VERIFIABLE CPD PAPER

Medical emergencies CLINICAL

Management of anaphylaxis in the dental practice:

an update
Phil Jevon*1 and Shaam Shamsi2,3

Key points
Anaphylaxis is a life-threatening emergency and Adrenaline needs to be administered promptly to GDPs need to be competent at administering
the incidence is on the increase. optimise survival. adrenaline intramuscularly using a syringe and
needle.

Abstract
Anaphylaxis is a severe and potentially life-threatening allergic reaction that can occur in the dental practice. There are
a number of dental-related causes including mouthwashes, local anaesthetics, latex and antibiotics. The dental team
must be able to respond effectively and manage the life-threatening situation appropriately following Resuscitation
Council UK guidelines. The timely administration of adrenaline is life-saving; any delays can lead to a poor outcome.
With the current national supply issues with adrenaline auto-injector devices, there is an expectation that GDPs
should be competent at drawing up adrenaline from an ampoule and administrating it intramuscularly. The aim of this
article is to provide an update on the management of anaphylaxis in the dental practice with particular reference to
the procedure for intramuscular injection of adrenaline.

Introduction syringe and needle, a nationally expected Causes of anaphylaxis in dental

requirement.9,10 practice
Anaphylaxis is a severe and potentially life- The aim of this article is to provide an update
threatening allergic reaction1 which could on the management of anaphylaxis in the Antibiotics
occur in the dental practice. 2 The GDC dental practice. Antibiotics are among the drugs most
states that ‘all registrants must be trained likely to cause anaphylaxis.13 Amoxicillin,
in dealing with medical emergencies, Definition phenoxymethylpenicillin and metronidazole
including resuscitation, and possess up-to- are three antibiotics that are prescribed in
date evidence of capability’. 3 The dental Anaphylaxis is a severe, potentially life- dentistry.14 Amoxicillin is probably the one
team must be able to manage anaphylaxis threatening generalised allergic reaction most commonly associated with anaphylaxis.
effectively following Resuscitation Council characterised by rapidly developing Deaths from anaphylactic reactions to
UK guidelines.4 symptoms and signs including skin changes amoxicillin have been reported.15
The prompt administration of adrenaline (such as redness and itching), mucosal Antibiotics are the main cause of
is pivotal to a favourable outcome. However, changes (swelling below the skin surface), perioperative anaphylaxis in the UK, being
due to the ongoing supply issues and product swallowing and breathing difficulties (due to responsible for almost 50% of cases with an
recalls relating to adrenaline auto-injector swollen mouth, throat or tongue), wheezing, incidence of 4.0 per 100,000 administrations.16
devices (AAIs), 5,6,7,8 those who previously tachypnoea, tachycardia and hypotension.11 One recent study in France identified 17 cases
relied on using these simple devices now of anaphylaxis to amoxicillin administered for
need to be competent at intramuscular Incidence dental procedures.17
(IM) injection of adrenaline using a
The incidence of anaphylaxis in the UK Chlorhexidine
1
PGCE Academy Tutor, Walsall Teaching Academy, Manor
is increasing, with a reported increase in Chlorhexidine is an effective antiseptic
Hospital, Walsall, UK; 2Director, Horizons Dental Centre, hospital admissions for anaphylaxis from which is widely used in dentistry,18 being
Stoke-on-Trent, UK; 3HEWM FD Training Programme
Director, CQC Specialist Advisor, RCS Examiner.
one to seven cases per 100,000 population present in a number of dental products
*Correspondence to: Phil Jevon per year between 1992  and 2012. 12 This including some mouthwashes, toothpastes
Email address: phil.jevon@walsallhealthcare.nhs.uk
700% increase is fortunately not associated and dental implants.19,20 However, anaphylaxis
Refereed Paper. with an increase in mortality rates, which are to chlorhexidine has been increasingly
Accepted 25 June 2020 still very rare – approximately 20 in the UK reported worldwide, including two incidents
https://doi.org/10.1038/s41415-020-2454-1
every year.4 in the UK where chlorhexidine-containing

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Table 1 Products in the dental practice containing latex and latex-free alternatives44

Examples of dental equipment that may NRL-free alternative Manufacturer

contain NRL

Amalgam carriers Teflon amalgam carriers Austinell

Tyco-Healthcare
Aspirators Yankauer plastic wide-bore
Durr

Bunsen burner tubing Heating device

Roeko flexi-dam FE Cardozo Ltd

Dental dam
Hygenic non-latex Coltene/Whaledent

Hygenic Wedjets (dental dam stabilising cord) Not currently available

Endodontic* stops Silicone stops QED

Orthocare
Elastics (orthodontic) GAC ELF Latex-Free elastics
TOC (The Orthodontic Co.)

