Update on Management of

t h e Or a l an d M a x i l l o f a c i a l
Surgery Patient on
C o r t i c o s t e ro i d s
Michael H. Chan, DDSa,b,*

KEYWORDS
 Corticosteroids  Adrenal suppression  Dental extractions  Dental implants  Osteoporosis
 Osteonecrosis  Perioperative “stress steroids” dose

KEY POINTS
 Corticosteroids have beneficial therapeutic properties but it also has a wide range of adverse clin-
ical side effects.
 Most clinicians consider 3 weeks of continuous use of 20 mg of prednisone or its equivalent or
higher to cause tertiary adrenal insufficiency and this phenomenon will likely cease after 12 months
of drug discontinuation.
 Good perioperative pain control, especially during the postoperative phase, is crucial to decrease
cortisol demand.
 High-quality randomized control trials are needed to determine if perioperative “stress dose” ste-
roid is necessary for minor, moderate, and major surgeries.

INTRODUCTION targeted therapy to avoid numerous undesirable

side effects, but unfortunately, some patients
Corticosteroids have been used to treat a variety may require a lifelong treatment regimen. The pur-
of anti-inflammatory and immunosuppression pose of this article is to highlight some of the cur-
conditions such as arthritis (juvenile idiopathic rent adrenal insufficiency classifications,
arthritis, psoriatic arthritis, rheumatoid arthritis), significant drug-to-drug interactions, adverse ef-
polymyalgia rheumatica, autoimmune disease (ie, fects, and current perioperative recommendations
systemic lupus erythematosus, giant cell arteritis), for patients taking long-term corticosteroids
chronic obstructive pulmonary disease (COPD)/ suffering from these chronic ailments.
asthma, dermatologic lesions, inflammatory bowel
disease, oral mucocutaneous lesions, adjunctive
chemotherapy regimen, and organ transplant re- PATHOPHYSIOLOGY AND EFFECTS ON THE
cipients. It is estimated that 1.2% of the US popu- HYPOTHALAMUS-PITUITARY-ADRENAL AXIS
lation is on chronic steroids.1 With an aging
population, OMFS clinicians will likely encounter Daily endogenous cortisol production by the adre-
these patients in their daily practice. Currently, nal gland is approximately 8 to 10 mg/d2 or 20 mg/
physicians have been reconditioned to prescribe d3 with a higher output in the morning than in the
oralmaxsurgery.theclinics.com

the lowest dose and the shortest course for evening. Cortisol helps regulate a variety of normal
physiologic functions in response to stress. It

a
Oral & Maxillofacial Surgery, Department of Veterans Affairs, New York Harbor Healthcare System (Brooklyn
Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA; b Oral & Maxillofacial Surgery, Department of Oral
and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue (Box-187), Brooklyn, NY
11201, USA
* 800 Poly Place (Bk-160), Brooklyn, NY 11209.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 34 (2022) 115–126

https://doi.org/10.1016/j.coms.2021.08.011
1042-3699/22/Ó 2021 Elsevier Inc. All rights reserved.
116 Chan

