HYPERSENSITIVITY

Dr. Amit Makkar, Sudha Rustagi Dental College

• Hypersensitivity reactions are harmful antigen-specific immune
responses , occur when an individual who has been primed by an
innocuous antigen subsequently encounters the same antigen , produce
tissue injury and dysfuntion.

• It is defined as a state of exagerrated immune response to an antigen.

Coombs & Gell Classification (1963)
 Sell’s Classification (1972)
Immediate Delayed
(antibody mediated) (cell mediated)

Antibodies Involving
causing Involving perivascular
Early epithelial and
neutralization of round cell infiltration.
inflammatory giant cells
TB
biological Bacterialhypersensitivity (granulomatous)
molecules Contact dermatitis TB
Hormones Fungal Inf
Clotting factor

Atopic anaphylactic Arthus toxic

Hematologic reaction reaction associated complex associated
associated with cytotoxic with IgE antibodies with precipitating
effect, Hay fever IgG antibodies
IgG IgM cause lysis by Asthma Arthus reaction
complement Urticaria Serum sickness
 Chase Classification
IMMEDIATE REACTION DELAYED REACTION
Appears and recedes rapidly Appears slowly and lasts longer

Induced by antigen by any route Indued by infection, antigen injection, skin

contact
Circulating antibodies present and responsible Cell mediated reaction
for reaction
Passive transfer possible with serum Transfer possible by lymphocytes or tranfer
factors
Desensitisation is easy but short lived Desensitisation is difficult but long lasting

Lesions are acute exudation and fatty necrosis Mononuclear cell collection around blood
vessels
Wheal and flare with maximum diameter in ^ Erythema and induration with maximum
hours diameter in 24-48 hours
 I)Type I Hypersensitivity
(Anaphylactic, Atopic)

• It is defined as a state of rapidly developing immune response to an

antigen to which the individual is previously sensitised.

• The response is mediated by humoral antibodies of IgE type or reagin

antibodies.
The process and mechanism of Type I hypersensitivity

Priming Activating Effect

stage stage stage
1) Priming stage：last more than half a year

2) Activating stage：

Cross-linkage Enzyme reaction

De-granulation of mast cell , basophil

 3) Effect stage

Immediate/early phase response Late-phase response

•Mediated by histamine •Mediated by new-synthesized

lipid mediators
•Start within seconds •Take up 8-12hours to develop
•Last several hours •Last several days
Mechanism of type I hypersensitivity
Primary Generation
Allergen Individual IgE
Adhesion
Secondary IgE binds to the FceRI on mast cell and basophil

Allergen binds to the IgE on primed target cell

Crosslikage of FceRI

Degranulate and release the biological mediators

Preformed granule mediators New generated mediators

Histamine Bradykinin Leukotrienes PAF Prostaglandin D2

Dilate capillaries,increase permeability, increase mucus secretion, contract smooth muscle

Systemic anaphylaxis Skin Respiratory tract Degist tract

 Allergen

Hydroxyl Phosphatidylcholine Phosphalipid

phosphalipid

Phosphoration of ITAM
Activated
Arachidonic PKC
MAPK Activation of PTK
acid

Inactivated Myosin
Acetyl- PKC
COX LOX
transferases
Phosphoration of
Light chain
Endoplasmic
reticulum

Lipid mediatiors Degranulation

Cell membrane

Histamine

Degranulation ,release and synthesis

of biological mediators of primed target cells
The chemically active effectors within the granules released via

degranulation are called mediators. This group includes:

ANAPHYLAXIS
 Systemic Anaphylaxis
 The clinical features of systemic anaphylaxis include itching,

erythema, contraction of respiratory bronchioles, diarrhoea,

pulmonary oedema, pulmonary haemorrhage, shock and death.

 Examples of systemic anaphylaxis :-

i) Administration of antisera e.g. anti-tetanus serum (ATS)

ii) Administration of drugs e.g. penicillin

iii) Sting by wasp or bee.

 Pathophysiology of Systemic
Anaphylaxis
• Systemic vasodilation and smooth muscle contraction leading to
severe bronchiole constriction, edema, and shock.

• Similar to systemic inflammation.

wheal\ urticarial rash Thick lips and periorbital edema (angioedema)
 Localised Anaphylaxis

• Local anaphylaxis is common, affecting about 10% of population.

