An investigation into the need for supplementary steroids in organ transplant patients undergoing gingival surgery

Abstract

Organ transplant patients are frequently medicated with triple immunosuppressive therapy that includes both cyclosporin and the corticosteroid, prednisolone. Many of these patients experience gingival overgrowth that necessitates surgical intervention. Chronic dosing with corticosteroids can lead to suppression of the hypothalamic-pituitary axis, and subsequent adrenocortical suppression. To circumvent possible suppression, supplementary steroids are administered to such patients prior to so-called "stressful events". We have examined the need for supplementary steroids in 20 organ transplant patients undergoing gingival surgery under local anaesthesia to correct their drug-induced gingival overgrowth. All patients were operated upon in the first half of the morning. Prior to gingival surgery, resting blood pressure (BP) and serum ACTH concentrations were determined. Immediately before surgery patients received either intravenous hydrocortisone 100 mg or placebo in random, double-blind order. Each patient required 2 gingivectomies and thus acted as their own placebo control. BP was measured at various time points throughout surgery and upto 2 h postoperatively. On completion of surgery, a further blood sample was taken to determine ACTH concentration. There was no significant difference (p>0.05) between placebo and hydrocortisone treatments for BP and ACTH measurements. No patient experienced any symptoms that were suggestive of adrenocortical suppression. One patient did experience postural hypotension prior to gingival surgery, but this is attributed to his antidepressant medication. We can conclude from this study that immunosuppressed organ transplant patients taking the maintenance dose of prednisolone (5-10 mg/day) do not require corticosteroid cover prior to gingival surgery under local anaesthesia. We would however, advocate monitoring of their blood pressure throughout the procedure.

General medicine and surgery for dental practitioners. Part 4 – skin disorders part B

“…This is an area of controversy and some evidence suggests that the routine use of prophylactic steroids is unnecessary. 8 Many more patients will be using topical steroid medication, which could theoretically lead to adrenal suppression. However this appears not to be a problem and steroid cover for surgical dental procedures in this group is usually not required.…”

Preservation of the negative image of tooth enamel with dental impression material enhances morphometric measurements of gingival overgrowth

“…Both environmental and genetic factors are responsible, and usually interrelated, and especially affect those individuals with diabetes, leukemia, thrombocytopenia purpura, immunodeficiency states, and endocrine disorders. In addition, patients taking calcium antagonists, cyclosporine A, or other therapies for transplantation (Arora et al, 2001;Thomason et al, 1999), and certain anticonvulsants, are at greater risk; yet underlying mechanisms are largely unknown (Brunet et al, 2001;Hallmon and Rossmann, 1999). Thus, there are abundant reasons for studying genetic and environmental factors in the etiology of gingival disease (Weerheijm et al, 2001), but few examples exist in the literature where clinical landmarks of GO are incorporated into animal-research protocols for a comparative and quantitative search for risk factors.…”

General medicine and surgery for dental practitioners Part 6: The endocrine system

“…The use of supplemental steroids prior to dental surgery in patients at risk of an 'adrenal crisis' is a contentious issue 3,4 and is discussed in the Respiratory paper in this series. After unilateral adrenalectomy for a Cushing's ade- …”