provides anti-inflammatory properties by sup- MEDICATION DOSAGES

pressing prostaglandin production. Impairment of
chemotaxis and adequate immune cellular recruit- Prednisone is the most commonly prescribed
ment in particular polymorphonucleocytes and corticosteroid on the market.8 Relative potency of
leukocytes, respectively. Hyperglycemia results 5 mg of prednisone is equivalent to 20 mg of hydro-
from gluconeogenesis by the liver and the cortisone corresponding to the daily endogenous
dysfunction of insulin’s ability to reuptake serum production. Dexamethasone is 25 times more
blood glucose into adipose tissue.4 Enhancement potent than cortisol and only requires 0.75 mg to
of the cardiovascular system through catechol- have the same equivalency or approximately
amine stimulation resulting in increased cardiac 4 mg 5 100 mg of hydrocortisone (Table 1).3 Inha-
output and blood pressure.2 Promotion of osteo- lation preparation is commonly prescribed for
clasts and prevention of osteoblasts function on asthmatics and COPD patients with recommended
bone remodeling.4 adult dosing in metered-dose inhaler preparation
All 3 forms of adrenal insufficiencies can result in a provided (Table 2).9
net decrease in cortisol production. Secondary adre-
nal insufficiency is related to the inability of the ante- ADVERSE REACTION/EVENTS OF
rior pituitary to produce adrenocorticotropic CORTICOSTEROIDS
hormone (ACTH) due to the pituitary gland’s dysfunc-
tion (ie, tumor, irradiation, surgery, and genetic alter- There is no Black Box Warning Label associated
ations), whereas tertiary adrenal insufficiency reflects with corticosteroids.
the lack of corticotropin-releasing hormone, and/or
arginine vasopressin released by the hypothalamus Glucocorticoids and Nonsteroidal Anti-
with chronic steroid administration being the most Inflammatory Drugs
common etiology.5 One of vasopressin’s roles is to
The combination will increase the risk for gastroin-
promote vasoconstriction in response to low blood
testinal (GI) issues (ie, peptic ulcers and GI bleed).
pressure when sensed by the host’s baroreceptors.6
Two separate meta-analyses have demonstrated
Daily consumption of corticosteroids will trigger a
the adverse effects when these 2 drugs are used
negative feedback mechanism aimed to “halt” the
together. One study showed 4 times relative
body’s natural cortisol production. Currently, most
increased risk with the combination of glucocorti-
clinicians consider 3 weeks of continuous use of
coids and nonsteroidal anti-inflammatory drugs
20 mg of prednisone per day or its equivalent or
(NSAIDs) when compared to nonusers.10 Similarly,
higher to cause tertiary adrenal insufficiency and
a second analysis showed a 3 times relative
this phenomenon will likely cease after 12 months
increased risk when this combination is used
of drug discontinuation.4,7
when compared to nonusers. It also demonstrated
Patients with primary adrenal insufficiency
an odds ratio of 1.8 when compared to NASIDs
(Addison’s disease), however, lack the inability of
user group suggesting approximately twice the
the adrenal gland to produce 3 major hormones:
relative risk.11
mineralocorticoid (aldosterone), glucocorticoids
(cortisol), and androgens (dehydroepiandroster-
one) predominantly from autoimmune disease Glucocorticoids and Inducers of Cytochrome-
when a significant amount of the adrenal gland 450 (CYP3A4)
has been destroyed. Mineralocorticoid deficiency These inducers of CYP (ie, barbiturate, phenobar-
causes hyponatremia, hyperkalemia, and low bital, phenytoin, carbamazepine, rifampicin, and
intravascular volume (blood pressure). In a healthy troglitazone) increase the breakdown of cortisol
individual, aldosterone normally stimulates the and therefore will have decreased levels of circu-
reabsorption of sodium and water and excretion lating cortisol. If permissible by physician, these
of potassium at the distal and collecting tubules drugs should be discontinued 24 hours before
to help increase blood pressure via the renin- surgery.3,5
angiotensin-aldosterone-system. Cortisol’s avail-
ability is also devoid of its essential properties
Glucocorticoids and Inhibitors of Cytochrome-
which are to maintain cardiac output and increase
450 (CYP3A4)
vascular tone to catecholamine during a stressful
response. An inadequate amount of these func- The inhibitors of CYP such as the antifungal class
tioning hormones could result in adrenal crisis—a of azole (ie, fluconazole and ketoconazole) and
rare condition with potential for fatal outcome antiviral class (ie, ritonavir) decrease the break-
with vasodilation and severe hypotension with down of cortisol and therefore will have increased
eventual cardiovascular collapse2,3,5 (Fig. 1). levels of circulating cortisol.5,12
 Management of the OMFS Patient on Corticosteroids 117

Fig. 1. Hypothalamus-pituitary-adrenal (HPA) axis. The most common cause for tertiary adrenal insufficiency is
from chronic exogenous steroids use. This will trigger a negative feedback mechanism to the hypothalamus
and anterior pituitary gland creating a shut down in “natural” cortisol production. Secondary adrenal insuffi-
ciency reflects the pituitary gland’s dysfunction to produce ACTH to stimulate the adrenal gland to make cortisol.
While primary adrenal insufficiency is a result of damage from the adrenal gland itself to produce cortisol. Stress
is the major trigger for activating the HPA axis. ACTH, adrenocorticotropic hormone; AVP, arginine vasopressin;
CRH, corticotropin-releasing hormone.

