CORTICOSTEROIDS

INTRODUCTION

– Adrenal corticosteroids are necessary regulators of

homeostatic life processes.
– Natural hormones include

Glucocorticoid
Mineralocorticoid
Sex hormones
3
History
 By the middle of 19th century it was demonstrated that
adrenal glands were essential for life
 Later, it was appreciated that the cortex was more
important than the medulla
 A number of steroidal active principles were isolated
and their structures were elucidated by kendall and his
coworkers in the 1930s.
 However, the gate to their great
therapeutic potential was opened
by Hench (1949) who obtained
striking improvement in
rheumatoid arthritis by using
cortisone.
 The nobel prize was awarded the
very next year to kendall and
Hench.
 Currently, corticosteroids are
drugs with one of the broadest
spectrum of clinical utility.

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 CHEMICAL STRUCTURE
• 4 cycloalkane rings
• 3 cyclohexane rings
• 1 cyclopentane ring .
• Gonane is the simplest steroid
• Vary by the configuration of the side
chain, the number of additional methyl
groups, and the functional groups
attached to the rings
Functional anatomy and histology of adrenal
glands

Corticosteroid Hormones

• Epinephrine
• Norepinephrine
• Dopamine
Regulating salt and
water

• Suppress inflammation
and immunity
• Breakdown
of fats, carbohydrates,
and proteins,
• Resistance to stress
8Rate of secretion of the principal
steroids
Glucorticoids
10-20 mg daily

Mineralocorticoids – 0.125
mg daily

Textbook of Medical Physiology 11th Edition,

26/03/2019
Arthur C. Guyton, John E. Hall - 2006
 Cholesterol

Biosynthesis of steroids Pregnenolone

Progesterone 17α Hydroxy Dehydroepiandrosterone

pregnenolone

11- Deoxy corticosterone 17α Hydroxy Androstenidione

progesterone

Corticosterone Testosterone
11 Desoxyhydro
cortisone
Aldosterone
Hydrocortisone

Mineralocorticoid Glucocorticoid Androgens

 Regulation of Synthesis
• Synthesized and
released under
influence of ACTH - Ant.
Pituitary (HPA axis)

• Regulated by CRH
from hypothalamus
and by feedback
levels of blood
concentrations
Regulation of Synthesis - Others

1. Control by circadian rhythm

(Diurnal rhythm) – morning rise
2. Stress: hypoglycaemia, physical
stress etc.
 How exactly stress induces increases
12
Corticosteroid production?

– At the hypothalamus, fear-signaling impulses activate both the

sympathetic nervous system and the modulating systems of the
HPA axis.

– E/NE will positively feedback to the pituitary and increase the

breakdown of POMCs(Pro-opiomelanocortin ) into ACTH

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 release Corticotropin-
HYPOTHALAMUS
S Adrenocorticotr PITUTIARY
releasing hormone
(CRH)
T opic hormone
(ACTH) GLUCOCORTICOIDS
R
E
S
S cortisol
 PHYSIOLOGY

24-30mg of cortisol

300mg of cortisol

Sanghavi J, Aditya A. Applications of Corticosteroids in Dentistry. J

Dent Allied Sci 2015;4:19-24
 Classes of corticosteroids
– Corticosteroids are generally grouped into
four classes, based on chemical structure.
– Allergic reactions to one member of a class
typically indicate an intolerance of all
members of the class.
"Coopman classification"
– Group A
– (short to medium acting glucocorticoids)
Hydrocortisone, Hydrocortisone acetate, Cortisone
acetate, Tixocortol pivalate, Prednisolone,
Methylprednisolone, and Prednisone.
– Group B
– Triamcinolone acetonide, , Mometasone, Amcinonide,
Budesonide, Desonide, Fluocinonide, Fluocinolone
acetonide, and Halcinonide.
– Group C
– Betamethasone, Betamethasone sodium
phosphate, Dexamethasone, Dexamethasone
sodium phosphate, and Fluocortolone.
– Group D
– Hydrocortisone-17-butyrate,Betamethasone
valerate, Betamethasone dipropionate,
Prednicarbate and Fluprednidene acetate
Classification of steroids based on their
relative activity:

