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Disease/Medical Condition Disease/Medical Condition ALLERGY Date of Publication: March 5, 2019 (also known as “hypersensitivity reaction”; includes contact allergies, drug allergies, food allergies, environmental allergies, and the manifestations of anaphylaxis, urticaria, and angioedema) Is the initiation of non-invasive dental hygiene procedures* contra-indicated? Yes, if patient/client displays signs/symptoms of active allergic reaction that may affect the appropriateness or safety of procedures, including potential exacerbation by procedures. ■ Is medical consult advised? Yes, if patient/client presents with signs/symptoms of a potential allergic etiology (e.g., urticaria and/or angioedema) for which diagnosis has not been previously made by a physician or nurse practitioner. Yes, if patient/client presents with signs/symptoms of known allergic etiology (e.g., urticaria and/or angioedema) for which management/treatment has not been optimized. Is the initiation of invasive dental hygiene procedures contra-indicated?** Yes, if patient/client displays signs/symptoms of active allergic reaction that may affect the appropriateness or safety of procedures, including potential exacerbation by procedures. ■ Is medical consult advised? ....................................... See above. Yes, if, after history-taking, questions remain about the cause of previous reaction to local anaesthetics (when such anaesthetics are likely to be used during the visit)1. ■ Is medical clearance required? Yes, if asthma is suspected to be severe and unstable. Yes, if there is a history of hereditary angioedema2 (for assessment and potential use of preventive agents). ■ Is antibiotic prophylaxis required? No, not typically (although prolonged use and/or high doses of systemic corticosteroids may warrant consideration of antibiotic prophylaxis in light of potential immunosuppression)3. ■ Is postponing treatment advised? Yes, if there is acute respiratory distress. If anaphylaxis4 or angioedema of the tongue, pharyngeal tissues or larynx is suspected, emergency protocol should be initiated, and prompt transfer to an emergency department is indicated. Immediate intervention (e.g., administration of epinephrine) is required for these life-threatening conditions. Yes, if patient/client is currently manifesting signs/symptoms of allergy that may impede safety of dental hygiene procedures. 1 While adverse drug reaction due to overdose is much more frequent than allergic reaction to local anaesthetics, the oral health professional should assume the patient/client is allergic to the local anaesthetic in question until determined otherwise. 2 Hereditary angioedema is a rare genetic condition that results in low or non-functional levels of a blood protein called C1 inhibitor. As a result, swelling can occur in the mouth or throat (which can be potentially life threatening), hands, feet, genitals, and abdomen. Swelling in the gastrointestinal tract can cause extreme pain, nausea, vomiting, and diarrhea. Puffiness of the hands and feet can be painful and interfere with activities of daily living. Warning signs prior to swelling include: extreme fatigue, myalgia, tingling, abdominal pain, hoarseness, and mood changes. Common triggers include minor injury or surgery; stress or anxiety; illnesses such as the common cold or influenza; physical activities such as typing, hammering, or pushing a lawn mower, and certain medications (including some used for treatment of hypertension and heart failure). 3 When antihistamines fail in the treatment of acute or chronic urticaria, corticosteroids (such as prednisone) may be administered. While short course therapy is typical, patients/clients with severe, chronic urticaria may require long-term use of corticosteroids in order to alleviate signs and symptoms. Patients/clients with asthma may also take corticosteroids on an ongoing basis. 4 Signs/symptoms of anaphylaxis — which likely will occur within minutes after application, ingestion, or injection of a topical anaesthetic, medication, local anaesthetic, or dental product — include: “itching” of the soft palate, shortness of breath, substernal pressure, nausea, vomiting, hypotension, pruritis, urticaria, laryngeal edema, bronchospasm, and cardiac arrhythmias. cont’d on next page... Disease/Medical Condition ALLERGY (also known as “hypersensitivity reaction”; includes contact allergies, drug allergies, food allergies, environmental allergies, and the manifestations of anaphylaxis, urticaria, and angioedema) Is the initiation of invasive dental hygiene procedures contra-indicated?