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BDS (Lond), MFDS, RCSEd, MOral Surg, RCSEd, DClinDent in Oral Surgery (UOE), PgCAP (UOE), FHEA, Consultant in Oral Surgery; Department of Dental and Maxillofacial Services, East Surrey Hospital, Redhill
Corticosteroids are a common pharmacological treatment option used in a diverse range of clinical conditions. The diversity of guidance on their use has inevitably led to conflicting management plans between dental clinicians. For patients on long-term steroid cover, several guidelines highlight the importance of additional steroid prescribing during ‘stressful’ procedures. However, guidance on the definition of ‘stressful’ varies, as well as the recommended protocols. This article explores the existing evidence regarding steroid cover in patients taking long-term steroids, and proposes a protocol to help manage these patients in the dental environment.
CPD/Clinical Relevance: An understanding of the clinical implications of long-term steroid use in patients requiring dental treatment, as well as the appropriate management protocols is important.
Article
Corticosteroids were first introduced into medical care in the 1940s. The organic chemists, Hench, Kendall and Reichstein, were awarded the Nobel Prize for identifying that cortisone could be used for the treatment of other diseases beyond adrenocortical insufficiency.1 Corticosteroids are now recognized for their potent anti-inflammatory properties in helping to manage conditions characterized by chronic inflammation and patients requiring immunosuppression, in addition to those with primary adrenal insufficiency. Secondary adrenal insufficiency was first recognized approximately 70 years ago: patients on supplementary glucocorticoid therapy, who underwent routine surgical procedures experienced refractory hypotension and subsequently death.2 This is now commonly referred to as an adrenal crisis, caused by gradual suppression of normal adrenal gland function by exogenous steroids. This key finding resulted in the establishment and recommendation of ‘steroid cover’ for management of these patients. The past 40 years have provided further understanding and knowledge of both adrenal function and corticosteroids. Consensus on the use of peri-operative steroids for oral surgery procedures however, remains disputed.3
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