GLUCOCORTICOIDS
GLUCOCORTICOIDS

Source : zona fasciculata

Cortisol – Life protecting hormone

 • Most potent
Cortisol • Provides 95% of glucocorticoid
activity

• Most potent
Corticosterone • Provides 95% of glucocorticoid
activity

• Secreted in minute quantities

Cortisone • Provides 1% of glucocorticoid
activity
ACTION ON EFFECT
On carbohydrate Increases blood glucose level by
metabolism gluconeogenesis, inhibits glucose uptake
and utilization by peripheral cells
Promotes catabolism of protein and
Protein metabolism increases plasma amino acid and protein
content
Metabolism of fatty acid from adipose
Fat metabolism tissue increases in concentration of fatty
acid , increase utilization of fat for energy.
Mineral metabolism Enhances sodium retention, potassium
excretion.
Water metabolism Excretion of water
Muscles Increases the release of amino acid from
muscles by catabolism of protein

Blood vessel Decreases the release of eosinophil in RES,

decrease the number of lymphocytes, increase
in number of neutrophils , RBC and platelets .

Vascular response These are essential for constrictor action of

adrenaline and noradrenaline
CNS Essential for normal functioning, insufficiency
causes irritability and loss of concentration
 Permissive action
– Action of some hormones are executed only in presence of
glucocorticoids.. Examples are :
– Calorigenic effect of glucagon.

– Lypolytic effect of catecholamines.

– Pressor effect of catecholamines.

– Bronchodilation by catecholamines.
 Anti-
inflammatory
Action
Anti-allergic action

– Suppresses all type of hypersensitivity reaction

and allergic reaction.

– Suppresion of recruitment of leucocytes at the

site of contact with antigen and inflammatory
response to immunological injury
Immunosuppresive
action
– Suppresses immune system of body by
decreasing number of circulating T
lymphocytes.

– Prevent release of IL2 by T cells

 Regulation of Cortisol Secretion
Emotion, stress, trauma

Hypothalamus

Feedback inhibition
Corticotropin releasing factor

Anterior pituitary

ACTH

Adrenal cortex

Cortisol
MINERALOCORTICOIDS

Source : Zona glomerulosa

Aldosterone – life saving hormone

 Action on EEFECT
Sodium metabolism Increases sodium reabsorption
from renal tubules
On ECF Sodium reabsorption, stimulates
water reabsorption thus in term
increases ECF volume
Blood pressure Increases
Potassium ions Increases in excretion of potassium
ion s from renal tubules
Hydrogen ion Tubular secretion of hydrogen ion ,
essential to maintain acid base
balance.
FATE OF CORTICOSTEROIDS
 ROUTES OF ADMINISTRATION OF
CORTICOSTEROIDS
1. Topical steroid for use topically on the skin, eye, and mucous
membranes.

2. Inhaled steroids for use to treat the nasal mucosa, sinuses,

bronchii, and lungs.

3. Oral forms - such as prednisone and prednisolone.

4. Systemic forms - available in injectable for use intravenously

and parenteral routes
ADRENAL
INSUFFICIENCY
– Endocrine disorder
– Inadequate production of adrenal
androgens, mineralocorticoids and
glucocorticoids by the adrenal cortex
– Primary AI
– Secondary AI
PRIMARY ADRENAL
INSUFFICEINCY
– Addison disease
– Progressive destruction of the adrenal cortex
– Idiopathic nature (most commonly
autoimmune)
– Weakness, fatigue, loss of appetite, weight
loss and patchy hyperpigmentation of the
skin and oral mucosa.
 SECONDARY ADRENAL INSUFFICIENCY
Inhibition of
Hypothalamic/ feedback loop-
Pituitary disease pituitary and adrenal
glands
Failure to
Chronic produce cortisol
administration Failure of production
of exogenous of
corticosteroids adrenocorticotropin
– 2-3 Times more common
– Selectively causes glucocorticoid deficiency
– Mineralocorticoid function is better
maintained than in primary AI and the
condition is less likely to cause acute
adrenal crisis
 ADRENAL CRISIS
– Rare, potentially lethal event
– Precipitated by stress
– In patients with chronic AI.
– Primary AI > Secondary AI
– Susceptible patients have diminished adrenal reserve and
are unable to secrete sufficient amounts of the steroid the
body requires during a stressful event.
– Fever, gastrointestinal complaints, hypotension,
tachycardia and electrolyte disturbances.
– Hypovolemic shock and cardiovascular failure can
ensue.
– Few cases have been reported during dental care
RISK FACTORS OF
ADRENAL CRISIS
– Significant and unrecognized AI
– Poor health status and stability at the time of dental
treatment (acute illness, fever)
– Pain
– Infection
– Extractions or invasive procedures that caused bleeding
and discomfort
– Use of general anesthetic containing a barbiturate.
 Management Of Adrenal
Crisis
– Intravenous fluids (in the form of 5% dextrose in normal saline).
– Primary adrenal insufficiency: Start on 20-25 mg hydrocortisone
per 24 h.
– Secondary adrenal insufficiency: 15-20 mg hydrocortisone per
24 h; if borderline fails in cosyntropin test considers 10 mg or
stress dose cover only.
– Hydrocortisone should initially be given intravenously.
– If there is an improvement within 24 h, the hydrocortisone
dose can be reduced.
– Changed to an oral formulation whenever the patient is stable.
– The dose declined by one-third to one-half the doses daily
until a maintenance dose of 20 mg in the morning and 10 mg
in the afternoon or at night is attained.
– The condition that precipitated the crisis should be treated.
– Patients will not need mineralocorticoid replacement because
the renin angiotensin-aldosterone axis is intact.
Arlt W. The approach to the adult with newly diagnosed adrenal
insufficiency. J Clin Endocrinol Metab 2009;94:1059-67.
SUPPLEMENTATION

