Dental management

of
Allergy

PRESENTED BY
HOUSE SURGEONS GROUP 2B (1/2024)
D E PA R T M E N T O F O R A L M E D I C I N E ( U D M Y )
Participants of Group-2B
1. Myat Thu Aung

2. Saw Theingi Aung

3. Yamin Ko Ko Zaw

4. Aung Khant Min

5. Htet Myat Kyaw

6. Thant Zin Hein

7. Thiri Tin Zaw

1
Contents
1. Introduction

2. Definition of Allergy

2.1. Type of allergens

2.1.1. Skin contact allergens

2.1.2. Inhalant allergens

2.1.3. Ingestant allergens

2.1.4. Injectant allergens

2.2. Hypersensitivity

2
Contents ( Cont’d)

3. Epidemiology

4. Etiology

5. Pathophysiology

6. Clinical features

7. Diagnosis

8. Medical Management

3
Contents ( Cont’d)

9. Dental Management

9.1. Identification and Risk assessment

9.2. Type I Hypersensitivity

9.3. Type III Hypersensitivity

9.4. Type IV Hypersensitivity

9.5. Local Anesthetic Allergy

4
Contents ( Cont’d)

9.6. Drug Allergy

9.7. Allergy to Dental Materials

10. Conclusion

11. Take Home Message

12. References

5
1. Introduction
 Allergic diseases are a spectrum of clinical disorders that result from

immunologic reactions to a noninfectious foreign substance ( antigen) in a

sensitized host

 An allergic reaction either during or after any dental procedure, is one of the

most serious problems a dentist may encounter

 Sometimes, allergic reaction could be a life threatening emergency in the

dental clinic
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2. Definitions
Allergy – ‘an abnormal or hypersensitive response of the immune system to a
substance introduced into the body’

2.1. Types of Allergens

2.1.1. Skin Contact Allergens : Certain substances that come into contact with skin

 Poison plants ( Eg. Birch, Elm, Cedar and Oak)

 Topical medications ( Eg. Neomycin, Local Anesthetics and Eye drops) and topical
products ( Eg. Nickel, latex and Para aminobenzoic acid in some cosmetics)
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2.1.2. Inhalant Allergens : Substances that are distributed in the atmosphere and contact
the nasal or buccal mucosa during respiration
 Pollens and Environmental ( Eg. Tree, grass and flower pollens)
 Pets and animals ( Eg. Cats, dogs, horses and other mammals)

 Dust and mold

2.1.3. Ingestant Allergens : Those that occur in the foodstuff and are swallowed
 Oral Medications ( Eg. Chemotherapy, sulfa drugs, penicillin and NSAIDS)

 Food ( Eg. Tree nuts and peanuts, milk, eggs, soybeans and wheat)

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2.1.4. Injectant Allergens : Those may be present in the solutions intended for

parenteral administration

 Insects ( Eg. Stinging insects such as bees and wasps)

 Medications ( Eg.Chemotherapy, sulfa drugs, penicillin and NSAIDS)

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 2.2. Hypersensitivity – ‘exaggerated or inappropriate immunologic responses

occurring in response to an antigen or allergen

Type I, II and III hypersensitivity reactions are known as immediate

hypersensitivity reactions because they occur within 24 hrs of exposure to the

antigen or allergen. Type IV hypersensitivity reactions observed after 48-72 hrs of

antigen exposure’

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3. Epidemiology

 More than 25% of all people are allergic to some substances

 1-3% risk of allergy with drugs

 Risk of fatal drug reactions in 0.01% of surgical patients and 0.1% of medical

patients

 Urticaria/Hives seen in 15-20% of young adults.

 Penicillin allergy in 5-10% of patients who take it, with anaphylaxis in 0.04-0.2%

 10% risk of death in cases of anaphylaxis 11

4. Etiology
 Contact with foreign substances, called allergens or antigens

 Trigger hypersensitivity reactions involved in innate, humoral and cellular immune

system and release of chemical mediators

 Antigen or Allergen – “any substance foreign to the body that evokes an immune

response either alone or after forming a complex with a larger molecule ( as a

protein) and that is capable of binding with a product (as an antibody or T cell) of the

immune response
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5. Pathophysiology

Fig 1. Four Types of Hypersensitivity Reactions ( Coombs and Gell Classification)