About 50% of these conditions are familial with genetic
predisposition and therefore also called atopic reactions
Therapy of type I hypersensitivity
The basic 4A’s in the management of anaphylactic reaction :-

•Antihistaminic agent (benedryl 20-50mg)

•Adrenaline 0.5 ml of 1:1000 i.m
•Aminophylline 0.5mg i.m
•Airway oxygen

•Other---
Adrenaline inhalents
Hydrocortisone sodium succinate 100mg i.m
Cricothyrotomy for airway maintainance if required
Therapy of type I hypersensitivity
1. Allergen avoidance : Atopy patch test

2. Desensitivity therapy / Hyposensitization :

i) Allogenic serum desensitivity therapy:

Repeated injection small amounts of allergen (allergy shots)

ii) Specific allergen desensitivity therapy

IgG+allergen Neutralizing Blocking

antibody, antibody
3. Drug therapy：
i) Stabilization of triggering cells
Sodium cromoglycate stabilize the membrane,
inhibit mast cell degranulation
ii) Mediator antagonism
Chlor-Trimeton Antihistamine
Acetylsalicylic acid Bradykinin antagonism

iii) Improve the responsibility of target organs

4. Allergen immunotherapy ：Rehabilitates the immune system

and involves administering increasing doses of allergens to accustom
the body to substances that are generally harmless (pollen, house
dust mites) and thereby induce specific long-term tolerance.
Allergen immunotherapy can be administered under the tongue
(sublingually with drops or tablets) or by injections under the skin
(subcutaneous).
 I)Type II Hypersensitivity
(Cytotoxic Reaction)
• Cytotoxic reactions are defined as those reactions which cause injury
to the cell by combining humoral antibodies with cell surface
antigens; blood cells being affected more commonly.

Characteristic features

Primed IgG or IgM Antigen or hapten on membrane

+

Injury and dysfunction of target cells

• Involves the antibody mediated destruction of cells.

• Can mediate cell destruction by activating the complement system to

create pores in the membrane of the foreign cell.

• Can also be mediated by Antibody-Dependent Cell-Mediated

Cytotoxicity (ADCC) where the Fc receptors bind to Fc receptor of
antibody on the target cell and promote killing.
Allergen

Stimulate

Antibody

Cell

A. Opsonic phagocytosis

Combined opsonic activities

D. ADCC of NK

C. Effect of complement

Cell injury ways of type II hypersensitivity

Mechanism of type II hypersensitivity

1. Surface antigen on target cells

Target cells: Normal tissue cell, changed or modified self tissue cells

Antigen : Blood group antigen, Common antigen,

Drug antigen, Antigen-antibody complex
Self-antigen modified
by physical factors or
infection
2. Antibody, complement and modified self-cell

Activate complement Lyse target cells

Opsonic phogacytosis Destroy target cells

Mf、NK、 T ADCC

Stimulating or blocking effect Promote /surpress the target

cell funcion
 Antigen or hapten on cell

Antibody (IgG, IgM)

Activate complement Opsonic phagocytosis NK , phagocyte Stimulate / block

Lyse target cell Destroy target cell ADCC

Target cell injury Change the function ofTarget cell

Mechanism of Type II hypersensitivity

 Cytotoxic
antibodies to
tissue
components Antibody-
Cytotoxic dependent cell-
antibodies to mediated
blood cells cytotoxicity
(ADCC).

Mechanisms
involved in
mediating
cytotoxic
reactions
A. CYTOTOXIC ANTIBODIES TO
BLOOD CELLS
– Involves direct cytolysis of blood cells (red blood cells, leucocytes
and platelets) by combining the cell surface antigen with IgG or
IgM class antibodies.

– Complement system is activated resulting in injury to the cell

membrane.

– Cell surface is made susceptible to phagocytosis due to coating or

opsonisation from serum factors or opsonins.
Autoimmune hemolytic anemia and
type II drug reaction
FOREIGN ANTIGEN SELF-ANTIGEN
OR HAPTEN

Drug
1. Penicillin RBC
hemolytic anemia conversion from a hapten to
a full antigen
2.Quinine Platelet
induce self antibody
thrombocytopenic purpura

autoimmune hemolytic
3.Pyramidone Granulocyte
anemia
agranulocytosis
 Drug-Induced Hemolytic Anemia
• Where certain antibiotics can be absorbed nonspecifically to the
proteins on RBC membranes.

