Delayed-type hypersensitivity (type IV) reactions in dental anesthesia

Abstract

The recommended methodology of evaluating patients who have presented with reactions to local anesthetics consists of epicutaneous skin testing and serial subcutaneous challenge. However, the role of type IV reactions in this group has been poorly documented. Epicutaneous routine testing and subcutaneous challenge to local anesthetic was performed, as well as patch testing and subcutaneous rechallenge of both at 24 and 48 hours with evaluation up to 72 hours was performed. Three patients presented with a history of localized edema after dental anesthesia. All had negative lidocaine and mepivacaine testing as well as negative lidocaine challenge on evaluation at 1 hour. The first patient, who had previously reacted to EMLA, reacted to both lidocaine and mepivacaine patch testing and challenge, with delayed swelling at 24 and 48 hours after challenge. This patient subsequently tolerated the ester anesthetic chloroprocaine. Two other patients had strong histories of contact dermatitis. Patch testing and challenge with lidocaine was negative, but strong reactions were found to benzocaine on patch testing. Patients undergoing local anesthetic testing should be screened historically for features and risk factors associated with type IV reactions. This should be considered in patients who react to multiple amide anesthetics, who have delayed swelling, or who have a history of severe contact dermatitis. We confirm previous data showing that patients reacting to benzocaine can tolerate lidocaine and that lidocaine-allergic individuals can tolerate ester anesthetics.

<p>Successful Dental Treatments Using Procaine Hydrochloride in a Patient Afraid of Local Anesthesia but Consenting for Allergic Testing with Lidocaine: A Case Report</p>

“…Individuals allergic to lidocaine can tolerate ester-type local anesthetics. 8 Our experience in this case suggests that estertype local anesthetics are useful for patients with a history of allergic reactions to amide-type local anesthetics.…”

“…6,7 However, a previous study suggested that individuals allergic to lidocaine could tolerate ester-type anesthetics. 8 Herein, we report a case in which effective dental anesthesia was achieved using procaine hydrochloride in a patient who had an unknown history of allergic reactions to amide-type local anesthetics, ie, lidocaine and propitocaine (prilocaine). Furthermore, we discuss the effective control of pain perception in patients with an unknown history of allergy to amide-type local anesthetics during dental treatment.…”

“… 6 , 7 However, a previous study suggested that individuals allergic to lidocaine could tolerate ester-type anesthetics. 8 …”

Perianal Allergic Contact Dermatitis from Benzocaine – a Case Report

“…Skin patch testing for allergy should always be considered in recalcitrant cases and in cases with suspected allergic induction (10). It is estimated that 5% of patients who use topical benzocaine preparations may become sensitized to it and, thus, long-term use can result in increased incidence of hypersensitivity reactions (<1% of all adverse reactions) (11). Most of these reactions are T cell-mediated type IV delayed hypersensitivity reactions, including allergic contact dermatitis confi rmed by skin patch tests.…”

Eyelid necrosis after local anaesthesia for lacrimal sac surgery

“…We hypothesise that an immediate type IV hypersensitivity reaction to lidocaine occurred in these patients. 3,5 It may be impractical to avoid the repeated use of LLA in patients undergoing multiple surgeries, and in any case, a cross reaction between these two main classes of anaesthetic drugs may still occur. 5 What is important is to recognise the possibility of this complication, advise patients accordingly, and have corticosteroids on hand to limit the severity of the inflammatory reaction and ameliorate the progression of necrosis, should it appear.…”