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Anaphylaxis during dental care: Case report

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International Journal of Clinical Dentistry ISSN: 1939-5833
Volume 9, Number 3 © 2016 Nova Science Publishers, Inc.

ANAPHYLAXIS DURING DENTAL CARE:

CASE REPORT

Jorge Sá Elias Nogueira1,, DDs, MSc, Pedro Aleixo Nogueira2,

Brenna Magdalena Lima Nogueira3, DDs,
Ricardo Roberto de Souza Fonseca2, and
Sílvio Augusto Fernandes de Menezes1, DDs, MSc, PhD
1
Departament of Pharmacology, School of Dentistry, University Center of Pará,
Belém, Pará, Brazil
2
Undergraduate Student, School of Medicine, University Center of Pará,
Belém, Pará, Brazil
3
Departament of Endodontics, School of Dentistry, Federal University of Pará,
Belém, Pará, Brazil

ABSTRACT
Dipyrone is an analgesic widely used for the management of acute and chronic pain.
Although its use is restricted in some countries because of possible side effects such as
agranulocytosis and anaphylaxis, this potent analgesic is widespread and used in Brazil
and other countries. The objective of this study was to describe a case of severe
anaphylactic reaction caused by intravenous dipyrone to control postoperative pain of
root fragments. Difficulty breathing, hypotension, loss of consciousness and edema were
some of the symptoms observed. The appropriate maneuvers were performed and the
patient recovery was uneventful.

Clinical Relevance: Drug mechanism of action of knowledge commonly used to deal with
possible side effects that drugs are likely to trigger, and the maneuvers to be performed
during hypersensitivity reactions

Keywords: dentistry, anaphylaxis, adverse reactions to medications


Correspondent Author: Sílvio Augusto Fernandes de Menezes, Travessa 9 de Janeiro, no 927 – São Brás, Code
Postal: 66.070-360 Belém, Pará, Brazil. Phone: +55 91 84126230, e-mail: menezesperio@gmail.com.
150 J. Sá Elias Nogueira, P. Aleixo Nogueira, B. Magdalena Lima Nogueira et al.

INTRODUCTION
After dental surgery, pain is commonly observed in almost all patients. Pain control is
performed by the administration of anti-inflammatory and analgesics [1]. Dipyrone
(metamizole) is an analgesic recommended for acute and chronic pain [2]. It is an excellent
antipyretic analgesic and has spasmolytic properties [3-6]. This drug is indicated for pain
already installed [7].
It has been the drug of first choice, especially in public emergencies in Brazil3, because it
is effective and low cost, and also has different routes of administration. However, its use is
restricted in the United States and several European countries, due to the possibility of
agranulocytosis7, aplastic anemia and anaphylaxis [8, 9]. Anaphylaxis is a hypersensitivity
reaction mediated by Immunoglobulin E (IgE) which is produced by detection in the presence
of the drug or its metabolites in the organism [10].
A crucial issue of great importance to success in anaphylactic shock care is early
diagnosis for immediate installation of the emergency treatment [11, 12]. In extra hospital
ambience, such as those occurring in dental office, it must be prioritized basic support of
respiratory and circulatory assistance after the actuation of rescue service [13]. According to
the Brazilian Federal Council of Dentistry it is duty of the dentist prescribe and apply
emergency medication in the event of serious accidents that can jeopardize life.
Therefore, this case report aims to describe the case of a patient who sought the
Municipal Emergency of Belém with acute painful condition caused by the removal of root
fragments of a lower molar and had an anaphylactic reaction after intravenous administration
of dipyrone.

CASE REPORT
A 77 kg, 1,79 m, 65-year-old, male gender, and black ethnicity sought the Municipal
Emergency of Belém to make a dental surgery to remove the root fragments of the element
36. The surgery was uneventful and the patient's vital parameters remained within the normal
range. It was used as local anesthetic a 2% lidocaine with epinephrine 1/100,000 cartridge.

Figure 1. Blood pressure admeasurement 83X46 at the moment of the shock.

