The prevalence of allergic and pseudoallergic reactions to NSAIDs in the general population is not known. Pseudoallergic reactions are non- immunologic reactions that are believed to result from acquired alterations in the biochemical pathways upon which NSAIDs act (Johansson et al., 2004). These reactions occur sporadically in both children and adults. Symptoms include rhinoconjunctivitis, bronchospasm, urticaria, angioedema, and anaphylaxis. Patients with pseudoallergic NSAID reactions who require analgesic therapy have several treatment options, but the best treatment for an individual patient depends upon that patient’s anti-inflammatory and pain relief needs. Acetaminophen is usually tolerated in amounts up to 650 mg per dose and is the simplest option for patients with pseudo-allergic reactions, provided acetaminophen provides adequate pain relief and anti-inflammatory therapy is not needed. If a patient with a pseudoallergic NSAID reaction requires anti- inflammatory therapy, the non-acetyl salicylates are weak inhibitors of COX-1, and one of these agents is a reasonable choice, especially at low doses: ● Salsalate (up to 2,000 mg daily, divided into two or three doses. ● Choline magnesium trisalicylate (up to 2,000 mg daily, divided into two or three doses). ● Diflunisal (up to 1,000 mg daily, divided into two or three doses). Conclusion Oral healthcare practitioners regularly prescribe analgesics to either mitigate pain (preemptive analgesia) or to manage an existing orofacial pain that can be acute or chronic in nature. Orofacial pain typically results from one or both of two general pathologic mechanisms: tissue injury and inflammation (nociceptive pain) or a primary lesion or dysfunction of the nervous system (neuropathic pain). Acetaminophen and the nonsteroidal anti-inflammatory agents (NSAIDs such as ibuprofen) continue to be the mainstay of treatment; however, as patients present with more complex pain syndromes, oral healthcare professionals need to be aware of additional adjunctive medications. It is also important to be aware of the appropriate approach to pain in special populations, such Resources Helpful websites and literature to enhance further learning: ● American Academy of Orofacial Pain The American Academy of Orofacial Pain aims to establish acceptable criteria for the diagnosis and treatment of orofacial pain and temporomandibular disorders. Their purpose is to stress the significant incidence of orofacial pain problems for both medical and dental professions, striving to disseminate research and treatment for orofacial pain and The Oral Health Topics section on ADA.org is intended to provide dentists with clinically relevant, evidence-based science behind the issues that may affect their practice. Refer to the Oral Health Topics for current scientific reviews of subjects that relate to oral health, from amalgam separators and antibiotic prophylaxis to xerostomia and x-rays. Website : http://www.ada.org ● University of California, San Francisco: Center for Orofacial Pain The UCSF Center for Orofacial Pain provides diagnosis and management of pain in the head, face, temporomandibular joints (TMJs), mouth, and teeth, as well as associated headaches and neck pain. These services are rendered by dental faculty, with support of a radiologist, physical therapist, pharmacologist, and oral medicine and sleep apnea dental specialists. temporomandibular disorders. Website : http://www.aaop.org ● The American Dental Association (ADA)
In addition to allergic and pseudoallergic reactions, there are various types of idiosyncratic adverse reactions to aspirin and NSAIDs that are presumed or known to involve other types of immune mechanisms. These include, but are not limited to, aseptic meningitis, hypersensitivity pneumonitis, thrombocytopenia, interstitial nephritis, erythema multiforme, fixed drug eruptions, toxic epidermal necrolysis, Stevens- Johnson syndrome, erythema nodosum, maculopapular eruptions, and bullous leukocytoclastic vasculitis (Johansson et al., 2004). Most patients can safely receive quantities of up to 650 mg of acetaminophen per dose for the treatment of minor pain. This includes patients with aspirin-exacerbated respiratory disease (AERD) and those who are extremely sensitive to COX-1 inhibitors. However, approximately 20% of patients with AERD react to acetaminophen at a dose of 1,000 mg because acetaminophen weakly inhibits COX-1 at higher doses (Settipane et al., 1995). Patients with AERD are usually identifiable clinically by the presence of concomitant asthma and chronic rhinosinusitis. For more severe pain, narcotic pain medications are an option. Regardless, the type of NSAID reaction (i.e., allergic, pseudoallergic, or idiosyncratic) will determine the possible management options, and if the symptoms of the reaction were previously severe and the type of reaction is currently uncertain, the patient should avoid all NSAIDs until further evaluations can be performed (Donaldson & Goodchild, 2019a). as patients who are pregnant or breastfeeding or those who present with allergies. A review of current guidelines and evidence shows that the goal of analgesic therapy should be easily achieved by all practitioners to assure selection of the right drug at the right time and at the right dose for the right patient and the right procedure. Most importantly, the analgesic that works is the one the patient takes; in other words, it is important to set your patient up for success by selecting the most appropriate and most affordable analgesic with an administration schedule that the patient will be able to manage. Compliance is key in the successful pharmacological approach to orofacial pain management. Website : http://omfs.ucsf.edu/index.php/patient-care/center- for-orofacial-pain/ ● The University of Toronto Hospital for Sick Children: MotheRisk Program The MotheRisk Program (“Treating the mother – Protecting the unborn”) at the Hospital for Sick Children is affiliated with the University of Toronto and provides up-to-date information for mothers and professionals in regard to issues around medications, pregnancy, and lactation. MotheRisk counselors talk to hundreds of women and their healthcare providers each day, providing guidance, support, and peace of mind, as well as supporting research in this field. Website : http://www.motherisk.org ● www.SafeFetus.com SafeFetus.com is a website set up for pregnant mothers and their physicians and pharmacists in order to protect the baby, whether during pregnancy or during lactation, from any harmful effects of medication (whether prescribed or over- the-counter). The site also provides information on maternal exposures, whether to physical agents, infectious agents, or diseases, and ways they may affect the unborn child. The site is maintained by a fully qualified team of physicians and pharmacists who work continually to update the information, adding new drugs that are emerging in the markets, with the aim of producing a fully comprehensive worldwide database. All information is presented in an unbiased manner and is extracted from well-documented and respectable sources. Website : http://www.safefetus.com
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