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Human Disease > Allergy to Dental Materials > Flashcards

Allergy to Dental Materials Flashcards

1
Q

4 routes of entry for allergens and most important routes in dentistry

A

1) Percutaneous//mucosa- Plants/Pet scratch
2) Injection- Bee stings
3) Inhalation- Hay fever (pollen) or Asthma (dust)
4) Ingestion- Food (nuts) medicines

Medicines through injestion
Mucosal entry
Both important in dentistry

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2
Q

Allergy and toxicity definition and difference

A

Allergy is an immunologically based sensitivity

  • It is a specific immune response to the allergen
  • It is not dose dependent
  • Reaction will change on subsequent exposure (gets worse)

Toxicity is a non-immunologically based reaction or an intolerance

  • It is non-specific and not immune related
  • It is dose-dependent
  • May be similiar on subsequent exposure
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3
Q

Hypersensitivity definition

A
  • State of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance
  • Classified as immediate or delayed types I and IV respectively, in the Gell and Coombs classification of immune responses
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4
Q

Time courses for various types of hypersensitivties

A
  • Immediate hypersensitivity (Type I) takes place in the first hour
  • Type III gives a late response (between 4-12 hours)
  • Type IV hypersensitivity (delayed) occurs between 24-96 hours
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5
Q

Type I hypersensitivity definition, pathogenesis and examples

A
  • Mediated by IgE bound to high affinity Fc receptors on mast cells
  • Cross linking of the IgE/Fc receptor complex by antigen causes degranulation- release of histamine, serotonin, proteases, cytokines and leukotrienes
  • Activates and attracts eosinophils, neutrophils and macrophages
  • Leukotrienes, histamine induces vascular permeability, smooth muscle contraction, bronchoconstriction

Acute anaphylaxis
Hay Fever
Asthma
Urticaria (hives)

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6
Q

Type II hypersensitivity definition, pathogenesis

A

-Less common

  • Mediated by IgG binding to a modified self antigen (penicillin-modified cell surface proteins) or a self antigen
  • IgG Fc binds to Fc receptors of macrophages, NK cells
  • IgG Fc also activates complement- opsonisation and activation of phagocytic cells
  • Degranulation or phagocytosis (eg. of modified platelets)- tissue damage
  • Associated with organ-specific disease (self antigen on tissue)

-Pemphigus

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7
Q

Type III Hypersensitivity definition and pathogenesis

A
  • Mediated by IgG forming immune complex with soluble antigen
  • Immune complexes deposit in blood vessels, synovial fluid and other tissues
  • Activates complement and attracts neutrophils, macrophages and mast cells
  • Action of complement and degranulation- tissue damage
  • Associated with non organ-specific auto-immune disease

-Herpes and Erythema multiforme

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8
Q

Type IV Hyperpersensitivty

A
  • Mediated by T cells (th1, Th17, Tc)
  • Activated T cells secrete chemokines, cytokines to recruit and activate macrophages
  • Activated macrophages secrete further pro-inflammatory cytokines (IL-12 and TNF) tissue damage from degranulation
  • Formulation of a granuloma: macrophages/multi-nucleated giant cells, eosinophils, T cells, fibroblasts
  • Associated with organ-specific autoimmune disease

-Lichenoid

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9
Q

Relevance of allergy in dentistry

A
  • Dentist must know how to manage anaphylaxis
  • Potential contact dermatitis
  • Patients may have allergies
  • May not know about the allergy
  • Need to reduce exposure to potential allergens such as latex
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10
Q

Dental materials that can potentially cause allergic responses

A

Drugs

  • Local anaesthetics
  • Corticosteroids

Restorative materials

  • Amalgam
  • Ionomers
  • Composites

Clinical materials

  • Latex
  • Impression materials

Toothpaste/mouthwash

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11
Q

Different drugs and mucosal reactions to them

A 
Corticosteroids- Candidosis 
Methotrexate- Ulceration 
Gold- Lichenoid reactions 
Penecillamine- Loss of taste 
Antimalarials- Lichenoid reactions 
NSAIDs- Lichenoid reactions (rarely), oral ulceration
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12
Q

