Approximately 3 million Americans are allergic to peanuts or tree nuts, a number that has doubled since 1997. Since peanut allergy can be severe - even fatal - dental professionals must be armed with knowledge and sensitivity. After all, you could save someone’s life.
by Michele A. Fagan, EFDA, RDH, BS
Perhaps, like me, you have heard about peanut allergy, but are not really aware of how severe - even fatal - this allergy can be. Perhaps, like me, when you hear the term allergic reaction, you think it means intestinal upset or red, itchy hives. Perhaps, like me, you think parents of children with peanut allergy are either neurotic or overprotective.
According to research conducted by Scott Sicherer, MD, associate professor of pediatrics at Mount Sinai School of Medicine in New York City and a researcher in the Jaffe Food Allergy Institute, peanut allergy is the most deadly of all food allergies. Dr. Sicherer is also the author of the book, The Complete Peanut Allergy Handbook. The research states that for a person allergic to peanuts, it takes only one-fifth of a teaspoon, or as little as half of a peanut, to cause a fatal reaction ... and that can occur within minutes.
As an oral health professional, do you know if there are peanuts or peanut derivatives in the products you use or recommend? Do you ever touch any source of peanuts before seeing a patient?
How Big Is The Problem?
It is estimated that 3 million Americans are allergic to peanuts or tree nuts (walnuts, almonds, cashews, macadamia nuts). The prevalence of peanut allergies has doubled in five years from 1997 to 2002, according to the Academy of American Allergy, Asthma and Immunology (www.aaaai.org). Researchers have not yet found a reason for this increase. It is also estimated that approximately 100 to 150 people in the United States die each year from a peanut allergy.
In dentistry, peanut oil is sometimes used in the plasticizing process of thermoplastic impression trays, in the composition of zinc oxide eugenol cement, as a thickener for denture adhesive material, and in some toothpastes as a moisturizing agent. Another concern for the dental professional is that a patient may have unknowingly eaten something prior to his or her appointment that had a peanut or nut product in it, and consequently could have an allergic reaction while in the treatment room. It is important to note that while some reactions may occur within minutes, others may not occur until an hour after ingestion of a nut-containing food.
Are You Prepared?
As health-care workers, we need to have a varying amount of knowledge of medically related situations. Perhaps you are now wondering how this information about peanut allergy affects your life working in the dental profession. Here are some questions to think about:
- Would you know to ask a patient about food allergies? How would you ask? What questions are important?
- Would you know how to react if a patient was having a peanut allergy reaction?
- Do you know to ask a patient for his or her self-injectable epinephrine device (EpiPen, EpiPen Jr., Twinject)? Do you know how to administer it?
Epinephrine is the first-line treatment medication for a severe allergic reaction, or anaphylaxis (lack of breathing). Anaphylaxis is a sudden, severe, potentially fatal, systemic allergic reaction that can involve various areas of the body, such as the skin, respiratory tract, gastrointestinal tract, and cardiovascular system. Symptoms occur within minutes to two hours after contact with the allergy-causing substance. In rare cases, symptoms may occur up to four hours later. Anaphylactic reactions can be mild to life-threatening. Epinephrine is a medication that opens up airways so breathing can take place more easily. It strengthens the heartbeat and the ability of the blood vessels to transport blood to all parts of the body.
A person with peanut allergy should always carry a self-injectable epinephrine device, and it should be out and available in the dental treatment room if needed. A self-injectable epinephrine device contains a dose of epinephrine that is administered in the top of the outside thigh muscle. It must be administered intramuscularly. Oral health professionals must know how to react in such an anaphylactic emergency by following these steps:
- Step 1: Recognize the emergency and be prepared.
- Step 2: Administer or help administer self-injector. Pull off gray cap, place self-injectable pen in top of outer thigh, and hold for 10 seconds. Go right through clothing.
- Step 3: Call 911.
- Step 4: Call the emergency contact.
We should all know the plan of action to administer the self-injectable epinephrine device. Though learning the techniques of using self-injectors is not often part of routine CPR training, practicing these skills is part of the American Red Cross and the American Heart Association First Aid Training courses.
A Personal Experience
I personally witnessed an allergic reaction to peanuts with my son, Jake. He had to be rushed to the hospital emergency room from his preschool. After drinking his cup of juice, he rubbed his eye, causing it to become swollen almost completely shut within minutes. We later discovered his teacher had just finished making another student a peanut butter sandwich prior to handing Jake his cup of juice. The scariest part of this is that he had an intense reaction just from the touch of peanut butter oil on his skin. If he had ingested the peanut butter, the results could have been fatal. He was treated at the emergency room with a combination of an antihistamine, diphenhydramine (Benadryl), and a steroid (prednisone). Benadryl is used to block histamine, the chemical that is released from allergy cells during an allergic reaction. Prednisone is used as an antiinflammatory agent, as well as to prevent the progression of symptoms. Jake (and now some very worried parents) was released from the hospital after hours of observation and when the eye swelling had diminished.
