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Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy

Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy




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    Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy Allergy in exodontia /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

    • ALLERGY IN EXODONTIA INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    • • INTRODUCTION Definition : Allergy is a hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces a heightened capacity to react. An immuno logically mediated disease . Covers a broad range of clinical manifestations from mild, delayed reactions to immediate life threatening reactions. www.indiandentalacademy.com
    • CLASSIFICATION According to GELL&COOMBS TYPE I Anaphylatic(Immed Sec to iate mins hypersensitivity) IgE TYPE II Cytotoxic or cytolytic IgG,IgM TYPE III Immune complex disease 6-8 hrs Soluble immune complexes(AgAb) TYPE IV ‘Delayed’ or cellmedicated hypersensitivity 48 hrs _ www.indiandentalacademy.com _
    • CLASSIFICATION Based on time of onset: Reaction Onset Clinical reactions Immediate 0-1 h Anaphylaxis Hypotension Laryngeal oedema Accelerated 1-72 h Urticaria/angioedema Laryngeal oedema Wheezing Late >72 h Haemolytic anaemia Neutropenia, Thrombocytopenia serum sickness www.indiandentalacademy.com
    • PATHOGENSIS TYPE MECHANISMS TYPE I Free Ag binds to IgE fixed on mast cells and basophils,causing release of histamine etc. TYPE II Free IgG or IgM Ab binds to Ag on cell membranes to cause commplement activation,cell damage or phagocytosis. TYPE III Persistence of Ag/Ab complexes may lead to activation of complement,inflammation and tissue damage,particularly vasculitis and arthritis. TYPE IV Ag activates sensitized T-cells to become cytotoxic and to release factors(lymphokines) that stimulate other leucocytes. www.indiandentalacademy.com
    • ANTIGENS An antigen is any foreign substance capable of inducing the formation of an antibody. Most antigens are proteins with a molecular weight between 5000 and 40,000. Drugs,however,are not proteins and commonly possess a very low molecular weight(500 to 1000),making them unlikely antigens. ALLERGEN: An allergen is an antigen that can elicit allergic symptoms. An antigen or allergen may stimulate the production of several classes Ig which possess different functions. www.indiandentalacademy.com
    • HAPTENS A hapten is a specific,protein-free substance that can combine to form a hapten-protein complex with a carrier protien-circulating albumin. The hapten itself is not antigenic;however,when coupled with the carrier protein ,it may provoke an immune response. By this mechanism most drugs become antigens and thus capable of inducing anti-body formation and causing an allergic reaction. Pencillin,aspirin,and barbiturates are examples of haptens. Haptens are also called incomplete antigens. www.indiandentalacademy.com
    • ANTIBODIES (Ig) An antibody is a substance found in the blood or tissues that responds to the administration of an antigen or that reacts with it. The molecular weights of antibodies range from 150,000(immunoglobulin G[IgG]) to 900,000 (IgM). Immunoglobulins are produced by B lymphocytes and are classified as IgA,IgD,IgE,IgG,and IgM. Antibodies possess the ability to bind with the specific antigen that induces their production. Antibodies are not entirely specific,and cross-sensitivity is possible between chemically similar substances. www.indiandentalacademy.com
    • DEFENSE MECHANISMS OF THE BODY When a person is exposed to a foreign substance,the body attempts to protect itself through a number of mechanisms. ANATOMIC BARRIERS which attempt to exclude entry of the antigen into the body.Examples:epithelium of the gastrointestinal tract,the sneeze and cough mechanisms. MOBILIZATION OF PHAGOCYTIC BLOOD CELLS such as leukocytes,histiocytes,and macrophages. PRODUCTION OF NONSPECIFIC CHEMICAL SUBSTANCES such as lysozymes and proteolytic enzymes,which assist in removal of the foreign substances. IgA ANTIBODY is produced by plasma cells in response to the antigen.IgA then aids in the removal or detoxification of the antigen from the host. www.indiandentalacademy.com
    • DRUGS IN DENTISTRY CAUSING ALLERGY ANTIOBIOTICS • Penicillin • Tetracycline • Sulfonamides ANALGESICS • Acetylsalicylic acid • NSAIDs OPIOIDS • Morphine • Meperidine • Codeine www.indiandentalacademy.com
