ALLERGIC REACTIONS in the DENTAL OFFICE. Allergic Reactions Allergy is defined as a hypersensitive state aquired through exposure to a particular allergen,

ALLERGIC REACTIONS ALLERGIC REACTIONS in thein the

DENTAL OFFICEDENTAL OFFICE

Allergic ReactionsAllergic Reactions

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

Allergic ReactionsAllergic Reactions

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

Classification of Allergic Classification of Allergic ReactionsReactions

Type Mechanism Time Example Type Mechanism Time Example

I I AnaphylacticAnaphylactic sec/min sec/min AngioedemaAngioedema

II II CytotoxicCytotoxic -- -- Transfusion rxTransfusion rx

III III ImmuneImmune 6-8hrs 6-8hrs Serum sicknessSerum sickness

complex complex

IV IV Cell mediatedCell mediated 48 hrs 48 hrs ContactContact

dermatitisdermatitis

Most Common in Dental OfficeMost Common in Dental Office

Type IType I

   Immediate Localized or Generalized Immediate Localized or Generalized Anaphylaxis - The Type I allergic reaction is Anaphylaxis - The Type I allergic reaction is subdivided into several forms based upon the subdivided into several forms based upon the responseresponse

Type IVType IV

Contact DermatitsContact Dermatits

Type IType IImmediate HypersensitivityImmediate Hypersensitivity

Generalized (Systemic) AnaphylaxisGeneralized (Systemic) Anaphylaxis

Localized AnaphylaxisLocalized Anaphylaxis

UrticariaUrticaria

Bronchial AsthmaBronchial Asthma

Food AllergyFood Allergy

AntigenAntigen

A substance that elicits an allergic A substance that elicits an allergic reactionreaction

Antibody Antibody

A substance in blood or tissue that responds A substance in blood or tissue that responds and reacts with the antigenand reacts with the antigen

(different in structure than the antigen)(different in structure than the antigen)

AtopyAtopy

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

UrticariaUrticaria

Wheals (hives)Wheals (hives)

Smooth elevated patches surrounded by Smooth elevated patches surrounded by erythematous areaserythematous areas

Pruritus (itching)Pruritus (itching)

AngioedemaAngioedema

Non-inflammatory edema involving Non-inflammatory edema involving

skin, subcutaneous tissue, underlying muscle skin, subcutaneous tissue, underlying muscle & mucous membranes.& mucous membranes.

Occurs in response to allergenOccurs in response to allergen

Most critical in the larynxMost critical in the larynx

Predisposing Factors in Allergic Predisposing Factors in Allergic ReactionsReactions

Prior history of allergyPrior history of allergy

Genetic predisposition to allergyGenetic predisposition to allergy

- atopic patient- atopic patient

Patient with multiple allergiesPatient with multiple allergies

Drug that is utilized Drug that is utilized

Drugs that Cause Allergic Drugs that Cause Allergic ReactionsReactions

Up to 70% of Allergic ReactionsUp to 70% of Allergic Reactions

PenicillinPenicillin

MeprobamateMeprobamate

CodeineCodeine

Thiazide DiureticsThiazide Diuretics

Other Substances Causing Other Substances Causing ReactionsReactions

IodinesIodines VaccinesVaccines

InsulinInsulin HeparinHeparin

SalicylatesSalicylates SulfonamidesSulfonamides

OpiatesOpiates Local AnestheticsLocal Anesthetics

Venom from stinging insectsVenom from stinging insects

Antibiotic AllergyAntibiotic Allergy

Highest incidenceHighest incidence

Penicillins (anaphylactic reaction may Penicillins (anaphylactic reaction may prove fatal in 15 minutes)prove fatal in 15 minutes)

SulfonamidesSulfonamides

Reactions to erythromycins rarely seenReactions to erythromycins rarely seen

Analgesic AllergyAnalgesic Allergy

Incidence of Incidence of truetrue allergy to narcotics is low allergy to narcotics is low

