ALLERGY

Sering terjadi pd dental office : acute

allergy reaction
ETIOLOGI : an immunologic reaction to
a noninfectious foreign substance
(antigen).

TIPE
Type I = Anaphylactic or IgE
mediated
Type II = Cytotoxic
Type III = Immune complex mediated
Type IV = Cell mediated or delayed

HIPERSENSITIVITAS TIPE I
-umunya langsung terjadi beberapa saat seteah
berkontak dengan antigen, namun ada jg yg
menunjukkan setelah bbrpa kali kontak dgn
obat/alergen baru menunjukkan reaksi alergi
Anaphylaxis : an acute reaction involving the
smooth muscle of the bronchi in which the
antigen/antibody complex that is formed
causes histamine release from mast cells The
smooth muscle contracts, and this may lead
to acute respiratory distress or failure

 Atopy : hypersensitivity state that is influenced by hereditary

factors.
Ex : Hay fever, asthma, urticaria, and angioneurotic edema
Agents that commonly cause acute urticaria include shellfish,
nuts, eggs, milk, antibiotic drugs, and insect bites (bee stings).
Humoral antibodies involved in anaphylaxis and atopy are IgE
antibodies that are fixed to and sensitize mast cells, so that when
they encounter the antigen, they release histamine.
lesions result from the effects of antigens and their antibodies
(IgE) on mast cells in various locations in the body. The
antigen/antibody complex causes the release of mediators
(histamine) from mast cells; these mediators then produce an
increase in the permeability of adjacent vascular structures,
resulting in loss of intravascular fluid into surrounding tissue
spaces.

Type II hypersensitivity
reactions.
These reactions are IgG or IgM mediated
The classic example of type II (cytotoxic) hypersensitivity is
transfusion reaction caused by mismatched blood.
Type II Hypersensitivity
1. Antibody mediated
2. Cytotoxic hypersensitivity
a. Antibodies combine with host cells recognized as foreign
b. Foreign antigens bind to host cell membranes during
induced hemolytic anemia or thrombocytopenia
3. Common examples
a. Transfusion reactions from mismatched bloods
b. Rhesus incompatibility
c. Goodpasture's syndrome

Type III hypersensitivity

reactions.
These reactions take place in blood
vessels and involve soluble immune
complexes. They constitute what is
referred to as immune complex
mediated hypersensitivity . Their key
feature is vasculitis. Clinical
examples include systemic lupus
erythematosus and streptococcal
glomerulonephritis.


1.
2.
3.
4.

Type III Hypersensitivity

Antibody mediated via immune complex formation
Also known as immune complexmediated hypersensitivity
Local form is Arthus reaction
Immune complex formation
a. Hypersensitivity state: Complexes persist and lodge in blood vessel walls,
initiating inflammatory reaction
b. Large complexes
c. Removed by neutrophils and macrophages
d. Soluble complexes (more antigen than antibody)
(1) Most harmful
(2) Penetrate vessel wall
(3) Lodge in the basement membrane
e. Complement is activated
(1) Vascular permeability increased
(2) Neutrophils attracted
(3) Neutrophils release enzymes
(4) Vasculitis results
5. Sensitive sites
a. Renal glomeruli
b. Synovial membranes
6. Examples
a. Systemic lupus erythematosus
b. Poststreptococcal glomerulonephritis

Type IV hypersensitivity
reactions.
involve the cellular immune system, include infectious contact
dermatitis, transplant rejection, and graft-versus-host disease
Some of the more common antigens that cause contact dermatitis
include metal jewelry, perfumes, rubber products, chemicals such
as formaldehyde, and medicines such as topical anesthetics. Type
IV hypersensitivity reactions usually are delayed and appear about
48 to 72 hours after contact has been made with the antigen
In the cellular or delayed immune system, T lymphocytes play the
central role. The primary function of this system is to recognize
and eradicate antigens that are fixed in tissues or within cells. This
system is involved in protection against viruses, tuberculosis, and
leprosy. Antibodies are not operative in the cellmediated immune
system. Effector T lymphocytes produce various cytokines that
serve as active agents of this system

Type IV Hypersensitivity
SIGNS AND SYMPTOMS SUGGESTIVE OF AN ALLERGIC
REACTION
1. Mediated by T lymphocytes
2. Does not involve antibodies
3. Also called delayed-type hypersensitivity (response not seen
until about 2 days after antigenic exposure)
4. Examples include the following:
a. Contact dermatitis
b. Graft rejection
c. Graft-versus-host reaction
d. Some type of drug hypersensitivity
e. Some types of autoimmune disease

MEDICAL MANAGEMENT
atopy may be given injections to
gradually desensitize them so that
they are no longer allergic to the
antigen
Some individuals 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).