Table 1
The relative potency of corticosteroids

Anti-
Inflammatory Mineralocorticoid Equivalent
Name of Drug Potency Potency Dose (mg) Duration of Action
Cortisol 1 2 20 Short acting < 12 h
Hydrocortisone 0.8 2 20 Short acting < 12 h
Prednisone 4 1 5 Intermediate acting 12–36 h
Prednisolone 4 1 5 Intermediate acting 12–36 h
Triamcinolone 5 0 4 Intermediate acting 12–36 h
Methylprednisolone 5 0.5 4 Intermediate acting 12–36 h
Dexamethasone 25 0 0.75 Long acting > 36 h
Adapted from Little JW, Miller CS, Rhodus NL. Chapter 15: Adrenal Insufficiency. In: Little JW, Miller CS, Rhodus NL, eds.
Little and Falace’s Dental Management of the Medically Compromised Patient. 9th ed. Elsevier; 2018: 255-267.
118 Chan

Table 2
Inhalation preparation of corticosteroids

Dosages in Metered-Dose
Inhalation Corticosteroids Inhaler Preparation Brand Names Adult Dosing
Fluticasone propionate 50, 100, 250 mcg Flovent 2 puffs BID
Becalometasone Dipropionate 40 or 80 mcg Qvar 1–4 puffs BID
Ciclesonide 80 or 160 mcg Alvesco 1–2 puffs BID
Triamcinolone acetonide Azmacort
Budesonide 80 or 160 mg Symbicort 2 puffs BID
Adapted from Cox DP, Ferreira L. The Oral Effects of Inhalation Corticosteroid Therapy: An Update. J Calif Dent Assoc.
2017 May;45(5):227-33.

Despite its effectiveness, chronic systemic ste- gingival tissue. Prolonged tongue ulceration is
roid therapy has been documented to have another finding associated with this syndrome.9
numerous major adverse events and a wide range Patients with rheumatoid arthritis on daily oral
of clinical manifestations from mild to severe prednisone have dose and duration-dependent
forms. These manifestations include dermatologic related adverse effects based on several retro-
(cushingoid appearance, weight gain and skin at- spective studies. Those who took 5 to 10 mg/
rophy, ecchymosis, acne), ophthalmologic (cata- d of prednisone developed adverse effects such
ract, glaucoma), cardiovascular (hypertension, as severe infections, GI bleed, skeletal fracture,
fluid retention, arrhythmia [atrial fibrillation, atrial and cataract 10 years after the 10 to 15 mg/
flutter], premature arteriosclerosis), GI (gastritis, d group.4 A nationwide retrospective study in
peptic ulcer disease), musculoskeletal (osteopo- Taiwan investigated 2,623,327 people aged be-
rosis, avascular necrosis, bone fracture), myop- tween 20 and 65 years who consumed 5 mg of
athy, psychiatric (mania, depression, euphoria, prednisone per day or its equivalent within
akathisia, memory impairment, dementia), endo- 14 days were found to have increased association
crine (hyperglycemia), immune system (increase with (GI bleed, sepsis, and heart failure) within
risk of infection), and hematological (leukocy- 30 days, which dissipated after 31 to 90 days.13
tosis).4 Also, recent case reports of medication- Users of high dose with short-term duration have
related osteonecrosis of the jaw (MRONJ) have also been implicated. Of the 327,452 adults sur-
been documented. veyed in the study for the under 65-year-old group,
Chronic inhaled corticosteroids have been approximately 47% of these patients developed
shown to induce several intraoral adverse effects (sepsis, venous thromboembolism, and fractures)
such as oral candidiasis, oral hairy leukoplakia, within 30 days only after a 6-day course of
angina bulla hemorrhagic, and Churg-Strauss syn- medrol-dose pack (105 mg of prednisone
drome with oral candidiasis being the most com- equivalent).4
mon finding. The direct local effects of Glucocorticoid-induced osteoporosis (GIOP)
corticosteroids to the oropharyngeal region are and osteonecrosis has been well-documented in
from over suppression leading to overgrowth of medical literature in the past decade but not within
Candida albicans and the condition is fully revers- the dental community.14,15 Specifically, vertebral
ible upon discontinuation of the drug. For those and hip fractures are directly linked with chronic
who are reliant on this therapy, oral water rinses af- prednisone users with onset noted as early as
ter each use and/or attaching a spacer for these 3 months. Excess corticosteroids cause
inhalers could significantly reduce these occur- decreased osteoblast production by blocking the
rences. If needed, nystatin and fluconazole can Wingless (Wnt)/B-catenin signaling pathway along
be prescribed to treat these fungal infections. with osteoblast apoptosis resulting from an
Angina bullosa hemorrhage are blood-filled lesions increased level of reactive oxygen species. Simul-
with soft palate being the most common site and taneously, glucocorticoid exerts a direct effect on
are self-limiting within 1 weeks with rupture noted osteoblast to increase production of receptor acti-
within 48 hours of onset. Churg-Strauss syndrome vator of nuclear factor kappa-B (ligand) RANKL
is a rare inflammatory condition of the blood ves- available for RANK binding on preosteoclasts
sels. Patients with a history of asthma or allergies cells. Upon forming an RANKL/RANK complex,
may display intraoral findings commonly seen as the osteoclast will differentiate and develop into
“strawberry gingivitis” secondary to inflamed mature osteoclasts ready for bone resorption.
 Management of the OMFS Patient on Corticosteroids 119