"Allergy" is most often a side effect such as "Allergy" is most often a side effect such as nausea, vomiting, drowsiness, dysphoria, or nausea, vomiting, drowsiness, dysphoria, or constipationconstipation

Antianxiety Drug AllergyAntianxiety Drug Allergy

Barbiturates -most common but occur less than Barbiturates -most common but occur less than aspirin and penicillinaspirin and penicillin

Reactions -hives, urticaria, blood dyscrasia Reactions -hives, urticaria, blood dyscrasia (agranulocytosis / thrombocytopenia)(agranulocytosis / thrombocytopenia)

Allergy occurs more frequently with a history Allergy occurs more frequently with a history of asthma, urticaria, and angioedemaof asthma, urticaria, and angioedema

Local AnestheticsLocal Anesthetics

Reactions occur most frequently with EstersReactions occur most frequently with Esters

Preservatives also cause reactionsPreservatives also cause reactions

Ester DrugsEster Drugs

ProcaineProcaine PropoxycainePropoxycaine

BenzocaineBenzocaine TetracaineTetracaine

Related compoundsRelated compounds

Procaine Penicillin GProcaine Penicillin G

ProcainamideProcainamide

Amide AllergyAmide Allergy

The amide type anesthetic are essentially free The amide type anesthetic are essentially free of allergic reaction when of allergic reaction when given in their given in their pure formpure form

Although true allergy to amide type anesthetic Although true allergy to amide type anesthetic is extremely rare, patients have is extremely rare, patients have demonstrated allergic reaction to the demonstrated allergic reaction to the contents of the dental cartridgecontents of the dental cartridge

Ingredient - FunctionIngredient - Function

Anesthetic Agent - Conduction blockadeAnesthetic Agent - Conduction blockade

VasoconstrictorVasoconstrictor - Decrease absorption - Decrease absorptionof local anestheticof local anesthetic

Sodium MetabisulfiteSodium Metabisulfite - Preservative for - Preservative for vasoconstrictorvasoconstrictor

MethylparabenMethylparaben - Preservative to increase - Preservative to increase shelf life; bacteriostaticshelf life; bacteriostatic

Sodium Chloride - Isotonicity of solutionSodium Chloride - Isotonicity of solution

Sterile WaterSterile Water- Diluent- Diluent

Paraben ReactionsParaben Reactions

Preservative found in manyPreservative found in many non-drug itemsnon-drug items

Allergic reactions to topical anesthetics Allergic reactions to topical anesthetics are are those of contact stomatitis; erythema, those of contact stomatitis; erythema, edema, ulcerations - almost exclusively a edema, ulcerations - almost exclusively a dermatologic type reactiondermatologic type reaction

Clinical OptionsClinical Options

Determine type of “allergic” reactionDetermine type of “allergic” reaction

Substitute different drugs for those which Substitute different drugs for those which cause the allergic reaction.cause the allergic reaction.

Have patient evaluated by allergist Have patient evaluated by allergist

Management of Allergic Management of Allergic ReactionsReactions

Most severe allergic reactions are immediateMost severe allergic reactions are immediate

A number of organ oystems may be involvedA number of organ oystems may be involved

SkinSkin

CardiovascularCardiovascular

RespiratoryRespiratory

GastrointestinalGastrointestinal

Management of Allergic Management of Allergic ReactionsReactions

Generalized anaphylaxis involves all of the Generalized anaphylaxis involves all of the previously mentioned systems previously mentioned systems

When hypotension occurs, it is termed When hypotension occurs, it is termed Anaphylactic ShockAnaphylactic Shock

