Having a reasonably coherent conversation with parents about food allergies and intolerances
BY Cathy Hester Seckman, RDH
A mother comes into the office with her child. Her attitude says worry and determination in equal amounts, with just a bit of defensiveness and combativeness thrown in for good measure.
"My child has multiple food allergies," she begins. "I need your guarantee that nothing you put in his mouth will contain dairy, eggs, or wheat."
Oh, dear, you think. Can I guarantee that? What if I choose the wrong product, and little Tynan goes into anaphylactic shock right in the chair?
The first thing you need to do is determine whether Tynan has a food allergy or food intolerance. True food allergies can be life threatening, and sufferers should always carry emergency epinephrine (EpiPen, Auvi-Q, Adrenaclick, Twinject). Food intolerance, while it can be painful and troublesome, is not life threatening. If Tynan's mom isn't sure of the difference, and hasn't been told to carry epinephrine, a call to the allergist will give both of you more information.
Other articles about food allergies in the dental setting
A food allergy starts with immunoglobulin E (IgE), a protein antibody that is produced as part of the human immune response. Some people produce IgE against food. The IgE is then released into the bloodstream and attaches to the surface of mast cells, which are commonly found in the nose, throat, lungs, skin, and gastrointestinal tract; in other words, in the places where allergic reactions typically occur. Mast cells then release chemicals such as histamines, which produce the allergic reactions.1
The Mayo Clinic describes a food allergy as an immune system reaction to even a tiny amount of the trigger food that affects numerous organs in the body. Common signs and symptoms can be immediate, and can include nausea, vomiting, cramping, and diarrhea. Other signs and symptoms can be a tingling mouth, hives, and swelling of the lips, face, tongue, and throat, which can lead to anaphylaxis.
Food intolerance symptoms, in contrast, manifest more gradually and do not involve an immune system reaction. They include absence of a digestive enzyme, as in lactose intolerance; irritable bowel syndrome (IBS); sensitivity to additives such as sulfites; celiac disease; food poisoning; and recurring stress or psychological factors, which are not fully understood. Though IBS and celiac are chronic and serious conditions caused by a protein called gluten found in some grains, sufferers are not at risk of anaphylaxis.2
The American Academy of Allergy, Asthma & Immunology (AAAAI) tells us that food allergies are also linked to asthma, since a reaction to pollen proteins can occur along with reactions to similar proteins in foods. Some 24% of asthmatic children also have at least one food allergy. Twelve percent have multiple food allergies.3 The good news about food allergies is that most people outgrow most of them in childhood.
Dairy - Two-and-a-half percent of children younger than 3 have a milk allergy, and most will outgrow it. Anyone who suffers from a dairy allergy must avoid all milk products (butter, cheese, cream, yogurt, etc.) and everything made from milk products (baked goods, cereals, candy, creamed sauces and foods, and salad dressings). There are also plenty of dairy-containing ingredients and additives that those with the allergy must learn and remember: curd, ghee, casein or caseinates, hydrolysates, lactalbumin, lactalbumin phosphate, lactose, lactoglobulin, lactoferrin, lactulose, rennet, whey, or whey products.4
If casein rang a bell with you in the list above, give yourself a pat on the back for being an observant hygienist. Recaldent, which is found in Trident gum, some toothpastes, and in GC America's MI Paste and MI Paste Plus, contains casein, and should not be used for those with a dairy allergy.
Eggs - More than 600,000 people, or 0.2% of the American population, are allergic to eggs, making it one of the most common food allergens. Most who suffer from egg allergy outgrow it by age 16. Egg allergy commonly manifests as eczema in babies and young children, but can also be as severe as anaphylaxis. Those with the allergy must avoid eggs and many baked goods, and be aware that other processed foods such as canned soups, salad dressings, and some egg substitutes also contain egg protein.
In dentistry, an egg allergy is also a concern when using the general anesthetic propofol. A 2011 study concluded that propofol is "likely to be safe in the majority of egg-allergic children who do not have a history of egg anaphylaxis."5
Fish and shellfish - A shellfish allergy, unlike others, is usually lifelong, and more than half of those allergic had their first reaction as adults. Those who are allergic to shellfish or to finned fish such as salmon often have cross-reactivity to the other, and are advised to avoid both. Even the steam from cooking fish or shellfish can cause a reaction. Fish can be an ingredient in processed foods such as Caesar dressing, Worcestershire sauce, and barbecue sauce, and in the popular supplement glucosamine.6
Nuts (peanuts) - The Food Allergy Research and Education organization (FARE) has found that peanut allergies are increasing in the United States, having tripled between 1997 and 2008. Peanut allergies are more likely to be lifelong than are other food allergies. Since peanuts are a legume, those allergic to peanuts may also have reactions to other legumes such as beans, peas, lentils, and soybeans. About 25% to 40% of those allergic to peanuts are also allergic to tree nuts, so allergists recommend that tree nuts also be avoided.