– Supplementation dose level for the day -

minor to moderate surgery -25 to 75 mg
hydrocortisone equivalent.
– Higher doses of 100 to 150 mg -major
surgery and the following day.
– Postoperatively, appropriate patient
monitoring that is based on the risk factors
Prolonged therapy
Mineralocorticoids:
• Sodium and water retention
• Edema
• Hypokalemic alkalosis
• Progressive rise in B.P
• Weight gain
• Fluid and electrolyte disturbance
Glucocorticoid:
GIT:
• Acute erosive gastritis with hemorrhage
• Peptic ulcer
• Intestitial perforation
• Pancreatitis
Metabolic effects:
• Hyperglycemia
• Ketoacidosis
• Hyperosmolar coma
• Hypophosphatemia
CVS and renal system:
 Hypertension
 Salt and water retention
 Hypokalemic alkalosis
CNS:
 Influence mood, sleep pattern
 Insomnia
 Acute psychotic reactions
 Benign intracranial hypertension
 Epilepsy
 Musculoskeletal effects:
 Proximal myopathy and osteoporosis with
compression fractures of vertebrae
 Acute aseptic necrosis of bone
Eyes:
 Glaucoma
Suppression of inflammation and immune response:

 Latent infection may flare

 Opportunistic infection with low grade pathogens

Retardation of linear growth:

 Occurs in children who receive more than 50 mg of

cortisone per m2 of body surface per day.
 Cushingoidism:
Prolonged therapy causes
 Central obesity with moon face
 Buffalo hump
 Pink florid striae are liable to appear on the
abdomen, hips and pectoral region and
skin may become friable
 Peptic ulcer  Osteoporosis
 Diabetes mellitus  Psychosis
 Hypertension  Epilepsy
 Pregnancy  Renal failure
 Herpes simplex
keratitis
 Tuberculosis
 PULSE THERAPY
– Short term therapy

– High dose therapy -48-72 hours course of

intensive steroid administration

– Single I.V injection of a supra-physiological dose

of steroid

– Dose of 0.5-2g of prednisolone or equivalent

BENEFITS
– Avoids complications & side effects of long
term steroid therapy
– To achieve immunosuppressive effects
similar to those with higher doses of
steroids
Issued when

– Oral/systemic corticosteroids Patients prescribed oral steroids for periods of

more than 3 weeks Or those receiving more than four short oral courses per
year
– Inhaled corticosteroids (ICS) Patients receiving high dose inhaled
corticosteroids
– Other forms of corticosteroid Patients receiving topical or nasal corticosteroids
do not routinely require a steroid card unless systemic absorption likely to be
increased i.e. Crohn’s/Ulcerative colitis flare/prolonged usage/multiple
formulations prescribed/drug interactions
STEROIDS IN
DENTISTRY
ORAL MANIFESTATION OF
ADDISONS DISEASE
– Characteristic melanin pigmentation
– The skin darkens in the elbows, folds of the hands or areolas of the breasts.
– The oral mucosa can in turn develop black-bluish plaques, mainly affecting
buccal mucosa but it can also be seen on the gums, palate, tongue and lips.
 STEROIDS IN ORAL
SURGERY
– Post operative pain, edema and trismus after 3rd
molar surgery
– Post operative edema after orthognathic surgery
– Prevention of alveolar osteitis