Mixing bowls** (eg alginate nowls) NRL-free bowls Dentsply

Prophy cups, prophy heads

Young Dental
Disposable prophy angle to be used on nosecone of
W+H Dental (UK) Ltd
doriot-style handpiece
Polishing equipment
Enhance polishing cups Dentsply

Shofu Greenie & Brownie polishing points Minerva

Directa crowns (polycarbonate) Tower Dental

Temporary crowns and matrices Odus cervical matriza Hawes Neos
Odus Pella Crown Form Austinall
Key:
NRL = natural rubber latex
* = endodontic stop is a rubber stop on the hand files / rotary files that are used during root canal treatment and assists in the measuring of canals
** = Mixing bowls (it should read ‘e.g. alginate bowls’)- these are bowls in which the alginate impression material is hand mixed

mouthwash had been used to irrigate tooth pandemic advises patients to rinse with warm rather than to the drug itself.26 Excipients such
sockets following a recent tooth extraction;18 saltwater should the GDP suspect dry socket.25 as preservatives (for example, benzoates used in
unfortunately, the resulting anaphylaxis multi-dose vials) and antioxidants (for example,
resulted in the death of both patients.21,22 Local anaesthetic metabisulphites used in LA solutions containing
A national report 23 investigating 266 cases of Anaphylactic reactions to local anaesthetic adrenaline) can cause allergic reactions.27,33,34
anaphylaxis in the perioperative period in UK (LA) administered in the dental setting is It is also important to be aware of the risk of
hospitals found that chlorhexidine was: very rare,26 but they have been reported.27,28,29 allergy to natural rubber latex (NRL) contained
• The cause in nearly 10% of the cases The actual incidence of adverse effects from in bungs, gloves and dams, as well as other
• The third most common cause of LA is about 0.1–1%,30 with 1% of these cases dental materials23 (see below). Contrary to
anaphylaxis being confirmed allergic reactions.26,31 Actual some reports, the risk of latex allergies from
• Estimated to have an incidence of 0.78 per allergic reactions to LAs are either immediate LA carriages is minimal.35
100,000 exposures. hypersensitivity reactions (type  I: systemic Following administration of an LA, a
signs) or delayed hypersensitivity reactions few patients may suffer one of a range of
Interestingly, the authors also found that (type IV: localised reaction at the injection unwanted symptoms which sometimes can
three cases could potentially have been avoided site, contact dermatitis).26 be mistaken for allergic reactions and patients
by better history-taking or by heeding a Amide LA agents (for example, lignocaine) may be unnecessarily told they are allergic to
relevant history.23 are most commonly used in dentistry, but the anaesthetic.26 Most adverse reactions are
A Medicines and Healthcare products allergic reactions are very rare.26 The least psychogenic or vasovagal.36
Regulatory Agency (MHRA) alert in 201420 allergenic amide LA agents are mepivacaine
raised awareness about the risk of anaphylaxis and plain prilocaine.32 Allergic reactions are General anaesthetic
to products containing chlorhexidine. The more common with ester LA agents because Anaphylaxis to anaesthetic drugs is not
continued use of chlorhexidine as an irrigation they are metabolised to para-aminobenzoic uncommon.16 There have been a number of
solution for treating an established dry socket acid, a known allergenic compound. 33 cases in oral surgery theatres that have been
has been questioned.18 The SDCEP24 advises to Benzocaine is the only ester LA used in reported.37
consider saline to irrigate a dry socket because dentistry (topical preparations applied before
of the associated risks of anaphylaxis when using administration of LA).26 Latex
chlorhexidine and the lack of evidence to support Many LA-induced allergic reactions are due Allergy to NRL (latex) became increasingly
its use. The latest advice during the COVID-19 to other constituents in the injection solution common towards the end of the last century