Besides the obvious - peanut butter and peanut oil - other sources of peanuts can include baked goods, candy, African, Asian, and Mexican dishes, and some vegetarian products.7
Nuts (pine nuts) - These are actually a seed, and the jury is still out on whether people with nut allergies should avoid pine nuts. Some people have experienced anaphylactic reactions to pine nuts themselves, but there is usually no cross-reactivity with other nuts. The AAAAI recommends that anyone with a nut allergy avoid all nuts, even pine nuts.8
There have been questions in dentistry about the possible use of pine nuts in fluoride varnish resin, which can be made from pine stump wood; and in xylitol, which can be made from birch wood. Neither concern seems to be valid. The experts at www.xylitol.org report that "xylose and xylitol have no parts on a molecular level that are proteins, and proteins in combination with different sugars are what trigger allergic reactions."9
Nuts (tree nuts) - These also tend to be lifelong allergies. Only 9% of children with a tree nut allergy will outgrow it. Tree nuts include, but are not limited to, almonds, Brazil nuts, cashews, hazelnuts, pecans, pistachios, and walnuts. Those with the allergy are advised to avoid all nuts, including peanuts.10
Soy - Most people with a soy allergy will outgrow it by the age of 10. An anaphylactic reaction to soy is rare; most reactions are mild. Those with the allergy are also advised to avoid other legumes, including peanuts. Soy is found in edamame, miso, natto, soya, tamari, tempeh, textured vegetable protein (TVP), and tofu, among other things. Most soy used in the United States is in processed foods, where it might be hard to identify, so careful label reading is advised.11
Wheat - A true wheat allergy is usually outgrown in childhood, but since wheat is the most common grain used in North America, it can be a big problem for families trying to work around it. Anyone allergic to wheat must also avoid barley, bulgur, couscous, farina, matzo and matzo meal, rye, semolina, spelt, triticale, vital wheat gluten, wheat bran, and wheatgrass, among other things. As a thickening ingredient, wheat can also hide in surprising places, such as in soy sauce, starch, Play-Doh, beer, hot dogs, and imitation crab meat.12
Lactose intolerance - Lactose is a sugar found in milk and milk products. The National Digestive Diseases Information Clearinghouse (NDDIC) tells us the intolerance occurs when there is a deficiency of lactase enzyme in the small intestine and consequent lactose malabsorption. Undigested lactose then passes to the colon to cause excess fluid and gas. Some ethnic populations are more prone to the problem than others, including African Americans, Hispanics/Latinos, American Indians, and Asians.13
Most who have the problem can tolerate small amounts of lactose with no problem, but care should still be taken when recommending dental products containing casein.
Sulfite sensitivity does not appear to be well-understood. Sufferers are primarily adult female asthmatics, and symptoms can be dermatologic, respiratory, or gastrointestinal. Severe reactions are not common, but usually manifest as broncho-constriction.14
Sulfites are used as preservatives for processed food, wine, and beer, and in some medications, but have been banned for fresh fruits and vegetables since 1986.15
Irritable bowel syndrome (IBS), celiac disease, gluten intolerance - These can be linked together for our purposes since they have a common trigger, gluten, that concerns many of our patients.
IBS is an interruption of peristalsis through the intestinal tract, triggered by stress, hormones, another illness, or a wide range of foods.
According to the Mayo Clinic, celiac disease is a chronic condition characterized by an immune reaction to gluten. Over time, the reaction damages the lining of the small intestine and causes malabsorption of nutrients. The results include lack of growth in children, stomach pain, weight loss, bloating, and diarrhea. Vital organs can also be damaged over time because of the malabsorption. Celiac, which is four times more common today than it was 60 years ago, is considered an intolerance rather than an allergy because it is not life-threatening.16
Stopping just short of actual celiac disease is gluten intolerance, also called non-celiac gluten sensitivity. The condition sometimes seems to be the fastest-growing in the country, given the proliferation of gluten-free products in grocery stores. People intolerant of gluten can have symptoms ranging from mild to major digestive problems, and/or rashes and skin eruptions that can be so severe the sufferers scratch until they bleed.
