hypersensitivity manifestation and diagnosis in dentistry

1. DentalDental
DepartmentDepartment
HYPERSENSITIVITY REACTION
IN DENTISTRY
Manifestation, Diagnosis,
Management

2. Dr Jamal HUSSIEN
Oral mEDIcINE
SpEcIalISt

3. HYPERSENSETIVITY

4. Introduction
The immune response necessary for protection
against disease, can also cause disease or other
consequences when it react against tissues or
harmless antigen.

5. The immune system is the body's defense against
infectious organisms and other invaders. Through a
series of steps called the immune response, the
immune system attacks organisms and substances
that invade body systems and cause disease
immune system

6. 1-Innate system:-
first line defense of the body mainly are cellular component
(phagocytic cell+ molecular component (complement cascade
and cytokine)
---(mononuclear phagocytic or tissues macrophages)
—Neutrophils its phagocytic the microorganism mainly
bacteria
--NK CELLS that kill any antigen(virus—
bacteria—cancer cell)
Immune response divided into two
functional

7. cellular component

8. 2-Complement system
-it is serum proteins in the host tissues it activated by
microorganism
Function;
-Direct killing of microorganism or tumor by lysis the
organism
-The opsonization of M.O for phagocytosis to important host
- activate the
inflammatory response --
activation of immunocomplex and regulation of antibody
production by B Cells
--complement cascade it is about 9 plasma proteins the
processes same of clotting cascadeC1----C9

10. 2-Acquired immunity
A--T-lymphocytes system
T-lymphocytes 70%--80% in the peripheral blood are divided
into three group
1- inter act with B cells and help for differentiate and make
antibody
2-inter act with phagocytic cells to engulf the microorganism
3-Cytotoxic T cells
recognize cell infected by virus and destroys them
T-lymphocytes are
classified as (CD1----CD8) ACCORDING TO SURAEACE Molecules
CD4—T4 to help the B Cell to form the immuncomlex

13. 3-Cytotoxic T cells

14. B-lymphocytes have immunoglobulin receptors
It's differentiate to plasma cell and produce antibodies
Antibodies, also called immunoglobulin or Ig constitute
the gamma globulin part of the blood proteins .
It is poly peptide chain pair of light chain(L) and pair of
heavy chain(H)
Ig type according to the type of heavy chain (gama IgG—alpha
IgA—mu IgM---delta IgD—epislon IgE)
B-- (Humoral immunity system )

16. Function of Ig
IgG—Crossing the placental barrier and protection of the
new born
IgA— It is found in the external secretion of the
body(saliva-tears- ear) and make protection of the oral
tissues
IgM- activation of immune complex-
IgD— act as receptor of antigen in b lymphocytes
IgE--- bind in the mast cell and basophiles and make
allergic reaction due to increase the secretion of
histamine

17. HYPERSENSITIVITY
• Hypersensitivity (hypersensitivity reaction) refers
to undesirable immune reactions produced by the
normal immune system.
• Hypersensitivity reactions require a pre-sensitized
(immune) state of the host
Hypersensitivity reactions: four types; based on the
mechanisms involved and time taken for the
reaction

18. Coombs and Gell classification
1-Type I - immediate ( atopic, or
anaphylactic(
2-Type II - antibody-dependent
3-Type III - immune complex
4-Type IV - cell-mediated or delayed

20. TYPE I Hypersensitivity Classic allergy
Mediated by IgE attached to Mast cells.
The symptoms resulting from allergic responses are known as
anaphylaxis.
Includes: Hay fever, asthma, eczema, bee stings, food
allergies.
1-Allergens are nonparasite antigens that can stimulate a type I
hypersensitivity response.
Allergens bind to IgE and trigger degranulation of chemical mediators
2-Atopy is the term for the genetic trait to have a predisposition
for localized anaphylaxis.
Atopic individuals have higher levels of IgE and eosinophils

22. Immunologic
In the immunologic mechanism, (IgE) binds to
the antigen (the foreign material that provokes the
allergic reaction). Antigen-bound IgE then
activates receptors on mast cells and basophils. This
leads to the release of inflammatory mediators such
as histamim. These mediators subsequently increase
the contraction of bronchial smooth muscles,
trigger vasodilation, increase the leakage of fluid from
blood vessels, and cause heart muscle depression

25. Acute Phase Allergic Reaction:
•Occurs within seconds to minutes of IgE receptor activation
(mast cell mediator release) and resolving within an hour
•Intense pruritus, edema, erythema
•Almost all effects can be replicated with histamine
Late Phase Allergic Reaction:
•A delayed inflammatory response (peaking at 4-8 hrs and
persisting up to 24 hrs) following an intense acute phase
reaction •Skin: erythema, induration, burning
•Lungs: airway obstruction poorly responsive to
bronchodilators
•Nose/eyes: erythema, congestion, burning •Histology: mast
cell degranulation followed by influx of first neutrophils