Following the hospital episode, we made plans for allergy testing. Jake was seen by Dr. Jack Becker, an allergy specialist at Main Line Allergy in Ardmore, Pa. They did a skin prick test, which is performed by scratching the skin on the forearm with an instrument that contains a very diluted solution of the peanut protein, and then waited for a reaction. Within minutes, Jake had raised bumps up and down his arm that looked like mosquito bites with redness around them. The nurse’s response was: “Peanuts are not your friends!” Another blood test, called a RAST (RadioAllergoSorbent Test), which measures the level of allergen specific IgE (an antibody), revealed that Jake is categorized as severely allergic. My question to Dr. Becker was, “What if something says ‘may contain traces of nuts’?” He replied, “You are always taking a chance. The child may not have a reaction four times in a row eating that food, and then could have a reaction the fifth time. My advice to you is, if it says ‘may contain nuts,’ regard it as ‘it has nuts.’”
What Causes The Allergy?
Although scientific research has not come up with an explanation of why peanut allergy is becoming more prevalent these days, we do know the body senses the peanut protein as a foreign matter invading the body. The body’s immune system is designed to protect us from harmful bacteria, viruses, and other harmful agents. The immune system in an allergic person differs from that of a nonallergic person in that benign things such as food, pollen, animal dander, and medications are identified as harmful to the body and targeted for an immune response. This response is a very potent inflammatory reaction that results from the production of a special protein called Immunoglobulin E (IgE), which is an antibody that recognizes a specific allergic agent in the same way antibodies recognize bacteria and viruses. The specific types of IgE proteins each person has determine individual allergens. Someone allergic to peanuts may not be allergic to other foods, animals, or pollen unless the body has that specific IgE protein. The antibodies then cause mast cells (a type of immune system cell in the body) to release chemicals into the bloodstream, one of which is histamine. The histamine then causes symptoms in a person’s eyes, nose, throat, lungs, skin, or gastrointestinal tract.
What Are The Symptoms Of Allergic Reactions?
Common symptoms of allergic reactions are:
- Vomiting
- Swelling of the face and lips
- Coughing, sneezing, and watery eyes
- Skin that is bumpy, red, and itchy
- Difficulty breathing
The most severe allergic reaction to peanuts is anaphylaxis. This causes a drop in blood pressure, closing of the throat, and loss of respiration, leading to death. It can happen within minutes.
Other common food products that may trigger peanut allergy symptoms if they contain the peanut protein are:
- Peanut butter, peanuts, and peanut oil
- Peanut flour
- Baked goods (cookies and pastries)
- Candy, nougat
- Ice cream and frozen desserts
- Cereals and granola bars
Peanuts may be present in not-so-obvious foods including:
- Arachis oil - it’s another name for peanut oil.
- Artificial tree nuts - peanuts can be flavored to taste like other nuts such as walnuts or pecans.
- Chocolate candies - some plain versions are produced on the same equipment that is used for processing candies containing peanuts.
- Specialty items - foods sold in bakeries and ice cream shops may come in contact with peanuts.
- Sunflower seeds - many brands are processed on the same equipment used to produce peanuts.
- Ethnic food - Asian, Mexican, and African - peanut oils are used in these foods, as well as peanut butter to close an egg roll and in chili as a thickener.
- Pesto - an Italian sauce made with nuts.
Read The Labels And Avoid
These lists are limited and only begin to give you an idea of the variety of sources of peanuts and peanut derivatives. It is of the utmost importance to read all labels carefully. A law became effective in January 2006 requiring all foods to be labeled in plain English with their allergen declarations. The Food Allergen Labeling and Consumer Protection Act (FALPC http://www.cfsan.fda.gov/~dma/alrgact.html) is designed to ensure that people can easily and accurately identify ingredients that may cause an allergic reaction.
There is not a cure for peanut allergy at the present time. Total avoidance is the only method to prevent an allergic reaction. There are many risks when eating out and not knowing what is in foods. Ask if an ingredients list is available. Ask to speak to the cook/chef. The key is to ask questions and not take unnecessary chances.
The allergic person, or the parents of an allergic child, must carry a nonexpired, self-injectable epinephrine device wherever he or she goes. Another one should be kept at the child’s school, or be carried daily in his or her book bag. Schools must be informed and educated about peanut allergy.
