# Corticosteroid Use in OMFS

## Introduction

Corticosteroids are among the most frequently prescribed medications in OMFS practice, used for their potent anti-inflammatory, immunosuppressive, and anti-edema properties. From reducing postoperative swelling after third molar extraction to managing autoimmune oral mucosal diseases, corticosteroids have broad applications. However, their use must be balanced against a significant side effect profile, particularly with prolonged administration.

## Pharmacology

### Mechanism of Action

Corticosteroids bind to intracellular glucocorticoid receptors, forming a complex that translocates to the nucleus. Their genomic effects include upregulation of anti-inflammatory proteins (lipocortin-1/annexin A1) and downregulation of pro-inflammatory mediators (COX-2, phospholipase A2, cytokines IL-1, IL-6, and TNF-alpha). Non-genomic effects include rapid membrane-stabilizing actions and reduction of capillary permeability. The net result is decreased inflammation, edema, vascular permeability, and immune cell migration to the surgical site.

### Classification by Potency and Duration

| Agent | Relative Potency | Duration | Mineralocorticoid Activity | OMFS Use |
|---|---|---|---|---|
| Hydrocortisone | 1x | Short (8-12 hr) | High | Adrenal replacement |
| Prednisone / Prednisolone | 4-5x | Intermediate (12-36 hr) | Moderate | Oral mucosal disease |
| Methylprednisolone | 5x | Intermediate (12-36 hr) | Low | IV anti-inflammatory |
| Dexamethasone | 25-30x | Long (36-72 hr) | Minimal | Most common in OMFS (perioperative) |
| Betamethasone | 25-30x | Long (36-72 hr) | Minimal | Alternative to dexamethasone |

Short-acting corticosteroids (8 to 12 hours) include hydrocortisone (cortisol), which has 1x potency and the highest mineralocorticoid activity. Intermediate-acting agents (12 to 36 hours) include prednisone, prednisolone, and methylprednisolone at 4 to 5x potency. Long-acting agents (36 to 72 hours) include dexamethasone and betamethasone at 25 to 30x potency with minimal mineralocorticoid activity. Dexamethasone is the most commonly used corticosteroid in OMFS due to its high potency, long duration, and negligible mineralocorticoid effects.

### Pharmacokinetics

Dexamethasone has an oral bioavailability of 80%, a half-life of 36 to 54 hours, and reaches peak effect in 1 to 2 hours (IV/IM) or 1 to 3 hours (PO). Prednisone is a prodrug that must be converted to prednisolone in the liver, so it should be avoided in severe hepatic disease. Methylprednisolone is available as an IV formulation (Solu-Medrol) for acute inflammatory conditions.

## Clinical Applications in OMFS

### Perioperative Edema Reduction

For third molar surgery, dexamethasone 8 to 10 mg IV/IM at induction or 4 mg PO preoperatively reduces swelling by 40 to 60% and trismus by 25 to 40%. In orthognathic surgery, dexamethasone 8 to 10 mg IV is given preoperatively and may be repeated at 8 mg at 8 hours, significantly reducing facial edema. Perioperative dexamethasone also reduces postoperative swelling after facial fracture repair. For maximum anti-edema effect, corticosteroids should be administered before or at the time of surgical insult.

### Airway Edema Management

Post-extubation or post-surgical airway edema is treated with dexamethasone 8 to 10 mg IV. In Ludwig angina and deep space infections, IV dexamethasone serves as an adjunct to surgical drainage and antibiotics to reduce airway-threatening edema. Post-tracheostomy edema is also managed with corticosteroids.

### Oral Mucosal Disease

Oral lichen planus is treated with topical corticosteroids as first-line therapy (fluocinonide 0.05%, clobetasol 0.05%), with systemic prednisone reserved for severe erosive disease. Pemphigus vulgaris requires systemic corticosteroids (prednisone 1 to 2 mg/kg/day) combined with a steroid-sparing immunosuppressant such as azathioprine or mycophenolate. Mucous membrane pemphigoid is managed with topical corticosteroids for mild disease and systemic therapy for progressive or scarring disease. Aphthous stomatitis responds to topical corticosteroid gel (triamcinolone 0.1% in Orabase), with systemic corticosteroids reserved for major aphthae refractory to topical therapy. The use of corticosteroids in erythema multiforme and Stevens-Johnson syndrome remains controversial, though a short course may be beneficial early in the disease course.

### Temporomandibular Joint

Intra-articular corticosteroid injection with triamcinolone acetonide 10 to 20 mg is used for inflammatory TMJ arthritis, providing short-term pain relief lasting weeks to months. Injections should be limited to 2 to 3 per year, as repeated injections may cause cartilage degeneration and condylar resorption.

### Nerve Injury

Dexamethasone administered after inferior alveolar or lingual nerve injury may reduce neural edema and improve recovery. The typical protocol is dexamethasone 8 mg per day with a taper over 5 to 7 days. Evidence is limited, but there is theoretical benefit from reducing perineural inflammation.