26. Localized anaphylaxis
Target organ responds to direct contact with allergen.
•Digestive tract contact results in vomiting, cramping, diarrhea.
•Skin sensitivity usually reddened inflamed area resulting in itching.
Airway sensitivity results in sneezing and rhinitis OR wheezing and asthma.
Systemic anaphylaxis
•Systemic vasodilation and smooth muscle contraction leading to severe
bronchiole constriction, edema, and shock
Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause
death
it typically causes a number of symptoms including an itchy rash, throat
swelling, and low blood pressure
Common causes include insect bites and stings, foods, and
medications.
Anaphylaxis

29. Angioedema of the face such that the boy
cannot open his eyes. This reaction was
caused by an allergen exposure

30. Angioedema of the lips and
eyes

31. Angioedema of the lips and
eyes

32. Angioedema of half of the
tongue

33. Uriticaria and flushing on the
back of a person with
anaphylaxis

35. Uriticaria and flushing on the
a person with anaphylaxis

36. Uriticaria and flushing on the
back of a person with
anaphylaxis

37. Management
• Anaphylaxis is a medical emergency that may
require resucurment measures such for airway
supplemental oxygen , large volumes of I.V fluid, and
close monitoring.
• [
Administration of epinephrine is the treatment of choice
with antihistaminic and steroid (for
example, dexamethasone)
• A period of in-hospital observation for between 2 and 24
hours is recommended for people once they have
returned to normal

38. Allergic reactions to dental
materials, drugs
The reactions range from mild rash to a combination of
the most serious manifestations of anaphylaxis. In
generalized anaphylaxis, the patient can be clinically
dead within minutes from the onset of manifestations.
Manifestations include urticaria (hives), swelling of
tongue, pharynx, larynx, bronchospasm, hypotension,
cardiac arrhythmias, and abdominal pain.
•

39. , Drugs
local anesthesia
-- Amide-type anesthetics have not been a problem in allergic
reactions. such as Xylocaine and Carbocaine
--Ester-type anesthetics can cause allergic reactions
ester-type drugs are Novocaine, Ravocaine, Nesacaine,
and Hurricaine are not commonly used for local anesthesia
injections. The exception is for a patient with a liver disorder
which contraindicates the use of amide anesthetics. Ester
anesthetics are used for topical application for injection sites
and scaling sites

43. Drugs commonly prescribed in dentistry
Penicillins containing Amoxicillin which is used for
prophylactic antibiotic against infectious endocarditis 7%--
10%
Sulfonamides,,
Barbiturates have caused allergic reactions in asthmatic
patients
. Non-steroidal, anti-inflammatory drugs ibuprofen cause
allergic reactions in asthmatic patients as do aspirin and
other salicylates.

45. Dental materials
Dental materials causing stomatitis or contact dermatitis
1mm red dots are spotted throughout the oral cavity. or aphthous
ulcers, erythema multiforme, lichenoid reactions, glossitis, and
angioneurotic edema
Allergic to rubber (latex) gloves also allergic to rubber dams
,Vinyl gloves,rubber tube 0n b.p cuffe,.
Patients who have allergies to shellfish can have an allergic reaction
to alginate impression material.
Allergic reactions to prophy paste, mouthwashes, toothpastes,
disclosing tablets or solutions
include, also, amalgam, acrylic, composite resins, nickel in
prosthetics, and eugenol

46. COMMON ALLERGENS USED IN
DENTISTRY
Sulfa Allergy - sulfonamides used in dental materials
(Root Canals, Sealants
Sulfites. All dental local anesthetics that contain
epinephrine contain metabisulfite which is an antioxidant to
prevent breakdown of this ingredient.
Latex- gloves also allergic to rubber dams
Gutta-percha - Root Canals gutta percha has a potential for
cross-allergencity
Nickel sulfate 5% pet *Used in Metallic dental restorations
(Crowns etc).