Das JR, Sreejith VP, Anooj PD, Vasudevan A. Use of Corticosteroids in

third molar surgery: Review of literature. Univ Res J Dent 2015;5:171-5.
PERIOPERATIVE ANTI-
INFLAMMATORY
– Boc and Peterson -use of steroids for
orthognathic and traumatic oral surgical
procedures,
– 6mg of sodium dexamethasone or equivalent,
given 2-3 hours before surgery
– And repeated at surgery may accomplish this
purpose
 CORTICOSTEROIDS
IN ORTHODONTIC
TOOTH MOVEMENT
– Orthodontic tooth movement is by sequential
reactions of the periodontal tissue in response to
biomechanical forces.
– The arachidonic acid metabolites also play an
important role in the process of bone remodeling
during tooth movement
International Journal of Pharmaceutical Sciences Review and Research
– Hydrocortisone at a dose of 10 mg/kg/day for
7 days on Rats
– Lower amount of tooth movement
– It is essential that the patients are reviewed of
their prior history of
– Corticosteroids use.
– Longer interval between treatments
Yamane A, Fukui T, Chiba M, In vitro measurements of orthodontic tooth movement in rats
given B-amino propionitrile or hydrocortisone using a time-laps video tape recorder, Eur J
Orthod, 19, 1997, 21-28.
 STEROIDS IN
ENDODONTICS
– Steroid-antibiotic combinations like
Ledermix
– Steroids like hydrocortisone are also mixed
with zinc oxide eugenol as root canal
sealers.
International Journal of Pharmaceutical Sciences Review and Research
STEROID IN ORAL
MEDICINE
Recurrent aphthous stomatitis
Topical
– Hydrocortisone hemisuccinate (pellets of 2.5 mg)
– Triamcinolone acetonide (adhesive paste containing 0.1% of the
steroid).
– In inaccessible areas controlled by topical dexamethasone.(0.5 mg/5
ml held over the area or applied with a saturated gauge pad to the
ulcers, 4 times/day for 15 min )
– Betamethasone sodium phosphate rinse
• Major aphthous ulcers
systemic treatment
• Prednisone therapy 40
mg/day for 1 week
• 1.0 mg/kg a day as a single
dose in severe RAS patients
and should be tapered after
7-14 days
BEHCET’S DISEASE
• The mainstay of treatment for
Behcet’s disease is
immunosuppressive therapy.

• In the acute phase, prednisone, at doses of 40-60 mg/day

• It may be used alone or in combination therapy with other
immunosuppressive agents
 ULCERATIVE
VESICULOEROSIVE DISEASES

– Immunologically mediated diseases affecting

oral mucosa
– Inflammation and loss of epithelial integrity,
– Corticosteroids central role in the treatment

– Adverse effects of systemic corticosteroids

increased use of topical corticosteroids (TCs)
 TOPICAL
CORTICOSTEROIDS FOR
ULCERATIVE
VESICULOEROSIVE
LESIONS
Indications for use
– Short course of TC – accelerates remission without
producing adverse effects

– Ulcerative disease that have tendency to remit

spontaneously

– Eg RAS, some cases of EM, drug induced ulceration

Scully et al., 1999; Chan et al., 2002
TC for longer and less predictable periods

