EMERGENCY TREATMENT OF ALLERGIC REACTIONS IN DENTAL OFFICE TRATAMENTO EMERGENCIAL DE REAÇÕES ALÉRGICAS NO CONSULTÓRIO ODONTOLÓGICO

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1 480 EMERGENCY TREATMENT OF ALLERGIC REACTIONS IN DENTAL OFFICE TRATAMENTO EMERGENCIAL DE REAÇÕES ALÉRGICAS NO CONSULTÓRIO ODONTOLÓGICO Paulo Ricardo Saquete MARTINS-FILHO * Thiago de Santana SANTOS ** Clóvis MARZOLA *** Heitor Fontes da SILVA **** Daniel Galvão COSTA **** * Master of Health Sciences, Center of Postgraduate Medicine, Sergipe Federal University. ** Buco Maxillofacial Surgeon, School of Dentistry, University of Pernambuco. *** Professor of Surgery, Faculty of Dentistry of Bauru, USP, and retired Professor of specialization courses and Residency in Oral and Maxillofacial Surgery Maxillofacial promoted by the Brazilian College of Surgery and Traummatology BMF, Base Hospital Association's Hospital of Bauru and Regional APCD of Bauru. **** Academic School of Dentistry, Federal University of Sergipe.

2 481 ABSTRACT Allergic reactions are an important part of the complications that occur in the dental office and can be divided into late and immediate reactions. The dental professional has, therefore, the responsibility to prevent and treat these complications in their work environment. The aim of this study is, through a review of the literature, discussing the emergency treatment of allergic reactions that can develop in the dental office. RESUMO As reações alérgicas constituem uma fração importante das complicações que ocorrem no consultório odontológico e podem ser divididas em reações alérgicas imediatas e tardias. O profissional da área odontológica tem desta forma, a responsabilidade de prevenir e tratar estas intercorrências em seu ambiente de trabalho. O objetivo deste trabalho é, através de uma revisão da literatura, abordar o tratamento emergencial das reações alérgicas que podem se desenvolver no consultório odontológico. Uniterms: Allergic reactions; anesthetic; anaphylaxis. Unitermos: Reações alérgicas; anestesia; anafilaxia. INTRODUCTION Hypersensitivity reactions arising from the restatement of an organism to a particular allergen, presenting itself as a reaction affecting the tissues, called allergic reaction (CALICH; VAZ, 1989). Allergic reactions may be manifested by local anesthetics, although the incidence has decreased since the introduction of amide anesthetics in the 1940s. Lately there have reported allergic reactions to bisulfite or sodium metabisulfite, and antioxidant stabilizing agent present in vials of local anesthetic for dental use that contain vasoconstrictors (CAMPBELL; MAESTRELLO; CAMPBELL, 2001 e MALAMED, 2001). Special attention should be given to the administration of local anesthetics with adrenaline in the cortical-dependent asthmatics due to a higher risk of immediate and severe allergic reactions, especially in cases of intravascular injections (VASCONCELLOS; NOGUEIRA; LEAL et al., 2002). Drugs commonly used in dental practice, as penicillins, aspirin and NSAIDs, and other substances such as latex and methyl methacrylate which has to be a monomer of acrylic resins, can also trigger allergic reactions (ANDRADE; RANALI, 2002). Allergic reactions include a wide spectrum of clinical manifestations, ranging from mild and late responses to immediate and lethal reactions that develop seconds after exposure to the allergen. This is of great importance in Dentistry and comes fully justify the preparation of this work to the general practitioner.

3 482 Delayed Allergic Reactions Signs and symptoms related to allergic disorders are mediated primarily by the delayed release of histamine, which, acting at the level of skin, stimulates the nerve endings naked, causing rashes. Furthermore, histamine produces arteriolar vasodilation and increased capillary permeability, causing localized swelling and in some cases, generalized (SINGI, 1998). Histamine also has action on the bronchial smooth muscles, contracting them and causing bronchoconstriction (SILVA, 1994). The treatment of allergic late based on the severity of the table by the patient, which generally ranges from mild to moderate (Table 1). In a case report published recently, the patient developed swelling of the lips, face and eyelids after injection of articaine without symptoms of systemic order, with resolution of the case with administration of corticosteroids (EL-QUTOB; MORALES; PELÁEZ, 2003). The photos below illustrate a case of contact allergy after the use of povidone-iodine antisepsis for extra-oral, with promethazine treatment-based IM and dexchlorpheniramine in a single dose orally for 02 days (Fig. 1). Figure 1 - Allergic reaction after topical application of povidone-iodine. The patient developed erythema and itching in the area of contact with the product. Table 1 - Treatment protocol suggested for the late allergic reactions. Light Tables (Discrete urticarial lesions) Promethazine 01 amp. (50mg), IM Dexchlorfeniramine 01 tablet (2mg) from 06/06 hours, VO Moderated Tables (Diffuse urticarial lesions and / or angioedema of the face, without associated systemic manifestations) Adrenalina 1:1000; 0,2 to 0,3ml subcutaneous Promethazine 01 amp. (50 mg), IM Hydrocortisone 01 amp. (100mg), IM Dexchlorfeniramine 01 tablet (2mg) from 06/06 hours, VO Source: Marzola, C. Anestesiologia. São Paulo: Ed. Pancast, 1999.