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6. Clinical features

Oral Manifestations
I. Type I Hypersensitivity

 Atopic reactions to various foods, drugs, or anesthetic agents may occur within or

around the oral cavity

 The reaction generally is rapid, with soft tissue swelling developing within a short

time after coming into contact with the antigen

 Characterized by urticarial swelling or angioedema 14

 The lesion can last for 1 to 3 days if untreated but will resolve spontaneously

Fig 2. Angioedema of the upper lip that occurred

soon after injection of a local anesthetic

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II. Type III Hypersensitivity

 Foods, drugs, or agents that are placed within the oral cavity can cause white,

erythematous, or ulcerative lesions representative of type III hypersensitivity or

immune complex reactions

 Develop usually within a 24hr period, after contact is made with the offending

antigen

 Some cases of aphthous stomatitis may be caused by type III hypersensitivity, but

most are related to immune dysfunction that has not been fully characterized
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 Hypersensitivity reactions to orthodontic appliances are rare and seldom occur unless

the patient has nickel hypersensitivity and a history of previous cutaneous or skin

piercing

 Erythema multiforme represents an immune complex reaction that appears as

polymorphous eruption of macules, erosions, and characteristic “target” lesions that

are symmetrically distributed on the skin or mucosa

 Common sites in the mouth are the lips, buccal mucosa, and tongue

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 A predisposing factor such as a drug allergy or a herpes simplex infection is

involved in the onset of their disease

 Sulfa antibiotics are frequently associated with the onset of erythema multiforme

 Sulfonylurea hypoglycemic agents (e.g., tolbutamide, tolazamide, glyburide,

glipizide), which are used to treat diabetes, also have been associated with the

onset of erythema multiforme

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Fig 3. Stomatitis in a patient who was found to be

allergic to the tooth paste he was using

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Fig 4. Allergic rash on the abdomen of a patient in whom orthodontic

brackets and archwires were just placed. The patient was tested and was

found to be allergic to the nickle in the wires 20

Fig 5. Erythema multiforme that developed after oral
administration of a drug used to treat an oral infection.
Ulceration of the palatal mucosa
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III. Type IV Hypersensitivity

 Contact stomatitis is a delayed allergic reaction that often is associated with the

cellular immune response

 The antigen may be found in dental materials, toothpaste, mouth rinses, lipsticks and

cosmetics

 Impression materials containing an aromatic sulfonate catalyst cause a delayed allergic

reaction in postmenopausal women

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 Consists of tissue ulceration and necrosis that becomes progressively worse with

each exposure

 Oral lesions may be found in close association with amalgam restorations

 These (mucosal) lesions appear as whitish, reddish, ulcerative, or “lichenoid” and

appear to be a hypersensitivity reaction to components of the amalgam

restoration

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 Dental composite materials have been reported to cause allergic reactions

 The acrylic monomer used in denture construction has caused an allergic reaction;

however, the vast majority of tissue changes under dentures result from trauma and

secondary infection with bacteria or fungi

 Gold, nickel, and mercury have been reported to cause allergic reactions that result

in tissue erythema and ulceration

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Fig 6. Allergic reaction to removable partial denture

framework. Note the erythematous demarcation

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7. Diagnosis

 Patients with IgE-mediated allergy can have elevated levels of total IgE, allergen-

specific IgE, and eosinophils in their serum or nasal passages and test positive to a

specific allergen after skin testing (patch or skin-prick testing) performed by an

allergist

 Tryptase blood tests are helpful in diagnosing anaphylaxis

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 Patients who have hereditary angioedema typically have low C4 levels and

low levels of C1 inhibitor or low functional activity of C1 inhibitor and

mutations in the C1-inhibitor/SERPING1 gene as determined by genetic

testing

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8. Medical Management

 Atopic patients – desensitization

 Allergy desensitization is a treatment that trains immune system to tolerate seasonal,

environmental and food allergens

 Some patients with severe asthma may be forced to move to an area of the country

that does not contain the antigen (e.g., in the case of allergy to pollen)
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 Patients with asthma, immune complex injury, or cytotoxic immune reactions may

be treated with systemic steroids, and those with hay fever or urticarial are treated

with antihistamines

 Newer antihistamines are highly effective and produce fewer adverse effects (e.g.,

drowsiness) than older antihistamines

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 A variety of treatments, including topical steroids, have been used for patients with

contact dermatitis

 From a dental standpoint, a patient who is being treated for allergies has an

increased chance of being allergic to another substance

 In addition, if the person is taking steroids, the body’s reaction to stress may be

impaired
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9. Dental Management

