SEMINAR

PRESENTED BY- Dr NIKHIL SRIVASTAVA

MODERATED BY- Dr ADIL SHAFATH
HYPERSENSITIVITY REACTIONS
CONTENTS
INTRODUCTION
CLASSIFICATION
Type I
Type II
Type III
Type IV
DENTAL CONSIDERATIONS
ANAPHYLAXIS & its MANAGEMENT


INTRODUCTION
Immunity a Protective response, helping the
body to overcome infectious agents and their
toxins
Hypersensitivity an inappropriate or exagerrated
response
It is concerned with what happens to the host
HYPERSENSITIVITY
According to Von Pirquet, Allergy meant an
altered state of reactivity to an antigen ,&
included both types of immune responses
protective as well as injurious
Synonym for hypersensitivity
Ananthnarayans textbook of Microbiology
COOMBS & GEL CLASSIFICATIOM (1963)

TYPE I
TYPE II
TYPE III
TYPEIV
TYPE I ( IgE)
ACUTE
ANAPHYLAXIS



CHRONIC
ATOPY
Type I Hypersensitivity Reaction
ANAPHYLAXIS
Its an acute reaction involving the smooth
muscle of the bronchi in which antigen IgE
antibody complexes form on the surface of mast
cells which cause sudden histamine release
ANAPHYLAXIS
Coined by Richet
THEOBALD SMITH PHENOMENON
Sensitising Dose
Shocking Dose
Target Tissues or Shock Organs

TYPE II HYPERSENSITIVITY REACTION
Antibody Mediated
Cytotoxic Hypersensitivity
Antibodies combine with host cells recognized
as foreign
Foreign antigens bind to host cell membranes
during induced hemolytic anemia
Eg-
Transfusion reaction by mismatched blood
Rhesus incompatibility
Goodpastures Syndrome
TYPE III HYPERSENSITIVITY REACTIONS
Antibody Mediated through immune complex
formation
Local form is Arthus Reaction
Immune complex mediated Hypersensitivity
IMMUNE COMPLEX FORMATION
Hypersensitivity State:
Complexes persist & lodge in blood vessel walls,
initiating inflammatory reactions
Large complexes
Removed by neutrophils & macrophages

Soluble complexes (more antigen than antibody)
- Most harmful
- Penetrate vessel wall
- Lodge in basement membrane
Complement is activated
- Vascular permeability increased
- Neutrophils attracted
- Neutrophils release enzymes
- Vasculitis results


SENSITIVE SITES & EXAMPLES
Renal glomeruli
Synovial Membranes


Systemic Lupus Erythematosus
Poststreptococcal glomerulonephritis
TYPE IV HYPERSENSITIVITY REACTIONS

Mediated by T lymphcytes
Does not involve antibodies
Delayed type hypersensitivity

Contact Dermatitis
Graft Rejection
Graft-versus-host reaction
Drug hypersensitivity
Autoimmune disease
ANAPHYLACTOID REACTIONS
Anaphylaxis Like





Hereditary Angioedema
SIGNS & SYMPTOMS of ALLERGIC
REACTION
Urticaria
Swelling
Skin Rash
Chest Tightness
Dyspnoea,shortness of breath
Rhinorrhea
Conjunctivitis

