Management of Anaphylaxis in Dental Practice
Anaphylaxis is a potentially fatal systemic complication that can occur as a side effect of dental treatment, oral and intravenous sedation, and general anesthesia. Although anaphylaxis rarely occurs during dental treatment, once it develops, the signs and symptoms progress rapidly and may lead to upper airway obstruction, respiratory distress, cardiovascular collapse, and cardiac arrest; thus, a prompt response is critical for saving lives. When anaphylaxis develops in a dental office, it should be diagnosed and managed immediately. Based on the clinical findings, emergency medical services should be activated and epinephrine administered intramuscularly without hesitation followed by transportation to a hospital facility for further care. It is very important to establish a definitive diagnosis of anaphylaxis after emergent care to identify the causative agent and perform subsequent dental treatment without triggering a recurrence. This review aims to explain the different issues and necessary considerations in managing anaphylaxis in the office-based dental setting based on established guidelines and practical guides for treating anaphylaxis.
Skin Involvement and Anaphylaxis
(a) Skin findings developed after the oral administration of antibiotics and analgesics following the extraction of a third molar. (b) Skin findings on the face and ears immediately developed after the induction of general anesthesia. Lower left figure: At the onset of anaphylactic shock. Lower right figure: After treatment of anaphylactic shock.
Management of Anaphylaxis in the Dental Office
Anaphylaxis should be recognized at an early stage, epinephrine should be administered intramuscularly, and the patient should be transported immediately to a hospital.
*Implement steps 3–5 promptly and simultaneously.1
Changes in Blood Concentrations of Histamine and Tryptase After the Onset of Anaphylaxis
When anaphylaxis occurs, mast cells and basophils release histamine and tryptase. To diagnose anaphylaxis, blood samples should be collected at 2 times: the onset of anaphylaxis and after 24 hours. Histamine and tryptase levels should be compared.
Skin Prick and Basophil Activation Tests
Example of a skin prick test: 1. normal saline (negative control), 2. histamine (positive control), 3. fentanyl, 4. remifentanil, 5. atropine, 6. piperacillin, 7. propofol, and 8. rocuronium. All skin prick tests showed negative results. Intradermal skin test for rocuronium showed positive result at 10-fold dilution (15 minutes later, wheal: 5 × 7 mm; erythema: 25 × 22 mm). Basophil activation test showed that rocuronium and flomoxef were negative results, and a rubber dam sheet was a positive result.
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