Spread The Word
It is from the terrifying experience with my own son that I have had to do a great deal of self-education on this very serious topic. I am sure there are some of you out there who have had to deal with these same challenges. I have made newsletters for family, friends, and my son’s preschool. A new challenge arrived this year as Jake now attends kindergarten. I have given more newsletters to parents and teachers, have designed a flyer with Jake’s photo and allergy information to hang in the classroom, and had labels designed for his lunch box, back pack and books.
What you don’t know and need to know could save an allergic person’s life. I invite you to become a P.A.L. - Protect A Life from Food Allergies (http://www.foodallergy.org/pal.html.). This acronym was created by Anne Munoz-Furlong, who is the founder of The Food and Allergy Anaphylaxis Network (FAAN, www.foodallergy.org). FAAN is an extremely informative worldwide organization dedicated to building public awareness through the media, education, advocacy, and research. A medical advisory board reviews all of FAAN’s educational materials for accuracy. The organization’s motto is: Until there is a cure, education is the key.
I have a strong desire to turn all of my worry about Jake’s condition into positive action to help and inform others. My intent with this article is to help you become more aware of this potentially deadly allergy. It is my hope that you will share this information with your colleagues, family, friends, neighbors, and your children’s schools. It is also my hope that after reading this, you are more receptive to the fact that people with peanut allergy (and any food allergy) are not neurotic or overprotective - they are saving their own or their child’s life by avoiding certain foods, reading every label, and asking questions in restaurants. Perhaps you have gained some insights on what you may already know, or have been educated a little further on something you were not aware of. Perhaps it will make you instrumental in saving an allergic person’s life
About the Author
Michele A. Fagan, EFDA, RDH, BS, has more than 22 years’ experience in the dental field. She is currently working in private practice for Dr. Joseph Frankina in Philadelphia, Pa., and Dr. Paul Reuter in Rockledge, Pa. She is also an educator of dental hygiene at Manor College in Jenkintown, Pa. She can be contacted at [email protected]. For this article, she was mentored by Patti DiGangi, RDH, BS.
References
• DiGangi P. Food allergies can kill: are you prepared? 1996. http://rdhpennnet.com/display_article/280324/56/ARTCL/none/none/Food-Allergies-Can-Kill-are you prepared?/. Accessed March 3, 2007.
• Levine I. When food turns fatal. Reader’s Digest June 2006; 138-145.
• Munoz-Furlong A. The Food Allergy and Anaphylaxis Network. FAAN.www.foodallergy.org. Accessed August 2005.
• Nut and Peanut Allergy; http://www.kidshealth.org/kid/stay_healthy/food/nut-allergy.html. Accessed February 2007.
• Oxman J, et al. Preloaded thermoplastic dental impression. www.patentstorm.us/patents/5415544. May 16, 1995. Accessed March 2007.
• Saito S, Okita N, Futami S. Zinc oxide eugenol cement composition for dental purposes. www.freepatentsonline.com/5051130.html. August 24,1991. Accessed March 2007.
• Sicherer S, Malloy T. The complete peanut allergy handbook, 1st edition. January 2005; NewYork, N.Y., Berkley Publishing Group.
• Tidwell J. Peanut allergy can be deadly. http://allergies.about.com/cs/peanuts/a/aa/22898.htm. Accessed February 2007.
• Tips to remember: what is an allergic reaction? American Academy of Allergy, Asthma and Immunology. 2006. http://www.aaaai.org/patients/publicedmat/tips/foodallergy.stm. Accessed February 2007.
• Vellekoop L, et al. Stable single-unit dose oral product. www.freepatentsonline.com/4765984.html. Aug. 23, 1988. Accessed March 2007.
• Young M. The peanut allergy answer book, 1st edition. 2001; Gloucester, Mass. Fair Winds Press.
Take-home Tips To Read, Print, And Share- Never take food allergies lightly. Your caution can be instrumental in saving an allergic person’s life!
- Read all food and product labels.
- Your favorite sandwich spread, known as peanut butter, can be deadly to someone who is allergic. This includes candies, cakes, and cookies containing peanuts or peanut butter.
- Cross-contamination can occur on a baking tray in your home if you make your chocolate chip cookies on the same tray you just made peanut butter cookies on. It can also occur if you use the same knife in the jelly jar that was just in the peanut butter jar.
- A person can have a reaction from peanut oil residue left on a utensil, cup, table, or countertop.
- A reaction can occur if you kiss someone with peanut butter on your lips.
- Be conscious of what you send in children’s lunches or serve at birthday parties.
- Most people do not outgrow this allergy.