Affected Area - ManifestationAffected Area - Manifestation

SkinSkin Urticaria-Wheal & FlareUrticaria-Wheal & Flare

pruritis, angioedema, erythemapruritis, angioedema, erythema

RespiratoryRespiratory Dyspnea,wheezing,flushing, Dyspnea,wheezing,flushing,

cyanosis,perspiration,tachycardia,cyanosis,perspiration,tachycardia,

increased anxiety,use of accessoryincreased anxiety,use of accessory

muscles of respirationmuscles of respiration

Affected Area - Affected Area - ManifestationManifestation

GastrointestinalGastrointestinal Abdominal cramps, Abdominal cramps,

nausea, vomiting, diarrhea,nausea, vomiting, diarrhea,

incontinenceincontinence

Cardiovascular Cardiovascular Pallor, light-headedness, Pallor, light-headedness,

palpitations, tachycardia,palpitations, tachycardia,

hypotension, dysrhythmias,hypotension, dysrhythmias,

loss of consciousness, loss of consciousness, arrestarrest

Sequence of ReactionSequence of Reaction

1. Skin reaction1. Skin reaction

2. Smooth muscle spasm2. Smooth muscle spasm

(GI, GU, and bronchial)(GI, GU, and bronchial)

3. Respiratory distress3. Respiratory distress

4. Cardiovascular collapse4. Cardiovascular collapse

Type of ReactionType of Reaction

Quick Onset==> Rapid Progression==> Quick Onset==> Rapid Progression==> Intense ReactionIntense Reaction

Delayed Onset==> Slow Progression==> Delayed Onset==> Slow Progression==>

Less Severe ReactionLess Severe Reaction

Drugs Used in Allergic ReactionsDrugs Used in Allergic Reactions

EpinephrineEpinephrine

Has Alpha and Beta adrenergic effectsHas Alpha and Beta adrenergic effects

Acts as a physiologic antagonist to the events Acts as a physiologic antagonist to the events that occur during an allergic reactionthat occur during an allergic reaction

EpinephrineEpinephrine

Actions IncludeActions Include

BronchodilationBronchodilation

Increased heart rateIncreased heart rate

Arterial constrictionArterial constriction

Cutaneous, mucosal, and splanchnicCutaneous, mucosal, and splanchnic

vasoconstrictionvasoconstriction

Reverses rhinitis and urticariaReverses rhinitis and urticaria

EpinephrineEpinephrine

Risks of repeated use:Risks of repeated use:

Excessive elevation of blood pressureExcessive elevation of blood pressure

CVACVA

Cardiac rhythm abnormalitiesCardiac rhythm abnormalities

AntihistamineAntihistamine

Benadryl (chlorpheniramine) most often usedBenadryl (chlorpheniramine) most often used

H-1 blockerH-1 blocker

Inhibits action of histamine released during Inhibits action of histamine released during reaction to allergenreaction to allergen

CorticosteroidsCorticosteroids

Hydrocortisone used most oftenHydrocortisone used most often

Stablilizes cell membranes against actions of Stablilizes cell membranes against actions of histamines, bradykinins, and prostaglandinshistamines, bradykinins, and prostaglandins

Supplements adrenal steroid output during Supplements adrenal steroid output during stressstress

Treatment ofTreatment ofImmediate Skin ReactionsImmediate Skin Reactions

Epinephrine 0.3 mg IM or SCEpinephrine 0.3 mg IM or SC

(0.3ml of a 1:1000 Solution)(0.3ml of a 1:1000 Solution)

AntihistamineAntihistamine

Diphenhydramine (Benadryl) 50 mg IM Diphenhydramine (Benadryl) 50 mg IM

Treatment ofTreatment ofImmediate Skin Reactions Immediate Skin Reactions

Obtain medical consultationObtain medical consultation

Observe patient for at least one hourObserve patient for at least one hour

Prescribe oral antihistaminesPrescribe oral antihistamines

Benadryl 50 mg PO Q6H for 3-4 daysBenadryl 50 mg PO Q6H for 3-4 days

Treatment ofTreatment ofDelayed Skin Reactions Delayed Skin Reactions

AntihistamineAntihistamine

Diphenhydramine (Benadryl) 50 mg IMDiphenhydramine (Benadryl) 50 mg IM

Prescribe oral form Q6H for 3-4 daysPrescribe oral form Q6H for 3-4 days

Arrange medical consultationArrange medical consultation

Treatment ofTreatment ofRespiratory ReactionsRespiratory Reactions

Bronchial ConstrictionBronchial Constriction

Terminate dental treatmentTerminate dental treatment

Sit patient uprightSit patient upright

Oxygen 6 L/minOxygen 6 L/min

Epinephrine aerosol or 0.3 mg IM or SCEpinephrine aerosol or 0.3 mg IM or SC

(0.3 ml of a 1:1000 solution)(0.3 ml of a 1:1000 solution)

Treatment ofTreatment ofRespiratory ReactionsRespiratory Reactions

Bronchial Constriction (cont.)Bronchial Constriction (cont.)