• Sometimes antibodies form inducing complement-mediated lysis and

thus progressive anemia.

• Disappears on withdrawal of the drug.

Autoimmune haemolytic anemia

Red cell injury is brought about by autoantibodies reacting with antigens

present on red cell surface.
 Transfusion reaction

• Mismatch of ABO blood

group
Hemolysis
• Severely destroy RBC

• Repeat transfusion of
allogenic HLA
Nonhemolysis
• Drug anaphylactic shock：
penicilline
 Transfusion reactions
• Antibodies of the A,B, and O antigens are usually of the IgM class
(these antigens are call isohemagglutinins)

• For example an A individual produce isohemagglutinins to B-like

epitopes but not to A epitopes because they are self

• Person who are transfused with the wrong blood type will produce
anti-hemmagglutinins causing complement mediated lysis

• Antibodies are usually of the IgG class

• Transfusion reactions can be delayed or immediate but have different
Ig isohemagglutinins

• Immediate reactions has a complement-mediated lysis triggered by

IgM isohemagglutinins

• Delayed reactions induce clonal selection and the productions of IgG

which is less effective in activating the complement.

• This leads to incomplete complement-mediated lysis

• Cross-matching can detect antibodies in the sera to prevent this

 Haemolytic disease of the newborn

• Fetal red cells are destroyed by maternal isoantibodies crossing

placenta

• This is where maternal IgG antibodies specific for fetal blood group
antigens cross the placenta and destroy fetal RBC’s

• Erythroblastosis fetalis - severe hemolytic disease of newborns

– Most commonly develops when an Rh+ fetus expresses an Rh

antigen on it’s blood that and Rh- mother doesn’t recognize
 During the 1st pregnancy small amounts of fetal blood pass
through the placenta but not enough to induce a response

During delivery larger amounts of fetal blood cross the placenta

causing an activation of B-cells that are Rh specific thus
leading to memory B-cells (anti-Rh antibodies)

The IgM antibody clears the Rh+ cells from the mother

In subsequent pregnancies with an Rh+ fetus, the Rh+ RBC

cross the placenta activating the memory B-cells

These in turn cross the placenta and damage the fetal RBC
because they are seen as “foreign”
 Treatment of Erythroblastosis fetalis
• This type of reaction can be prevented by administering antibodies
against the Rh antigen within 25-48 hours after the 1st delivery

• Rhogam - is the antibody that is injected

– it will bind to the fetal RBC that enter the mother’s circulation and
facilitate the clearance of them before B-cell activation

– In subsequent pregnancies the mother is unlikely to produce IgG

anti-Rh antibodies

– If the mother doesn’t receive this injection there are other ways to
treat this, depending on the severity
B. CYTOTOXIC ANTIBODIES TO
TISSUE COMPONENTS
• Cell injury may be brought about by autoantibodies reacting, with
some components of tissue cells in certain diseases,

• Example –

In myasthenia gravis, antibody to acetylcholine receptors of skeletal

muscle is formed which blocks neuromuscular transmission at the
motor end-plate resulting in muscle weakness
C. ANTIBODY-DEPENDENT CELL
MEDIATED CYTOTOXICITY
(ADCC)
• Mediated by leucocytes like monocytes, neutrophils, eosinophils &
NK cells.

• Antibodies involved - mostly IgG

• The cellular injury occurs by lysis of antibody-coated target cells

through Fc receptors on leucocytes.

• The examples of target cells killed by this mechanism are tumour

cells, parasites etc.
 OTHER DISEASES
1.Anti -glomerular basement membrane nephritis

β-Hemolytic streptococcus and human glomerular basement membrane ----

cross reaction
Common antigen ---nephrotoxic nephritis

2. Super acute rejection in allogenic organ transplantation

3. Goodpasture syndrome

4.Hyperthyroidism or hypothyroidism—receptor diseases

 III) Type III Hypersensitivity
(Immune Complex Reaction)
Type III reactions results from formation of immune complexes by

direct antigen-antibody (Ag-Ab) combination as a result of which the

complement system gets activated causing cell injury.