9.1. Identification and Risk Assessment

 Dentists are often confronted with problems related to allergy

 One of the most common concerns is a patient who reports allergy to a local

anesthetic, antibiotic, or analgesic

 In this case, the history must be expanded, with specific efforts made to determine

exactly what the offending substance was and exactly how the patient reacted to it
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 If the adverse reaction was of an allergic nature, one or more of the classic signs or

symptoms of allergy should have been present

 If these signs or symptoms were not reported, the patient probably did not

experience a true allergic reaction

 Common examples of reactions mislabeled as “allergy” are syncope after injection of

a local anesthetic and nausea or vomiting after ingestion of codeine

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9.2. Type I Hypersensitivity

 Even when the dentist has taken appropriate precautions, an allergic reaction may

occur

 Most of these reactions are mild and of a nonemergency nature; however, some

may be severe and life threatening (anaphylactic)

 The dentist must be ready to deal with either type

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 In handling the anaphylactic reaction, the dentist should remember that it has an

allergic origin

 The reaction occurs soon (within minutes) after the injection, ingestion, or application

of a topical anesthetic, medication, drug, local anesthetic, or dental product

 The dentist must immediately take the following actions

 Place the patient in a head-down or supine position

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 Make certain that the airway is open

 Administer oxygen

 Be prepared to send for help and support respiration and circulation

 The rate and depth of respiration should be noted, as should the patient’s

other vital signs

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 In addition, the dentist may administer aromatic spirits of ammonia through

inhalation, which encourages breathing through reflex stimulation

 If these initial steps have not solved the emergency problem and the cause

is highly likely to be allergic, an edematous-type or anaphylactic reaction

should be considered

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Angioedema

 If an immediate type I hypersensitivity reaction has resulted in edema of the

tongue, pharyngeal tissues, or larynx, the dentist must take additional emergency

steps to prevent death from respiratory failure

 At this point, if the patient has not responded to the initial procedures and is in

acute respiratory distress, the dentist should do the following:

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 Activate emergency medical service (EMS)

 Inject 0.3 to 0.5 mL of 1 : 1000 epinephrine by an intramuscular (into the

tongue) or subcutaneous route

 Supplement with intravenous diphenhydramine 50 to 100 mg every 4 hours

for 1 to 3 days

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 Support respiration, if indicated, by mouth-to-mouth breathing or bag and mask;

the dentist should make sure the chest rises and falls when either of these

methods is used

 Check the carotid or femoral pulse; if a pulse cannot be detected, closed chest

cardiac massage should be initiated

 Confirm EMS is on their way and transport to medical facility if needed

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Anaphylaxis

 Anaphylaxis is a potentially life-threatening emergency that usually occurs

rapidly (i.e., within minutes) but may take longer

 The signs and symptoms are: nausea or vomiting , substernal pressure with

dyspnea, hypotension and pruritus of skin and soft palate

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 Respiratory distress occurs first, both respiratory and circulatory

components of depression occur early in the anaphylactic reaction

 Anaphylaxis often is fatal unless vigorous, immediate action is taken

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9.3. Type III Hypersensitivity

 A severe form of erythema multiforme is called Stevens Johnson syndrome or

erythema multiforme major

 Erythema multiforme, as a skin disease, occurs most often as the result of an allergic

reaction

 Many patients with erythema multiforme can be treated with symptomatic therapy
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 Topical and systemic corticosteroids syrup or elixirs

 Systemic therapy:

 Prednisone tablets 10 mg

Disp: 100 tablets

Sig: Take 6 tablets in the morning until lesions recede; then decrease by 1 tablet

on each successive day for 5 days

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9.4. Type IV Hypersensitivity

 Further treatment is necessary after the source of the antigen has been identified and

removed from further contact with the patient

 Oral epimucous testing for contact stomatitis consists of placing the suspected antigen in

contact with the oral mucosa and observing for any reaction over a period of several days

(e.g., erythema, sloughing, ulceration) that might indicate an allergy to the test material

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 Basic management of contact stomatitis requires removal of common sources of

antigens known to cause hypersensitivity reactions and assessment for lesion healing

