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Allergy and Hypersensitivity

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John Tankersley

on 5 November 2014

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Transcript of Allergy and Hypersensitivity

Profile: William is a 47 year-old African-American male who presents for routine dental care.

Medical History: He has a history of recent surgery (hernia repair,Jan. 2011), from which he recovered uneventually. He takes no medications, has no history of allergy and is ASA Physics Status I.

Dental History: He has no problems with previous dental treatment, but he has not seen a dentist since 2008.
Advice for the Patient
What advice should be given to the patient regarding the immediate management of the complaint of the swollen lip?
What factor(s) may be contributing to the patient's complaint of a swollen lip?
Profile: William is a 47 year-old African-American male who presents for routine dental care.

Medical History: He has a history of recent surgery (hernia repair,Jan. 2011), from which he recovered uneventfully. He
takes no medications
, has
no history of allergy and is ASA Physics Status I

Dental History:
He has no problems with previous dental treatment
, but he has not seen a dentist since 2008.

Oral Exam:
Poor oral hygiene
Supragingival calculus on the lingual surfaces of the lower anterior teeth.

The dental care today consists of examination, complete intraoral radiographs, and periodontal debridement. Because his lower right
teeth are especially sensitive, you administer an inferior alveolar nerve block using 1 cartridge of 2% lidocaine with
1:100,000 epinephrine,
and the removal of calculus is accomplished in a routine manner, followed by rubber cup prophylaxis, irrigation of gingival tissues with
chlorhexidane mouthrinse
, and finally, application of
topical fluoride

Follow up: 45 minutes after being dismissed,
the patient calls the office complaining of a swollen lower lip.

ASA Physical Status
A classification system developed by the ASA (American Society of Anesthesiologist) to assess the severity of a patients "illness" prior to a surgical procedure(3).
ASA Physical status
What questions should you ask the patient to help diagnose this reaction?
I. Patient is a completely healthy fit patient.
II. Patient has mild systemic disease.
III. Patient has severe systemic disease that is not incapacitating.
IV. Patient has incapacitating disease that is a constant threat
to life.
V. A moribund patient who is not expected to live 24 hour with or without surgery.

Symptoms: (1)
Tongue Swelling/ difficulty breathing
Common Causes: (1)
Insect Stings
Immediate treatment: (1)
Call 911
EpiPen if available
If conscious, lie down and elevate feet
CPR if necessary (unconscious)
Severe Reactions: Anaphylaxis
What is your differential diagnosis for this problem?
Chlorhexidine gluconate is a germicidal mouthwash that reduces bacteria in the mouth
Used to treat gingivitis (swelling, redness, bleeding gums)
Approximately 30% is retained in mouth after rinsing
Allergic reactions like glossal edema in less than 1%

Allergic Reactions
Common side effects:
Itching and redness
Severe side effects:
Rash, hives, itching
Swelling of the mouth, face, lips or tongue (13, 14)
Symptoms: (2)
Mild Swelling
Itchy/ Red/ Watery eyes & Runny Nose
Common Causes: (2)
Common allergies (hay fever, etc.)
Bug bites/ Stings
Contact with certain allergens
Immediate Treatment: (2)
Eye Drops
Cold Compress
Mild Reactions
-Disregarded the suggested 30 minute wait time after the fluoride varnish and chomped down on his lip while eating lunch
Subjective assessment of a patients overall health(3).
E. Emergency Case