Additionally, osteoblast decreases the secretion of vascular endothelial growth factor (less VEGF)
osteoprotegerin (OPG) making it less available to resulting in osteoporosis or osteonecrosis bony ar-
bind with RANKL further tipping the scale toward chitecture14,15 (Fig. 2).
bone resorption. Lastly, osteocyte’s apoptosis is As mentioned previously, 2 case reports of
enhanced thus altering normal bony remodeling MRONJ associated with chronic steroid therapy
resulting in poorer bone quality and increased both resulted from an extraction of a single
risk for fracture despite maintaining bone mineral mandibular premolar. Wong and colleagues re-
density (BMD) values. The net effect is less bone ported a 30-year-old female who took prednisone
formation (decrease quantity of osteoblasts, oste- 5 mg and 7.5 mg on alternative days for systemic
ocytes, and OPG), more bone resorption lupus erythematosus (SLE) for the past 9 years
(increased osteoclast’s action), decreased (e-mail communication with the author). Although

Fig. 2. Glucocorticoid-induced osteoporosis. The deleterious effects of chronic glucocorticoid on osteoblast, oste-
ocytes, and osteoclast with their impact on bone remodeling.
120 Chan

this patient took oral bisphosphonate 2 years after period from 4 to 13 years.22 A variety of autoim-
her sequestrectomy was performed from her lower mune diseases encompassed this successful
jaw, it was to counteract the osteoporosis diag- group which included Sjogren’s syndrome, SLE,
nosed on her hip which subsequently required a polymyalgia rheumatica, scleroderma, and
femoral head prosthesis replacement. In this pemphigus vulgaris.22 He calculated an 88.75%
case, BP acted as an adjunctive medication to overall implant survival rate for this group
cause MRONJ.16 A second case involved a 50- (n 5 100) being able to be followed for more than
year-old male with a history of psoriatic arthritis 24 months with an average duration of
on 7.5 mg of prednisone per day for the past 72.6 months.22 Furthermore, rheumatoid arthritis
2 years. His mandible was treated with surgical patients recorded 92.9% and 100% survival
debridement for localized sclerotic bone with based on 236 implants in 56 patients from 1 pro-
complete resolution observed after 30 days.17 spective and 3 retrospective studies, respectively.
Recent animal studies on the mandible have Finally, organ transplant recipients on immuno-
demonstrated excess glucocorticoids caused a suppressants and chronic steroids had a 100%
significant alteration to the osteocyte orchestrated survival rate up to approximately 4 years of
perilacunar-canalicular remodeling (PLR) network follow-up.22 Despite these promising data, Dutten-
within 2 months to incite MRONJ. Osteocyte’s hoefer concluded that risk stratification and more
cell-to-cell signaling is significantly altered specif- randomized control studies are needed to ascer-
ically by blocking the perilacunar enzymes (matrix tain the validity of immunosuppressants and the
metallopeptidase 13 [MMP13]) responsible for clinical effects on dental implants.22
maintenance of normal bony turnover. The disrup-
tion of the PLR results in the mandible having the PERIOPERATIVE MANAGEMENT OF THE
following manifestations: (1) decreased bone vol- OMFS PATIENT ON CORTICOSTEROIDS (DOSE
ume, (2) decreased BMD, (3) decreased trabecular AND DURATION, TYPE OF SURGERY, AND
(marrow) bone thickness, (4) increased incidence STEROID SUPPLEMENTAL
of jaw fracture posterior to the molar site, and (5) RECOMMENDATION)
decreased vascularity18 (see Fig. 2).
Clinicians should be cognizant with the potential Historically and still, some current surgeons are
concurrent use of bisphosphonate for the treat- conditioned to give perioperative “stress dose” ste-
ment of glucocorticoid-induced osteoporosis roids for patients with a history of adrenal insuffi-
(GIOP). Alendronate and denosumab are ciency and/or on chronic steroid
commonly prescribed antiresorptive medications supplementation. This practice was widely adop-
proven to prevent further deterioration of bone ted primarily based on 2 historical case reports in
loss and prevent skeletal fractures.14 the 1950s of adrenal crisis resulting in a fatal
outcome.23,24 Within the past two decades, some
CORTICOSTEROIDS AND DENTAL IMPLANTS authors questioned these guidelines and started
to extrapolate data from anesthesia and surgery
The general consensus among the dental commu- literature, mainly case series and cohort studies,
nity has categorized dental implants as a contrain- to formulate their own recommendations for peri-
dication for chronic steroid users primarily due to operative “stress dose.” These formulations are
the impaired wound healing, disruption of bone based on the patient’s daily intake and the amount
formation, and increase in osteoclastic activity necessary to match the anticipated perioperative
creating an osteoporotic environment.19,20 How- requirement or the degree of hypothalamus-
ever, a recent retrospective study by Petsinis pituitary-adrenal (HPA) axis suppression. The
and colleagues in 2017 has shown an osseointe- body normally produces 10 to 20 mg of cortisol
gration success rate of 99% (103/104 implants) per day and this would represent the “physiologic
up to 3 years for 31 patients.21 Daily corticoste- dose.” However, patients undergoing minor sur-
roids ranging from 5 to 60 mg were reported in gery will require “supra-physiological doses” of
this group of patients being used to treat various 50 mg/d and moderate and major groups needing
autoimmune disease conditions. Petsinis 75 to 150/d of endogenous cortisol production.25
concluded traditional 2-stage implant surgery Although some authors’ steroid requirements
without bone grafting could be performed for escalate as the type of surgery to be done in-
chronic glucocorticoid users but highlights the creases in complexity, others simply do not recom-
importance of future investigation of implant suc- mend additional corticosteroids but rather have
cess is warranted.21 Yet another systematic re- patients maintain their daily prescribed dose. The
view with meta-analysis revealed a positive lack of general consensus for exogenous steroid
implant survival rate of 100% with a follow-up supplementation guidelines is the reason for
 Management of the OMFS Patient on Corticosteroids 121