47. Gold sodium thiosulfate 2% pet *Used in metallic restorations,
Bridges, Crowns Contact allergy to gold as demonstrated by patch
testing is very common among patients with eczematous disease and
seems
Balsam of Peru 25% pet *(Used in DENTAL CEMENTS/Root
Canals).
Metallic Mercury 1% pet - *Used in Silver Fillings - Amalgam
Amalgam with mercury 5% pet (contains mercury 2.5%, silver 1.73%,
copper 0.3%, tin 0.44%, and zinc 0.03%(

48. Fragrance mix 8% pet *Used in dental cements etc
Palladium chloride 1% pet - Used in Metal Restorations
Copper sulfate 2% pet - *Used in Dental Cements and Metal
Restorations
Methacrylates: 2-Hydroxyethylmethacrylate 2% pet *(Dental Cements
- Root Canals etc).
2,2-bis (2-Hydroxy-3-methacryloxy-propoxyl)-phenylpropane (BIS-
GMA) 2% pet
Menthol 1% pet - Used in Dental products, mouthwashes etc
Eugenol 1% pet *(Used in Dentistry - Fillings/Root Canals

49. Cinnamic aldehyde 1% pet - Used in Dentistry - Toothpaste etc.
Propolis 10% pet - Used in Dentistry - sealants -
Colophony 20% pet - used in Dentistry SFC
Benzalkonium chloride 0.1% pet - used in Dentistry
Benzocaine 5% pet - *Used for Pain Relief in Dental Anesthetics
Formaldehyde - Used in Root Canal disinfectants -
FUNGUS/MOLD Dental Materials enabling fungal growth and
mycetoma formation. These materials occur in the pastes used for
root filling and contain oxides of zinc, titanium and lead, salts of
calcium, barium, sulfur, titanium, zinc and bismuth, and also some
organic substances.

53. Perioral dermatitis in patient with a latex sensitivity after
being treated by a dentist wearing rubber gloves

58. Allergic patch test due to acrylate

61. Management in the dental office
Anaphylaxis is not the most common medical emergencies
that occurs in the dental office
the emergency drug kit can save valuable time.
The AnaKit is a beesting kit that is available for allergic
reactions.
It contains two 50 mg tablets of Benadryl or
Diphenhydramine (Benadryl) 50 mg IM
. Three doses of 0.3 mls of epinephrine are in the Tubex
syringe
0.3 mg IM or SC (0.3ml of a 1:1000 Solution)

62. Management in the dental office
1-You call for the emergency cart. As soon as ,You administered
epinephrine by sublingual injection in sever cases call EMS
The sublingual area is the best site for injection of epinephrine with
this syringe. The short needle is designed for a subcutaneous
injection. Delivering the drug to such a vascular area can produce
drug efficacy in five minutes
2-Then administered oxygen and cheek the vital signs.
3-Patient placed inTrendelenburg position and increased the oxygen
flow rate by delivering the oxygen by non-rebreather bag
4--Patient should be transported to a hospital for evaluation. Later,
patch test to find the type of allergen

63. 1-Epinephrine block the action of chemical mediators of
anaphylaxis that cause bronchospasm and
cardiovascular collapse
2-Benadryl is against histamine release and the mild
reaction of rash or hives
3-Cortisone provides anti-inflammatory effects.
N.B In generalized anaphylaxis Epinephrine must be
administered no matter what medication the patient has
taken. At that point, if epinephrine is not administered,
the patient will die

66. Blood transfusion reactions
Hemolytic disease of the newborn (Rh disease(
Autoimmune hemolytic anemia
Drug reactions
Drug-induced loss of self-tolerance
Hyper acute graft rejection
Myasthenia gravis (acetylcholine receptor(
Sensitivity to tissue antigens
Type II Hypersensitivity
In type II hypersensitivity, the antibodies produced by the immune
response bind to antigens on the patient's own cell surfaces.
Examples

67. Type III - immune complex
• In type III hypersensitivity, over production of
immunoglobulin G (IgG) and IgM to a foreign or self-antigen
can lead to the formation and deposition of excessive
amounts of insoluble intermediate-sized immune complex
that activate complement.chemotactic factor.PMNS which
attaract to the copmlex relase the lysosomal enzyme
damaging the immune complex produce the disease
Localized depositions of immune complexes within a
tissue cause type III hypersensitivity

68. Serum Sickness

69. Type IV - cell-mediated or delayed
The classical example of this hypersensitivity is tuberculin
(Montoux) reaction
Type IV hypersensitivity is involved in the pathogenesis
of many autoimmune and infectious diseases
Tuberculosis
Leprosy
Blastomycosis
Histoplasmosis
Toxoplasmosis
Another form of delayed
hypersensitivity is contact
dermatitis (poison), chemicals,
heavy metals, etc.) in which the
lesions are more papular

70. • Type IV hypersensitivity can be classified into three categories
depending on the time of onset and clinical and histological
presentation

71. Poison Ivy
contact
dermatitis

72. THANK
YOU

80. Perioral dermatitis in patient with a latex sensitivity after
being treated by a dentist wearing rubber gloves

82. Allergic patch test due to acrylate