4 483 In cases of bronchospasm, there should be the same approach adopted for a moderate allergic reactions late traders can use oxygen therapy is 5 to 6 liters / minute, with a mist agonist for 8 to 10 minutes. To perform the mist, you can use 5 to 8 drops of fenoterol diluted in 5ml of 0.9% or 0.5 ml of salbutamol in 2ml of 0.9%. Immediate Allergic Reactions Immediate reactions are anaphylactic or systemic reactions mediated by excessive formation of specific IgE antibodies, with a rapid release of potent mediators of mast cells and basophils (CALICH; VAZ, 1989). Differently localized reactions, usually mediated by histamine, there are additional release of leukotrienes, which are more reactive than histamine, determining responses characterized by signs and symptoms much more intense (ANDRADE; RANALI, 2002). The severity of anaphylactic reactions is also closely related to the rapidity of onset of symptoms, the delay in initiating treatment and prior history of asthma. Signs and symptoms anaphylactic dominant in different systems may be involved (Quadro 2): Table 2 - Signs and symptoms of anaphylactic reaction. Systems Neurological Eyes Upper Airway Lower Airway Cardiovascular Skin Gastrointestinal Manifestações Convulsions, stupor, syncope Itchy, watery eyes Nasal congestion, stridor, laryngeal edema, cough, obstruction Dyspnea, bronchospasm, cyanosis, respiratory arrest Tachycardia, hypotension, myocardial ischemia, cardiac arrest. Erythema, pruritus, urticaria, angioedema, maculopapular rash. Nausea, vomiting, abdominal pain, diarrhea. Source: Ellis, A. K.; Day, J. H. Diagnosis and management of anaphylaxis. CMAJ., v. 169, n. 4, p , It is important to emphasize that true allergic reactions should be differentiated from those related to fear of dental treatment, since anxiety can cause reactions such as psychogenic and vaso vagal. In a study of 5018 patients who received local anesthetics for dental treatment, it was observed that only 0.5% developed some type of reaction after the anesthetic injection. Of these, 88% had reactions in the range of 30 minutes after application of anesthesia, where the most common clinical presentation was dizziness, sweating and loss of consciousness. The authors concluded that in any situation a true allergic reaction was observed and all cases were related to anxiety of dental treatment. The recognition of these situations also has a direct influence in the emergency treatment instituted, since the patients reported symptoms revert the table after