various published recommendations ultimately 2. More than or equal to 2 g/d of high potency or
leaving the shared decision between the surgeon super high potency of corticosteroids (class I–
and anesthesiologist. III) for more than 3 weeks before surgery.
Liu and colleagues’ recommendation is based 3. Any individual who has signs of Cushing
on the risks group stratification (dose and dura- syndrome.
tion) and the anticipated amount of endogenous 4. Those who had 3 or more intraarticular or spinal
cortisol needed to respond to the type of surgery injections within 3 months or have signs of
performed.2 The low-risk group for adrenal sup- Cushing should be clinically evaluated and
pression (those who use steroids <3 weeks and tested.
on 5 mg of prednisone per day or less, or predni-
sone 10 mg every other day) would not require Chilkoti and colleagues proposed a slightly
additional supplementation or ACTH stimulation higher threshold for his supplementation regimen.
test. However, the intermediate (5–20 mg) and Patients taking more than 10 mg/d prednisone for
high-risk groups may benefit from the ACTH stim- the last 3 months should be considered adrenally
ulation test using cosyntropin (ACTH 1–24). High- suppressed with supplementation dosage based
risk group is defined as (>3 weeks of 20 mg pred- on surgery type. Minor surgery would only require
nisone/day [equal or greater] or with clinical signs an additional 25 mg of hydrocortisone during in-
of Cushing syndrome). Cushing syndrome is a duction, whereas moderate surgery would need
result of corticosteroid toxicity resulting in an extra 100 mg of hydrocortisone/day for 24 hours
numerous undesirable adverse effects mentioned and extended up to 72 hours with major surgery
previously (ie, weight gain, round face, etc) with (Table 5).25 By supplementing and maintaining a
chronic daily use being the most common cause. serum level of 100 mg of daily hydrocortisone,
250 mcg of cosyntropin either intramuscular (IM)/ the body should be able to withstand succumbing
intravenously (IV) is administered and measure- to hemodynamic instability (vasodilation and hy-
ments are taken postinjection at 60 minutes. potension) even at critical levels25.
Normal values of 18 mcg/dL or higher suggest Little and Falace suggested that secondary or
adequate production and therefore no additional tertiary adrenal insufficiency group do not require
stress steroids are needed.2,26 additional supplemental steroids regardless of
Liu and colleagues also categorized 4 types of dosage and length of steroid use or type of surgery
surgery based on anticipated stress of surgery: to be done unless patients have other comorbid-
(1) routine/superficial, (2) minor, (3) moderate, ities (ie, cancer, infection, trauma, liver dysfunc-
and (4) major. As dentoalveolar surgery is tion, and significant pain; Table 6). Moreover,
regarded as “routine” and 8 to 10 mg of cortisol additional steroid requirements should be based
production is expected, continuation of the daily on the overall health of the patient and the demand
dose without additional further supplementation required by the body during the perioperative re-
is suggested. However, patients undergoing minor covery period. Authors also proposed surgical
to major surgery should take their normal daily procedures more than 1 hour should be consid-
dose in addition to supplemental hydrocortisone ered as major because of the increased stress
because of the increased demand for physiologic and cortisol demand. If the OMFS clinician is still
glucocorticoids (Table 3).2 unsure, a physician consultation with ACTH stimu-
Hamrahian and colleagues’ findings in the most lation test may be warranted.3 Their recommenda-
recent UpToDate are very similar to Liu and col- tion was based on a systematic review by Marki
leagues’ recommendations (Table 4). They added and Varon who analyzed 9 studies and found no
long-term use of inhaled and topical corticoste- additional supplementation of steroids was neces-
roids can suppress the HPA axis but generally sary independent of the type of surgery and only
without the same degree of clinical adrenal insuffi- recommended a normal daily dose to be taken.28
ciency when compared to the oral/parenteral Finally, the latest systemic review performed by
version. They recommended clinical evaluation Groleau and colleagues in 2018, examined 2 ran-
and ACTH stimulation testing for those who use domized control trials (37 patients), 5 cohort
inhaled, topical preparations, and intraarticular in- studies (462 patients), and 4 systematic reviews.
jections with the following parameters:12 Despite these low-quality studies and limited evi-
dence, he concluded that the above literature
1. More than or equal to 750 mcg (0.75 mg/d) of daily have shown maintenance of daily dose of steroid
fluticasone or 1500 mcg (1.5 mg/d) with either be- therapy should meet the cortisol demand in many
clomethasone, triamcinolone, or budesonide) for surgical scenarios. Furthermore, there is no need
more than 3 weeks before surgery.12,27 This sug- for perioperative supplementation of exogenous
gests fluticasone is twice as potent. corticosteroids and the use of additional steroids
122 Chan

