allergic reactions in the dental office. allergic reactions allergy is defined as a hypersensitive...
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ALLERGIC REACTIONS ALLERGIC REACTIONS in thein the
DENTAL OFFICEDENTAL OFFICE
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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
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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
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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
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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
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Type IType IImmediate HypersensitivityImmediate Hypersensitivity
Generalized (Systemic) AnaphylaxisGeneralized (Systemic) Anaphylaxis
Localized AnaphylaxisLocalized Anaphylaxis
UrticariaUrticaria
Bronchial AsthmaBronchial Asthma
Food AllergyFood Allergy
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AntigenAntigen
A substance that elicits an allergic A substance that elicits an allergic reactionreaction
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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)
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AtopyAtopy
Clinical hypersensitivity state, subject Clinical hypersensitivity state, subject to to heredity (asthma, hay fever, etc.)heredity (asthma, hay fever, etc.)
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UrticariaUrticaria
Wheals (hives)Wheals (hives)
Smooth elevated patches surrounded by Smooth elevated patches surrounded by erythematous areaserythematous areas
Pruritus (itching)Pruritus (itching)
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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
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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
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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
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Other Substances Causing Other Substances Causing ReactionsReactions
IodinesIodines VaccinesVaccines
InsulinInsulin HeparinHeparin
SalicylatesSalicylates SulfonamidesSulfonamides
OpiatesOpiates Local AnestheticsLocal Anesthetics
Venom from stinging insectsVenom from stinging insects
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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
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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
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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
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Local AnestheticsLocal Anesthetics
Reactions occur most frequently with EstersReactions occur most frequently with Esters
Preservatives also cause reactionsPreservatives also cause reactions
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Ester DrugsEster Drugs
ProcaineProcaine PropoxycainePropoxycaine
BenzocaineBenzocaine TetracaineTetracaine
Related compoundsRelated compounds
Procaine Penicillin GProcaine Penicillin G
ProcainamideProcainamide
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Drugs Used in Allergic ReactionsDrugs Used in Allergic Reactions
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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
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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
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EpinephrineEpinephrine
Risks of repeated use:Risks of repeated use:
Excessive elevation of blood pressureExcessive elevation of blood pressure
CVACVA
Cardiac rhythm abnormalitiesCardiac rhythm abnormalities
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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
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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
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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
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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
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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
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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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)
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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!