Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature

Abstract

Based to a great extent upon mainly anecdotal case reports and theory, there is a general acceptance that patients on longterm systemic steroid medication should receive supplementary glucocorticoids or 'steroid cover' when undergoing certain types of stressful treatment including dentistry. The theoretical basis to this practice is that exogenous steroids suppress adrenal function to an extent that insufficient levels of cortisol can be produced in response to stress, posing the risk of acute adrenal crisis with hypotension and collapse. The purpose of this paper is to review relevant literature and propose clinical guidelines for dental practitioners. Of numerous reported cases of adrenal crisis following procedural interventions, few stand up to critical evaluation. Other reviewers have reached similar conclusions. A number of studies confirm the low likelihood of significant adrenal insufficiency even following major surgical procedures. Various authors have suggested modified guidelines for management of patients on steroid medications. Patients on long-term steroid medication do not require supplementary 'steroid cover' for routine dentistry, including minor surgical procedures, under local anaesthesia. Patients undergoing general anaesthesia for surgical procedures may require supplementary steroids dependent upon the dose of steroid and duration of treatment.

Role of Corticosteroids in Oral Lesions

“…Any patient that does not fit the above criteria or if the clinician is in any doubt then the patient should not be treated in the primary care setting and should be referred (Gibson 2004). …”

“…Glucocorticoids decrease the production of cytokines, chemokines, and eicosanoids and enhances the production of macrophage migration inhibitory factor (Gibson 2004).…”

“…Corticosteroids are involved in a wide range of physiologic processes, including stress response, immune response, and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels, and behavior. They are some of the most common drugs for management of patients undergoing stressful situations such as surgery and dentstry (Gibson 2004). …”

Dental management of patients with endocrine disorders

“…Hypertension, glucose intolerance, menstrual irregularity, osteoporosis and pathological fractures, delayed healing, increased risk of infection and neuropsychological disturbances including depression, emotional irritability, sleep disturbances and cognitive deficits are also observed. Purple striae and muscular atrophy are particularly positive stigmata in adults, whereas in child growth retardation are frequently present (18,19).…”

“…The second most common cause is a high production of ACTH as a result, in most cases, of the presence of a pituitary corticotroph adenoma or less frequently by an extrapituitary tumor or very rarely by a tumor secreting CRH. (18,19). CS is suspected in the presence of central obesity with supraclavicular fat accumulation and a cervical fat pad, moon face, thinned skin, acne and hirsutism.…”