– When disease is chronic

– Marked tendency for recurrence

– Eg. RAS, erosive OLP, aspecific form of EM, MMP

In severe cases of ulceration

– After a short course of systemic corticosteroids,

maintenance regimen of TC

– Prevent recurrence, and avoids adverse effects

associated with long course of systemic
corticosteroids
Patients prescribed TC in an adherent vehicle should be
instructed to
Apply a small amount to the target area after meals, and
Not to eat or drink for at least 30 min.
It is best not to rub the TC in, because this can produce
irritation.
JDR April 2005 vol. 84 no. 4 294-301
 Prolonged topical therapy
– Can cause atrophy of epidermis, dermis
– Subcutis
– Disturbed wound healing
– Hypertrichosis
–Heike
Perioral dermatitis
Scha¨cke, Wolf-Dietrich Do¨cke, Khusru Asadullah; Mechanisms involved in
the side effects of glucocorticoids; Pharmacology & Therapeutics 96 (2002) 23 – 43
Major aphthae or severe
multiple minor aphthae
– Prednisone therapy 1.0 mg/kg/day in
patients with severe RAU and tapered after 1
to 2 weeks.
– Predisone therapy 1- 2mg /kg/day after
breakfast until the disease is controlled and
then maintenance dose of 2.5 to 15mg daily (
Burket 11th edition )
ERYTHEMA
MULTIFORME
• Minor EM – 20 to 40
mg/day for 4 to 6 days
• Severe or rapidly progressing lesions – 60
mg/day slowly tapered by 10mg/day over 6
weeks Indian J Ophthalmol Jan-Feb 2010;58(1):64-66
 PEMPHIGUS VULGARIS
– Mainstay 1-2mg/kg/d.

– Initial dose of treatment – 0.5 mg/kg/day to 3

mg/kg/d

– Dose that achieves clinical control is maintained

for 2-3 weeks and then gradually tapered.
Burket’s Oral Medicine, 11th edition
 CICATRICIAL PEMPHIGOID
• Prednisolone – 30 to 60 mg/day 2 to 3
weeks to stop new bullae formation.
Tapered by 20% every 2 to 3 weeks until
the dose of 10 mg is reached
• Then maintained on alternate day and
reduced by 5 mg every 2 week then
stopped
 Bullous pemphigoid
• Clobetasol propionate
• 20 -40 mg/day is most effective for the
treatment.

JIAOMR, April-June 2011;23(2):128-131

 Lichen planus
• Prednisolone - 1mg/kg/d for <7 days
• Tapered to 10-20mg per day for 2 weeks

Burkit’s Oral Medicine, 11th edition

JIAOMR, April-June 2011;23(2):128-131
 Lupus erythematosus

• Prednisolone – 20 - 30 mg/day for 2- 6 weeks

• Tapered gradually
 STEROIDS IN THE
TREATMENT OF BENIGN
LESIONS
 CENTRAL
GIANT CELL
GRANULOMA
• Intralesional injection of triamcinolone can be
given in a dose of 1 to 2 mg/kg/d (maximum of 60
mg).
• The treatment interval at 4 to 6 weeks.
J Med Assoc Thai 2008; 91 (Suppl 3): S90-6
 Hemangioma

• Prednisone at a dose of 20-30 mg/d can be given

for 2 weeks to 4 months
• Intralesional triamcinolone acetonide (4 mg/mL)
 STEROIDS IN
SALIVARY GLAND
DISORDERS
 Mucocele

• 0.05% clobetasol propionate 3 times a day for 4

weeks in a mucosal adhesive base.
• Intralesional injections have also been tried with
success.
(JOMS 2008;66:1737-9)
STERIODS IN NEURALGIA
 Post herpetic
neuralgia
To reduce incidence of post herpetic neuralgia:

• Prednisolone 20 to 30 mg/day for 7 – 10 days

tapered to 10 mg/day for 1 week
STEROIDS FOR TMJ
DISORDERS
 ARTHRITIS
• Rheumatoid arthritis - Intraarticular injection – 10 to 40
mg/ml
• Osteoarthritis - Intraarticular injection – 20 mg/ml(2
injections 14 days apart)

Oral Surgery Volume 1 Issue 2, Pages 88 - 95

 BELL’S PALSY
• Prednisolone is started within
72 hours of symptom onset
• May prevent denervation,
autonomic synkinesis and
progression of paresis to
palsy.
STEROID TAPPERING
DOSE
– Fagan recommends

– 60 mg x 3 days
– 40 mg x 3 days
– 20 mg x 3 days
– 10 mg x 3 days
– 5 mg x 3 days
ORAL SUBMUCOUS
FIBROSIS
– The initial symptomatic relief
the anti-inflammatory action of
the steroids
– Clearing the juxta epithelial
inflammatory reaction.
• Biweekly submucosal
injectionscombination of
dexamethasone (4mg/ml) and two parts
of hyaluronidase, diluted in 1.0 ml of 2%
xylocaine by means of a 27 gauge
needle, not more than 0.2ml solution per
site, for a period of 20 weeks.
• Significant relief of burning sensation
(88%) and improvement of trismus (83%)
can be seen in most patients.
 Protocol for
Supplementation of Patients
on Glucocorticoid Therapy
Who Are Undergoing Dental
Care (Burket’s 10th ed)
Dental Previous Systemic Current Daily Current
Procedure Steroid Use Systemic Steroid alternating topical
Use Systemic Systemic
Steroid Use Steroid Use