DENTAL CONSIDERATIONS
Allergy to Local Anaesthesia
Toxic Reaction
IV Injection
Procaine
Methylparaben or Bisulfite
TOXIC REACTION TO LA
Talkativeness
Slurred Speech
Dizziness
Euphoria
Excitement
Convulsions
A
Anesthesia
Anxiety
Allergy
B
Bleeding
Breathing
Blood Pressure
C
Chair Position
D
Devices
Drugs
E
Equipment
Emergencies
F
Follow Up
PATIENT
EVALUATION
Diphenhydramine as a L.A.
Provocative Drug testing
PENICILLIN
Common cause of drug allergy
5-10% population allergic
.04-.2 % develop an Anaphylactic reaction
Varies with routes
RISK OF REACTION
History of Previous reaction
Time interval since previous reaction
Persistence of specific IgE antibodies
History of multiple drug sensitivities
Test for major & minor determinants
Use Alternative drug-
Erythromycin or clindamycin
Cephalosporins
But can cross react
PREVENTION OF PENICILLIN REACTION
Emergency Kit
Medical History
Not use penicillin in patient with history of reactions to
drugs
Tell Patient
No topical preparations
Dont use penicillinase-resistant penicillins unless
infection caused by specific bacteria
Oral penicillin
Disposable syringes
Ask patient to wait for 30 min after Ist dose
given
Inform about signs & symptoms of allergic
reaction
MANAGEMENT OF SEVERE TYPE I
REACTIONS
Within Minutes
Head Down position
Airway patent
Support respiration & circulation
Note the rate & depth of Respiration
ANGIOEDEMA
Edema of tongue
Pharyngeal tissues
larynx
Activate EMS
Inject 0.3 to 0.5 ml 1:1000 epinephrine IM into
tongue or SC
Supplement with IV diphenhydramine 50mg
100 mg
Support Respiration
Carotid or femoral pulse
ANAPHYLAXIS
Both respiratory & circulatory components of depression occur early
Two symposia have been held by the National Institute of Allergy and
Infectious Diseases (NIAID) and the Food Allergy and Anaphylaxis Network
(FAAN) to review knowledge and to discuss a definition of anaphylaxis.
The following definition was recommended: Anaphylaxis is a serious
allergic reaction that is rapid in onset and may cause death.
PATHOPHYSIOLOGY
Ist contact with antigen results in formation of antibodies by plasma
cells
Antibodies circulate in IgE
Antibodies attach to target tissue
Next contact with antigen may result in combination of antigen with
antibody
Degranulation of mast cells
Smooth muscle contracts, vessels lose fluid
Acute respiratory distress and cardiovascular collapse

SIGNS & SYMPTOMS
Itching of palate
Nausea,vomitting
Substernal Pressure
Shortness of Breath
Hypotension
Pruritus
Urticaria
Laryngeal Edema
Bronchospasm
Cardiac Arhytmmias
MANAGEMENT
Call for help
Supine position
Open airway
Administer O2
Check pulse, B.P.,respiration
Inject 0.5 ml of epinephrine into tongue
Provide CPR
Repeat IM injection if no response
Ref: The prevention and
management of anaphylaxis
CONTENTS
DEFINITION
INCIDENCE
ETIOLOGY
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
LABORATORY FINDINGS
MEDICAL MANAGEMENT
COMPLICATIONS
DENTAL MANGEMENT



DEFINITION
Classical example of systemic autoimmune or
collagen disease
lupus
Its a generalised form of lupus erythematosus
which affects multiple organ systems
It is a more serious form
DLE predominantly affects the skin & course
tends to be benign
INCIDENCE & PREVALENCE
Autoimmune disease
Female to Male ratio-5:1
Presence of Antibodies directed against
components of cell nuclei
Antinuclear antibodies
ETIOLOGY
Unknown
Autoimmune Disease
Familial Aggregation
Triggering Exogenous & Endogenous factors
Infectious agents,stress,diet,toxins,
drugs & sunlight
PATHOPHYSIOLOGY
Production of pathogenic antibodies & immune
complexes & their deposition with resultant
inflammation & vasculopathy
CLINICAL PRESENTATION
Polyarthritis
Butterfly-shaped rash across the nose & cheek
Renal failure
Neuropsychiatric Symptoms
Pulmonary manifestations
Cardiac involvement with clinically detectable heart
murmur
Libman-Sacks endocarditis
LABORATORY FINDINGS
Antinuclear antibody
test
Hematologic
Abnormalities
Clotting
abnormalities-Lupus
Anticoagulant,
elevated PTT
ESR
Proteinuria,
Haematuria
MEDICAL MANAGEMENT
Symptomatic or Palliative t/t
Avoid Sun exposure
Aspirin & NSAIDs for mild disease
Antimalarials
Glucocorticoids
Cytotoxic agents
Plasmaphersis
Lymph node irradiation
Cyclosporine injection
Sex hormone therapy
Immune gamma globulin
COMPLICATIONS
Neurologic or psychiatric involvement
Infection
Coronary Artery Disease
Osteonecrosis
ORAL MANIFESTATIONS
Oral lesions of lip &
Mucous membrane
Erythematous with
white spots or radiating
lines
On lip, a silvery,scaly
margin develops
Xerostomia, dysguesia
& hyposalivation
DENTAL MANAGEMENT
Physician Consultation
Drug considerations
Haematologic considerations
Infective endocarditis-But no Antibiotic
Prophylaxis
Establishment & Maintainence of Optimal Oral
Health Care
BIBLIOGRAPHY
Little & Fallaces Dental Management of the
Medically Compromised Patient
Ananthanarayans Textbook of Microbiology
Kubys Immunology
Prevention & Management of Anaphylaxis:
A Symposium on Allergy