Topical corticosteroids used in dentistry

In dentistry, topical corticosteroids (eg creams, ointments, mouthwashes, sprays) are used to manage the symptoms of immune-mediated oral mucosal diseases, including conditions that present with recurrent or persistent oral ulceration. Although there is substantial clinical experience with intraoral use of topical corticosteroids, this practice is off-label and supported by little published evidence.

In the general practice setting, only mild or moderate potency corticosteroid creams or ointments should be used. Potent or very potent creams or ointments, or other formulations of topical corticosteroids, should not be started without specialist advice. Properties of topical corticosteroids used on the oral mucosa lists the relative potency of corticosteroid creams and ointments.

Prolonged or sustained use of moderate, potent or very potent topical corticosteroids requires regular monitoring. Use of these higher potency corticosteroids increases the risk of systemic absorption, either through the oral mucosa or if inadvertently swallowed. Adrenal suppression has been documented with the use of high-potency topical corticosteroids.

Local adverse effects include superimposed candidiasis, mucosal atrophy, capillary fragility, telangiectasia, delayed wound healing and altered pigmentation. Predisposing factors for candidiasis include immune compromise, smoking, denture use and hyposalivation.

Table 1. Properties of topical corticosteroids used on the oral mucosa

Comparative potency on oral mucosa [NB1]

Drug [NB2]

Strength

Suitable to prescribe without specialist advice

mild

hydrocortisone acetate

1%

moderate

triamcinolone acetonide

0.02%

betamethasone valerate

0.02%, 0.05%

Do not prescribe without specialist advice

potent

betamethasone valerate

0.1%

methylprednisolone aceponate

0.1%

betamethasone dipropionate

0.05%

mometasone furoate

0.1%

very potent

betamethasone dipropionate

0.05% in optimised vehicle

clobetasol propionate [NB3]

0.025 to 0.05%

Note:

NB1: Topical corticosteroids are more potent when applied to the oral mucosa than when applied to the skin.

NB2: All formulations in this table are available as both a cream and an ointment.

NB3: Clobetasol propionate as a cream or ointment is not registered for use in Australia, but is available via the Special Access Scheme or compounding pharmacies. Use only under specialist supervision.

Select a topical corticosteroid based on potency, lesion size and location, and the patient’s preference and ability to adhere to instructions. Creams are water-based and easily applied to the oral mucosa, whereas oil-based ointments may be more difficult to apply; however, patients may have a preference because of taste, texture and ease of use.

The patient’s pharmacist or medical practitioner may not be familiar with intraoral use of topical corticosteroids. Provide patients with written instructions that can be shared with their healthcare practitioner to explain the practice. See Patient instructions for applying a topical corticosteroid to the oral mucosa for instructions on application of topical corticosteroids to the oral mucosa.

Figure 1. Patient instructions for applying a topical corticosteroid to the oral mucosa
  • It is not necessary to dry the mucosa first.
  • Apply a pea-sized amount of the cream or ointment to a clean fingertip, then smear a thin layer onto the affected area.
  • Hold in the mouth for 1 to 2 minutes without swallowing, and then spit out excess.
  • Follow the dentist’s instruction for frequency of application.
  • Ideally, apply the corticosteroid after meals or oral hygiene practices.
  • Although the cream will be labelled ‘For external use only’, use on the oral mucosa is safe—systemic absorption from the mouth is minimal if used as instructed.