Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy

ALLERGY IN EXODONTIA

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


• INTRODUCTION
Definition : Allergy is a hypersensitive state
acquired through exposure to a particular
allergen, re-exposure to which produces a
heightened capacity to react.
An immuno logically mediated disease .
Covers a broad range of clinical manifestations
from mild, delayed reactions to immediate life
threatening reactions.


CLASSIFICATION
According to GELL&COOMBS

TYPE
I

Anaphylatic(Immed Sec to
iate
mins
hypersensitivity)

IgE

TYPE
II

Cytotoxic or
cytolytic

IgG,IgM

TYPE
III

Immune complex
disease

6-8 hrs Soluble immune
complexes(AgAb)

TYPE
IV

‘Delayed’ or cellmedicated
hypersensitivity

48 hrs

_


_

CLASSIFICATION
Based on time of onset:

Reaction

Onset

Clinical reactions

Immediate

0-1 h

Anaphylaxis Hypotension
Laryngeal oedema

Accelerated

1-72 h

Urticaria/angioedema
Laryngeal oedema
Wheezing

Late

>72 h

Haemolytic anaemia
Neutropenia, Thrombocytopenia
serum sickness


PATHOGENSIS
TYPE

MECHANISMS

TYPE I

Free Ag binds to IgE fixed on mast cells and
basophils,causing release of histamine etc.

TYPE II

Free IgG or IgM Ab binds to Ag on cell membranes to cause
commplement activation,cell damage or phagocytosis.

TYPE III

Persistence of Ag/Ab complexes may lead to activation of
complement,inflammation and tissue damage,particularly
vasculitis and arthritis.

TYPE IV Ag activates sensitized T-cells to become cytotoxic and to
release factors(lymphokines) that stimulate other leucocytes.

ANTIGENS
An antigen is any foreign substance capable of inducing the
formation of an antibody.
Most antigens are proteins with a molecular weight between 5000
and 40,000.
Drugs,however,are not proteins and commonly possess a very low
molecular weight(500 to 1000),making them unlikely antigens.

ALLERGEN:
An allergen is an antigen that can elicit allergic symptoms.
An antigen or allergen may stimulate the production of several
classes Ig which possess different functions.


HAPTENS
A hapten is a specific,protein-free substance that can
combine to form a hapten-protein complex with a carrier
protien-circulating albumin.
The hapten itself is not antigenic;however,when coupled
with the carrier protein ,it may provoke an immune
response.
By this mechanism most drugs become antigens and thus
capable of inducing anti-body formation and causing an
allergic reaction.
Pencillin,aspirin,and barbiturates are examples of
haptens.
Haptens are also called incomplete antigens.

ANTIBODIES (Ig)
An antibody is a substance found in the blood or tissues
that responds to the administration of an antigen or that
reacts with it.
The molecular weights of antibodies range from
150,000(immunoglobulin G[IgG]) to 900,000 (IgM).
Immunoglobulins are produced by B lymphocytes and are
classified as IgA,IgD,IgE,IgG,and IgM.
Antibodies possess the ability to bind with the specific
antigen that induces their production.
Antibodies are not entirely specific,and cross-sensitivity
is possible between chemically similar substances.

DEFENSE MECHANISMS OF
THE BODY
When a person is exposed to a foreign substance,the body attempts to
protect itself through a number of mechanisms.
ANATOMIC BARRIERS which attempt to exclude entry of the
antigen into the body.Examples:epithelium of the gastrointestinal
tract,the sneeze and cough mechanisms.
MOBILIZATION OF PHAGOCYTIC BLOOD CELLS such as
leukocytes,histiocytes,and macrophages.
PRODUCTION OF NONSPECIFIC CHEMICAL SUBSTANCES
such as lysozymes and proteolytic enzymes,which assist in removal
of the foreign substances.
IgA ANTIBODY is produced by plasma cells in response to the
antigen.IgA then aids in the removal or detoxification of the antigen
from the host.

