THE EFFECTS OF STEROIDS ON ORAL HEALTH: APPLICATIONS AND SIDE EFFECTS

Updated 31 July 2024

Steroids (or Corticosteroids) are a class of drugs that resemble steroid hormones produced naturally in the body. These chemicals are produced in laboratories and are known for their anti-inflammatory and immune-modifying properties. Steroids are widely used to treat diseases such as asthma, allergies, COPD (Chronic obstructive pulmonary disease), inflamed joints, and inflammatory bowel disease.

In dentistry, they are widely used to treat post-surgery discomfort and various oral diseases such as oral lichen planus (white and red patches on the inner skin of the mouth), pemphigus (blisters and sores in the oral cavity), recurrent aphthous stomatitis (ulcers in the mouth), and temporomandibular joint disorders. (discomfort in the jaw joints).

While short-term usage of steroids is helpful in easing recovery in individuals, the long-term use of steroids or overprescription of the drug may affect systemic and oral health.

Little is known about the effects of steroids on oral health. In this article, we discuss both the uses and side effects of steroids on oral health.

What Are the Most Used Steroid Drugs to Treat Oral Conditions?

Commonly used steroids include hydrocortisone, prednisone, dexamethasone, triamcinolone, clobetasol, and mometasone. They are primarily used in both systemic (oral or injectable) and topical forms in dentistry. The topical form is the most common form of treatment for oral lesions.

How do Steroid Drugs Function?

Steroid drugs exhibit both anti-inflammatory and immunosuppressive properties.

The anti-inflammatory properties of these drugs inhibit the synthesis of chemicals (e.g., phospholipase A2, leukotrienes, and prostaglandins) that cause inflammation. This reduces inflammatory signs such as swelling, pain, and redness.

The immune-suppressing property of steroids enables the suppression of the immune system (e.g., inhibition of the exaggerated activity of a certain type of white blood cells), which is responsible for stimulating inflammation in the body.

What are The Applications of Steroids in Restoring Oral Health?

Steroids have been used to treat several oral diseases and conditions. These include:

Oral lichen planus: 2% of the population suffers from the chronic inflammatory illness known as oral lichen planus. It affects the lining (inner skin) of the oral cavity, especially the cheeks, tongue, and gums. They are present as white or red thread-like lacy patches that are slightly elevated. Open sores are also present in severe cases. Individuals complain of burning sensations and pain while eating or drinking. The application of topical steroids such as 0.05% clobetasol propionate gel, 0.1-0.05% betamethasone valerate gel, 0.05% fluocinonide gel, 0.05% clobetasol ointment or cream, and 0.1% triamcinolone acetonide ointment is recommended for the treatment of oral lesions. Oral steroid drugs are recommended in severe cases. Steroid injections may be administered directly to the lesions for faster relief.

Vesiculobullous diseases: Vesiculobullous diseases such as erythema multiforme, pemphigus, and pemphigoid present as painful fluid-filled blisters in the oral cavity. These blisters measure approximately 5–10 mm and are present on the skin covering the cheeks, tongue, gums, and soft palate. These blisters may rupture, sometimes resulting in painful ulcers that cause discomfort while eating and drinking. Mild to moderate forms of these diseases are treated with topical steroids in the form of gel (0.05% fluocinolone acetonide or 0.05% clobetasol propionate), mouthwashes (e.g., clobetasol propionate mouthwashes), and intralesional injections (steroid injection into the lesion). Moderate to severe forms of the disease that spread to the skin is treated with oral (100–200 mg/day of prednisone) or through intravenous infusion of steroid drugs. Once these signs decline, a maintenance dose of 40–50 mg/day may be administered.

Systemic lupus erythematosus: This is an autoimmune disorder wherein the immune system destroys its tissues, resulting in inflammation and tissue damage in different organs. It may affect organs, such as the joints, skin, brain, lungs, blood vessels, and kidneys. In the oral cavity, it can cause oral ulcers, pigmentation, decreased saliva flow, and dryness of the mouth and tongue. To treat oral lesions, the topical application of betamethasone, clobetasol, or intralesional injections (triamcinolone) is recommended.