Revised several times with an E suffix included denoting an emergency case (3).
Factors from patient overview:
1. Anaphylaxis (Severe Allergic Reaction) Symptoms, Treatment, Causes, Diagnosis, and Prevention - MedicineNet. (2013, November 5). MedicineNet. Retrieved November 6, 2013, from http://www.medicinenet.com/anaphylaxis/article.htm
2. Allergic Reaction Treatment: First Aid Information for Allergic Reaction. (2013, November 4). WebMD. Retrieved November 6, 2013, from http://www.webmd.com/first-aid/allergic-reaction-treatment
3. Mohamed Daabiss, American Society of Anesthesiologists physical status classification, Indian journal of Anastesia. 2011 Mar-Apr 55(2)
4. Eric, Macy. Immediate Hypersensitivity to Methylparaben Causing False-Positive Results of Local Anesthetic Skin Testing or Provocative Dose Testing. The Permanente Joural. COmplementary and Alternative Medicine. @002/ Vol 6. No 4
5. Allergic Reactions Did you know. Volume IV, Number 1 http://www.clevelandclinicmeded.com/medicalpubs/pharmacy/JanFeb2001/allergicreaction.htm
6. "Hereditary Angioedema Clinical Presentation." <i>Hereditary Angioedema Clinical Presentation</i>. N.p., n.d. Web. 6 Nov. 2013. &lt;http://emedicine.medscape.com/article/135604-clinical&gt;.
7. Bowen, Tom. "Hereditary angioedema consensus 2010." Allergy Asthma Clin Immunol 6.1 (2010): 13.
8. Bas, M., et al. "Nonallergic angioedema: role of bradykinin." Allergy 62.8 (2007): 842-856.
9. "Types." <i>AInotes</i>. N.p., n.d. Web. 6 Nov. 2013. &lt;http://ainotes.wikispaces.com/Hereditary+and+Acquired+Angioedema&gt;.
10. "F12." <i>- coagulation factor XII (Hageman factor)</i>. N.p., n.d. Web. 6 Nov. 2013. &lt;http://ghr.nlm.nih.gov/gene/F12&gt;.
11.Reed, K. (2007). Allergy and anaphylaxis. Inside Dentistry, 11(7). Retrieved from http://www.dentalaegis.com/id/2011/03/allergy-and-anaphylaxis
12. M.P.C. Van Leeuwen, Essential Oils Compared to Chlorhexidine With Respect to Plaque and Parameters of Gingival Inflammation: A Systematic Review, J Periodontol. 2011 Feb;82(2):174-94. doi: 10.1902/jop.2010.100266. Epub 2010 Nov 2.
13. http://www.drugs.com/sfx/chlorhexidine-side-effects.html
14. http://www.drugs.com/pro/chlorhexidine.html
15. http://www.drugs.com/sfx/fluoride-topical-side-effects.html
16. http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=26733
17. http://www.drugs.com/pro/lidocaine.html
Examination, intraoral radiographs, periodontal debridement
Administered 1 carp of 2% lidocaine with 1:100000 epinephrine
Rubber cup prophylaxis
Chlorohexidine mouthrinse was used to irrigate the gingival tissue
Topical fluoride was administered
No medications
No history of allergy
Oral Examination:
William's ASA Status
Allergic Reactions
Allergy-related emergencies are actually quite common.
Mild-allergy reaction
was second most common medical emergency (fainting was first)
(serious rapid onset reaction) was the 11th most common medical emergency seen in dental offices. (11)

The most common allergen was
Other common allergic reactions were to: penicillin, penicillin-like drugs, injected local anesthesia. (11)

Immediate onset
- Allergic reactions occurs within seconds or minutes after exposure
Delayed onset
- after hours of exposure to allergen. (11)

Prior to dental treatment
ASA PS 1 : healthy and fit patient with no known systemic disease.
What should the dentist ask?
-Latex Gloves
When did the swelling begin?
Is there a feeling of numbness?
Does the swelling cause you pain?
Do you have difficulty breathing?
Do you feel dizzy?
Have you ever had this happened before? If so when? During a dental visit?

To determine whether the allergy is mild or severe?
-2% Lidocaine Anesthetic
Have you ever received local anesthesia?
Do you have any allergic reactions to latex? If so, to what degree? Mild, moderate, severe?
Have you ever used the medicated mouthwash in past dental treatments? If so, was it chlorohexidine?
Have you ever used fluoride before either at the dentist office or at home?
Have you ever had any reactions to rubber?
Do you have any known allergic reactions? If so, to what?
Have you ever had an allergen test before?

The dentist may want to ask the patient to return to the office. The dentist can administer a histamine blocker via intramuscular or intravenous injection.
If the patient does present pain, numbness,dizziness, and/or difficulty breathing the patient may be experiencing a severe allergic reaction (anaphylactic shock) and should be sent to the emergency room.
Following dental treatment
ASA PS E: Angiodema can present itself in a life threatening manner.
risk of suffocation considered a medical emergency
Unknown cause
-Chlorhexidine Mouthrinse
-Inferior Alveolar Nerve Block
Immune Response In Angioedema
Case 11: Allergy and Hypersensitivity
Group 12

