Glucocorticosteroid replacement therapy: a literature review and suggested replacement therapy

Cortisol in Oral and Maxillofacial Surgery: A Double-Edged Sword

Cortisol is a hormone that is naturally produced by the zona fasciculata of the cortex in the adrenal gland. One of its main functions is to decrease inflammation, particularly in areas where an inflammatory response is not necessary. In the field of oral and maxillofacial surgery, cortisol is used to improve the outcomes of surgical procedures and to make the postoperative period more comfortable for the patient. However, cortisol is considered a double-edged sword because its use is associated with both benefits and adverse effects. It is imperative to use cortisol following an accurate diagnosis, in addition to clarity regarding the desired surgical procedure for treating the acute or chronic condition affecting the patient. When used with caution, cortisol can serve as a valuable agent for reducing the postoperative inflammatory response in patients undergoing moderate as well as moderately severe surgical procedures.

Death related to dental treatment: a systematic review

OBJECTIVE

The aim of this study was to identify factors associated with death in relation to dental care.

STUDY DESIGN

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Dental and Oral Sciences Source, Web of Science, and the Cochrane database were searched, and the references of all retrieved articles were analyzed. Studies were included if death had occurred within 90 days of the dental appointment, and if the patient's age, procedure, and information regarding cause or time of death were provided. Factors associated with death were assessed by multivariate analyses and logistic regression.

RESULTS

Fifty-six publications, including retrospective studies and case reports/series that reported 148 fatalities, were analyzed. On average, 2.6 deaths were reported per year. The leading cause of deaths was anesthesia/sedation/medication-related complications (n = 70). Other causes were cardiovascular events (n = 31), infection (n = 19), airway-respiratory complications (n = 18), bleeding (n = 5), and others (n = 5). Age (P < .0001), disease severity (P < .02), disease stability (P < .006), dental provider characteristics (P < .05), level of consciousness/sedation (P < .02), and drug effects (P < .03) had significant associations with death.

CONCLUSIONS

Reports of death were rare; however, specific risk factors associated with dentistry were identified. A better understanding of these factors is important for the development of guidelines that help prevent fatalities in dentistry.

Immune suppression and considerations for dental care

Immunocompromised individuals present a challenge to oral health care providers. As the spectrum of patients with dysfunctional immune responses continues to broaden, practitioners should be able to identify these patients, understand the potential for complications, and manage their dental care safely and effectively. This article reviews various immune deficiencies, addresses complications that may result from an individual's immune status, and discusses dental considerations for these patients.

Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem

BACKGROUND

Dental patients with primary or secondary adrenal insufficiency, or AI, may be at risk of experiencing adrenal crisis during or after invasive procedures. Since the mid-1950s, supplemental steroids in rather large doses have been recommended for patients with AI to prevent adrenal crisis.

METHODS

To evaluate the need for supplemental steroids in these patients, the authors searched the literature from 1966 to 2000 using MEDLINE and textbooks for information that addressed AI and adrenal crisis in dentistry. Reference lists of relevant publications and review articles also were examined for information about the topic.

RESULTS

The review identified only four reports of purported adrenal crisis in dentistry. Factors associated with the risk of adrenal crisis included the magnitude of surgery, the use of general anesthetics, the health status and stability of the patient, and the degree of pain control.

CONCLUSIONS

The limited number of reported cases strongly suggests that adrenal crisis is a rare event in dentistry, especially for patients with secondary AI, and most routine dental procedures can be performed without glucocorticoid supplementation.

CLINICAL IMPLICATIONS

The authors identify risk conditions for adrenal crisis and suggest new guidelines to prevent this problem in dental patients with AI.

The dental patient with asthma. An update and oral health considerations

OVERVIEW

Asthma is a serious global health problem that has steadily increased in prevalence during the past two decades. New classification and treatment guidelines have been published, and dental providers need to be aware of these changes.

LITERATURE REVIEWED

The authors searched textbooks and MEDLINE, looking for the most updated medical information on asthma, as well as for previous publications on treatment of asthmatic patients in a dental setting.

RESULTS

More than 9,000 articles on asthma were published in English between 1997 and 2000. From 1960 until 2000, approximately 40 articles specifically addressed asthma and dental care. The authors reviewed more than 300 articles from the medical literature and all articles after 1980 that directly focused on oral health issues for importance and relevance.

CONCLUSIONS

Recent information regarding the etiology, pathogenesis and treatment of asthma had not been adequately addressed in the dental literature. Dental care of asthmatic patients may necessitate considerations beyond what has previously been published in the dental literature.

CLINICAL IMPLICATIONS

In the treatment of asthma, as with treatment of most medical conditions, oral health care providers play a role that is important in terms of both the patient's overall health and the systemic condition's effect on oral health. This article provides dentists with a timely update on asthma and the relationship between asthma and oral health, and it offers suggestions for safe and appropriate dental care.

Rheumatoid arthritis: a review and suggested dental care considerations

BACKGROUND

Rheumatoid arthritis, or RA, is a chronic multisystem disease of presumed autoimmune etiology. It is estimated that arthritis and other rheumatic conditions affect 42.7 million Americans. Medical complications due to RA and its treatment may affect the provision of oral health care.

METHODS

The authors undertook an extensive review of the English literature relating to RA and dental care. They used primarily MEDLINE searches, which included such key words as "rheumatoid arthritis" and "dental care" and subsequent appropriate subheadings. While the MEDLINE search spanned the years from 1975 to the present, the most recent literature was prioritized. Appropriate medical and dental textbooks were also used. The authors extrapolated information from selected texts based on its relevance to dentistry, oral health and the role of the dental provider in the overall treatment of RA patients.