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Iodoform
Table 2 Recognition of anaphylaxis using the ABCDE approach: signs and symptoms that
may be present4,53 Iodoform is in a number of endodontic
products51 including Alvogyl.52 Alvogyl’s
ABCDE Signs and symptoms product information stipulates that it shouldn’t
Swollen tongue be used in patients with known allergies to
Difficulty swallowing/speaking
Airway Throat tightness
procaine (novocaine)-type anaesthetic, iodine
Hoarse voice or compounds related to iodine.52 The authors
Stridor are aware of two anecdotal reports of anaphylaxis
Difficult or noisy breathing to Alvogyl; in one case, the GDP discovered after
Chest tightness
Breathing Persistent coughing
the event that the patient was allergic to iodine.
Wheeze
Tachypnoea
Clinical features and diagnosis
Hypotension
Tachycardia
Circulation The lack of a consistent clinical picture can
Pallor
Collapse sometimes make an accurate diagnosis
Feeling dizzy or faint difficult.4 Anaphylaxis is characterised by
Confusion quick onset and rapid deterioration. As soon
Disability Agitation
as possible, a detailed history should be
Syncope
Loss of consciousness taken and the patient assessed (and treated)
Skin changes: urticarial, angioedema and erythema following the ABCDE approach (Table 2) to
Rhinitis and conjunctivitis help in the recognition and initial diagnosis
Abdominal pain/cramps
Exposure of anaphylaxis.
Nausea and vomiting
Diarrhoea In a study of 593 cases of anaphylaxis, the most
Sense of impending doom common findings were urticaria (Fig. 1) and
angioedema (87%), shortness of breath/wheeze
(partly due to increased use of latex gloves in whenever possible and be alert to patients (59%) and symptoms of hypotension (33%).53
healthcare settings), though it is now on the with latex allergies. Anaphylaxis Campaign has It is more likely to be anaphylaxis if all three
decline.38 It is estimated that approximately produced helpful guidance raising awareness of the following criteria are met:4
1–6% of the UK’s population have a latex of the presence of latex in dental products and 1. Sudden onset and rapid progression of
allergy. 35,39 Worldwide, reported data listing latex-free alternatives (Table 1).44 symptoms
suggest that the average prevalence of latex The incidence of latex allergy among 2. Life-threatening airway and/or breathing
allergy remains 9.7%, 7.2% and 4.3% among healthcare workers is higher than in the general and/or circulation problems
healthcare workers, susceptible patients and population,28,40,45 emphasising the importance 3. Skin and/or mucosal changes (flushing,
the general population, respectively.40 for all dental team members to be particularly urticaria, angioedema).
At-risk groups include spina bifida patients vigilant.35 The incidence of latex allergy in the
(67% chance of latex allergy), healthcare workplace among healthcare workers is one Mistaken diagnosis
professionals, and patients with an existing that is clearly addressed in several specific
allergy to Elastoplast and certain foods areas of health and safety legislation.46 It is possible to mistake a panic attack or a
(particularly banana, kiwi and avocado).38,41 vasovagal attack for anaphylaxis. Following
Latex allergy-induced anaphylaxis is more Toothpastes the familiar ABCDE approach (Table 2) will
likely to be severe in patients with uncontrolled Allergic reactions to toothpaste, including help to distinguish between a panic attack and
asthma.38 anaphylaxis47 and even fatal anaphylaxis, have vasovagal syncope from anaphylaxis:
Although an allergy to latex is relatively been reported.48 In the US, a young person • Panic attack: hyperventilation, tachycardia
common and may cause severe reactions,42 with a known dairy product allergy developed and anxiety-related erythematous (red)
latex allergy-induced anaphylaxis is extremely anaphylaxis and died after using a toothpaste rash. The absence of urticaria, hypotension,
rare.39 A review of the literature found only containing Recaldent (a milk-derived pallor and dyspnoea helps to exclude
one case report in the last 20 years of latex- protein) which had been recommended by anaphylaxis
induced anaphylaxis in the dental practice – a her dentist.49 • Vasovagal syncope: pallor, sweating,
patient who had a reaction to a rubber dam.43 A similar case was reported recently in hypotension, nausea, vomiting and
Interestingly, a recent study examining 266 Australia where a child with a milk allergy bradycardia. The absence of a rash,
cases of perioperative anaphylaxis reported developed anaphylaxis after a ‘tooth mousse’ tachycardia and dyspnoea helps to exclude
no cases were due to latex.16 containing Recaldent was used during dental anaphylaxis.
Even rarer is fatal anaphylaxis due to a latex treatment.50 The child began to complain of
allergy, with only isolated case reports being discomfort in her mouth, which progressed Adrenaline
found in the literature42 and none related to to difficulty swallowing which prompted
dentistry. The dental team will be aware of her alert mother to administer her AAI Adrenaline remains the most important
the importance of using latex-free products immediately.49 drug in anaphylaxis, but to be effective, it