Table 3
Liu et al’s procedure-based stratification for stress dose steroid recommendation

Endogenous
Cortisol
Surgery Secretion
Type Rate Examples Recommended Steroid Dosing
Superficial 8–10 mg/d Dental surgery Usual daily dose
(baseline) Biopsy
Minor 50 mg/d Inguinal hernia repair Usual daily dose
Colonoscopy plus
Uterine curettage Hydrocortisone 50 mg IV before
Hand surgery incision
Hydrocortisone 25 mg IV every
8 h  24 h
Then usual daily dose
Moderate 75–150 mg/d Lower extremity Usual daily dose
revascularization plus
Total joint replacement Hydrocortisone 50 mg IV before
Cholecystectomy incision
Colon resection Hydrocortisone 25 mg IV every
Abdominal hysterectomy 8 h  24 h
Then usual daily dose
Major 75–150 mg/d Esophagectomy Usual daily dose
Total proctocolectomy plus
Major cardiac/vascular Hydrocortisone 100 mg IV before
Hepaticojejunostomy incision
Delivery Followed by continuous IV infusion
Trauma of 200 mg of hydrocortisone more
than 24 h
or
Hydrocortisone 50 mg IV every
8 h  24 h
Taper dose by half per day until
usual daily dose reached
plus
Continuous IV fluids with 5%
dextrose and 0.2%–0.45% NaCI
(based on degree of
hypoglycemia)

Abbreviation: IV, intravenous.

Data from Axelrod.4 Salem et al.,13 and Bornstem et al.6; and From Liu MM, Reidy AB, Saatee S, Collard CD. Perioper-
ative Steroid Management: Approaches Based on Current Evidence. Anesthesiology. 2017 Jul;127(1):166-172.

should be weighed against the adverse effects of suppressors of cortisol production. A double-
the drug during the postoperative course. Lastly, blinded randomized clinical trial has demonstrated
Grouleau recommended high-quality randomized the use of 7.5 mg of sublingual midazolam to
control trials are needed in the future on this topic reduce surgical stress of healthy ASA I patients un-
so a general consensus can be reached.30 dergoing wisdom teeth removal. Through saliva
collection, they were able to determine plasma
ANESTHESIA MANAGEMENT cortisol of the control group to be higher than the
test group suggesting good sedative effects of
There are no anesthetic technique restrictions for midazolam. In addition, he reported cardiovascu-
adrenal insufficiency patients except for the use lar stability and mild transient respiratory depres-
of etomidate (inhibitor of glucocorticoids produc- sion associated with this technique.31
tion). However, OMFS clinicians should be cogni- All patients under anesthesia should have their
zant of the fact that general anesthesia, vital signs monitored (blood pressure [BP], heart
anxiolytics, and analgesics are also known rate [HR], respiration rate [RR], oxygen saturation
 Management of the OMFS Patient on Corticosteroids 123