    • Cont. ANTIANXIETY DRUGS • Barbiturates LOCAL ANAESTHETICS • Esters - Procaine - Benzocaine - Tetracaine - Propoxycaine • Antioxidant Sodium bisulfite • Parabens Methylparaben • OTHER AGENTS www.indiandentalacademy.com Latex
    • CLINICAL MANIFESTATIONS May be immediate or delayed reaction. Number of organs and tissues are affected – Generalised Anaphylaxis. Reactions involving one organ or system is localised anaphylaxis. When hypotension occurs as a part of a reaction resulting in loss of consciousness is anaphylactic shock. ONSET:Time between antigenic exposure & clinical symptoms. More rapid-more intense reactions. If they appear and rapidly increase in intensity, the reaction may be life threatening. www.indiandentalacademy.com
    • SKIN REACTIONS Allergic skin reactions are the most common sensitization reactions are of three types as,(1)Localised anaphylaxis,(2)Contact dermatitis,&(3)Drug eruption. Includes Urticaria erythema & angioedema Urticaria is associated with wheals & frequently with intense itching or pruritis. In angioedema,localised swelling occurs in response to an allergic with pain & itching. Periorbital,perioral & intraoral regions of face,as well as extremities are involved. Lips,tongue,pharynx & larynx involvement can lead to airway obstructis. CONTACT DERMATITIS: Allergic reactions in dental professionals. www.indiandentalacademy.com Includes erythema,induration,edema & vesicle formation .
    • RESPIRATORY REACTIONS  Respiratory reactions normally follow skin,exocrine & gastrointestinal responses but precede cardiovascular reactions.  Bronchospasm:-classical respiratory manifestation which clinical result of bronchial smooth muscle constriction.  Includes respiratory distress,dyspnoea,wheezing, flushing,possible cyanosis,tachycardia.  Rhinitis:-Nasal congestion itching,sneezing. LARYNGEAL OEDEMA: Swelling of the vocal apparatus with obstruction in airway.  Dyspnoea,hoarseness,throat tightness,hypersalivation. www.indiandentalacademy.com
    • CARDIOVASCULAR REACTIONS • • • • • Circulatory Collapse:Light headedness,generalised weakness,syncope,ischaemic chest pain. Tachycardia,hypo tension,shock. Dysrrhythmias:-Includes all symptoms & palpitations. Cardiac Arrest:-Pulselessness,ECG changes,ventricular fibrillation. Gastro-intestinal reactions:Nausea & vomiting,diarrhoea,cramping,abdominal pain. In case of fatal anaphylaxis,prominent pathologic features are observed in RS & CVS. Includes laryngeal edema,pulmonary hyperinflation,peribronchial vascular congestion,intra-alveolar Haemorrhage,pulmonary edema varying degree of myocardial damage. www.indiandentalacademy.com
    • DIAGNOSIS-ALLERGY TESTING Skin Testing Patch Test Intra cutaneous Testing PRIST Test RAST Test Lymphocyte blast transformation www.indiandentalacademy.com
    • SKIN TESTING • • Two forms of skin testing are used: Intradermal tests in which the drug is diluted and injected into the dermis. Prick testing the drug is introduced into the dermis by pricking the patient’s skin through a drop of undiluted drug. The allergy skin test procedure includes a positive control(usually histamine),a negative control(a solution without allergens) and then various suspect allergens. Medications such as antihistamines or antipressants must be stopped from 2 days to 6 weeks or more before. If an extract provokes an allergic reaction,a raised,red www.indiandentalacademy.com itehy wheal may develop within about 20 min.
    • INTRACUTANEOUS TEST o o o o o o o This test is considered to be among the most reliable. In this test 0.1ml of the following solutions is deposited intravenously: 0.9% of normal saline solution 1% or 2% Lidocaine 3% Mepivacaine 4% Prilocaine 0.1ml of bacteriostatic water One or more local anesthetics with methylparaben Patients vital signs are monitored through out the procedure www.indiandentalacademy.com
    • Contd... After this phase of testing 1ml of one of the preceding LA that tested negative is administered intraorally by supraperiosteal infiltration above a maxillary anterior tooth. This is called the “CHALLENGE TEST” Emergency drugs,equipment and personnel for resuscitation must be readily available when allergy testing is done. www.indiandentalacademy.com
    • OTHER TEST PATCH TESTING Applying the allergen in an absorbent dressing which is taped on to the skin. PRIST TEST Paper radio – immuno sorbent test which measures serum IgE levels. RAST TEST Radio allergo sorbent test which measures the IgE anti bodies level. The level of radio activity indicates the www.indiandentalacademy.com level of specific IgE anti bodies.