Researchers at the Mayo Clinic and other institutions have been studying possible environmental causes. A "hygiene hypothesis" theorizes that our environment is so clean the immune system turns on itself, instead of outside causes. Many feel that overprocessed wheat is to blame. The wheat we grow today is far different from that grown by our grandparents, being hybridized, fertilized, and genetically modified beyond recognition.16 Anecdotal stories on Internet blogs suggest that wheat grown in Europe is less engineered than wheat grown in the United States and Canada and can be eaten by the gluten-intolerant.
Gluten is not only an ingredient in the food products listed above under wheat allergy, but may also be found in self-stick labels, glove powder, lip balm, and medications. Gluten can be used as a filler or coating in pill and capsule formulation. The only way to identify gluten content for sure in these products is to contact the manufacturer.17,18
What about gluten in dental products? A paper published in Clinical Pediatrics in 2013 detailed a case in which a nine-year-old diagnosed with celiac disease was unable to resolve nonspecific abdominal discomfort until it was discovered that she was being continually exposed to small amounts of gluten in the plasticized methacrylate polymer of her orthodontic retainer.19
There appears to be no definitive list of gluten sources in dental products. Many dental product websites state that while there is no gluten added to their products, they will not guarantee gluten had not been inadvertently added during the manufacturing process. A search did find that products including Kolorz, Nada, Next, Nupro, Premier Enamel Pro, Crosstex Sparkle, Tom's of Maine, and Zooby by Denticator are listed on their websites as gluten free.
The safest thing to do, when confronted with an allergic or sensitive patient, is still to call the manufacturer directly. In the case of little Tynan and his mother, his appointment time can be reserved for checking with his allergist and calling relevant manufacturers. Possibly he could have his exam and any necessary radiographs, then return for a hygiene appointment after both you and his mother are confident you can treat him without exacerbating his allergy problems. RDH
Cathy Hester Seckman, RDH, has worked in pediatric dentistry for 11 years. She is a frequent contributor to dental magazines, works part-time as an indexer, and is the author of two novels and more than a dozen short stories.
1. http://www.webmd.com/allergies/guide/food-allergy-intolerances. Accessed 7-21-14
2. http://www.mayoclinic.org/diseases-conditions/food-allergy/expert-answers/food-allergy/faq-2005853. Accessed 7-21-14
3. http://www.aaaai.org/global/latest-research-summaries/New-Research-from-JACI-In-Practice/food-allergy-asthma-in-children.aspx. Accessed 7-21-14
4. http://www.foodallergy.org/allergens/milk-allergy. Accessed 7-21-14
5. Murphy AI, Campbell DE, Baines D, Mehr S. Allergic reactions to propofol in egg-allergic children. Anesth Analg. 2011 Jul;113(1):140-4. doi: 10.1213/ANE.0b013e31821b450f. Epub 2011 Apr 5.
6. http://www.foodallergy.org/allergens/shellfish-allergy. Accessed 7-21-14
7. http://www.foodallergy.org/allergens/peanut-allergy. Accessed 7-21-14
8. http://www.aaaai.org/ask-the-expert/pine-nut-allergy.aspx. Accessed 7-21-14
9. Email communication with xylitol.org 7-21-14 to 7-22-14
10. http://www.foodallergy.org/allergens/tree-nut-allergy. Accessed 7-21-14
11. http://www.foodallergy.org/allergens/soy-allergy. Accessed 7-21-14
12. http://www.foodallergy.org/allergens/wheat-allergy. Accessed 7-21-14
13. http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/. Accessed 7-23-14
14. Lester MR. Sulfite sensitivity: significance in human health. J Am Coll Nutr. Jun. 1995;14(3):229-232.
15. http://my.clevelandclinic.org/disorders/sulfite_sensitivity/hic_sulfite_sensitivity.aspx. Accessed. 7-23-14
16. http://www.mayo.edu/research/discoverys-edge/celiac-disease rise
18. Conversation with Tom Viola, RPH, CCP, 8-16-14.
19. Memon Z, et al. An orthodontic retainer preventing remission in celiac disease. Clin Pediatr. Nov. 201352(11):1034-1037.