Drugs that can cause lichenoid reactions

A
  • Nifedipine

- Sulfsalazine used in treatment of uc, arhtritis and crohns

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13
Q

Drug that can cause burn in the mouth

A

-Aspirin

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14
Q

Drug that can cause gingival hyperplasia

A
  • Ca channel blockers (nifedipine)
  • Phenytoin (Anti-epileptic)
  • Cyclosporin (immunosuppresent)
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15
Q

Potential oral reactions to toothpastes and mouthwashes

A
  • Gingival desquamation
  • Gingival swelling and granulomatous reactions
  • Benign migratory glossitis
  • Epithelial desquamation, inflammation
  • Ulceration
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16
Q

Potential oral reactions to creams, ointments, impression materials

A

-Contact stomatitis
-Gingival deaquamation
-Swelling and granulomatous reactions
-Mucosal swelling
-Epithelial desquamation
-Inflammation
Ulceration

17
Q

Adverse reactions to LA

A
  • Very rare
  • Associated with blocking ion channels in membranes (CVS and CNS toxicity)
  • Due to other effects of drug or vehicle (mainly peripheral nerve complications such as vasoconstriction in digits)
  • Allergic reaction (often a mistaken diagnosis)
  • Mechanical or other effects of technique such as needle trauma or introduction of infection
18
Q

Reasons for referral after adverse reactions to LA

A
  • Collapse (immediate or 2h later)
  • Swellings of lips, eyes, cheeks or face
  • Rash on chest, limbs or contact area
  • Breathlessness, sweating, nasuea, disorientation
  • Headaches, irregular pulse and low BP
  • Swelling of throat
  • Behaviour changes
  • Sleepiness and dizzines
19
Q

How would you test for a local anaesthetic allergy

A
  • Initially try a scratch test
  • Check if anyone is extremely allergic before giving an intradermal
  • Scratch test didnt really differentiate between those who had an allergy and those who didn’t
  • During intra-dermal testing, it was found that most people, if allergic, reacted to the prilocaine
  • Perhaps this is because of the plastic encasing
  • Scratch skin tests alone are not good discriminators of allergy, intradermal are better discriminators
  • Lidocaine produced more positive skin reactions than any other local anaesthetic agent tested (prilocaine was due to plastic casing)
  • Negative skin reactions to at least one of the agents means that that agent can be recommended for intrabuccal agents for future use
20
Q

Patch Testing definition

A
  • Patches left in place for 48 hours
  • Hypo-allergic paper
  • Number of different allergens
  • Read at 48th hour and 96th hour
  • Check to see which allergens produced a response
21
Q

Clinical manifestations of urticaria

A
  • Hives
  • Wheals- spots or patches of raised red or white skin
  • Usually clear away in a few hours, and are replaced by other fresh wheals
  • Itchy, painful or cause a burning sensation
  • Sometimes occurs together with angiodema
22
Q

Angiodema definition and clinical manifestations

A
  • Swelling of the soft tissues
  • Fluid from blood vessels into tissue
  • Angiodema is the name given to deeper swelling affecting the skin over the arms, legs, torso or face
  • May also affect the tongue, mouth, throat and sometimes the upper airway
  • Swellings commonly last for more than 24 hours, and usually there is no itching
23
Q

Causes of chronic angiodema

A

Food Allergy (particularly nuts, shellfish, milk and eggs)

Oral Allergy Syndrome

Medicines

  • Antibiotics
  • ACE inhibitors (ramipril, enalopril, lisinopril)
  • Angiotensin 2 receptor blockers (Losartan)
  • Aspirin and NSAIDs
  • Beta Blockers

Latex

Hereditary (C1 Esterase Inhibitor Deficiency)
-Attacks triggered by-stress/injury/surgery/dental treatment/pregnancy/medications

-Often not possible to identify cause of chronic angiodema

24
Q

Reactions to latex and management , investigations

A

-Dental school staff and students are at high risk of sensitzation to latex

  • Use non-latex gloves: plastic or polyvinyl
  • Sensitisation by contact, inhalation of protein dust so use powderless gloves
  • Specific RAST test
  • Skin scratch test
  • 70% have atopic history
  • Avoid contact with latex at home and work
  • Patients are advised to carry non latex gloves with them to the hairdressers etc
  • Polyurethane condoms
  • Non rubber erasers
  • Dental practices should have a latex allergy policy in place
  • Antihistamines
  • Some patients may need to carry an Epipen
25
Q

