Allergies

Donald Trump

What you as a DDS should know about allergies

• Prevent med emergency

• Oral soft tissue changes in an allergic reaction

• Treatment planning

• Recognize signs and symptoms of an acute allergic reaction

Hypersensitivity

Type 1

• Oral manifestations: various foods, drugs, or anesthetic agents

• Occurs rapidly• Painless soft tissue swelling• Itching and burning may occur• Lesion present ~1-3 days, • Tx: oral antihistamines

Type 2• No oral manifestations

Type 3• White erythematous ulcerative lesions• Food or drugs• Usually occurs w/in 24 hrs of contact w/ antigen• Tx: steroids, avoid contact with causative agent

Hypersensitivity

Type 4

• Contact stomatitis, delayed response

• Toothpaste, mouth rinses, impression materials, lipsticks

• Tx: ID causative agent, remove, sit back and watch it clear up

Hypersensitivity

• Type 5

Questions to ask the Donald

• Are you on any medications right now?

• Have you had this swelling before? (Y) when, where, what tx?

• What happened with your previous rxn to the anesthetic/antibiotic?

• How fast was the onset?

Questions cont.

• Was the problem treated or did it go away by itself?• Have you ever been treated at the hospital for an

allergic reaction?• Are you aware of any allergies that you may have?• Has your physician diagnosed you with any

allergies?• Have you taken penicillin or amoxicillin before?

What is His Physical Status?

• ASA PS II

If Donald required dental treatment today, what precautions would you take?

• Antibiotic allergy • Penicillin (-illins, cephalosporin)• Give him something else

(erythromycin or clindamycin)

Local anesthetic allergy

• If you know what type– give one from another chemical group

– aspirate, one drop, wait 5 min, if no signs of reaction aspirate and give the rest

• If you don’t know what type or if Mr. Trump is allergic to many types

a: use an antihistamine (diphenhydramine)

*May need to refer Mr. Trump to an allergist for PDT*

Anaphylaxis -Signs and symptoms-

• Itching of soft palate• nausea, vomiting• substernal pressure• shortness of breath• hypotension

• pruritis• urticaria• laryngeal edema• bronchospasm• cardiac arrhythmias

What to do?• Call for medical help• Lay patient back in

supine position• Check airway• Administer oxygen

• Monitor pulse, BP, and respiration– If depressed or absent:

inject .3-.5mL 1:1000 epi, CPR, repeat injection

Pathophysiology

• Hypersensitivity is an exaggerated response of the immune system. The immune system could be:

• Non specific• Specific

– Humoral– cellular

• Humoral involves B cells, antibodies and hypersensitivity type I, II, and III.

• While cellular immunity involves T lymphocytes and hypersensitivity type IV.

Hypersensitivity type Cause Mediated by Manifestation

I Dust, pollen food IGE AtopyAnaphylaxis

Asthma

II Blood transfusion Cytotoxic, antibody-dependent

IgM or IgG

erythroblastosis fetalisGoodpasture's

syndromeautoimmune hemolytic

anemia

III Immune complex disease

IgG Serum sicknessArthus reaction

SLE

IV Contact with metal, perfume,

chemicals TB skin test

cell-mediated Contact dermatitisTuberculosis

Chronic transplant rejection

Pathophysiology

Dental Algorithm-A • Antibiotics – Not recommended for treatment of

allergic reaction but may be causative agent of allergy (i.e., Penicillin)

• Anesthetics – Not recommended for treatment of allergies but may be another causative agent. Signs and symptoms are tachycardia, apprehension, sweating, and hyperactivity. Ester LA are most commonly associated with allergic reactions. When patient with past history of LA allergy presents, inject slowly using aspiration first, place 1 drop on tissues, withdraw and watch to see if reaction occurs

Dental Algorithm-A cont.

• Analgesics – Aspirin may cause GI upset, • Aspirin may also provoke severe reaction in

asthmatics. Other NSAIDs may cause similar effects

• Anxiety – Make appointment as comfortable as possible for patient who thinks allergy to local anesthetic is possible

Dental Algorithm – B

Bleeding

• Aspirin inhibits platelet function and prolongs the prothrombin time (PT)

Dental Algorithm – C

Complications • systemic anaphylaxis,• vasodilation,• respiratory distress, • hypotension,• pruritus,• conjunctivitis,

• nausea & vomiting, • substernal pressure,• laryngeal edema, • bronchospasm, • rhinitis, • death• itchiness & rash,

Dental Algorithm – C cont

Cardiac

• tachycardia

• cardiovascular collapse

• cardiac arrythmias

Dental Algorithm – D

Drug Interactions • Aspirin and other NSAIDs may cause GI upset • LA are associated with allergic reactions because of

constituents in LA suspension and metabolic by-products of LA

• Antibiotics like Penicillin may cause allergic reaction• Lichenoid drug eruptions may be caused by thiazides,

methyldopa, and photographic dyes

Dental Algorithm – E

Emergency • Call for immediate medical help• Place patient in the supine position• Check for an open airway• Administer oxygen• Check pulse, BP, and respiration

– if depressed or absent, inject 0.3-0.5 mL 1:1000– epinephrine IM into tongue– provide cardiopulmonary resuscitation if needed– repeat injection of epinephrine if no response

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