PRACTICE MANAGEMENT

ALLERGIC REACTIONS IN THE DENTAL OFFICE

GROUP 1 RASHIDI B.ATEFEH JAFARABADI ARMAGHAN ALMASI HASTI

Allergy: Is defined as a hypersensitive state acquired through exposure to a particular allergen, exposure to which produces a heightened capacity to react.

Allergic Reactions:
Allergic reactions range from mild, delayed reactions occurring as long as 48 hours after exposure, to immediate life threatening reactions that occur within seconds after exposure.

Classification of Allergic Reactions

Type Mechanism Time I Anaphylactic sec/min
II Cytotoxic III Immune

Example
Angioedema

-Transfusion rx 6-8hrs Serum sickness complex

IV Cell mediated

48 hrs

Contact dermatitis

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

Type I Immediate Hypersensitivity

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

Of all medical emergencies that can and do occur in dental offices, allergy-related emergencies are actually quite common. As a matter of fact, A mild allergic reaction was the second most common medical emergency seen in dental offices behind only syncope (fainting) Additionally, anaphylaxis was the 11th most common medical emergency seen in dental offices. The most common allergen in the dental environment today, of course, is latex.

Penicillin is the most common cause of druginduced anaphylaxis. Patients will always have allergies to penicillin and the penicillin-like drugs (amoxicillin, Augmentin, etc) and other drugs and agents prescribed, administered and dispensed in dental offices. It should be noted here that a true allergic reaction to an injected local anesthetic in dentistry has an incidence that approaches zero. It simply does not occur to any measurable degree

If the allergic reaction presents as itching, hives, or a rash as the only signs and symptoms, the allergy may be considered mild (non-life threatening). However, if the patient experiences cardiovascular and/or respiratory embarrassment, which are normally seen as dizziness or loss of consciousness due to an inadequate blood pressure and/or inadequate blood flow to the brain (cardiovascular issues), or difficulty in breathing (respiratory issues), the dental professional must treat the allergy as a life-threatening situation.

Allergic reactions occurring many minutes to m any hours after exposure to the allergen may be termed delayed onset while those that occur within a few seconds to a few minutes after contact with the allergen are termed immediate onset. As a general rule, the faster the signs and/or symptoms occur, the more severe the allergy typically will be.

Mild Allergy:
If the allergy is mild (that is, itching, hives, and/or rash only) and the patient remains conscious, he or she should be made comfortable. There are two main positions that we may choose to place patients in as they are experiencing a medical emergency

1.If the patient remains conscious, we want to make them comfortable. These patients may wish to sit upright or be reclined. Either is acceptable. 2. If the patient loses consciousness, the patient is placed supine (flat). Almost all medical emergencies where loss of consciousness occurs share the same cause, low blood pressure in the brain. Making the patient supine will increase blood pressure in the brain and allow the patient to regain consciousness in most cases

Also, the conscious patient who is talking has verified that their airway is patent, he or she is breathing, and cardiovascular function is adequate to maintain consciousness. We have just verified the ABC steps of CPR. Even though the new CPR guidelines call for CAB, for medical emergencies occurring in dental offices, ABC is still appropriate.

Treatment for a mild allergic reaction involves the administration of a histamine blocker, such as diphenhydramine, via intramuscular or intravenous injection. The adult patient should be administered 50 mg, and the child patient should receive 25 mg. Oxygen is never wrong, but often is not required in cases such as these.

Oral administration of diphenhydramine may have too long an onset of action to be of any practical use during this type of medical emergency so parenteral administration of the diphenhydramine is preferred. Patients administered parenteral diphenhydramine should also be prescribed oral diphenhydramine for a period of 3 days; 50 mg four times daily for an adult and 25 mg four times daily for a child. Histamine and other substances that contribute to allergy may circulate in the bloodstream for 3 days after the initial insult, so it is important to have the patient prophylactically covered during this time.

Severe Allergy (Anaphylaxis)

Anaphylaxis is an acute life-threatening systemic reaction with varied mechanisms and clinical presentations. Immediate discontinuation of the offending drug(s) and early administration of epinephrine are the cornerstones of treatment. Epinephrine is the drug of choice in the treatment of anaphylaxis, because its alpha-1 effects help to support the blood pressure while its beta-2 effects provide bronchial smooth-muscle relaxation.

Absorption is more rapid and plasma levels are higher in patients who receive epinephrine intramuscularly in the thigh with an autoinjector.Intramuscular injection into the thigh is also superior to intramuscular or subcutaneous injection into the arm.

No established dosage or regimen for intravenous epinephrine in anaphylaxis is recognized. Because of the risk for potentially lethal arrhythmias, epinephrine should be administered intravenously only during cardiac arrest or to profoundly hypotensive subjects who have failed to respond to intravenous volume replacement and several injected doses of epinephrine

If the allergy is severe, the patient has lost, or soon will lose, consciousness. The dentist should place the patient in a supine position, open the airway, and evaluate breathing. Often, breathing is spontaneous and adequate. If the patient is not breathing, the dental professional must administer positive pressure oxygen via a bag valvemask device. If the patient has lost consciousness, his or her cerebral blood pressure is too low. Another dental staff also must contact EMS as the patient requires additional treatment in the hospitals emergency department.

Options:
Several options exist for treating patients who may have a history of allergic reactions. First is consultation with an allergist to test the patient for allergy to the drug in question. Treatment should be postponed if at all possible until this can be accomplished. Next is the use of general anesthesia if the allergy was to a local anesthetic. Although general anesthesia is highly useful, it is not available in most dental offices.

Another option if the allergy was to a local anesthetic is the use of a histamine blocker, such as diphenhydramine, as a local anesthetic for pain management during treatment. Most injectable histamine blockers possess local anesthetic properties. Diphenhydramine has been the most commonly used histamineblocker in this regard

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