Observe for at least 1 hrObserve for at least 1 hr

Antihistamines - Benadryl 50 mg IMAntihistamines - Benadryl 50 mg IM

Obtain medical consulatationObtain medical consulatation

Prescribe oral antihistaminesPrescribe oral antihistamines

(Q6H for 3-4 days)(Q6H for 3-4 days)

Treatment ofTreatment ofRespiratory ReactionsRespiratory Reactions

Laryngeal EdemaLaryngeal Edema

Sit patient uprightSit patient upright

Epinephrine 0.3 mg IM or IVEpinephrine 0.3 mg IM or IV

Maintain airwayMaintain airway

Summon medical assistanceSummon medical assistance

Treatment ofTreatment ofRespiratory ReactionsRespiratory Reactions

Laryngeal Edema (cont.)Laryngeal Edema (cont.)

Oxygen 6 L/minOxygen 6 L/min

CricothyroidotomyCricothyroidotomy

Additional drug therapyAdditional drug therapy

Diphenhydramine 50mgDiphenhydramine 50mg

&/or&/or

Hydrocortisone 100 mg Hydrocortisone 100 mg

Generalized AnaphylaxisGeneralized Anaphylaxiswithwith Signs of Allergy Signs of Allergy

Place patient in a supine postionPlace patient in a supine postion

Basic Life Support (ABCs)Basic Life Support (ABCs)

Administer epinephrine 0.3 mg IM or SCAdminister epinephrine 0.3 mg IM or SC

(0.3 ml of a 1:1000 solution)(0.3 ml of a 1:1000 solution)

Summon medical assistance - call 911Summon medical assistance - call 911

Generalized AnaphylaxisGeneralized Anaphylaxiswithwith Signs of Allergy Signs of Allergy

Monitor vital signsMonitor vital signs

Additional drug therapyAdditional drug therapy

AntihistaminesAntihistamines

CorticosteroidsCorticosteroids

Repeat epinephrine Q5min prnRepeat epinephrine Q5min prn

Generalized AnaphylaxisGeneralized Anaphylaxiswithoutwithout Signs of Allergy Signs of Allergy

Place patient in a supine positionPlace patient in a supine position

Basic Life SupportBasic Life Support

Monitor vital signsMonitor vital signs

Summon medical assistance prnSummon medical assistance prn

Generalized AnaphylaxisGeneralized Anaphylaxiswithoutwithout Signs of Allergy Signs of Allergy

Consider possible causes of unconsciousnessConsider possible causes of unconsciousness

SyncopeSyncope

Overdose ReactionOverdose Reaction

HypoglycemiaHypoglycemia

CVACVA

Acute Adrenal InsufficiencyAcute Adrenal Insufficiency

Prevention of Allergic ReactionsPrevention of Allergic Reactions

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

Other Means of PreventionOther Means of Prevention

Medical consultationMedical consultation

Dental office skin testingDental office skin testing

(not foolproof and not advisable)(not foolproof and not advisable)

Take Home LessonsTake Home Lessons

All positive responses to an allergy history are All positive responses to an allergy history are true until exact nature is determined!true until exact nature is determined!

Patients reporting allergies should be critically Patients reporting allergies should be critically evaluated -refer for allergy testing if history, evaluated -refer for allergy testing if history, reaction, or management are suspect.reaction, or management are suspect.

Be prepared to manage difficulties! Always!Be prepared to manage difficulties! Always!