** (cont’d) Yes, if there is suspicion of current or potential allergic reaction to dental/dental hygiene materials. Yes, for dental procedures requiring local anaesthesia when the patient/client’s past history reveals confirmed allergy, or suspicion of allergy, to local anaesthetic. Dental/dental hygiene procedures that do not require anesthesia may be performed in the interim. Oral management implications ■ Two forms of allergy are particularly relevant for the dental hygienist. A type I, or anaphylactic (immediate), reaction, may present in the dental/dental hygiene office with an acutely life-threatening situation. A type IV, or delayed, reaction is seen clinically as contact dermatitis5, which affects a significant number of oral health professionals. ■ Acute allergic reaction is one of the most common medical emergencies in the dental/dental hygiene office. Of particular importance is patient/client-reported allergy to a local anaesthetic, analgesic, or antibiotic. Such a history must be expanded to determine what the specific drug was and how the patient/client reacted to it. Signs and symptoms suggestive of a true allergic reaction include urticaria, swelling, rash, dyspnea, chest tightness, rhinorrhea, and conjunctivitis. Often, a patient/ client may mislabel a non-allergic reaction as an “allergy”, such as syncope after injection of a local anaesthetic, nausea or vomiting after ingestion of codeine, or gastrointestinal discomfort or diarrhea after taking an antibiotic. ■ Pre-anaesthetic assessment is key in preventing allergic reactions in the dental/dental hygiene office. The patient/client with multiple allergies (e.g., asthma, hay fever, and food allergy) is at elevated risk for allergic reactions to medications, including local anaesthetic agents. While only 1% or so of all reactions that occur during local anaesthetic administration are true allergic reactions, a documented local anaesthetic allergy represents an absolute contraindication to use6. Allergic response spans the spectrum from dermatitis and bronchospasm to life-threatening reaction. ■ Antibiotics such as penicillins and sulfonamides are frequently associated with allergic responses, whereas others such as erythromycin are rarely implicated. ■ Non-steroidal anti-inflammatory drugs (NSAIDs) can be problematic for persons with asthma. 1% to 5% of patients/clients with asthma are unable to take non-selective NSAIDs (e.g., ibuprofen, naproxen, and diclofenac, as well as aspirin) without developing a severe and sometimes life-threatening asthma attack. Therefore, NSAIDs should be used cautiously, if at all, in patients/clients with asthma; history of NSAID allergy is an absolute contraindication to use. ■ The patient/client with a known food allergy should carry an auto-injector of epinephrine to facilitate appropriate emergency treatment at the earliest sign of a reaction. The wearing of a MedicAlert identifier should also be encouraged. ■ The dental/dental hygiene management of asthma is primarily focused on preventing severe asthma attacks from happening in the office and dealing with an attack if it occurs. ■ Mouth rinses and toothpastes containing antiseptics, astringents, phenolic compounds, and/or flavouring agents can cause hypersensitivity reactions affecting the oral mucosa or lips. 5 Other clinical examples of type IV cell-mediated (delayed) allergic reactions include infectious granulomas (e.g., resulting from tuberculosis and mycoses), tissue graft rejection, and chronic hepatitis. 6 All local anaesthetic agents in the same chemical class (i.e., para-aminobenzoic acid esters [procaine and tetracaine] vs. amides [articaine, lidocaine, bupivacaine, mepivacaine, and prilocaine]) should be avoided. A true allergic response to a pure amide drug is very rare; as a result of their nonallergenic nature, amide-type local anaesthetics are now used almost exclusively for pain control during dental procedures. A reported sulfa allergy precludes use of sulfur-containing local anaesthetics (e.g., articaine). cont’d on next page... 2 Disease/Medical Condition ALLERGY (also known as “hypersensitivity reaction”; includes contact allergies, drug allergies, food allergies, environmental allergies, and the manifestations of anaphylaxis, urticaria, and angioedema) Oral management implications (cont’d) ■ Allergic reactions to various dental cartridge contents can occur. In particular, allergy to sulfites (acetone sodium bisulfite and sodium metabisulfite), which are antioxidants used as preservatives for the vasoconstrictor in local anaesthetic solutions), has been reported. Patients/clients with asthma may be particularly susceptible. Therefore, local anaesthetics without vasoconstrictor (and therefore without sodium bisulfite or metabisulfite) must be used when there is a history of sulfite sensitivity7. ■ If respiratory distress is suspected secondary to an allergic reaction, the following should occur: terminate procedures; place patient/client
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