Oral Cavity reactions to food

A
  • Usually type 1, sometimes type 4
  • Oral cavity less sensitive than skin or nose
  • Peanuts most common
  • Pumpkin seeds lead to swelling and asthma sometimes
  • Octyl gallate oxidant preservative can lead to sore tongue and erythema
26
Q

Immediate food allergy definition and clinical features

A

Type I Hypersensitivity reaction
-Anaphylaxis

  • Perioral erythema
  • Lip swelling
  • Oral itching
  • Tongue and pharyngeal swelling
  • Nausea and vomiting
  • Reaction develops in minutes to hours
  • Diagnostic skin tests available
27
Q

Delayed food allergy and symptoms

A
  • Don’t really know if it exists
  • Coeliac disease and dermatitis herpetiformis well-established
  • Large quantity of food needed
  • Develops in hours and weeks

-No diagnostic test except withdrawal and rechallenge

Food intolerances much more common

  • Exzema
  • Arthralgia (achy joints)
  • Poor concentration/headaches/depression
  • IBS/ Crohn’s
  • Urinary frequency
  • Arthrits and rhinitis
28
Q

Food intolerances

A
  • Food intolerances (non allergic hypersensitivity) are much more common nowadays than delayed food allergies
  • Onset of symptoms is usually slower and may be delayed by many hours after eating the offending food

-Can be difficult to decipher which foods are causing the tolerance

29
Q

Oral manifestations of food allergy

A
  • Oral pruritis
  • Taste changes
  • Perioral rashes
  • Fissured tongue
  • Facial swelling
  • Buccal lip swelling
  • Erythema
  • Burning mouth
  • Gingivo-stomatitis
  • Orofacial-granulomatosis
  • Orodynia
  • Oral ulceration
  • Erythema migrans
30
Q

Oral Allergy Syndrome/Pollen Food Syndrome definition

A
  • Type of food allergy classified by a cluster of allergic reactions in the mouth and throat in response to eating certain fruits, nuts and vegetables
  • Pollen allergens for example tree birch
  • Adults>Children
  • Usually occurs in people allergic to pollen from trees, grasses and weeds
  • Proteins of similiar structure in fruit
  • Distinctive type 1 reaction following direct contact of food and oral mucosa
31
Q

Clinical features of AES and common allergens

A
  • Swelling of the mouth, peri-orbital tissues and pharynx
  • Birch allergy strongest association, 20% may be scratch positive to apples, peaches, kiwifruit and almonds
  • Antigens are inactivated by cooking
32
Q

Guidelines for management of allergic reactions

A

-Establish provisional diagnosis
What it is the allergen
Previous history of reaction- mild/severe
Onset- rapid/delayed- how soon after contact
Type of symptoms- rash, oedema, conscious level, breathing difficulties and oral ulcers
-Previous management of reaction
None, medication or hospitalisation

-Investigations

33
Q

Investigations of Type I and IV hypersensitivities

A

Type I

  • allergy testing- scratch test/intradermal/intrabuccal
  • Check for oedema

Serology

  • Mast cell tryptase levels
  • Complement

Routine blood tests

  • FBC
  • B12
  • Folate
  • Ferritin

Type IV:
Allergy testing- patch tests

34
Q

Complementary and alternative allergy testing

A
  • Leukocytotoxic Test
  • IgG Elisa Test
  • Kinesiology
  • VEGA testing
  • Hair analysis
  • Auriculo-cardiac reflex
  • stools test
35
Q

Management of patients

A

-If allergy not proven with allergy testing, clear types letter to referrer of findings and diagnosis
-If allergy proven, give information to patient on proven allergens identified
Consider advice such as stay away
-Prophylactic antihistamines/corticosteroids
Fexafenadine
Prednisolone
Adrenaline

Human Disease (19 decks)

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