 Skin or mucosal testing for sensitivity also can be performed. After the offending

agent or antigen has been identified, the patient should be told to avoid any future

contact with the antigen

 Again, if the lesions persist, topical steroids can be applied

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9.5. Local anesthetic (LA) allergy

 Local anesthetics are used extensively in dentistry and are normally tolerated well

 Procaine (ester L.A.) has the highest incidence for allergic reactions: due to

presence of Para-amino benzoic acid (PABA)

 Cross reactivity between xylocaine and procaine has been reported: due to

presence of preservative methyl paraben

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 Definitive history of L.A. allergy

- Identify the L.A. agent that caused allergy

- History / Medical records / Previous dentist or physician

 Definitive history of LA allergy – but no information available

 Refer patient to an allergist for evaluation & testing include both skin testing &

provocative dose testing (PDT)

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 1% solution of diphenhydramine prepared with 1:100,000 epinephrine for injection

 Maximum dose of diphenhydramine in one appointment 50 mg q.i.d for 5 days

 LA effect lasts up to 30 minutes

 Non-definitive history of LA allergy or history of allergy to a specific LA agent

 History about previous allergic reaction and its nature

 If allergic reaction is confirmed use alternative LA

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 While using alternative LA

 Select LA from different chemical group and beware of preservatives

 Firstly, aspirate and inject 1 drop of LA submucosally

 Wait for 5 minutes

 If no reaction – inject the LA as required for the procedure

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9.6. Drug Allergy

Penicillin Allergy

 Patients allergic to penicillin are apparently normal after the first dose (sensitizing dose)

 They develop allergy with the second dose (reactive dose)

 Risk of allergy: - Parenteral administration > Oral administration

 Allergy to penicillin can be tested by a skin test

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 Choose alternative antibiotics for a patient allergic to penicillin.;

E.g. erythromycin 250mg every 6hrs or

clindamycin 300mg every 6hrs or

clarithromycin 500 mg twice a day for 5 to 7 days

 5-10% cross reactivity exist with cephalosporin antibiotics

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 Preferable to use alternate antibiotic in patient with history of penicillin reaction and

not to skin test

 If penicillin must be used, skin test first with major and then with minor determinants

 If both test negative, penicillin can be used

 If either or both test positive, patient must be desensitized before using standard

dose of penicillin
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 Allergy to Analgesics

 Allergic reactions to aspirin also take the form of angioedema and bronchospasm

 Bronchospasm is the chief allergic manifestation in most persons sensitive to aspirin,

but especially in the middle-aged woman who also has nasal polyps, pansinusitis, and

rhinitis

 Alternative Drugs: Paracetamol 500mg t.d.s for 3 days and/or Codeine 30 mg every 4-

6 hrs 53
 Reactions occur in conjunction with NSAID intolerance and relate to the

pharmacological action of COX-1 inhibition

 Cyclooxygenase inhibition blocks the conversion of arachidonic acid to

prostaglandins and thromboxane resulting in a therapeutic anti-inflammatory

effect

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 Increase in free arachidonic acid convert to leukotrienes

 These leukotrienes may result in clinical features of allergy (Angioedema, urticaria

and bronchospasm)

 Skin prick, specific Ig E and basophil activation testing perform poorly in the

diagnosis of IgE-mediated reactions

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 If react to both paracetamol and aspirin, all COX-1 inhibitors should be

avoided

 Highly selective COX-2 inhibitors, such as celecoxib 200mg twice a day for 3

days, may be used as a safe alternatives after challenge under medical

supervision

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9.7. Allergy to dental materials

Latex Allergy

 Commonly induced by latex in dental equipment like gloves, surgical gowns and

rubber dams

 Glass fiber in masks can also cause respiratory allergic reactions

 3 types of latex reactions: irritant contact dermatitis, allergic contact dermatitis and

immediate allergic reaction

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 Dentist should be aware that latex allergy can manifest an anaphylaxis

during dental work when the patient or dentist has been sensitized to latex

 Nitrile gloves should be considered for use to minimize these adverse

reactions to latex proteins

58
Resin-based Dental materials ( Methyl methacrylate)

 Composite resins and denture based materials come into direct contact with oral

mucosa and can cause adverse reactions on oral mucosa

 Restorative materials and dentine bonding agents can also affect the pulp due to

release of leachable components through the permeable dentin

 Local adverse reactions caused by resin-based materials :Mucosal toxicity and pulpal