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needs to be administered promptly. Delays in

administering adrenaline increases the risk
of death54,55 and failure to give adrenaline is
the most common cause of death associated
with anaphylaxis.56 A study of the UK registry
found that, in almost 40% of all deaths due
to anaphylaxis, adrenaline had not been
administered.57

Actions
Adrenaline:
• Reverses peripheral vasodilation
• Reduces oedema
• Dilates the airways
• Increases myocardial contractility
• Suppresses histamine and leukotriene
release.
Fig. 1 Urticaria (image courtesy of James Halpern, consultant dermatologist)

Dose
The recommended4 doses of adrenaline are as
follows:
• Adults: 500 micrograms IM (0.5 ml of
1:1,000)
• Child >12  years: 500 micrograms IM
(0.5 mL)
• Child 6–12 years: 300 micrograms IM (0.3
ml of 1:1,000)
• Child <6 years: 150 micrograms IM (0.15
ml of 1:1,000).

The dose can be repeated at five-minute

intervals until there has been an adequate
response.11

Route
Adrenaline should be administered
intramuscularly, ideally into the anterolateral
aspect of the middle third of the thigh.11

Injections through clothing Fig. 2 Adrenaline 1:1,000 ampoules (box of ten)

IM injections should ideally be administered
into the bare leg. This may prove difficult in
the dental practice if the patient is wearing and in fact this technique is recommended by literature) and in all three adrenaline self-
clothing that is difficult to remove quickly or some.61 It would therefore seem reasonable to injector devices prescribed in the UK (as well
indeed is reluctant to be exposed. consider this technique in a life-threatening, as in some drinks and food products).64
AAIs can be administered through light time-critical anaphylaxis situation in a dental Adrenaline should still be administered to a
clothing.58,59,60 This sensible and practical practice if the patient is wearing light clothing, patient in anaphylaxis who has hypersensitivity
advice enables the prompt administration of taking care to avoid the seam in the trousers to sodium metabisulphite, as the need for the
adrenaline which otherwise could be delayed and items in the patient’s pocket. life-saving drug far outweighs any theoretical
if the patient had to undress first to expose the risk from sulphites.64,65
leg. Sometimes, other injections (for example, Allergy to adrenaline
insulin) are advocated to be administered A question often asked is whether the patient Adrenaline in dental medical
through clothing. can be allergic to the adrenaline injection.62 emergency drugs kits
The authors are aware of a number of The answer is yes, but it is very rare and is
anecdotal reports of adrenaline injections usually due to hypersensitivity to sodium Adrenaline auto-injectors
routinely administered through clothing in metabisulphite, 63 a preservative which is Many dental practices stock AAIs in their
emergency departments without any difficulties found in adrenaline 1:1,000 solution (product medical emergency drugs kit. The AAIs

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dental practices that stock AAIs in their

medical emergency drugs kit to renew them
with adrenaline ampoules, in order to preserve
national stocks of the devices.9 Also, both the
CDO9 and the Department of Health10 stipulate
that all healthcare professionals providing
services where anaphylaxis treatment may be
required (for example, dentistry) should have
the competency to draw up and administer
IM adrenaline from ampoules with a normal
syringe and needle.
The Resuscitation Council UK has reiterated
that, in anaphylaxis, healthcare professionals
should be administering the recommended
dose of adrenaline in anaphylaxis; that is,
500 mcg for a patient over 12  years of age
(an AAI should only be used if it is the only
available adrenaline preparation when treating
anaphylaxis in a healthcare setting).68

Fig. 3 Adrenaline 1:1,000 ampoule Adrenaline 1:1,000

If not already, it is expected that dental practices
will start stocking adrenaline 1:1,000 (1 mg/
ml) ampoules (Fig. 2) in their emergency drugs
kit (adrenaline 1:1,000 prefilled syringes are
also available and are preferred by some to
negate the need to draw up from an ampoule,68
though the authors are aware of recent supply
issues with this product as well).
Dental practices are advised to follow Public
Health England’s69 guidelines, ensuring the
following are available:
• Adrenaline 1:1,000 (1 mg/ml) ampoules x2
(usually come in a box of ten)
• Blue 23G 25 mm needles x4
• Graduated 1 ml syringes x4.