Table 4
Hamrahian et al.’s risk stratification for stress dose steroid recommendation

Dose, Time of day, and Stress Dose Supplementation

Duration Recommendation
Low risk (nonsuppressed HPA <5 mg/d of prednisone (or Normal daily dose
axis) equivalent) taken in the AM;
or <10 mg of prednisone (or
equivalent) every other day
Intermediate risk (unknown 5–20 mg/d of Clinical evaluation for Cushing
HPA axis suppression) prednisone >3 wk (or & ACTH stimulation test. If
equivalent); or 5 mg/d of necessary, supplement
prednisone taken in the PM according to anticipated
level of stress of surgery
High risk (suppressed HPA axis) 20 mg of prednisone per day Supplement with steroids
(equivalent) or more >3 wk; according to anticipated
or clinical signs of Cushing level of stress of surgery
syndrome
History of corticosteroid use in <5 mg/d of prednisone <3 wk No clinical evaluation or
the past year (no evidence (or equivalent) within 6–12 testing required
to support) mo
History of corticosteroid use in >5 mg/d of prednisone >3 wk Clinical evaluation for Cushing
the past year (no evidence (or equivalent) within 6–12 & ACTH stimulation test. If
to support) mo necessary, supplement
according to anticipated
level of stress of surgery
Inhaled corticosteroids27 More than or equal to 750 mcg Clinical evaluation for Cushing
of daily of fluticasone or & ACTH stimulation test. If
(1500 mcg with necessary, supplement
beclomethasone, according to anticipated
triamcinolone, or level of stress of surgery
budesonide) >3 wk before
surgery; or signs of Cushing
Topical corticosteroids More than or equal to 2 g/d of Clinical evaluation for Cushing
high potency corticosteroids & ACTH stimulation test. If
(class I–III) >3 wk before necessary, supplement
surgery; or signs of Cushing according to anticipated
level of stress of surgery
Intraarticular and spinal 3 or more intraarticular or Clinical evaluation for Cushing
glucocorticoids injection spinal injections within 3 mo & ACTH stimulation test. If
of surgery; or signs of necessary, supplement
Cushing according to anticipated
level of stress of surgery
Data from Hamrahian AH, Roman S, Milan S. Perioperative glucocorticoids - Uptodate. Walters Kluwer; Feb 2021.

[O2 sat], and end-tidal carbon dioxide [ETCO2]) Good postoperative analgesia either through
with close attention paid to fluid and blood loss. PO/IM/IV route or long-acting local anesthesia
Recognition of adrenal crisis can be challenging (ie, bupivacaine) should help diminish the host’s
while patients are under sedation since altered response to cortisol demand3. Interestingly, the
mental status can be one of the signs of crisis. highest demand for cortisol is actually during the
Although it is a diagnosis out of exclusion, a sud- postoperative phase (ie, during extubation and
den drop in BP should alert the clinician to be sus- postoperative recovery).12 Sustained high levels
picious especially when treatment is refractory to of plasma cortisol are found even 7 hours after
fluid and vasopressor challenge. Immediate ste- dentoalveolar surgery, indicating increased de-
roid supplementation is necessary to prevent mand in the postoperative phase mainly in
mortality. response to pain.32,33
124 Chan

Table 5
Chilkoti et al’s procedural-based stress dose steroid recommendation

Patients On Daily
Prednisone >10 mg/d or
Equivalent in the Last 3 mo
(Perioperative Steroid
Recommendation)
Minor Surgery (Hernia, Hand 25 mg of hydrocortisone at
Surgery) induction
Moderate Surgery Usual daily dose 1 25 mg of
(Hysterectomy) hydrocortisone at
induction 1 100 mg of
hydrocortisone for 24 h
Severe Surgery (Major Trauma, Usual daily dose 1 25 mg of
Prolonged Surgery) hydrocortisone at
induction 1 100 mg of
hydrocortisone per day up
to 72 h
Data from Chilkoti GT, Singh A, Mohta M, Saxena AK. Perioperative “stress dose” of corticosteroid: Pharmacological and
clinical perspective. J Anaesthesiol Clin Pharmacol. 2019 Apr-Jun;35(2):147-152.