Other possible factors?
-Got into a fight in the parking lot
What caused William's allergic response
Allergic Reactions
Possible allergens
Common side effects:
Severe side effects:
Rash, hives, itching
Tight chest, difficulty breathing
Swelling of mouth, face, lips, or tongue (15)
To determine what caused the reaction:
Methylparaben in Lidocaine (4)
Fluoride Varnish
Used for individuals who are at high risk for caries or during their 6 month dental check
Patient should avoid eating or drinking for at least 30 minutes after application
Patient Management
Patient follow-up with his physician to determine cause of reaction.
Discontinue further treatment until the patient receives a confirmed diagnosis and the cause of the angiodema.
Refer the patient if immediate care is needed
Hereditary Angioedema (HAE)
Rapid swelling of the dermis, subcutaneous tissue and mucosal tissue
Swelling can affect any part of the body. However, the swelling is most common in the face, GI tract and extremities.
HAE is inherited as an autosomal dominant disorder. This disorder results from a mutation of the C1-esterase inhibitor gene (C1-INH) on chromosome 11 .
Nesacaine-MPF, Lidocaine-MPF, Polocaine-MPF, and Sensorcaine-MPF(5)
If the patient is allergic to methylparaben
Patient Management
Vinyl or nitrile gloves as an alternative to latex gloves
Stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action
How Does it Work?
HAE is a result of a mutation in C1-inhibitor/ C1 esterase [6]
C1-INH prevents the association of C1r, C1s and C1 q from forming the C1 complex of the complement pathway.
Well C1-INH also inhibits plasma kallikrein. [6]
Kallikrein is the enzyme that cleave plasma kininogen to produce bradykinin. [7]
Kallikrein is also inhibited by C1-INH.
Bradykinin is the important product of the complement pathway that is continually activated as a result of this mutation.
Bradykinin is the major mediator in the swelling that occurs during angioedema.
Bradykinin functions as a vasodilator and increase vascular permeability. This leads to fluid accumulating in the interstitium.
Bradykinin also functions as a pain mediator. By inhibiting bradykinin we can minimize the pain symptoms of HAE. [7]

Type 1- Decreased levels of C1-INH (85%) [9]
Type 2- Normal levels but decreased function of C1-INH
Type 3- In this HAE we don’t find any abnormalities of the C1esterase.
However, we do find that it is inherited as an x-linked dominant trait so it usually affects women.
It has been linked with mutations in the factor XII gene. [9]
When factor XII is activated it interacts with plasma prekallikrein to ultimately result in the release of bradykinin. [10]

Edema of the Tongue in a Patient with Acquired Angiodema
AAE (Acquired Angioedema)

Type 1
Like HAE type 1, AAE type 1 also results from a deficiency of C1-INH. [8]
Type 1 is associated with diseases such as B-cell lymphoproliferative disorder.
This type exhibits increase consumption of C1-INH by neoplastic lymphatic tissue.
Characterized by low C1-INH and low C1q. [8]

Type 2
Results from an autoimmune disorder where the individual has an autoantibody against the C1-esterase. [7],[8]
Autoantibody is usually IgG.
The autoantibody inactivates the function of C1-esterase. However, C1-INH levels may be normal. [8]

-Hematoma from injection
-Topical Fluoride
-Many different factors in the dental office can play a role in allergic reactions
-In the event of an allergic reaction review of the procedures and any relevant patient history can help determine the root cause
-If the patient experiences a reaction: Immediate treatment for severe reactions would include calling 911, EpiPen, CPR. Treatment for mild reactions would include antihistamines, cold compresses, or decongestants
-Diagnoses could be allergic reactions to the latex, rubber prophy cup, cholorhexidine, fluoride, or lidocaine preservatives
-Immune responses could trigger angioedema which is a rapid swelling of the dermis, subcutaneous tissue and mucosal tissues
-Hereditary Angioedema is a result of a mutation in C1-inhibitor/C1 esterase
-Acquired Angioedema also results from a deficiency of C1-INH
-The patient should follow up with his physician to determine the cause of the reaction and discontinue treatment until the problem is determined
-After determining the cause of the allergic reaction alternatives can be used that do not contain the allergens
-ASA Physical Status is a classification system developed by the American Society of Anesthesiologist and is used assess the severity of a patients "illness" prior to a surgical procedure
Allergic Reactions
Side effects:
Hypotension, headache, backache (less than 3%)
Cutaneous lesions, anaphylactoid reactions, edema (16,17)

Extremely rare
Essential oils antimicrobial mouth rinse as an alternative to chlorhexidine mouthrinse
Rubber on prophy cup
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