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.