DRUGS IN DENTISTRY
CAUSING ALLERGY
ANTIOBIOTICS
• Penicillin
• Tetracycline
• Sulfonamides
ANALGESICS
• Acetylsalicylic acid
• NSAIDs
OPIOIDS
• Morphine
• Meperidine
• Codeine

Cont.
ANTIANXIETY DRUGS
• Barbiturates
LOCAL ANAESTHETICS
• Esters
- Procaine
- Benzocaine
- Tetracaine
- Propoxycaine
• Antioxidant
Sodium bisulfite
• Parabens
Methylparaben
• OTHER AGENTS
Latex

CLINICAL MANIFESTATIONS
May be immediate or delayed reaction.
Number of organs and tissues are affected – Generalised
Anaphylaxis.
Reactions involving one organ or system is localised anaphylaxis.
When hypotension occurs as a part of a reaction resulting in loss of
consciousness is anaphylactic shock.
ONSET:Time between antigenic exposure & clinical symptoms.
More rapid-more intense reactions.
If they appear and rapidly increase in intensity, the reaction may be
life threatening.

SKIN REACTIONS
Allergic skin reactions are the most common sensitization reactions
are of three types as,(1)Localised anaphylaxis,(2)Contact
dermatitis,&(3)Drug eruption.
Includes Urticaria erythema & angioedema
Urticaria is associated with wheals & frequently with intense itching
or pruritis.
In angioedema,localised swelling occurs in response to an allergic
with pain & itching.
Periorbital,perioral & intraoral regions of face,as well as extremities
are involved.
Lips,tongue,pharynx & larynx involvement can lead to airway
obstructis.
CONTACT DERMATITIS:
Allergic reactions in dental professionals.
Includes erythema,induration,edema & vesicle formation .

RESPIRATORY REACTIONS
 Respiratory reactions normally follow skin,exocrine &

gastrointestinal responses but precede cardiovascular reactions.
 Bronchospasm:-classical respiratory manifestation which clinical
result of bronchial smooth muscle constriction.
 Includes respiratory distress,dyspnoea,wheezing, flushing,possible
cyanosis,tachycardia.
 Rhinitis:-Nasal congestion itching,sneezing.
LARYNGEAL OEDEMA: Swelling of the vocal apparatus with obstruction in airway.
 Dyspnoea,hoarseness,throat tightness,hypersalivation.

CARDIOVASCULAR REACTIONS

•
•

•
•
•

Circulatory Collapse:Light headedness,generalised weakness,syncope,ischaemic chest
pain.
Tachycardia,hypo tension,shock.
Dysrrhythmias:-Includes all symptoms & palpitations.
Cardiac Arrest:-Pulselessness,ECG changes,ventricular fibrillation.
Gastro-intestinal reactions:Nausea & vomiting,diarrhoea,cramping,abdominal pain.
In case of fatal anaphylaxis,prominent pathologic features are
observed in RS & CVS.
Includes laryngeal edema,pulmonary hyperinflation,peribronchial
vascular congestion,intra-alveolar Haemorrhage,pulmonary edema
varying degree of myocardial damage.

DIAGNOSIS-ALLERGY TESTING
Skin Testing
Patch Test
Intra cutaneous Testing
PRIST Test
RAST Test
Lymphocyte blast transformation

SKIN TESTING
•
•

Two forms of skin testing are used:
Intradermal tests in which the drug is diluted and
injected into the dermis.
Prick testing the drug is introduced into the dermis by
pricking the patient’s skin through a drop of undiluted
drug.
The allergy skin test procedure includes a positive
control(usually histamine),a negative control(a solution
without allergens) and then various suspect allergens.
Medications such as antihistamines or antipressants
must be stopped from 2 days to 6 weeks or more before.
If an extract provokes an allergic reaction,a raised,red
itehy wheal may develop within about 20 min.

INTRACUTANEOUS TEST

o
o
o
o
o
o
o

This test is considered to be among the most reliable.
In this test 0.1ml of the following solutions is deposited
intravenously:
0.9% of normal saline solution
1% or 2% Lidocaine
3% Mepivacaine
4% Prilocaine
0.1ml of bacteriostatic water
One or more local anesthetics with methylparaben
Patients vital signs are monitored through out the
procedure

Contd...
After this phase of testing 1ml of one of the preceding LA
that tested negative is administered intraorally by
supraperiosteal infiltration above a maxillary anterior
tooth. This is called the “CHALLENGE TEST”
Emergency drugs,equipment and personnel for
resuscitation must be readily available when allergy
testing is done.