RESULTS

The authors reviewed nearly 200 articles and seven textbooks. Their determination of the texts' relevance to oral health care was based on content, significance, quality, journal in which articles were published and year of publication. Major features of RA--including its diagnosis, pathophysiology, clinical features and medical treatment--were identified, as well as complications due to treatment modalities and various related oral manifestations and conditions.

CONCLUSIONS

Medical complications due to RA and its treatment can affect oral health care. Oral health care providers need to recognize and identify modifications of dental care based on the medical status of patients with RA. Furthermore, oral health care providers play an important role in the overall care of these patients as it release to early recognition, as well as control of the disease.

CLINICAL IMPLICATIONS

In most patients with RA, the condition will necessitate few or no changes in routine dental care. However, considerations include the patient's ability to maintain adequate oral hygiene, xerostomia and its related complications, the patient's susceptibility to infections, impaired hemostasis, and untoward drug actions and interactions. Patients with RA may require antibiotic prophylaxis owing to joint replacement and/or immune suppression, glucocorticosteroid replacement therapy and modifications in oral hygiene procedures. Intra- and extraoral conditions such as ulcerations, gingival overgrowth, disease-associated periodontitis and temporomandibular pathology also need to be recognized.

Lupus erythematosus: considerations for dentistry

Lupus erythematosus, or LE, is a connective tissue disease that affects a number of organ systems. Patients with this condition can experience several other serious conditions--bleeding, infection, endocarditis, adrenal insufficiency and mucocutaneous disease--that can affect the provision of dental care. The authors describe considerations for managing dental treatment of patients with LE.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

Dental considerations in asplenic patients

The spleen plays an important role in the body's defense mechanism against microbial infections. However, trauma or diseases sometimes make removal of this important organ necessary, which predisposes patients to certain infections. This increased risk of infection and the underlying reason for the organ's removal both may affect the provision of dental care. This article reviews the structure and function of the spleen, conditions that may require its removal or cause its dysfunction, and provides considerations for dentists who care for asplenic patients.

Salivary cortisol response to dental treatment of varying stress

The physiologic stress of various dental procedures (dental examination, dental prophylaxis, restoration, root canal therapy, and tooth extraction) was measured in 50 nonsmoking healthy men between the ages of 18 and 55 years (mean 34.6 years, range 21 to 53 years) with a salivary cortisol assay. Expectorated saliva was collected at four time points: 10 minutes before the start of the procedure, 15 minutes after the patient was seated, at the end of the procedure, and 1 hour after the completion of the procedure. Of the 196 samples included for analysis, mean cortisol values ranged from 0.1 to 3.8 micrograms/dl with a recovery of 100% +/- 8.4%. The mean cortisol value for the extraction group (1.09 +/- 0.42 microgram/dl) was significantly different (p < 0.05) from the mean values of the examination (0.46 +/- 0.10 microgram/dl), prophylaxis (0.64 +/- 0.64 microgram/dl), root canal (0.49 +/- 0.07 microgram/dl), and restorative (0.60 +/- 0.04 microgram/dl) groups as determined by the Duncan's multiple range test. Cortisol levels decreased from the initial reading to the end of the procedure by about 15% for patients undergoing an examination, root canal, and restorative procedure. Cortisol levels at the end of the procedure were elevated in the prophylaxis (55%) and extraction (148%) groups compared with the baseline cortisol recording. A minority of patients in the prophylaxis group had elevated cortisol levels throughout dental treatment, whereas cortisol levels were elevated during treatment in 80% of patients undergoing extraction. These data suggest that the adrenal stress response associated with tooth extraction(s) is greater than that associated with other routine dental procedures.

Effect of variable doses of dexamethasone on posttreatment endodontic pain

One hundred six patients with pretreatment pain presenting for endodontic treatment participated in a controlled double blind study. After root canal therapy, the patients were given an intraoral intramuscular injection of either a saline placebo or various dosages of dexamethasone. Posttreatment pain incidence and severity were evaluated at 4, 8, 24, 48, and 72 h. Injection of the various dosages of dexamethasone, taken as a group, was shown to significantly reduce the severity of pain at 4 and 8 h, and 0.07 to 0.09 mg/kg dosage alone significantly reduced pain at 8 h. Patients who received dexamethasone took significantly fewer posttreatment pain medications than those who received the placebo. Although there was a trend toward a reduction in the incidence of posttreatment pain for patients who received dexamethasone, the difference was not statistically significant.

Monitoring for adverse effects from systemic drugs used in dermatology

Systemic drugs with an associated element of risk are essential in managing many important dermatoses. This review identifies eight major drugs or drug groups used in dermatology that require systematic monitoring for adverse effects. The complete monitoring process is emphasized, including significant patient involvement in reporting key signs or symptoms that allow early diagnosis of many of these adverse effects. The concepts of "risk-risk" assessment and "critical toxicities" are defined, emphasizing their important role in maximizing drug benefits and safety. Drug-related risk factors, disease-specific risk factors, and patient characteristics or habits that increase the risks from systemic drugs are identified. Basic principles of monitoring for adverse effects, specific clinical features of the most important adverse effects, along with detailed monitoring guidelines for methotrexate, retinoids, dapsone, corticosteroids, and cyclosporine are presented.