamus to release corticotropin-releasing hormone which acts on the pituitary gland.  The pituitary gland secretes adrenocorticotropic hormone which stimulates the adrenal cortex to release hydrocortisone.  Once sufficient levels of hydrocortisone have been reached, hydrocortisone causes the pituitary gland and hypothalamus to inhibit the release of their respective hormones. 2

3. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Classification  Glucocorticosteroids  These steroids affect intermediate carbohydrate metabolism.  Mineralocorticosteroids  These steroids affect the water and electrolyte composition of the body. 3

4. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Effects  Exogenous steroids (drugs) produce many different effects on the body.  Glucocorticosteroid effects are as follows:  Broad Carbohydrate metabolism Carbohydrate metabolism Antiinflammatory Antiinflammatory Antiallergenic Antiallergenic Enzyme action Enzyme action Membrane function Membrane function Nucleic acid synthesis Nucleic acid synthesis 4

5. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Effects  Glucocorticosteroids  Specific Catabolic (breaking down muscle mass) Catabolic (breaking down muscle mass) Increased gluconeogenesis Increased gluconeogenesis Decreased glucose use Decreased glucose use Inhibit protein synthesis Inhibit protein synthesis Increase protein catabolism Increase protein catabolism Decrease growth Decrease growth Decrease bone density Decrease bone density Decrease resistance to infection Decrease resistance to infection 5

6. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Pharmacologic Effects  Mineralocorticosteroid Effects  Increase in sodium retention  Increase in potassium loss  Edema and hypertension 6

7. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Reactions  Metabolic changes include moon face, buffalo hump, truncal obesity, weight gain, and muscle wasting.  Corticosteroids decrease resistance to infection. They also delay healing and mask the symptoms of infection.  Corticosteroids stimulate the increase in the production of stomach acid and pepsin. As a result, they can cause ulcers. 7

8. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Adverse Reactions  Corticosteroids can cause premature closure of the growth plates and can delay or stop growth in children.  They can also cause osteoporosis.  Corticosteroids increase intraocular pressure and can exacerbate glaucoma.  Some glucocorticosteroids can cause sodium and water retention and can cause hypertension.  Adrenal suppression can occur with long-term use and cause adrenal crisis. Adrenal crisis is characterized by weakness, syncope, cardiovascular collapse and death. 8

9. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Medical Uses 9

10. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dental Uses  Systemic steroids are often effective in the treatment of oral lesions due to noninfectious inflammatory disease.  Topical steroids are used to treat aphthous stomatitis.  Temporomandibular joint responds to systemic steroids.  Systemic steroids are used during oral surgery to reduce postoperative edema, trismus, and pain. 10

11. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dental Concerns  Gastrointestinal Adverse Effects  Dental patients should avoid aspirin and NSAIDs because of the increased risk for GI distress and ulcer. Acetaminophen is an acceptable pain reliever.  Blood Pressure  Check the patient’s blood pressure since steroids have the ability to raise blood pressure. Epinephrine use may need to be avoided if the patient’s blood pressure is elevated. 11

12. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dental Concerns  Behavioral Changes  Steroids can cause behavioral changes to include psychosis, euphoria, and depression. Appointments may need to be rescheduled if the patient becomes aggressive or psychotic.  Osteoporosis  Osteoporosis may occur in the patient’s jaw with long-term steroid use. Dental radiographs may be helpful in identifying patients with osteoporosis. 12

13. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dental Concerns  Infection  Steroids can mask the symptoms of infection. Patients taking long-term oral steroids may be needed to be seen more frequently to assess for signs of infection.  Patients may require antibiotics after a procedure because of their higher risk for infection and because of delayed wound healing. 13

14. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Dental Concerns  Antibiotic Prophylaxis  Because steroids can delay wound healing, patients receiving long-term oral steroids may require antibiotic prophylaxis prior to dental appointments.  Adrenal Crisis  Patients taking long-term oral steroids may require steroid supplementation prior to an oral surgical procedure because of the body’s inability to increase steroid production on its own. 14

15. Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Management of Dental Patients Taking Steroids 15