DCA02AR Allergic Reactions in Dental Patients _ _________________________________________________
Nonsteroidal Anti-Inflammatory Drugs Ibuprofen and naproxen are the most common nonsteroidal anti-inflammatory drugs (NSAIDs) used in dentistry. Because they are available over the counter, patients may underestimate the potential for adverse effects with these drugs. Irritation and ulceration of the gastrointestinal tract is a known adverse effect with prolonged use, as is renal impairment. In dentistry, the frequency of hypersensitivity reactions among NSAIDs is second only to those caused by beta-lactam antibiotics [31]. IgE-mediated reactions are rare, but when they do occur, they tend to develop soon after ingestion of either ibuprofen or naproxen and can feature urticaria, angio- edema, respiratory distress, and anaphylaxis. Type IV (delayed) hypersensitivity reactions may also occur; manifestations can include cutaneous reactions such as maculopapular lesions, erythema multiforme, and Stevens-Johnson syndrome, any of which can take 24 to 72 hours to develop. Cross-reactivity among all NSAIDs is possible but infrequent, as the molecular structures of this group of medications can vary considerably [32]. However, if a patient indicates he or she has had an aller- gic reaction to ibuprofen, naproxen, or any other NSAID, it would be prudent to consult with the patient’s physician before prescribing or administering any medication in this group. A hypersensitivity reaction to ibuprofen contraindicates its use when combined with other medications, such as hydroco- done. Patients who have had allergic reactions to ibuprofen or naproxen should also be advised to exercise caution when selecting over-the-counter analgesics. Acetaminophen Acetaminophen obtained initial approval in 1951 and is a widely available over-the-counter medication that is sold under many different brand names. It is also combined with opioid medications (e.g., codeine, hydrocodone, oxycodone) in prescribed medications. While a hypersensitivity reaction to acetaminophen is not dose-dependent, hepatic toxicity is a potentially serious adverse effect of excessive use of this medication. Type I and type IV hypersensitivity reactions to acetaminophen are rare but can occur in reaction to any formulation of the medication [22]. Patients who have a history of hypersensitivity to acetaminophen should be advised to refrain from the use of any of the more than 600 formulations of this medication [33]. Opioids Opioids are used in dentistry to alleviate moderate-to-severe postprocedural pain associated with oral surgery, periodontal surgery, and oral and maxillofacial trauma. These medica- tions are used for the shortest possible duration due to the potential for tolerance and dependence. The opioids codeine, hydrocodone, and oxycodone are usually combined with a non- opioid component, such as acetaminophen or, less frequently, ibuprofen, for use in dental treatment.
The use of a broad-spectrum antibiotic such as clindamycin can be bactericidal to several bacterial species in the gastrointestinal tract and promote the overgrowth of Clostridioides difficile . C. difficile can then release toxins that cause C. difficile -associated diarrhea and pseudomembranous colitis. These adverse clinical manifestations, characterized by persistent abdominal cramps, watery or bloody diarrhea, and fever, may be misconstrued by patients as an allergy, but true allergy is very rare. Azithromycin Azithromycin is one of the few macrolide antibiotics used in dentistry. The base and ethylsuccinate forms of erythromycin, another macrolide, were the long-standing antibiotics of choice for acute odontogenic infections and for bacterial endocarditis prophylaxis. However, frequent issues with gastric intolerance and increased bacterial resistance have relegated them to infrequent use in dentistry. Azithromycin was approved for use in 1996, and unlike erythromycin, it is still in regular use for prophylaxis and dental treatment, typically for patients who cannot tolerate beta-lactam antibiotics or clindamycin. Hypersensitivity reactions to macrolide antibiotics are uncom- mon, occurring in 0.4% to 3% of patients [27]. There is cross-sensitivity among the macrolide antibiotics, so a patient who has had a hypersensitivity reaction to erythromycin or clarithromycin should not take azithromycin [25]. Tetracyclines In dentistry, the primary use of tetracycline antibiotics is as a supplement to the definitive treatment of periodontal disease. In addition to oral formulations, this group of antibiotics is available as gels or microspheres that can be placed directly into the depth of a periodontal pocket. The two tetracycline products most commonly used in the treatment of periodontitis are doxycycline periodontal gel (Atridox) and minocycline hydrochloride periodontal micro- spheres (Arestin) [28; 29]. Although these products are applied directly into the periodon- tal pocket, as opposed to being administered orally, a history of hypersensitivity to any tetracycline precludes the use of these agents, as there is cross-reactivity among all members of the class. Hypersensitivity reactions can occur even though these locally delivered tetracycline medications are not significantly absorbed into systemic circulation [30]. Localized tissue irrita- tion can occur during the placement of these medications, but this does not constitute an allergic reaction. ANALGESICS Analgesic medications are used to relieve the pain associated with acute dental problems, oral and maxillofacial trauma, and tissue manipulation during dental procedures. These formulations are available over the counter or by a prescrip- tion. Although most analgesics used in dentistry have a short duration of action, a hypersensitivity reaction can occur, even with the initial dose.
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