Antigens causes immune complex mediated tissue injury

Exogenous Endogenous
Antigens Antigens
Exogenous Antigens Endogenous Antigens
– Blood components
– Infectious agents (bacteria, (Ig, tumour antigens)
viruses, fungi, parasites) – Antigens in cells & tissues
– Certain drugs & chemicals (nuclear antigens in SLE)
Depending upon the distribution & location
of antigens, Type III are of 2 types

LOCAL
Arthus reactions

SYSTEMIC
Circulating immune
complex disease or
Serum sickness
 1. Local : Arthus Reaction

• Localised inflammatory reaction, usually an immune complex

vasculitis of skin of an individual with circulating antibody.

• Large immune complexes formed due to excess of antibodies, which

precipitate locally in the vessel wall causing fibrinoid necrosis.
Injection of an Antigen:
• Can lead to an acute Arthus reaction within 4-8 hours

• Localized tissue and vascular damage result from accumulation

of fluid (edema) and RBC (erythema)

• Severity can vary from mild swelling to redness to tissue necrosis

EXAMPLES :-

1. Injection of Antitetanus serum

2. Farmer`s lung (allergic alveolitis in response to bacterial antigen from
mouldy hay)

3. Insect bite:

• May first have a rapid type I reaction

• Some 4-8 hours later a typical Arthus reaction develops

4. Ulcer

5. Local Human Reaction :- Insulin Dependent Diabetes Mellitus

 2. Systematic : Circulating immune
complex disease or serum sickness

• Develops when antigen is intravenously administered resulting in

formation of large amountsvantigen-antibody complexes and their
deposition in the tissues.

• These circulating complexes can’t be cleared by phagocytosis and can

cause tissue damaging Type III reactions
• Ag-Ab complexes are deposited at different tissue sites containing
basement membrane exposed to circulating blood.

• Following this deposition, there is acute inflammatory reaction &

activation of complement system with elaboration of chemotactic
factors, vasoactive amines & anaphylatoxins.

• This all causes type III hypersensitivity reactions

• Eg of circulating immune complex diseases are:-
– Skin diseases
– Various forms of Glomerulonephritis

• Other conditions caused by Type III-

1. Infectious Diseases
• Meningitis

• Hepatitis

• Mononucleosis
2. Drug Reactions
• Allergies to penicillin and sulfonamides
3. Autoimmune Collagen Diseases
• Systematic lupus erythematosus

• Rheumatoid arthritis
 Serum Sickness
Systemic immune complex disease

Large amounts of antigen

such as injection of
foreign serum.

Days after Antigen Injection

 Soluble antigen Body Antibody

Immune complex

Small molecular soluble intermediate molecular soluble Large molecular insoluble

Immune complex Immune complex Immune complex

Deposit on the basement of capillaries Eliminate by phogacytosis

Combine and activate complement system

Basophils and mast cells C3a,C5a,C3b Platelets

Infiltration of neutrophils
Blood Clotting Mechanisms
Release of vasoactive amine Phagocytose complex Release of vasoactive amine
Aggregation of platlets

Increase vascular permeability Release the enzymes in lysosome Increase vascular permeability
Thrombus

Edema Tissue injury Bleeding Edema

Local or systemic immune complex diseases

 IV) Type IV Hypersensitivity
(Delayed or Cell Mediated Reaction)
1. Mediated by specificallysensitised T lymphocytes produced in the
cell-mediated immune response.

2. The delay in the appearance of a type IV hypersensitivity reaction (2-

3 days) is due to the time it takes to recruit antigen-specific T cells and
other cells to the site of antigen localization and to develop the
inflammatory response.
 Antigen introduced to
Macrophages process Th1 effector cell
the tissue modifies
antigen, present to Th1 recognizes the antigen
extracellularand cell
cells and
surface proteins

Further activateion of
Releases cytokines
T cell recruitment (CD4 macrophages (increase
which act on local
& CD8), fluid and in size, microbicidal
vascular endothelium
protein activity, & lysosome
and
content)

Absorption by
interstitum (edema
Types of Cell mediated Reactions

Classical
delayed
hypersensitivity T Cell-mediated
cytotoxicity
 Classical delayed
hypersensitivity

– Mediated by specifically
sensitised CD4+ T cell
subpopulation on contact with
antigen.

– These cells possess surface

receptors which bind to the
antigen, resulting in cell injury
characterised by slowly
developing inflammatory response
 T Cell-mediated cytotoxicity

CD8+ subpopulation of T lymphocytes are the cytotoxic T cells are

generated in response to antigens like virus-infected cells, tumour

cells and incompatible transplanted tissue or cells.

