ALLERGIC REACTIONS in the DENTAL OFFICE

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ALLERGIC REACTIONS in theDENTAL OFFICE
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Allergic Reactions

• Allergy is defined as a hypersensitive state
  aquired through exposure to a particular
  allergen, reexposure to which produces a
  heightened capacity to react

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Allergic Reactions

• Allergic reactions range from mild, delayed
  reactions occuring as long as 48 hours after
  exposure, to immediate life-threatening reactions
  that occur within seconds after exposure

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Classification of Allergic Reactions

• Type Mechanism Time Example
• I Anaphylactic sec/min Angioedema
• II Cytotoxic -- Transfusion
  rx
• III Immune 6-8hrs Serum sickness
• complex
• IV Cell mediated 48 hrs Contact
• 
  dermatitis

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Most Common in Dental Office

• Type I
•  Immediate Localized or Generalized
  Anaphylaxis - The Type I allergic reaction is
  subdivided into several forms based upon the
  response
• Type IV
• Contact Dermatits

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Type IImmediate Hypersensitivity

• Generalized (Systemic) Anaphylaxis
• Localized Anaphylaxis
• Urticaria
• Bronchial Asthma
• Food Allergy

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Antigen

• A substance that elicits an allergic reaction

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Antibody

• A substance in blood or tissue that responds and
  reacts with the antigen
• (different in structure than the antigen)

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Atopy

• Clinical hypersensitivity state, subject to
  heredity (asthma, hay fever, etc.)

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Urticaria

• Wheals (hives)
• Smooth elevated patches surrounded by
  erythematous areas
• Pruritus (itching)

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Angioedema

• Non-inflammatory edema involving
• skin, subcutaneous tissue, underlying muscle
  mucous membranes.
• Occurs in response to allergen
• Most critical in the larynx

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Predisposing Factors in Allergic Reactions

• Prior history of allergy
• Genetic predisposition to allergy
• - atopic patient
• Patient with multiple allergies
• Drug that is utilized

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Drugs that Cause Allergic Reactions

• Up to 70 of Allergic Reactions
• Penicillin
• Meprobamate
• Codeine
• Thiazide Diuretics

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Other Substances Causing Reactions

• Iodines Vaccines
• Insulin Heparin
• Salicylates Sulfonamides
• Opiates Local Anesthetics
• Venom from stinging insects

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Antibiotic Allergy

• Highest incidence
• Penicillins (anaphylactic reaction may prove
  fatal in 15 minutes)
• Sulfonamides
• Reactions to erythromycins rarely seen

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Analgesic Allergy

• Incidence of true allergy to narcotics is low
• "Allergy" is most often a side effect such as
  nausea, vomiting, drowsiness, dysphoria, or
  constipation

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Antianxiety Drug Allergy

• Barbiturates -most common but occur less than
  aspirin and penicillin
• Reactions -hives, urticaria, blood dyscrasia
  (agranulocytosis / thrombocytopenia)
• Allergy occurs more frequently with a history of
  asthma, urticaria, and angioedema

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Local Anesthetics

• Reactions occur most frequently with Esters
• Preservatives also cause reactions

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Ester Drugs

• Procaine Propoxycaine
• Benzocaine Tetracaine
• Related compounds
• Procaine Penicillin G
• Procainamide

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Amide Allergy

• The amide type anesthetic are essentially free of
  allergic reaction when given in their pure form
• Although true allergy to amide type anesthetic is
  extremely rare, patients have demonstrated
  allergic reaction to the contents of the dental
  cartridge

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Ingredient - Function

• Anesthetic Agent - Conduction blockade
• Vasoconstrictor - Decrease absorption of
  local anesthetic
• Sodium Metabisulfite - Preservative for
  vasoconstrictor
• Methylparaben - Preservative to increase
  shelf life bacteriostatic
• Sodium Chloride - Isotonicity of solution
• Sterile Water - Diluent

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Paraben Reactions

• Preservative found in many non-drug items
• Allergic reactions to topical anesthetics are
  those of contact stomatitis erythema, edema,
  ulcerations - almost exclusively a dermatologic
  type reaction

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Clinical Options

• Determine type of allergic reaction
• Substitute different drugs for those which cause
  the allergic reaction.
• Have patient evaluated by allergist

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Management of Allergic Reactions

• Most severe allergic reactions are immediate
• A number of organ oystems may be involved
• Skin
• Cardiovascular
• Respiratory
• Gastrointestinal

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Management of Allergic Reactions

• Generalized anaphylaxis involves all of the
  previously mentioned systems
• When hypotension occurs, it is termed
  Anaphylactic Shock

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Affected Area - Manifestation