OTHER TEST
PATCH TESTING
Applying the allergen in an absorbent
dressing which is taped on to the skin.
PRIST TEST
Paper radio – immuno sorbent test
which measures serum IgE levels.
RAST TEST
Radio allergo sorbent test which
measures the IgE anti bodies level.
The level of radio activity indicates the
level of specific IgE anti bodies.

POSSIBLE SUBSTITUTES
Antibiotics:
Penicillin – Erythromycin
Antibiotics:
Acetylsalicylic acid – Acetaminophen
Opioids – NSAIDs
Barbiturates – Diazepam, triazolam
Ester LA – Amide LA
Antioxidants – Non- vasopressor containing LA
Latex - Vinyl

GENERAL MANAGEMENT
ELECTIVE DENTAL CARE:
• Elective dental case requiring local anesthesia may need to be
postponed until a thorough evaluation of the patient is completed by
a competent individual.
• Dental case not requiring injectable or topical A may be carried out
during this period.
EMERGENCY DENTAL CARE:
Option 1:Consultation:• Immediate consultation to test the patient for allergy to LA.
• If pain is present it may be managed orally with various analgesics
and infections can be controlled with antibiotics.
Option 2:General Anesthesia:• Use of GA in place of LA to manage the dental emergency.
• Highly useful and relatively safe technique but has complications and
unavailability in dental office.

Cont…
Option 3:Histamine blocker:• Use of a histamine blocker like diphenhydramine as LA.
• 1% solution with 1 in 100,000 epinephrine,pulpal
anesthesia upto 30 mins is produced.
• Burning or stinging sensation is produced which can be
minimized by using nitrous oxide and O2.
• Post-operative tissue swelling and soreness may be
present.
Appropriate drug therapy with immediate medical
consultation (Option 1)is the most reasonable mode of
action.

MANAGEMENT
SKIN REACTIONS:• Step 1:-Termination of dental procedure.
• Step 2:-P-Position.
• Step 3:-(A-B-C)-Airway-Breathing-Circulation & Basic life support.
• Step 4:-Definitive care.
• DELAYED:(4a)Administration of histamine blocker.
IV or IM-Diphenhydramine-50mg for adults,25mg for children.
-Chlorpheniramine-10mg for adults,5mg for children.
Orally-Diphenhydramine-3-4 times a day.
-Chlorpheniramine-4mg for adults,3/4 times a day.
-2mg for children (4-6hrs).
(4b)(1)Monitoring of vital sign.
(2)Repositioning of pt.
(3)O2 & venipuncture adm.
(4)Adm of epinephrine.

MANAGEMENT
•
•
•
•
•
•
•

Respiratory reactions:Step 1:-Termination of dental procedure.
Step 2:-Position.
Step 3:-A-B-C assess & BLS.
Step 4:-Definitive care.
Administration of bronchodilator:Aersol inhaler.
IM or SC-0.3ml of a 1:1000 dilution.
IV-0.1ml of 1:10,000,15 to 30 mins.

MANAGEMENT OF
LARYNGEAL OEDEMA
• Step 1:-Termination.
• Step 2:-Position.
• Step 3:-A-B-C.
• Step 4:-Definitive care.

Administration of Epinephrine:• IM-0.3ml of 1:1000 for adults & 0.5ml for child,0.075 for
infants.
• IV-10ml of 1:10,000 over 5 mins.
CRICOTHYROTOMY:www.indiandentalacademy.com

MANAGEMENT OF
GENERALISED ANAPHYLAXIS
•

Step 1:-P-Position.
• Step 2:-ABC.
• Step 3:-D-Definitive care.
• Adm of Epinephrine:-Sublingually/Intralingually.
• Adm of O2:-5 to 6l per min via nasal hood or full face mark.
If no clinical signs:• Step 1 :- Termination.
• Step 2:-Position.
• Step 3:- ABC or BLS.
• Step 4:- Definitive care.


CONCLUSION
Thus allergy plays a vital role among
the medical emergencies in exodontia.Timely
identification and treatment of allergic reactions avoids
fatalities.
However,as per the saying,”When you
prepare for an emergency,the emergency ceases to
exist”,a proper history, diagnosis and planning always
reduces the risk of adverse reactions.


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Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy

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