 Mechanism of type IV hypersensitivity

Formation of effector and memory T cells

Inflammation and cytotoxicity caused by effector T cells

1) Inflammation and tissue injury mediated by CD4+Th1

Release chemokines and cytokines

Immune injury mainly caused by infiltration of mononuclear cells and

lymphocytes

2) Cytotoxicity of CD8+CTL
 Induce
Antigen T cell
(CD4+,CD8+) CD4+ Release Cytokines Infiltration of
T cell IL-2 monocyte and Mf
TNF-b
INF-g Proliferation of T cell

Secondary MCF
Exudation and edema
contact MIF
Primed T cell SRF
Cytotoxicity

CD8+
T cell Directly kill target cells

Inflammation characterized by infiltration of Mf , monocyte,

And tissue injury

Mechanism of type IV hypersensitivity

Stages of a Type IV Hypersensitivity Reaction
Th1 derived
cytokines and
chemokines
direct Type IV
reactions
Delayed Type Hypersensitivity (DTH)

DTH is a type of immune

response classified by Th1 and
macrophage activation that results
in tissue damage.

DTH can be the result of Chronic

infection or Exposure to some
antigens.
PHASES OF DTH RESPONSE

Induction Elicitation
Or Or
Sensitization Effector
 Sensitization Phase

Occurs 1-2 weeks after primary contact with Ag

• TH cells are activated and clonally expanded by Ag presented together with class II MHC
on an appropriate APC, such as macrophages or Langerhan cell (dendritic epidermal cell)

• Generally CD4+ cells of the TH1 subtype are activated during sensitization and designated
as TDTH cells
 Effector Phase

Occurs upon subsequent exposure to the Ag

• TDTH cells secrete a variety of cytokines and chemokines, which recruit and activate
macrophages

• Macrophage activation promotes phagocytic activity and increased concentration of lytic

enzymes for more effective killing

• Activated macrophages are also more effective in presenting Ag and function as the primary
effector cell
 Chemical Factors Involved
IL-12: (macrophages). Drives differentiation of T cells, induces IFN-
gamma secretion

IFN-gamma (T cells). Further activates macrophages

IL-2: (T cells). Increases T cell proliferation within tissue

IL-3: (T cells). Stimulates monocyte production

TNF (T cells). Increase secretion of Nitric Oxide & Prostacyclins by

endothelial cells, local tissue destruction, and increase
expression of adhesion molecules on vessels

E- selectins: vascular adhesion molecule, increases mononuclear cell

attachment
 Prolongation of DTH Response
A granuloma develops…

• Continuous activation of
macrophages induces the
macrophages to adhere closely
to one another, assuming an
epithelioid shape and sometimes
fusing together to form giant,
multinucleated cells.
 Detrimental Effects of DTH Response
• The initial response of the DTH is nonspecific and often results in
significant damage to healthy tissue.

• In some cases, a DTH response can cause such extensive tissue

damage that the response itself is pathogenic.

• Example: Mycobacterium tuberculosis – an accumulation of activated

macrophages whose lysosomal enzymes destroy healthy lung tissue.
In this case, tissue damage far outweighs any beneficial effects.
 How Important is the DTH Response?
• The AIDS virus illustrates the vitally important role of the DTH
response in protecting against various intracellular pathogens.

• The disease cause severe depletion of CD4+ T cells, which results in a

loss of the DTH response.

• AIDS patients develop life-threatening infections from intracellular

pathogens that normally would not occur in individuals with intact
DTH responses.
 Common disease of type IV
hypersensitivity

1) Infectious delayed type hypersensitivity

OT( Old Tuberculin ) test

2) Contact dermatitis :

Paint, drug red rash, papula, water blister, dermatitis

3) Acute rejection of allogenic transplantation and

immune response in local tumor mass

 TUBERCULIN REACTION
– On intradermal injection of tuberculoprotein (PPD), an unsensitised
individual develops no response (tuberculin negative).