toxicity
59
Allergy to dental Alloys

 Base metal alloys containing Nickel used to make crowns and bridges

Eg. a ‘non-precious’ metal alloy used to make a Porcelain Fused to Metal (PFM) crown

or bridge

 Clinical signs & symptoms of nickel allergy: burning sensation, gingival hyperplasia,

numbness on sides of tongue

60
 Confirmed by patch test using 5% nickel sulphate in petroleum jelly

 For Nickel allergy, the Ni-Ti arch wire should be replaced with stainless steel

wire or titanium molybdenum alloy

61
 Titanium allergy can be suscepted after dental implant placement including episodes

of hives, eczema, edema, reddening, and itching of the skin or mucosa, which may

be localized, or generalized

 For Titanium allergy, alternate substitues like Polyetheretherketone (PEEK) which

offer mechanical properties and bone forming capacity similar to titanium

62
Allergy to root canal sealers and obturating materials

 Gutta-percha is the main filling material used in root canal treatment

 Zinc oxide is the main component (60-70% of the cone)

 Zinc oxide allergy is rare; however the high content of zinc oxide can contribute to

toxicity

 Resin-based filling material (Resilon) as a alternative to gutta-percha which is composed

of polyester, difunctional methacrylate resin, bioactive glass and a resin sealer

63
 Resilon is biocompatible and a good alternative for patients allergic to zinc

oxide-eugenol based dental materials

 Allergic reaction to eugenol occur in a patient with gingival inflammation in the

mucosal area adjacent to metal-ceramic bridge

 Allergic contact stomatitis occur when eugenol was used as a temporary

restorative material and on replacement with glass ionomer

64
Allergy to suturing materials

 Allergic contact dermatitis (ACD) to suture material due to new synthetic, slowly

absorbed and less reactive sutures, such as polyglactin rather than silk or catgut

 Allergic reactions to suture typically interfere with the wound healing process and may

result in wound dehiscence

 Once the allergen is identified and removed, the treatment includes corticosteroid

creams, oral antihistamines, topical immune response modifiers, and moisturizers

65
Allergy to chlorhexidine gluconate

 In chlorhexidine allergy, contact with chlorhexidine results in symptoms including

itching, hives and angioedema

 Treatment : A topical steroid, hydrocortisone 1% and a systemic antihistamines are

recommended

 If there is no improvement within 3 days, transition to triamcinolone 0.5% ointment

 Alternative antiseptics : povidone iodine, alcohols, benzalkonium chloride or

benzethonium chloride

66
10. Conclusion

 History is most important

 All known allergies must be documented and displayed at a prominent place on the

patient’s file

 For establishing diagnosis, it is essential to obtain proper history related to allergy, clinical

examination and confirmatory tests

 Avoiding the allergen/suspected antigen is the best way of treatment

 since there is risk of cross reactivity – be prepared for emergency allergic reactions
67
11. Take Home Message

 Thorough history should be taken for patients with a positive history of any kind of

allergy

 Patients reporting allergies should be critically evaluated

 Refer for allergy testing if history, reaction, or management are suspect

 Allergy tests must be performed to determine exact causative agent

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12. References

Thompson G, Bundell C, Lucas M. (2019). AJGP VOL 48, NO 4, APRIL 2019,pp.217

Klimek L,Sperl A,Worm M,Ring J. (2017). Anaphylaxis-Causes ,therapy and prevention.

MMW Fortschr Med, 159(3), pp.76-84

Lyapina M, Krasteva A, Dencheva M, et al. J of IMAB – Annual Proceeding (Scientific

Papers) 2013, vol. 19, issue 4, pp.363

69
Little JW, Miller CS, Rhodus NL (2018). Little and Falace’s Dental Management of the

Medically Comprimised Patient. 9th ed. pp.330-344

Arya V, Arora G, Kumar S, et al. J Dent Anesth Pain Med. 2021 Dec; 21 (6): 583-587

Wray D ,Rees SR, Gibson J, Frrsyth A,(2000). The Role of Allergy in Oral Mucosal

Diseases,QJM, 93(8), pp.507-511

 Doughter,y J, Alsayouri K & Sadowski A, Allergy –StatPearls, July 31, 2023, pp

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