Oral submucous fibrosis (OSMF): This is a disorder caused by abnormal deposition of collagen on the inner skin of the oral cavity, causing difficulty in opening the mouth. Individuals often complain of mouth ulcers, dryness of the mouth, a burning sensation on eating spicy foods, and difficulty swallowing food. The anti-inflammatory properties of steroids reduce inflammation and prevent collagen deposition. Along with topical steroids, intralesional steroids are recommended (dexamethasone 4 mg/ml, with hyaluronidase). Oral steroids are recommended to relieve the burning sensation (prednisone (30–40 mg/day] or hydrocortisone [100 mg/day] ) until the symptoms subside.

Bell’s Palsy: The facial muscles become temporarily weak or paralyzed as a result of this condition. To lessen inflammation of the facial nerve, which regulates the action of the face muscles, oral steroids (prednisolone) are recommended. Intake of oral steroids (as prescribed by the doctor) within 72 h of symptom onset resulted in faster recovery.

Post-herpetic neuralgia: This is a common complication of herpes zoster (shingles) infection. This mainly affects older individuals. It is characterized by pain in the nerves and skin. Oral steroids (prednisone) are recommended to treat the associated pain, swelling, and recurrence of post-herpetic neuralgia.

Multiple mouth ulcers: Steroids can be prescribed to manage pain and multiple mouth ulcers. Typically recommended steroids for mouth ulcers include topical (fluocinonide, clobetasol, hydrocortisone gel, or dexamethasone solution) or oral treatments (prednisone).

Temporomandibular disorders (TMD): TMD includes disorders of the jaw joint, jaw muscles, and nerves around the joint. It is distinguished by jaw pain and tenderness, trouble chewing, and difficulty opening or closing the mouth. In severe cases, steroid injections into the jaw joint are recommended to overcome pain and discomfort.

Restorative dentistry: Steroids can be used as dressings in deep cavities to overcome inflammatory pulp response or to reduce post-treatment discomfort.

Post-dental surgery: Oral steroids, especially dexamethasone, are administered after third molar extraction or other dental surgeries to reduce pain, swelling, and inflammation.

What Are the Side Effects of Steroids?

Impact on Overall Health

Overall side effects: The prolonged use of systemic steroids to treat oral lesions can result in weight gain, delayed healing, increased susceptibility to infections, weak and porous bones (osteoporosis), fractures, increased blood pressure, peptic ulcers, and steroid-induced diabetes.

Adrenal insufficiency: Normally, adrenal glands produce steroids. However, long-term external use of steroids (in the form of oral pills or injections) can result in suppression of the natural pathway (hypothalamic-pituitary-adrenal axis), which induces the secretion of steroids in the body. In such scenarios, if the external supply of steroid medications is suddenly stopped, individuals may develop steroid deficiency, also known as adrenal insufficiency. Individuals with steroid-induced adrenal insufficiency may complain of dizziness, nausea, vomiting, dehydration, or extreme fatigue. This condition may be avoided by tapering the steroid dose and deferring it slowly instead of suddenly stopping it.

Impact on Oral Health

Decreased bone density in the jaws: Research suggests that prolonged use of steroids can lead to a significant decrease in calcium absorption and increased bone loss. This causes decreased bone mineral density in the jawbone, which may impact the stability of the tooth held by the jawbone. This may be a risk factor for tooth loss.

Fungal infection: Candidiasis is a type of fungal infection commonly observed in the oral cavity of individuals undergoing long-term steroid therapy. This side effect may be due to a decrease in the immune response of individuals, promoting the growth of the fungus Candida albicans. It is characterized by creamy, curdy, white-colored overgrowth on the inner skin of the lip, cheeks, gums, and tonsils that causes a burning sensation or discomfort while eating food.

Gum diseases: Another common concern is, can steroids cause gum problems?

Research suggests that the long-term use of steroid therapy is associated with an increased risk of gum diseases, such as gingivitis (inflammation of gums) or periodontitis (inflammation of tissues surrounding gums). When steroids are administered topically or injected into gum tissues, they cause a disturbance in the blood supply and collagen formation. They also favor the production of cells that destroy tooth-supporting bones and tissues.

Others: Altered taste sensation, burning mouth, skin atrophy (thinning of the skin), and delayed healing post-surgery are some of the drawbacks of long-term steroid therapy.