–A person who has developed cell-mediated immunity to

tuberculoprotein as a result of BCG immunisation (exposed to
tuberculous infection) develops typical delayed inflammatory reaction,
reaching its peak in 48 hours (tuberculin positive), after which it
subsides slowly.
Contact Dermatitis
Allergic Contact Dermatitis: A type IV reaction
Blistering skin lesions
on hand of patient with
poison ivy
contact dermatitis (a
type IV reaction)
Granulomatous inflammation is
a consequence of chronic Type
IV reactions
Type IV Hypersensitivity Reactions
 V) Type V Hypersensitivity

• occurs when IgG class antibodies directed towards

cell surface antigens have a stimulating effect on their
target

• E.g.s Graves disease(also considered as type II hypersensitivity

reaction)

• Instead of dysfunction, there is antibody mediated

stimulation of cell function. So, some have isolated
this special type and have named it type V
hypersensitivity reaction.
HYPERSENSITIVITY DUE
TO VARIOUS DENTAL
MATERIALS
 LOCAL ANAESTHESIA
Allergy in case of anaesthetics may be :-

1) Methyparaben allergy (preservative)

2) Epinephrine allergy (vasoconstrictor)
3) Latex allergy (plunger and diaphragm at the ends of the cartridge)
4) Topical anaesthetic allergy (benzocaine, tetracaine)

CLINICAL MANIFESTATIONS
• Immediate reactions develop within seconds to hours includes type
I,II,III
• Delayed reactins shows manifestations in hours to days.
SIGNS AND SYMPTOMS

1 Dermatological Reactions
Urticaria associated with wheals
Angioedema of face, hand, feet, genitalia

2 Respiratory Reactions
Bronchospasm(distres, dyspnoea, cyanosis, flushing,
tachycardia, perspiration)
Laryngeal edema
Reaction progression in generalised anaphylaxis
1. Early phase skin reactions including itching, flushing, nausea,
conjunctivitis, rhinitis.

2. Associated GIT disturbance including vomiting, diarrhoea, abdominal

cramps, faecal and urinary incontenance

3. Respiratorty symptoms including cough, wheezing, pain in chest,

cyanosis, laryngeal edema

4. CVS symptoms including tachycardia, hypotention, palpitation,

unconscoiusness, cardiac arrest
MANAGEMENT
1. Delayed skin reactions : oral histamine blocker (50g
diphenhydramine or 10g chlorpheniramine)
2 Immediate skin reactions : Epinehrine 0.3mg i.m
oral histamine blocker
3. Respiratory reactions : oxygen administration
Epinehrine or bronchodilator
Histamine blocker i.m
4. Laryngeal edema : epinehrine
airway mainantance, emergency call
Histamine blocker i.m , i.v
Hydrocortisone 100mg
Cricothyrotomy
 TITANIUM

Ti can induce clinically relevant hypersensitivity and other immune

dysfunctions in certain patients chronically exposed to this reactive
metal. At the same time, no standard patch test for Ti has so far been
developed.
Hypersensitivity reaction to a metal comes from the presence of ions
following ingestion, skin or mucosal contact, or from implant corrosion
processes. In their ionic form, metals can be bonded with native proteins
to form haptenic Antigens ,or can trigger the degranulation of mastocytes
and basophiles, being capable of developing type I or type IV
hypersensitive reactions according to Schramm and Pitto

Sensitivity to titanium is characterized by the local presence of abundant

macrophages and T lymphocytes and the absence of B lymphocytes,
indicating type IV hypersensitivity

J Indian Prosthodont Soc (Oct-Dec 2012) 12(4):201–207

 METHY METHACRYLATE
Allergy to methyl methacrylate monomer in acrylic resin are less
common and usually are of the delayed or contact allergy. Residual
monomer left by incomplete polymerization is the allergen in contact
stomatitis caused by acrylic resin.

The patient may complain of a burning sensation, soreness, dryness, or

excessive salivation. Examination of the oral mucosa may show
punctuate or diffuse redness with or without erosions.
Contact type dermatitis - due to acrylic resin materials acting as
haptens via delayed hypersensitivity mechanism, which is observed in
several dentists and dental laboratory technicians.

Allergic Stomatitis - The term “sore mouth due to dentures” is applied

to any pathologic change of the oral mucosa due to dentures, whether the
cause is allergic, traumatic, or toxic.

Patch testing is a reliable method to check

for Allergy

Clinical Dentistry, Mumbai • September 2012

Dr. Suraj R Suvarna
 EUGENOL
Eugenol is a material commonly used in dentistry but is not a bio-
friendly material when in contact with oral soft tissues

Intra-orally it causes destruction of the interdental col and surrounding

gingivae..