    • POSSIBLE SUBSTITUTES Antibiotics: Penicillin – Erythromycin Antibiotics: Acetylsalicylic acid – Acetaminophen Opioids – NSAIDs Barbiturates – Diazepam, triazolam Ester LA – Amide LA Antioxidants – Non- vasopressor containing LA Latex - Vinyl www.indiandentalacademy.com
    • GENERAL MANAGEMENT ELECTIVE DENTAL CARE: • Elective dental case requiring local anesthesia may need to be postponed until a thorough evaluation of the patient is completed by a competent individual. • Dental case not requiring injectable or topical A may be carried out during this period. EMERGENCY DENTAL CARE: Option 1:Consultation:• Immediate consultation to test the patient for allergy to LA. • If pain is present it may be managed orally with various analgesics and infections can be controlled with antibiotics. Option 2:General Anesthesia:• Use of GA in place of LA to manage the dental emergency. • Highly useful and relatively safe technique but has complications and www.indiandentalacademy.com unavailability in dental office.
    • Cont… Option 3:Histamine blocker:• Use of a histamine blocker like diphenhydramine as LA. • 1% solution with 1 in 100,000 epinephrine,pulpal anesthesia upto 30 mins is produced. • Burning or stinging sensation is produced which can be minimized by using nitrous oxide and O2. • Post-operative tissue swelling and soreness may be present. Appropriate drug therapy with immediate medical consultation (Option 1)is the most reasonable mode of action. www.indiandentalacademy.com
    • MANAGEMENT SKIN REACTIONS:• Step 1:-Termination of dental procedure. • Step 2:-P-Position. • Step 3:-(A-B-C)-Airway-Breathing-Circulation & Basic life support. • Step 4:-Definitive care. • DELAYED:(4a)Administration of histamine blocker. IV or IM-Diphenhydramine-50mg for adults,25mg for children. -Chlorpheniramine-10mg for adults,5mg for children. Orally-Diphenhydramine-3-4 times a day. -Chlorpheniramine-4mg for adults,3/4 times a day. -2mg for children (4-6hrs). (4b)(1)Monitoring of vital sign. (2)Repositioning of pt. (3)O2 & venipuncture adm. www.indiandentalacademy.com (4)Adm of epinephrine.
    • MANAGEMENT • • • • • • • Respiratory reactions:Step 1:-Termination of dental procedure. Step 2:-Position. Step 3:-A-B-C assess & BLS. Step 4:-Definitive care. Administration of bronchodilator:Aersol inhaler. IM or SC-0.3ml of a 1:1000 dilution. IV-0.1ml of 1:10,000,15 to 30 mins. www.indiandentalacademy.com
    • MANAGEMENT OF LARYNGEAL OEDEMA • Step 1:-Termination. • Step 2:-Position. • Step 3:-A-B-C. • Step 4:-Definitive care. Administration of Epinephrine:• IM-0.3ml of 1:1000 for adults & 0.5ml for child,0.075 for infants. • IV-10ml of 1:10,000 over 5 mins. CRICOTHYROTOMY:www.indiandentalacademy.com
    • MANAGEMENT OF GENERALISED ANAPHYLAXIS • Step 1:-P-Position. • Step 2:-ABC. • Step 3:-D-Definitive care. • Adm of Epinephrine:-Sublingually/Intralingually. • Adm of O2:-5 to 6l per min via nasal hood or full face mark. If no clinical signs:• Step 1 :- Termination. • Step 2:-Position. • Step 3:- ABC or BLS. • Step 4:- Definitive care. www.indiandentalacademy.com
    • CONCLUSION Thus allergy plays a vital role among the medical emergencies in exodontia.Timely identification and treatment of allergic reactions avoids fatalities. However,as per the saying,”When you prepare for an emergency,the emergency ceases to exist”,a proper history, diagnosis and planning always reduces the risk of adverse reactions. www.indiandentalacademy.com
    • www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com