Discussion
The scientific literature lacks clinical studies directly comparing the use of corticosteroids and the outcomes of lateral MSA procedures. To the authors’ knowledge, this is the first systematic review providing data with the use of corticosteroids during MSA procedures to help clinicians to reduce MSA post-operative sequelae.
The most unfavorable side effects of corticosteroid use in oral surgery are avascular osteonecrosis, adrenal suppression, impaired healing, and increased risk of infections. Avascular osteonecrosis occurs more often when high doses of corticosteroids are taken for a long duration, which results in an inhibition of micro vascularity in the bone and necrosis. There are no studies reporting avascular osteonecrosis after low dose and short terms use of corticosteroid use in oral surgery procedures. Corticosteroid related adrenal suppression involves a reduced production of cortisol resulting from exposure of the hypothalamic-pituitary-adrenal axis to exogenous glucocorticoids and can have serious consequences including coma and death. However, the dosage and time required to reach these serious consequences are beyond those used in oral surgery. To avoid these side effects, it would be advisable not to administer corticosteroids in patients who are concurrently taking steroid doses for other pathologies, moreover, the most recent evidence-based guidelines advise against this practice .
Corticosteroids administration may also inhibit fibroblasts activity and proliferation causing delayed wound healing and increased rate of infections. The current review this hypothesis, reporting the highest number of wound dehiscences in the study with the longest duration of corticosteroid therapy. Infections can be a side effect of corticosteroids as they limit the inflammatory response by decreasing lymphocytes, monocytes, and macrophages migration and activity. However, Dan et al. support the use of corticosteroids in oral surgery, reporting a nonsignificant increase in the rate of infections compared to placebo. The authors mention that it is important to consider the combination of corticosteroids with antibiotics, which can lead to superinfections, when bacteria is not covered by the spectrum of action. It is not recommended, according to Dan et al. they be used in combination unless other indications are present. low or medium risk patients, antibiotics can be avoided or limited to a short pre-operative prophylaxis, pre- and post-operative prophylaxes are strongly recommended for guided bone regeneration procedures and especially for bone grafts in the maxillary sinus. Finally, the current review showed that the two studies reporting the longest duration of corticosteroid therapy (5 days) showed the absolute highest rates of postoperative swelling. This event was not confirmed by Dan et al.
The limitations of this systematic review are the absence of comparative studies specifically designed to investigate the use of corticosteroids in lateral MSA procedures, the extreme heterogeneity of reported complication outcomes, and the subjectivity of parameters such as pain.