Erythema and ulceration in left buccal

mucosa, adjacent to UL7 (27) on closure
of the mouth
1. Eugenol is generally cytotoxic at high concentrations and has an
adverse effect on fibroblasts and osteoblast-like cells. Thus at high
concentrations it produces necrosis and reduced healing.
This effect is dose related and will potentially affect all patients.

2. In lower concentrations, eugenol can act as a contact allergen

evoking a localised delayed hypersensitivity reaction.

3. Rarely, eugenol when placed in the mouth, can cause a more

significant generalised allergic response.
 Erythema and ulceration on the inner
surface of the upper lip and around the
gingival margin ofUR1 (11)

The patient was prescribed benzydamine hydrochloride mouthwash and

triamcinolone in orobase for relief of his acute symptoms

BRITISH DENTAL JOURNAL VOLUME 193 NO. 5 SEPTEMBER 14 2002

N. Sarrami1 M. N. Pemberton2 M. H. Thornhill3 E. D. Theaker4
 AMALGAM

Hypersensitivity to the constituents of dental amalgam is

uncommon.

1. When hypersensitivity reactions occur, they most commonly take

the form of delayed type IV lichenoid reactions affecting oral
mucosa in direct contact with amalgam fillings.
2. Much more rarely a more acute generalised mucocutaneous response
can occur.

BRITISH DENTAL JOURNAL, VOLUME 188, NO. 2, JANUARY 22 2000

B.McGivern, M.Pemberton, E.D. Theaker, J.A.G.Buchanan, and M.H.Thornhill
Buccal lichenoid reaction
to a large amalgam
restoration of 7

Resolution of the
lichenoid reaction
following crowning
of 7
Red, itchy rash on the neck and arm following contact with mercury
while performing amalgam restorations
PREVENTION AND TREATMENT
1. A detailed history of occupation, lifestyle, environment and prevention of exposure
to mercury is important.

2. Various barrier techniques like using a mask, gloves, hair caps and eye-shields are
advised while working.

3. Careful handling of silver amalgam waste

4. Air conditioners and proper ventilation of the operating room, intermittent use of
the rotary along with coolant to avoid excess heat, high vacuum suction, proper
cleaning and proper handling Of amalgam scraps in a covered container or under
sulphide solution is advocated to avoid vapour production.
Dermashield (dimethisone) is a silicone polymer. Pharmologically inert, it has
water repellant and surface tension. It adheres to skin and protects it and avoid contact
with mercury vapour on the skin. This helps in reducing the lesion’s development.

Clonate lotion contains 0.05% clobetasol propionate which is a glucocorticoid

used topically for a large variety of dermatological conditions due to their anti-
inflammatory, immunosuppressive, vasoconstrictor and antiproliferativev(for scaling
lesions) property.

Strong positive skin patch test response, with

vesiculation, spreading erythema and oedema,
following 24 hours exposure to ammoniated
mercury

BRITISH DENTAL JOURNAL VOLUME 205 NO. 7 OCT 11 2008

V. K. Bains,1 K. Loomba,2 A. Loomba3 and R. Bains4
 LATEX
Natural rubber latex, which is an extract from the sap of Hevea
brasiliensis trees, contains 256 proteins,2 including 11 potential
allergens.

Exposure to latex poses the risk of sensitizing both clinicians and their
patients.

Adverse reactions to latex range from mild irritant contact dermatitis to

potentially life threatening hypersensitivity and its risk increases with
prolonged and repeated exposure.
Exposure to latex allergens occurs via mucous membranes, the
vascular system, inhalation and direct skin contact.

Adverse reactions to latex include nonallergic contact dermatitis,

delayed type IV

Immunoglobulin E (IgE) mediated type I responses to latex proteins

result in adverse reactions within minutes to hours of exposure ranging
from mild irritation to loss of life.

Symptoms include pruritis, erythema, edema, rhinoconjunctivitis,

urticaria, dyspnea, palpitations, dizziness, bronchospasm, vasodilation,
gastrointestinal cramping, vomiting, hypotension and even death
“LATEX–FRUIT SYNDROME”

well-documented phenomenon
involving IgE antibodies in fruit-
allergic patients that cross-react
with latex proteins, culminating in
allergic responses to latex.