DENTAL MANAGEMENT

Oral Complications and

Manifestations
Hypersensitivity
Type I hypersensitivity.

This reaction is generally rapid, with the lesion

developing within a short time after coming into
contact with the antigen. This painless, soft tissue
swelling produced by transudate from the
surrounding vessels may cause itching and burning.
The lesion is usually present for 1 to 3 days and then
begins to resolve spontaneously. Oral antihistamines
should be given; oral diphenhydramine, 50 mg every
4 hours, is the recommended regimen. Treatment is
provided for 1 to 3 days. Further contact with the
antigen must be avoided

Oral or Paraoral Type I Hypersensitivity Reactions

1. Urticarial swelling (or angioneurotic edema)
a. Reaction occurs soon after contact with antigen
b. Reaction consists of painless swelling
c. Itching and burning may occur
d. Lesion may remain for 1 to 3 days
2. Treatment
a. Reaction not involving tongue, pharynx, or larynx and with no respiratory
distress noted requires 50 mg of diphenhydramine 4 times a day until
swelling diminishes
b. Reaction involving tongue, pharynx, or larynx with respiratory distress
noted requires the following:
(1) 0.5 mL of 1 : 1000 epinephrine, IM or SC
(2) Oxygen
(3) Once immediate danger is over, 50 mg of diphenhydramine
should
be given 4 times a day until swelling diminishes

 Type III hypersensitivity

Foods, drugs, or agents that are placed within
the oral cavity can cause white, erythematous,
or ulcerative lesions as determined by the
presence of type III hypersensitivity or immune
complex reactions.
These lesions develop rather quickly, usually
within a 24-hour period, after contact is made
with the offending antigen. Some cases of
aphthous stomatitis

Type III Hypersensitivity Reactions

1. Usually occur within 24 hours after contact with antigen
2. Consist of
a. Erythema
b. Rash
c. Ulceration
3. Treatment requires
a. Topical steroids
b. Systemic steroids (in severe cases)
c. Identification of antigen
d. Avoidance of any further contact with antigen

 Type IV hypersensitivity.
Contact stomatitis is a delayed
allergic reaction that is associated
with the cellular immune response in
most cases.

MANAGEMENT OF SEVERE TYPE I

HYPERSENSITIVITY REACTIONS
Place the patient in a head-down or supine position.
Make certain that the airway is patent.
Administer oxygen.
Be prepared to send for help and to support respiration and
circulation. The rate and depth of respiration should be noted,
as should the patient's other vital signs. Most reactions in
dental patients consist of simple fainting, which can be well
managed by the preceding actions. 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 problem is of an allergic cause, the dentist is faced with
an edematous-type or an anaphylactic reaction.

if the patient has not responded to the initial procedures

and is in acute respiratory distress, the dentist should do
the following
Inject 0.3 to 0.5 mL of 1 : 1000 epinephrine through an
IM (into the tongue) or subcutaneous (SC) route.
Support respiration, if indicated, by mouth-to-mouth
breathing or bag and mask; the dentistmshould make
sure the chest moves 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. By this time, someone in the office should have
called a nearby physician or hospital

Anaphylaxis
BASIS
1. First contact with antigen results in formation of antibodies by plasma cells.
2. Antibodies circulate in bloodstream (immunoglobulin [Ig]E antibodies).
3. Antibodies attach to target tissues (mast cells near smooth muscle of bronchi).
4. Next contact with antigen may result in combination of antigen with antibody.
5. Antigen/antibody complex causes degranulation of mast cell(s) with release of histamine.
6. Smooth muscle contracts and vessels lose fluid, etc.
7. Acute respiratory distress and cardiovascular collapse may occur within minutes.

Managemen
1. Call for medical help.
2. Place patient in the supine position.
3. Check for open airway.
4. Administer oxygen.
5. Check pulse, blood pressure, and respiration.
a. If depressed or absent, inject 0.3 to 0.5 mL 1 : 1000 epinephrine IM into the tongue.
b. Provide cardiopulmonary resuscitation if needed.
c. Repeat injection of 0.5 mL 1 : 1000 epinephrine if no response.