 Anaphylaxis during Dental Care: Case Report 151

Finished the procedure, the patient complained of severe pain in the surgical area. It was
given an ampoule of 500mg intravenous dipyrone. Immediately after, he had difficulty
breathing, blood pressure drop (83/46 mmHg) (Figure 1), loss of consciousness (Figure 2)
and symmetrical edema involving the face lips and eyelids, with characteristics of
anaphylactic shock.
As emergency treatment, it has been administered 0.5 mg of epinephrine subcutaneously
in the anterior region of the forearm and a funnel dexamethasone 10 mg intravenous, ringer
lactate for intravenous fluid replacement and vein maintenance, also an ampoule of
promethazine 50 mg intramuscular (vastus lateralis thigh), oxygentherapy catheter glasses
type number 16. After remission of acute state and having restored vital signs, he was
discharged with guidance for medical evaluation after two hours.

Figure 2. View showing venous access with Ringer's lactate solution.

Figure 3. Blood pressure 142X71 at the moment of discharge.

152 J. Sá Elias Nogueira, P. Aleixo Nogueira, B. Magdalena Lima Nogueira et al.

DISCUSSION
Rosário and Ribeiro [16] conducted a study regarding the sensitivity of analgesics and
anti-inflammatories. They observed the involvement of allergic reaction to dipyrone in 7.6%
and to aspirin by 30%. Although it has been described in some literature cases [17-24], this
serious adverse reaction is still considered rare.
Non-opioid analgesics, such as dipyrone, are used with high frequency in treating pain.
Analgesia controlled by the administration of intravenous drugs is an effective method of
treatment for postoperative pain [25]. Dipyrone is usually indicated as an analgesic drug to
control pain following surgery, obtaining satisfactory results, since it presents peripheral
distinct mechanism of action compared to other analgesic drugs. Apparently, his performance
promotes desensitization of peripheral nociceptors, blocking inflammatory hyperalgesia [26].
Therefore, the literature confirms the effectiveness as well as the drug´s administration for the
patient to control post-surgical pain.
The symptoms reported after administration of the drug is in line with those described to
a hypersensitivity reaction. This reaction is mediated by IgE specific derivatives antibodies
related to mastocytes cells and basophils to trigger the release of histamine and other
chemical mediators that produce inflammatory reactions. The effects can be local, limited to
the upper respiratory tract (early stage of asthma), skin (hives) and the gastrointestinal tract.
When the reaction is more general anaphylactic shock occurs [27].
It is reported that after intravenous administration of dipyrone, in some cases, a severe
hypotension was observed. The decrease in systolic blood pressure at least 20 mmHg occurs
within a few minutes up to 6 hours after the administration of the drug. In our patient, the
drop in blood pressure was noted in a short time and we believe that the loss of consciousness
is closely related to that process [28].
Epinephrine (adrenaline) is the drug of choice for the reversal of anaphylaxis frame,
having agonist activity exerted on adrenergic receptors [29]. This drug reverses and controls
hypotension phenomena and especially bronchospasm. Yet its activity by beta1-adrenergic,
epinephrine can diminish late allergic responses, reducing the risk of a possible biphasic
anaphylaxis above which is a recurrence of symptoms within 72 hours without any re-
exposure to the allergen [30, 31]. In adults should be administered 0.5 ml of epinephrine 1:
100029. We used 0.5 ml of epinephrine, although other authors recommend the dosage of 0.01
mg / kg, the drug was effective in controlling the reaction [32].
Regarding anti-edema, there is no agreement regarding the prescription of corticosteroids.
Andrade et al. [29] recommend the use of hydrocortisone, unlike Gonzalez et al. [33],
mentioning dexamethasone. It is worth the time to report that corticosteroids and
antihistamines have secondary role in the treatment of anaphylaxis, helping prevent swelling,
skin symptoms and recurrence of the reaction up to 24 hours [32]. Dexamethasone was used
and found to be effective in reducing and preventing some of the symptoms.
Despite being allowed to dentists intervene in cases of medical emergencies, the
preparation of dentists in Brazil is still a question that deserves attention, related to the
medical emergencies in dentistry. According to Caputo [35], training in basic life support is
essential to the dental professional. However, the same author states that most professionals
are still only concerned with the update in dental techniques, materials and equipment. Lucio
[36] concluded in his work that it is visible the insecurity of CDs in facing such situations,
 Anaphylaxis during Dental Care: Case Report 153

probably because of inadequate preparation for graduation and lack of update during the
practice of their profession.

CONCLUSION
The dentist must know the mechanism of action of the most used drugs, in order to deal
with possible complications that these drugs can cause. We emphasize the importance of
dentist´s knowledge on the mechanisms of action and possible adverse reactions to the drugs
are likely to trigger, and the maneuvers to be performed during hypersensitivity reactions.

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