The recommended needle length for IM

injections is 25 mm (a blue 23G 25 mm needle)
for all ages to ensure that the drug is injected
into the muscle; a longer 21G 38 mm needle
may be needed in some adults.4 Safety needles
should ideally be used for IM injections to
reduce the risk of needle-stick injury.70
Fig. 4 IM injection – insert needle at 90 degrees

Suggested procedure for IM

currently available in the UK are Emerade, • Recalls for Emerade following failed injection of adrenaline
EpiPen and Jext, which are designed for self- activations
use.60 The obvious perceived advantages of • EpiPen 300 mcg device: needle length Which muscle?
AAIs are that they are quick and relatively alleged to be too short for IM use in adults67 IM injection into the vastus lateralis muscle
easy to use. If an AAI is used, it is important (same will also apply to Jext) (thigh) is advised because a high drug plasma
to follow the manufacturer’s guidelines for its • EpiPen 300 mcg device: incorrect dose of level can be achieved within minutes.4,71 This
use, taking particular care to avoid accidental adrenaline in adults67 (same will also apply is the ideal route.11
self-injection which has been reported.66 to Jext). Although in the dental practice, the deltoid
However, key concerns have been raised in muscle (arm) is usually easier to access, the
the last two years concerning AAIs: The AAI supply issues led to the Chief rate of absorption of adrenaline from this
• Ongoing supply issues Dental Officer for England (CDO) requesting site is slower compared to the recommended

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vastus lateralis muscle.72 The deltoid muscle is

therefore not routinely recommended,4 though
it may need to be considered in a desperate
situation.11

IM injections in the thigh: recent changes

in advice
• Wearing gloves routinely is not necessary,73
although dental staff will probably already
be wearing them
• Routinely using an ‘alcohol swab’ to clean
the skin is no longer deemed necessary 69
• Leaving a small gap between the skin and the
hub of the needle in case the needle breaks off
during the injection is no longer advocated,71
as this may result in the drug being injected
into subcutaneous fat, not muscle72
• Aspirating or drawing back on a syringe
to check if the needle is in a blood vessel
is no longer advised for IM injections in
the thigh69
• Massaging the site following the injection is
no longer advocated because it may dispel
the drug out of the muscle tissue.74,75

Opening the glass adrenaline ampoule

Before opening the ampoule, it may be
necessary to gently tap the top to dispel any
remnants of the drug back to the bottom. Cuts
and lacerations can occur when opening glass
ampoules,76 particularly if the glass ampoule
shatters due to too much pressure being
applied. To minimise the risk of injury:77
• Ideally, use a paper towel, piece of
gauze or similar to protect the fingers
and thumbs. Alternatively, use an
ampoule-opening device
• Only apply pressure to the ‘neck’ of
the ampoule
• Always apply pressure away from the
coloured dot (Fig. 3) and never in any other
direction Fig. 5 Initial management of anaphylaxis, reproduced with kind permission from the
• Apply sufficient light pressure to ‘snap’ the Resuscitation Council (UK)4
top off the ampoule
• Don’t apply any pressure to the base of
the ampoule as this will probably cause it ideal procedure described comprehensively • Draw up the required dose of adrenaline.
to shatter elsewhere, reflecting the urgency of the Assemble the syringe and needle, safely
• Avoid pulling or twisting actions while life-threating situation and the need to open the adrenaline 1:1,000 ampoule (see
applying pressure on the glass ampoule. administer adrenaline without delay in order above) and withdraw the required amount
to save life: of drug (see above) from the ampoule; if
If the glass does shatter, then the broken • Advise the patient of the urgency of the present, quickly expel any large air bubbles
glass and contents will need to be carefully situation and that the adrenaline injection • Change needle (ideally now use a safety
discarded and another ampoule used. is required needle),70 dispose of used needle in sharps
• Ask colleagues to prepare the patient; container, and take syringe and needle in a
Procedure for IM injection for example, expose the thigh if able. If tray to the patient
The suggested procedure for IM injection not possible, plan to inject through light • Use non-dominant hand to taut the skin
below is a practical modification of the clothing (trickier to do this through clothing)

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Box 1 SBAR communication tool for use in healthcare settings
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