Can Steroids Prescribed for Other Health Problems Cause Mouth Ulcers or Oral Conditions?

The long-term use of inhalational steroids (e.g., fluticasone) to treat breathing disorders such as asthma and chronic obstructive pulmonary disease (COPD) can affect oral health. When using an inhalational form of steroid, mouth ulcers are one of many side effects that can occur since 80% of inhaled drugs tend to be deposited in the mouth and throat. The increased level of inhaled drugs in the mouth directly affects the oral tissues, causing the following side effects:

• Candidiasis (fungal infection which results in white patches in the mouth)
• Dryness of mouth
• Change in the composition and flow of the saliva
• Ulcers on the tongue
• Irritation inside and around the corners of the mouth
• Tooth decay
• Inflammation of gums and tooth-supporting tissues (Gingivitis & periodontitis)
• Disturbance in the enamel and dentin layer of the teeth
• Thirst sensation
• Soreness in the throat
• Hoarseness in the voice or abnormal voice
• Cough

Research suggests that these local side effects of inhalational steroid therapy are visible in 10-30% of individuals. However, the severity of side effects is mainly dependent on the dosage, frequency, and duration of inhalational steroid use.

Prolonged use of steroids such as prednisolone and dexamethasone, either alone or with oral bisphosphonates used for osteoporosis, has been associated with the rare but serious condition known as Medication-related Osteonecrosis of the Jaw (MRONJ). The reason for this condition is attributed to decreased immune cells and delayed wound healing with long-term steroid use, which often aggravates inflammation, increasing the risk of MRONJ. This condition frequently affects older adults over 65 years. This condition is commonly seen in older adults over 65 years of age. It is associated with symptoms such as pain, numbness, swelling in the oral region, delayed healing of oral tissues after tooth removal or minor surgery, exposed bone, and infection. 

Research suggests that the risk of MRONJ associated with dental implants in the posterior jaw (back region of the jaw) increases in individuals on bisphosphonate therapy for more than 3 years and receiving steroids. However, these claims lack sufficient evidence and require more robust data. 

Can Prednisone Cause Mouth Ulcers?

Prednisone at optimal doses for a short duration (as prescribed by doctors) is used to treat multiple ulcers (recurrent aphthous stomatitis) present in the mouth. However, with intake of higher doses or long-term use of prednisone, mouth sores and ulcers, fever, chills, sore throat, cough, ear pain, and changes in the composition of saliva can present as side effects. Furthermore, as mentioned above concerning the side effects of steroids, long-term effects of prednisone on the teeth can include decay and erosion of the supporting alveolar bone. In such cases, it is recommended to consult a physician.

When to Avoid Steroid Therapy

Any injectable form of steroid should be avoided in individuals who are allergic to steroids or with active tuberculosis infection. Topical steroids are contraindicated in individuals with cellulitis, impetigo (skin infection), and carbuncle (multiple boils). Steroids should be administered with caution in individuals with diabetes, glaucoma (fluid build-up in the eye), viral infections (herpes type), osteoporosis (decreased bone density), immune deficiency, pregnancy, and hypothyroidism.

What are the Recommended Oral Hygiene Practices to Follow While Taking Steroids? 

Since long-term use of steroids (oral or inhalational route) can affect oral health, the following oral hygiene practices are recommended to mitigate their impact:

• Brush twice and floss at least once a day.
• Rinse your mouth regularly with mouthwash to maintain oral hygiene. Additionally, using neutral pH mouthwashes or rinsing with water after inhalation of steroids helps neutralize the acidic pH of dry powder inhalers.
• To avoid dry mouth, drink water frequently during the day instead of drinking sugary or acidic beverages.
• Chew on hydrating fruits such as grapes, lemon, or sugar-free chewing gums containing xylitol to stimulate saliva flow.
• Visit your dentist regularly for dental check-ups, cleanings, and fluoride applications (if necessary) to reduce the risk of tooth decay and gum infections. Your dentist may also prescribe antibacterial mouthwash to address bad breath or bleeding gums.
• Limit excessive consumption of sugary foods and increase fiber intake in your diet.

These practices can help promote oral health and minimize the negative effects of steroid therapy on oral tissues.

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