Oral Lesions and Corticosteroids
NOTE: The pharmacologic management suggestions and sample prescriptions in this handbook represent a general recommendation. Clinicians are responsible to adjust the prescription dose, frequency and length of treatment based on the procedure performed, the medicine prescribed, and the patient conditions such as age, weight, metabolism, liver and renal function.
Overview
Steroids, often referred to as corticosteroids, are hormones produced by the adrenal cortex, the outer part of the adrenal gland. The hormone cortisol is the principal corticosteroid. Cortisol secretion is regulated via the hypothalamic-pituitary-adrenal axis (HPA axis) and by the circadian rhythm. It plays a role in carbohydrate, protein, lipid and nucleic acid metabolism. In addition, cortisol is the main hormone involved in the human stress response with levels being highest in the early morning. Synthetic steroids (i.e., hydrocortisone) are derivatives of cortisol. Synthetic steroids can be used in dentistry topically or systemically as a palliative measure to relieve pain, inflammation or edema.
1 | Oral Lesions: Etiology and Treatment
Topical steroids are not curative but rather palliative. Topical steroid may reduce the severity of oral lesions, reducing pain and improving patient function and quality of life. Topical steroids should be considered the first course of treatment.
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Table 1. Aphthous Stomatitis (also known as canker sores) |
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Etiology |
• Common oral condition, esp. in young adults •Familial tendency •May be caused by stress, physical or chemical trauma, food sensitivity and infection •May be associated with use of NSAIDs |
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Treatment Rationale |
• Most ulcers heal spontaneously in 10-14 days •Inflammation reduction •Pain relief |
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Suggested Pharmacologic Management |
• Rx. Triamcinolone 0.1% in Orabase – Sig: apply to dried ulcer 2-4 times daily until healed •Rx. Dexamethasone elixir, 0.5 mg per 5 mL – Sig: rinse with 5 mL for 2 minutes four times daily and spit out. Discontinue when lesions become asymptomatic •Rx. Tetracycline 250 mg/5 mL syrup – Sig: 5 mL “swish and spit” four times daily for 4-5 days •Viscous lidocaine, 2% used to relieve pain |
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Table 2. Erythema Multiforme (EM) |
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Etiology |
• Autoimmune disorder •Severe form is called Stevens Johnson syndrome or Erythema Multiforme Major •Allergic reaction to antibiotics, e.g., penicillin •Post-herpetic infection |
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Treatment Rationale |
• Inflammation reduction (systemic steroid therapy) •Following a thorough medical history, if a link to viral infections is established 48 hours following experiencing the symptoms (rash), suppressive antiviral therapy should be considered; due to interference of systemic steroids with the immune system. This approach, if used, should be initiated prior to steroid therapy. The goal of antiviral therapy is to shorten the clinical course of EM, prevent further complications and prevent recurrences and the development of latent viral infections and transmission |
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Suggested Pharmacologic Management |
• Rx: Prednisone 10 mg tablets – Sig: take SIX tablets in the morning after breakfast then decrease dose by ONE tablet every other day. (Disp. 42 tablets) Do NOT use for more than 14 days; if lesions do not resolve following 14 days of therapy, patient should contact primary physician •Rx.: Valacyclovir 500 mg tablets – Sig: take one tablet twice daily (Disp. 20 tablets) •Rx.: Acyclovir 400 mg tablets – Sig: take one tablet twice daily (Disp. 20 tablets) |
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Table 3. Lichen Planus |
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Etiology |
• Autoimmune disorder •May be caused by stress, drug hypersensitivity or allergen exposure |
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Treatment Rationale |
• Pain relief •Inflammation reduction (Topical steroid application is preferred) •Expect Candida overgrowth to occur and treat accordingly; monitor the patient for opportunistic oral infections including candidosis – consider prophylactic antifungal therapy in certain patients, the elderly and denture wearers |
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Suggested Pharmacologic Management |
• Rx.: Fluocinonide Gel 0.05% mixed with equal parts plain Benzocaine 20% – Sig.: Apply to oral lesions 3-4 times daily using a cotton tip applicator (Disp.: 30 g tube) Discontinue when symptoms disappear. If symptoms persist for more than 2 weeks, patient should contact primary physician. •Rx.: Dexamethasone Elixir 0.5 mg/5 mL – Sig.: swish with 5 mL (1 tsp) for 2 minutes four times per day then spit out (Disp.: 100 mL) Discontinue when symptoms disappear. If symptoms persist for more than 2 weeks, patient should contact primary physician. |
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Table 4. Mucous Membranes Pemphigoid (MMP) and Pemphigus Vulgaris (PV) |
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Etiology |
•Autoimmune disorder with antibodies |
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Treatment Rationale |
• Management requires a physician and a dental professional •Control and reduction of the symptoms with systemic corticosteroids, topical steroids and immunomodulators (Tacrolimus has been proven to aid in the control of oral lesions) •Topical steroids usually used as adjunct to oral therapy but can be used as monotherapy in patients with limited oral disease |
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Suggested Pharmacologic Management |
Topical steroid therapy (as for Lichen Planus but part of a larger treatment plan): •Rx.: Fluocinonide Gel 0.05% mixed with equal parts plain Benzocaine 20% (consider using a custom tray) – Sig.: Apply to oral lesions 3-4 times daily using a cotton tip applicator (Disp.: 30 g tube) Discontinue when symptoms disappear. If symptoms persist for more than 2 weeks, contact your doctor •Rx.: Dexamethasone elixir 0.5 mg/5 mL – Sig.: swish with 5 mL (1 tsp) for 2 minutes four times per day then spit out. (Disp.: 100 mL) Discontinue when symptoms disappear. If symptoms persist for more than 2 weeks, patient should contact primary physician |
2 | Oral Lesions: Size and Location
Current dosage forms of topical steroids include creams, gels, powders, lotions, oils, ointments, solutions and sprays. Of interest to the dental clinician are ointments, such as fluocinonide and triamcinolone, due to their carrier being suitable for use in the oral cavity; creams are indicated for dermatologic conditions and are best avoided intra-orally.
Treatment success is related to the location and accessibility of the lesion, and patient compliance:
Lesions Accessible to the Patient
To facilitate adhesion to the oral lesions, which improves contact time and outcome, the clinician should direct the pharmacist to compound topical steroids with equal parts plain Orabase which contains 20% benzocaine in an alcohol-free paste.
Instruct the patient to apply the ointment as follows:
1. Rinse oral cavity with salt water (1 tsp salt in one cup of water).
2. Wash hands prior to applying ointment.
3. Apply ointment to oral lesions 3-4 times daily using a cotton tip applicator.
Lesions Confined to the Gingival Tissue
The clinician can fabricate custom-fitted trays to be filled with the compound described above.
Instruct the patient to apply the ointment as follows:
1. Brush teeth prior to applying medication.
2.
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