MANAGEMENT OF ADRENAL CRISIS SIGNS AND SYMPTOMS OF ADRENAL

CRISIS12,25
Early recognition and treatment of adrenal crisis
can prevent morbidity and mortality. Initial man- 1. Hypotension
agement consists of hypotension support, ste- 2. Hypoglycemia
roid supplementation, and correction of 3. Dehydration
electrolytes. 4. Nausea/Vomiting
5. Abdominal pain (awake patient)
6. Altered mental status (awake patient)

Table 6
Little and Falace et al’s procedural based for stress dose steroid recommendation

Primary Adrenal Insufficiency Secondary & Tertiary Adrenal

(Perioperative Steroid Insufficiency (Perioperative
Recommendation)29 Steroid Recommendation)28
Routine Dentistry None None
Minor Surgery 25 mg of hydrocortisone (or Normal daily dose
equivalent) preoperative
dose
Moderate Surgery 50–75 mg of hydrocortisone Normal daily dose
(or equivalent) preoperative
dose and up to 24 h. Revert
to preoperative dose on
postoperative day 2
Major Surgery 100–150 mg of hydrocortisone Normal daily dose
(or equivalent) per day as a
preoperative dose and
continue for the next 2–3 d.
After preoperative dose,
hydrocortisone 50 mg IV
q8h after initial dose for the
initial 2–3 d.
Adapted from Little JW, Miller CS, Rhodus NL. Chapter 15: Adrenal Insufficiency. In: Little JW, Miller CS, Rhodus NL, eds.
Little and Falace’s Dental Management of the Medically Compromised Patient. 9th ed. Elsevier; 2018: 255-267.
 Management of the OMFS Patient on Corticosteroids 125

TREATMENT OF ADRENAL CRISIS12,34  Good analgesia and sedation perioperatively

would decrease the demand for cortisol, there-
1. Vasopressor fore, decrease the chances of an adrenal crisis.
2. Fluid replacement 5 rapid isotonic saline infu-  Combination of glucocorticoid and NSAID
sion (1 L) or 5% glucose isotonic saline infusion have 3 to 4 times increased risk for GI bleeds
followed by fluid replacement to match pa- versus nonusers.
tient’s requirement (4–6 L/d)  Avoid using medications that are either inhib-
3. Steroid supplementation 5 100 mg of hydro- itors of glucocorticoids or inducers of CYP-
cortisone (bolus) then 200 mg of hydrocorti- 450 as both will lower the cortisol level. If
sone for the next 24 hours permissible by physician, these drugs should
4. Transport to hospital for electrolyte correction be discontinued 24 hours before surgery.
(hyponatremia, hyperkalemia, hypoglycemia,  Early recognition of signs and symptoms of
and possible hypercalcemia) adrenal crisis can prevent a catastrophic
outcome.
SUMMARY  Chronic glucocorticoid users will develop
skeletal osteoporosis and decreased BMD
OMFS clinicians should be familiar with corticoste- with resultant fragility fracture (vertebral and
roid pharmacology and its wide range of delete- hip).
rious clinical effects it has on all age groups.  Beware of adjunctive antiresorptive medica-
With its powerful anti-inflammatory therapeutic tions (ie, alendronate and denosumab) used
properties, the decision to administer periopera- to treat glucocorticoid-induced osteoporosis
tive steroids should be weighed against the poten- (GIOP).
tial adverse effects on healing capacity.  Limited case reports of MRONJ have been
Commonly used medication, such as NSAIDs, linked to chronic steroid use even at low
can increase the risk for GI bleeding with concom- doses.
itant use with corticosteroid and should be
avoided. Although perioperative recommenda-
tions for absolute indication for “stress dose” ste- ACKNOWLEDGMENTS
roids are still under considerable debate, most
The author wants to extend a very special thanks
researchers are in agreement that good perioper-
to Ms Maya Nunez for her brilliant illustrations for
ative pain control is essential and will diminish
Figs. 1 and 2.
the host’s cortisol demand. And with suppression
of the cortisol demand, this will also help decrease
the chance of precipitating an adrenal crisis. Long- DISCLOSURE
term users of corticosteroids will develop osteo-
porosis in particular with hip and vertebrae and The author has nothing to disclose.
OMFS should beware of adjunctive use of antire-
sorptive medications to prevent fragility fractures.
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