1. ALLERGIC REACTIONS in the DENTAL OFFICE

2. 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

3. 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

4. Classification of Allergic Reactions
Type Mechanism Time Example
I Anaphylactic sec/min Angioedema
II Cytotoxic Transfusion rx
III Immune hrs Serum sickness
complex
IV Cell mediated 48 hrs Contact
dermatitis

5. 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

6. Type I Immediate Hypersensitivity
Generalized (Systemic) Anaphylaxis
Localized Anaphylaxis
Urticaria
Bronchial Asthma
Food Allergy

7. Antigen
A substance that elicits an allergic reaction

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

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

10. Urticaria Wheals (hives)
Smooth elevated patches surrounded by erythematous areas
Pruritus (itching)

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

15. Predisposing Factors in Allergic Reactions
Prior history of allergy
Genetic predisposition to allergy
- atopic patient
Patient with multiple allergies
Drug that is utilized

16. Drugs that Cause Allergic Reactions
Up to 70% of Allergic Reactions
Penicillin
Meprobamate
Codeine
Thiazide Diuretics

17. Other Substances Causing Reactions
Iodines Vaccines
Insulin Heparin
Salicylates Sulfonamides
Opiates Local Anesthetics
Venom from stinging insects

18. Antibiotic Allergy Highest incidence
Penicillins (anaphylactic reaction may prove fatal in 15 minutes)
Sulfonamides
Reactions to erythromycins rarely seen

19. 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

20. 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

21. Local Anesthetics Reactions occur most frequently with Esters
Preservatives also cause reactions

22. Ester Drugs Procaine Propoxycaine Benzocaine Tetracaine
Related compounds
Procaine Penicillin G
Procainamide

23. 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

24. 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

25. 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

28. Clinical Options Determine type of “allergic” reaction
Substitute different drugs for those which cause the allergic reaction.
Have patient evaluated by allergist

29. Management of Allergic Reactions
Most severe allergic reactions are immediate
A number of organ oystems may be involved
Skin
Cardiovascular
Respiratory
Gastrointestinal

30. Management of Allergic Reactions
Generalized anaphylaxis involves all of the previously mentioned systems
When hypotension occurs, it is termed Anaphylactic Shock

31. 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

32. Affected Area - Manifestation
Gastrointestinal Abdominal cramps,
nausea, vomiting, diarrhea,
incontinence
Cardiovascular Pallor, light-headedness,
palpitations, tachycardia,
hypotension, dysrhythmias,
loss of consciousness, arrest

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

34. Type of Reaction
Quick Onset==> Rapid Progression==> Intense Reaction
Delayed Onset==> Slow Progression==>
Less Severe Reaction

35. Drugs Used in Allergic Reactions

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

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

38. Epinephrine Risks of repeated use:
Excessive elevation of blood pressure
CVA
Cardiac rhythm abnormalities

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

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

41. Treatment of Immediate Skin Reactions
Epinephrine 0.3 mg IM or SC
(0.3ml of a 1:1000 Solution)
Antihistamine
Diphenhydramine (Benadryl) 50 mg IM

42. Treatment of Immediate Skin Reactions
Obtain medical consultation
Observe patient for at least one hour
Prescribe oral antihistamines
Benadryl 50 mg PO Q6H for 3-4 days

43. Treatment of Delayed Skin Reactions
Antihistamine
Diphenhydramine (Benadryl) 50 mg IM
Prescribe oral form Q6H for 3-4 days
Arrange medical consultation

44. Treatment of Respiratory 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 1:1000 solution)

45. Treatment of Respiratory 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)

46. Treatment of Respiratory Reactions
Laryngeal Edema
Sit patient upright
Epinephrine 0.3 mg IM or IV
Maintain airway
Summon medical assistance

47. Treatment of Respiratory Reactions
Laryngeal Edema (cont.)
Oxygen 6 L/min
Cricothyroidotomy
Additional drug therapy
Diphenhydramine 50mg
&/or
Hydrocortisone 100 mg

48. Generalized Anaphylaxis with 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 1:1000 solution)
Summon medical assistance - call 911

49. Generalized Anaphylaxis with Signs of Allergy
Monitor vital signs
Additional drug therapy
Antihistamines
Corticosteroids
Repeat epinephrine Q5min prn

50. Generalized Anaphylaxis without Signs of Allergy
Place patient in a supine position
Basic Life Support
Monitor vital signs
Summon medical assistance prn

51. Generalized Anaphylaxis without Signs of Allergy
Consider possible causes of unconsciousness
Syncope
Overdose Reaction
Hypoglycemia
CVA
Acute Adrenal Insufficiency

52. Prevention of Allergic Reactions
HISTORY - a thorough, complete history of any previous allergic response or tendency prior to starting treatment will avoid most emergencies

53. Other Means of Prevention
Medical consultation
Dental office skin testing
(not foolproof and not advisable)

54. 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!