• Skin Urticaria-Wheal Flare
• pruritis, angioedema,
  erythema
• Respiratory Dyspnea,wheezing,flushing,
• cyanosis,perspiration,tachycardia
  ,
• increased anxiety,use of
  accessory
• muscles of respiration

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Affected Area - Manifestation

• Gastrointestinal Abdominal cramps,
• nausea, vomiting,
  diarrhea,
• incontinence
• Cardiovascular Pallor, light-headedness,
• palpitations,
  tachycardia,
• hypotension,
  dysrhythmias,
• loss of consciousness,
  arrest

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Sequence of Reaction

• 1. Skin reaction
• 2. Smooth muscle spasm
• (GI, GU, and bronchial)
• 3. Respiratory distress
• 4. Cardiovascular collapse

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Type of Reaction

• Quick Onsetgt Rapid Progressiongt Intense
  Reaction
• Delayed Onsetgt Slow Progressiongt
• Less Severe Reaction

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Drugs Used in Allergic Reactions
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Epinephrine

• Has Alpha and Beta adrenergic effects
• Acts as a physiologic antagonist to the events
  that occur during an allergic reaction

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Epinephrine

• Actions Include
• Bronchodilation
• Increased heart rate
• Arterial constriction
• Cutaneous, mucosal, and splanchnic
• vasoconstriction
• Reverses rhinitis and urticaria

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Epinephrine

• Risks of repeated use
• Excessive elevation of blood pressure
• CVA
• Cardiac rhythm abnormalities

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Antihistamine

• Benadryl (chlorpheniramine) most often used
• H-1 blocker
• Inhibits action of histamine released during
  reaction to allergen

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Corticosteroids

• Hydrocortisone used most often
• Stablilizes cell membranes against actions of
  histamines, bradykinins, and prostaglandins
• Supplements adrenal steroid output during stress

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Treatment ofImmediate Skin Reactions

• Epinephrine 0.3 mg IM or SC
• (0.3ml of a 11000 Solution)
• Antihistamine
• Diphenhydramine (Benadryl) 50 mg IM

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Treatment ofImmediate Skin Reactions

• Obtain medical consultation
• Observe patient for at least one hour
• Prescribe oral antihistamines
• Benadryl 50 mg PO Q6H for 3-4 days

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Treatment ofDelayed Skin Reactions

• Antihistamine
• Diphenhydramine (Benadryl) 50 mg IM
• Prescribe oral form Q6H for 3-4 days
• Arrange medical consultation

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Treatment ofRespiratory Reactions

• Bronchial Constriction
• Terminate dental treatment
• Sit patient upright
• Oxygen 6 L/min
• Epinephrine aerosol or 0.3 mg IM or SC
• (0.3 ml of a 11000 solution)

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Treatment ofRespiratory Reactions

• Bronchial Constriction (cont.)
• Observe for at least 1 hr
• Antihistamines - Benadryl 50 mg IM
• Obtain medical consulatation
• Prescribe oral antihistamines
• (Q6H for 3-4 days)

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Treatment ofRespiratory Reactions

• Laryngeal Edema
• Sit patient upright
• Epinephrine 0.3 mg IM or IV
• Maintain airway
• Summon medical assistance

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Treatment ofRespiratory Reactions

• Laryngeal Edema (cont.)
• Oxygen 6 L/min
• Cricothyroidotomy
• Additional drug therapy
• Diphenhydramine 50mg
• /or
• Hydrocortisone 100 mg

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Generalized Anaphylaxiswith Signs of Allergy

• Place patient in a supine postion
• Basic Life Support (ABCs)
• Administer epinephrine 0.3 mg IM or SC
• (0.3 ml of a 11000 solution)
• Summon medical assistance - call 911

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Generalized Anaphylaxiswith Signs of Allergy

• Monitor vital signs
• Additional drug therapy
• Antihistamines
• Corticosteroids
• Repeat epinephrine Q5min prn

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Generalized Anaphylaxiswithout Signs of Allergy

• Place patient in a supine position
• Basic Life Support
• Monitor vital signs
• Summon medical assistance prn

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Generalized Anaphylaxiswithout Signs of Allergy

• Consider possible causes of unconsciousness
• Syncope
• Overdose Reaction
• Hypoglycemia
• CVA
• Acute Adrenal Insufficiency

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Prevention of Allergic Reactions

• HISTORY - a thorough, complete history of any
  previous allergic response or tendency prior to
  starting treatment will avoid most emergencies

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Other Means of Prevention

• Medical consultation
• Dental office skin testing
• (not foolproof and not advisable)

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Take Home Lessons

• All positive responses to an allergy history are
  true until exact nature is determined!
• Patients reporting allergies should be critically
  evaluated -refer for allergy testing if history,
  reaction, or management are suspect.
• Be prepared to manage difficulties! Always!