![Table comparing corticosteroid agents used in OMFS with relative potencies, durations, and common indications](images/corticosteroid-comparison-table.jpg)

## Adrenal Suppression and Stress-Dose Steroids

### HPA Axis Physiology

The hypothalamic-pituitary-adrenal (HPA) axis regulates endogenous cortisol production. Normal daily cortisol secretion is approximately 10 to 20 mg of hydrocortisone equivalent, and under surgical stress, the adrenal glands increase cortisol output 5 to 10 fold.

### Risk of Adrenal Suppression

Exogenous corticosteroid administration suppresses ACTH secretion, leading to adrenal atrophy. Clinically significant suppression may occur with prednisone at 5 mg per day or greater (or equivalent) for greater than 3 weeks, any dose of systemic corticosteroid for greater than 3 weeks within the past year, or in patients with a Cushingoid appearance regardless of documented dose. Topical, inhaled, and intra-articular steroids rarely cause clinically significant HPA suppression but can do so at high doses.

### Stress-Dose Supplementation Protocol

For minor procedures under local anesthesia such as simple extractions, no supplementation is needed and the patient should take their usual morning dose. For moderate procedures such as third molar extraction under sedation or minor ORIF, hydrocortisone 50 mg IV at induction or doubling the usual daily dose is appropriate. For major procedures including orthognathic surgery, major ORIF, or oncologic surgery, hydrocortisone 100 mg IV at induction followed by 50 mg IV every 8 hours for 24 hours with a taper to baseline over 48 hours is recommended. The current trend has shifted toward less aggressive supplementation, as most patients tolerate their usual daily dose for minor to moderate procedures.

### Adrenal Crisis

Acute adrenal insufficiency can be triggered by surgical stress without adequate corticosteroid coverage. Signs include profound hypotension refractory to fluids, weakness, nausea, abdominal pain, and altered consciousness. Emergency treatment consists of hydrocortisone 100 mg IV bolus, aggressive IV fluid resuscitation with normal saline, and vasopressors if needed.

![Flowchart for determining stress-dose steroid supplementation based on chronic steroid use and procedure type](images/stress-dose-steroid-flowchart.jpg)

## Adverse Effects

### Short-Term (1-2 weeks)

Short-term adverse effects include hyperglycemia, which is particularly problematic in diabetic patients, as well as insomnia, mood changes, anxiety, increased appetite, and weight gain. GI irritation may occur and should be managed with a PPI if concurrent NSAID use is present. Immunosuppression with increased infection risk is possible with prolonged courses.

### Long-Term (greater than 3 weeks)

Long-term adverse effects include adrenal suppression and HPA axis dysfunction. Osteoporosis with vertebral and femoral neck fractures is a concern, and calcium, vitamin D supplementation, and bisphosphonates should be considered for long-term use. Cushing syndrome manifests as moon facies, central obesity, striae, and buffalo hump. Avascular necrosis, most commonly of the femoral head, is dose and duration dependent. Hyperglycemia and steroid-induced diabetes require blood glucose monitoring. Immunosuppression leads to opportunistic infections, reactivation of tuberculosis, and impaired wound healing. Myopathy presents as proximal muscle weakness. Cataracts and glaucoma may develop with prolonged systemic or topical ocular use. Peptic ulcer disease risk is increased especially with concurrent NSAID use.

## Corticosteroids and Wound Healing

Corticosteroids impair all phases of wound healing: inflammation, proliferation, and remodeling. They reduce fibroblast activity, collagen synthesis, and angiogenesis. However, short perioperative courses of 1 to 3 doses do not significantly impair healing in clinical studies. Prolonged therapy increases wound dehiscence and infection rates. The anti-edema benefit must be balanced against healing impairment in each clinical scenario.

![Diagram showing the effects of corticosteroids on the inflammatory cascade and wound healing pathways](images/corticosteroid-mechanism.jpg)

## Clinical Pearls

Dexamethasone 8 to 10 mg preoperatively is the standard for perioperative edema reduction in OMFS and does not significantly impair wound healing. Short perioperative steroid courses of 1 to 3 doses are safe and effective, while prolonged courses carry significant risk. Patients on chronic corticosteroids (greater than 5 mg prednisone for greater than 3 weeks) require assessment for adrenal suppression and possible stress-dose supplementation. For minor OMFS procedures under local anesthesia, steroid-dependent patients usually need only their usual morning dose. Blood glucose should always be checked in diabetic patients receiving corticosteroids, as hyperglycemia is expected and must be managed.

## References

1. Markiewicz MR, et al. "Corticosteroids Reduce Postoperative Morbidity After Third Molar Surgery: A Systematic Review and Meta-Analysis." *Journal of Oral and Maxillofacial Surgery*. 2008;66(9):1881-1894.
2. Liu CL, et al. "Perioperative Corticosteroid Administration in Oral and Maxillofacial Surgery." *Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology*. 2019;128(3):243-252.
3. Salem M, et al. "Perioperative Glucocorticoid Coverage: A Reassessment 42 Years After Emergence of a Problem." *Annals of Surgery*. 1994;219(4):416-425.
4. Courtney CA, et al. "Perioperative Corticosteroid Supplementation in the Dental Patient." *General Dentistry*. 2020;68(2):22-27.