JCDA • www.cda-adc.ca/jcda • May 2009, Vol. 75, No. 4 •

Tara Kean, BSc, DDS; Mary McNally, BSc, DDS, MA
CDC recommendations to help minimize potential adverse

reactions to dental items.

1 Educate DHCP regarding the signs, symptoms and diagnosis of skin

reactions associated with frequent hand hygiene and glove use
2 Screen all patients for latex allergy (e.g., take a health history and refer for
medical consultation when latex allergy is suspected)
3 Ensure a latex-free environment for patients and DHCP with latex
allergy
4 Have emergency treatment kits with latex-free products available at
all times
5 Develop a written health program for DHCP that includes policies,
procedures and guidelines for contact dermatitiS and latex hypersensitivity
 PREVENTION AND TREATMENT
1. Administering prophylactic antihistamines, such as diphenhydramine, or
corticosteroids,such as prednisone, before dental treatment to those at
known risk

2. Reduce the amount of latex allergens present in their products, which are
labeled as "low protein" products (Powder-free gloves)

3. Contact dermatitis and type IV allergy - topical corticosteroids.

4. Mild type I reactions without respiratory distress - topical steroids and

antihistamines (50 mg diphenhydramine 4 times a day until swelling
resolves). Cynthia A. Chillock, CDA, RDH, EF, and Charles John Palenik, MS, PhD, MBA; January 2006 RDH
5 Severe type I hypersensitivity with respiratory distress, swelling of the
tongue, larynx or pharynx and anaphylaxis - assessment of ABCs (airway,
breathing and circulation) and activation of emergency medical services

6 For anaphylaxis - latex-free resuscitation carts are used to administer high-

flow oxygen and deliver 0.3–0.5 mL intramuscular or subcutaneous doses
of 1:1000 epinephrine15 (0.1 mL/kg every 5 minutes for children).

6 Vitals and ABCs should be continually monitored and cardiopulmonary

resuscitation provided if necessary

7 Following stabilization, antihistamines, such as diphenhydramine and

corticosteroids, should be prescribed
 ORTHODONTICS RELATED

The causes comprised the metal parts of fixed appliances, polymer-

based activators, retention appliances and brackets, and latex-based
elastics or gloves

Most of the reactions associated with the metallic parts of orthodontic

appliances were either presumed to be a nickel allergy or were

unexplained.
The adverse effects comprised intra-oral reactions such as marked
redness, swelling and soreness of the oral mucosa and palate and similar
symptoms of the gingiva and lips.

Occasionally reactions of a systemic nature, compatible with general

allergic symptoms are seen.

Ezema of the peri-oral area, the cheeks, chin, neck, scalp, earlobes and
skin elsewhere. Occasionally rashes and swelling were seen in the peri-
ocular region.
 SODIUM HYPOCHLORITE
A 12-year-old girl, with a previous history of bronchial reaction and
contact dermatitis to sodium hypochlorite, was referred for root canal
treatment.

Complete immunologic evaluation revealed a mild hypersensitivity

condition, as it was assessed by the RAST(Radioallergosorbant test)
investigation to different allergens and the DTH reactivity expressed
though migration inhibition test.

Dandakis C, Lambrianidis T, Boura P. Immunologic evaluation ofdental patient with

history of hypersensitivity reaction to sodium hypochlorite. Endod Dent Traumatol
2000; 16: 184–187.
 ALGINATE

This study describes a case of fatal anaphylaxis that appeared

immediately after the oral mucosa came into contact with an alginate
paste used for dental impressions.

The cadaveric examination and the postmortem toxicology

report confirmed that the cause of death was anaphylactic shock. The
patient was affected by both cardiovascular and lung diseases that
worsened the condition and forbade the use of epinephrine.

Int J Prosthodont 2009;22:33–34

Sebastiano Gangemi, PhDa/Elvira Ventura Spagnolo, PhDb/Giulio Cardia, PhDc/Paola L. Minciullo, PhDad.
Severe occlusion of the laryngeal ostium at the Edema of the tongue.
cadaveric
.
Hypothesized trigger factor, Kromopan, is not a known allergenic
or anaphylactoid. Kromopan is an alginate used to make high-
precisionimpressions with chromatic phase indicators.

Among the various Kromopan components, only phenolphthalein has

been reported as causing toxic epidermal necrolysis and fixed drug
eruption
THANK YOU!!!!