Pediatric dental care comes with various risks, including the possibility of anaphylactic reactions. Although rare, anaphylactic shock represents a life-threatening emergency that requires immediate recognition and management.
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✅ Definition
Anaphylactic shock is an acute, severe, and rapidly progressive systemic allergic reaction characterized by cardiovascular, respiratory, and/or gastrointestinal dysfunction, potentially fatal if not treated immediately (Simons et al., 2020). Anaphylaxis occurs after exposure to an allergen, such as local anesthetics, latex, antibiotics, or dental materials, and can develop within seconds or minutes.
According to the World Allergy Organization (WAO), anaphylactic shock involves severe hypotension or circulatory collapse associated with signs of organ hypoperfusion due to the massive release of inflammatory mediators (Muraro et al., 2022).
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Early identification of signs and symptoms is crucial for successful management. These can be classified as:
➤ Cutaneous
Generalized urticaria
Angioedema (swelling of the lips, eyelids, or tongue)
Erythema
Itching
➤ Respiratory
Dyspnea
Laryngeal stridor
Bronchospasm
Persistent cough
Hoarseness
➤ Cardiovascular
Hypotension
Tachycardia
Arrhythmias
Dizziness or syncope
➤ Gastrointestinal
Nausea
Vomiting
Abdominal pain
Diarrhea
In children, respiratory symptoms tend to predominate over cardiovascular ones, highlighting the need for special attention to airway alterations during dental care (Turner et al., 2019).
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The success of managing an anaphylactic reaction in the dental office depends on the preparation of the team, the knowledge of emergency protocols, and the availability of appropriate medications.
➤ Prevention
Before treatment:
° Conduct a thorough medical history.
° Identify any known allergies (latex, local anesthetics, antibiotics).
° Avoid sensitizing agents if there is a history of hypersensitivity.
➤ Immediate Management
1. Discontinue the dental procedure and remove the allergen if possible.
2. Administer intramuscular epinephrine (IM) in the anterolateral thigh. It is the first-line treatment:
° Pediatric dose: 0.01 mg/kg body weight (maximum 0.5 mg) every 5-15 minutes as needed (Shaker et al., 2020).
3. Place the patient in a supine position with the lower extremities elevated to favor venous return.
4. Administer supplemental oxygen at high flow (8–10 L/min).
5. Establish intravenous access for the administration of fluids if signs of shock are present.
6. Complementary therapies:
° Antihistamines (such as diphenhydramine) to control cutaneous symptoms.
° Systemic corticosteroids (such as hydrocortisone) to prevent biphasic reactions.
° Bronchodilators (such as albuterol inhaled) if bronchospasm occurs.
7. Activate emergency medical services for hospital transfer, even if symptoms are controlled in the office
➤ Special Considerations in Pediatrics
° Adjusted doses based on body weight.
° Closer respiratory monitoring, due to the high frequency of airway obstructions in children.
° Availability of pediatric epinephrine autoinjectors in high-risk offices.
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New clinical guidelines emphasize the importance of early administration of epinephrine, even with mild symptoms, to improve prognosis (Muraro et al., 2022).
Standardized dental emergency protocols have been developed, including visual algorithms to facilitate rapid response (Simons et al., 2020).
Research highlights the use of pediatric epinephrine autoinjectors as a safety measure in high-risk dental offices (Turner et al., 2019).
✅ Conclusion
Anaphylactic shock in children during dental care, while infrequent, represents a critical emergency that requires immediate intervention. Early recognition of symptoms, prompt epinephrine administration, and activation of emergency services are key to a successful outcome. Ongoing training of dental staff in emergency management protocols, the availability of emergency equipment, and thorough medical histories are essential for preventing fatal outcomes. Adhering to updated protocols based on current evidence ensures safer and more effective care in pediatric dental settings.
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✔ Muraro, A., Worm, M., Alviani, C., Cardona, V., DunnGalvin, A., Eigenmann, P., ... & Sheikh, A. (2022). EAACI Guidelines on Anaphylaxis: 2022 update of the evidence base and support for the use of adrenaline auto-injectors. Allergy, 77(2), 358-377. https://doi.org/10.1111/all.15027
✔ Shaker, M. S., Wallace, D. V., Golden, D. B. K., Oppenheimer, J., Bernstein, J. A., Campbell, R. L., ... & Greenhawt, M. (2020). Anaphylaxis—a 2020 practice parameter update, systematic review, and GRADE analysis. Journal of Allergy and Clinical Immunology, 145(4), 1082-1123. https://doi.org/10.1016/j.jaci.2020.01.017
✔ Simons, F. E. R., Ardusso, L. R. F., Dimov, V., Ebisawa, M., El-Gamal, Y. M., Lockey, R. F., & World Allergy Organization. (2020). World Allergy Organization Anaphylaxis Guidance 2020. World Allergy Organization Journal, 13(10), 100472. https://doi.org/10.1016/j.waojou.2020.100472
✔ Turner, P. J., Jerschow, E., Umasunthar, T., Lin, R., Campbell, D. E., & Boyle, R. J. (2019). Fatal anaphylaxis: mortality rate and risk factors. Journal of Allergy and Clinical Immunology, 137(2), 597-606. https://doi.org/10.1016/j.jaci.2015.11.017
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