Routine If prior usage lasted No Treat on No

procedures for > 2 weeks and supplementation steroid dosage supplementati
ceased < 14–30 days needed day; no further on needed
ago, give previous supplementati
maintenance dose on needed

If prior usage ceased

> 14–30 days
ago, no
supplementation
needed
Dental Previous Systemic Current Systemic Daily alternating Current topical
Procedure Steroid Use Steroid Use Systemic Steroid Systemic Steroid
Use Use

Extractions, If prior usage lasted Double daily dose Treat on steroid

surgery, or > 2 weeks and on day of dosage day, and
extensive ceased < 14–30 procedure give double daily
procedures days ago, give dose on day of
previous procedure
maintenance dose No
supplementation
If prior usage Give normal daily needed
ceased > 14–30 Double daily dose dose on first
days ago, no on first postoperative day
supplementation postoperative day when pain is
needed when pain is anticipated
anticipated
94Some Commonly Prescribed
Steroids

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95

Triamcinolone
Oral:1,4,8mg syrup
Kenacort, Topical:0.1% eye drops,
Tricort, ointment
kenalog, Tess
buccal paste Parentral: 3,10,40 mg/ml
for I.M, intraarticular,
intralesional injections
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96

Dexamethasone
Oral:0.25,0.5,0.75,1,2,4,6mg
tablets
Decadron, Topical:0.1% eye drops, ear
Dexasone, drops, skin ointment
Wymesone
Parenteral: 4,8,10,20 mg/ml for
IV, IM, intralesional and
intraarticular.
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97

Betamethasone
Oral: oral drops – 0.5 mg/ ml,
Betnesol, tablets – 0.5 to 1 mg.
Betnovate,
Betnesol forte, Topical – 0.1% eye drops,
Betawin forte, ointment,0.05% nasal drops,
Walacort, 0.12% skin creams
Stemin Parenteral:4 mg/ml for IM, IV,
intralesional, intraarticular
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98

Hydrocortisone
Oral:5mg,10mg,20mgtab
Topical:
Wycort, Hycort, 1%eye drops
Unicort, 0.025%nasal drops
Cipcorlin, Efcorlin
0.25-2.5%skin cream
Parenteral:25, 50 mg/ml for
IV,IM,SC Injections
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 Cortisone
Oral: 5, 10, 25 mg
Corlin, tablets
Cortone Parentral:22,25
mg/ml of solution
 Prednisolone
Oral:5,10, 20 mg tablets,
Wysolone, 15mg/5 ml syrup, 5mg/ml
Prelone, suspension as pediatric
Nucort, drops
Cecort,
Parenteral:25,50 mg/ml
IM,IV,Intralesional
 Mineralosorticoid Lifesaving ..
Why ??
– Without mineralocorticoids, potassium ion concentration of the
extracellular fluid rises markedly, sodium and chloride are rapidly
lost from the body, and the total extracellular fluid volume and
blood volume become greatly reduced.

– The person soon develops diminished cardiac output, which

progresses to a shock like state, followed by death.

– This entire sequence can be prevented by the administration of

aldosterone or some other mineralocorticoid
 Conclusion
– Corticosteroids play an important role in control of pain & inflammation associated with
numerous disease states of oral cavity.

– Currently corticosteroids are drugs with one of the broadest spectrum of clinical utility.

– But it should never be used as a substitute to other treatments

– Lets keep it mind that these drugs do not cure the disease but rather control or relieve the
symptoms.
 References
– Risk of adrenal crisis in dental patients Results of a systematic search; May/June 2014

– Burket’ s Oral Medicine 9th and 11th edition

– Corticosteroids in Dentistry, Basavaraj Kallali et al JIAOMRApril-June 2011;23(2):128-131

– Steroids in Dentistry - A Review Sambandam V, Int. J. Pharm. Sci. Rev. Res., 22(2), Sep – Oct 2013;
nᵒ 44, 240-245

– Steroids Application In Oral Diseases, Int J Pharm Bio Sci 2013 Apr; 4(2): (P) 829 – 834

– Murthy, J. M. K., and Amrit B. Saxena. “Bell’s Palsy: Treatment Guidelines.” Annals of Indian
Academy of Neurology 14.Suppl1 (2011): S70–S72. PMC. Web. 23 Jan. 2017.