5 484 being placed supine or Trendelenburg (BALUGA; CASAMAYOU; CAROZZI et al., 2002). The initial approach, the most important is the suspected reaction, although there is no order of appearance of the signs, the picture may settle gradually or catastrophically. Anyway, the anaphylactic reaction is a condition of absolute emergency, making it necessary to maintain oxygenation and perfusion of vital organs by blocking the action of chemical mediators, until the arrival of an emergency team to transfer the patient to the environment hospit (PRADO; SILVA, 1999). Immediate treatment against this type of allergic reaction is thus in keeping the patient supine and institute measures for basic life support (ABC) (Table 3). At the same time, should be administered 0.01 ml / kg of epinephrine at a maximum of 0.5 ml subcutaneously, and observe the evolution of the patient. This dosage can be repeated twice at intervals of 20 minutes if necessary. Intramuscular administration of epinephrine should be reserved for severe cases of anaphylactic reaction, since this pathway promotes more rapid absorption and higher plasma levels of the drug (CANADA COMMUNICABLE DISEASE REPORT, 1996 and PRADO; SILVA, 1999). The administration of epinephrine reverses the hypotension (α activity), increases myocardial contractility and blood pressure (β1 activity), and promote a bronchodilatation (β2 activity) (PRADO; SILVA, 1999). Table 3 - Measures of basic life support against anaphylactic reactions unresponsive to initial administration of adrenaline. ABC Observing Behaviour A (Air way) Tongue edema Swelling of lips Cough Hoarseness Oxygen delivery (6 8 l/min) Emergency intubation or cricothyroidotomy. B (Breathing) C (Circulation) Wheezing Subcrepitation Tachycardia Hypotension β2 agonist nebulization (Salbutamol 2,5 to 5 mg in 3 ml of SF 0,9%) Rapid infusion of SF 0,9% (20 mg/kg) Source: Prado, E.; Silva, M. J. B. Anafilaxia e reações alérgicas. J. Pediatria, v. 72, supl.2, p , For patients not responding adequately to epinephrine or to cases where the transfer to an intensive care unit cannot be done in the next 30 minutes, a dose of diphenhydramine hydrochloride may be administered. The approximate dose of the drug, according to age, can be observed (Table 4). In frames of greater stability, can be administered hydrocortisone (100 mg) and promethazine (50mg), intramuscular (ANDRADE; RANALI, 2002).

6 485 Although 80% of cases are unifasics, there are risks of a new crisis (biphasic reaction) from 1 to 8 hours after the initial symptoms. Thus, keeping the patient in a hospital setting and under specialist care should be made for 12 to 24 hours after stabilization, with maintenance of antihistamines and steroids (ELLIS; DAY, 2003). Table 4 - Approximate doses of diphenhydramine for treatment of anaphylactic reaction. Dose Idade Intramuscular Oral < 2 anos 0,25 ml 12,5 mg 2-4 anos 0,5 ml 25 mg 5-11 anos 1,0 ml 50 mg 12 anos 2,0 ml 100 mg Source: Canada Communicable Disease Report. Can. Med. Assoc. J. v. 54, p , FINAL CONSIDERATIONS It is for the dentist to prescribe and implement emergency medication in case of serious accidents that endanger the lives and health of the patient (Lei 5081/66, Art. 6º, VIII). During the interview, it is necessary to seek information about the patient being allergic to certain chemicals. The owner must be prepared to prevent, diagnose and treat complications of allergic reactions that may occur in the dental office. REFERENCES * ANDRADE, E. D.; RANALI, J. Emergências Médicas em Odontologia. Artes Médicas, BALUGA, J.C.; CASAMAYOU, R.; CAROZZI, E. et al., Allergy to local anaesthetics in dentistry. Mith or reality? Allergol et Immunopathol., v. 30, n. 1, p.14-9, CALICH, V. L. G.; VAZ, C. A. C. Imunologia Básica. Porto Alegre: Ed. Artes Médicas, CAMPBELL, J. R.; MAESTRELLO, C. L.; CAMPBELL, R. L. Allergic response to metabisulfite in lidocaine anesthetic solution. Anesth. Prog., v. 48, p. 21-6, * According of the ABNT norms.

7 486 CANADA COMMUNOCABLE DISEASE REPORT. Anaphylaxis: statement on initial management in non-hospital settings. CMAJ., v. 154, p , EL-QUTOB, D.; MORALES, C.; PELÁEZ, A. Allergic reaction caused by articaine. Allergol Immunopathol., v. 33, n. 2, p.115-6, ELLIS, A. K.; DAY, J. H. Diagnosis and management of anaphylaxis. CMAJ., v.169, n.4, p , MALAMED, S. F. Manual de Anestesia Local. Rio de Janeiro: Ed. Guanabara/Koogan, MARZOLA, C. Anestesiologia. Panamericana: São Paulo, PRADO, E.; SILVA, M. J. B. Anafilaxia e reações alérgicas. J. Pediatria, v. 72, supl.2, p , SILVA, P. Farmacologia. Rio de Janeiro: Ed. Guanabara/Koogan, SINGI, G. Fisiologia para Odontologia Atendimento de Pacientes Especiais e Primeiros Socorros Médicos. Rio de Janeiro: Ed. Guanabara/Koogan, VASCONCELLOS, R. J. H.; NOGUEIRA, R. V. B.; LEAL, A. K. R. et al., Alterações sistêmicas decorrentes do uso da lidocaína e prilocaína na prática odontológica. Rev. Cir. Traumat. Buco-Maxilo-Facial, v. 1, n. 2, p. 13-9, o0o

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