How could this be happening? Every second felt like an hour. She was still coughing and wheezing, and that was a good sign. If she stopped, it meant her airway was completely closed. Even though she couldn’t breathe, she still didn’t want me to call 911, but of course I did. We were eating and talking one moment; she jumped up and was gone the next. All of my training in CPR wouldn’t make much difference if her airway closed completely. Hopefully the epinephrine and Benadryl would help keep her airway partially open until more help arrived. Did I start hyperventilating myself? No, I knew what to do. I realize now that staying current in my first aid training, not just the required CPR, could mean the difference between life and death. I know after this experience that I am going to do everything I can to help more people, particularly oral health professionals, realize that this scenario could happen to them.
This emergency happened to my sister and me. My sister has life-threatening food allergies that have forced her to go to the emergency room many times. Some people call her a picky eater, but she isn’t. She simply must avoid certain foods. She has become so sensitive that she reacts not only to food, but also to flour and many hair, make-up, and other self-care products most of us use every day.
Do we know what is in the products that we recommend to patients every day? More patients need to know and are asking (see sidebar.) Professionals assume products are safe for everyone because they are not aware of any problems occurring in the past. But what if they’re wrong? In the case of my sister and many others, serious injury and death could occur because of our incorrect assumptions.
The American Academy of Allergy, Asthma, and Immunology (www.aaaai.org, Milwaukee, Wis.) states there are approximately 50 million Americans suffering from some form of allergy, and those numbers are growing. The immune system serves as our defense against countless substances in the air we breathe, things we touch, and food we eat. The term allergen refers to any substance that can trigger an allergic response. When allergens enter the body of a person predisposed to allergies, a series of reactions occur and allergy-specific antibody immunoglobulin E (IgE) is produced. IgE antibodies travel to the plentiful mast cells of the eyes, nose, lungs, and gastrointestinal tract. The IgE antibodies attach to the mast cells and wait for their “radar” to detect their specific type of allergen. The next time the person is exposed to the allergens to which they are sensitive, the allergens are captured by the IgE, and mast cells release chemical mediators such as histamine. The mediators produce the symptoms and continue to recruit other inflammatory cells, resulting in more inflammation. Though it is not fully understood, substances that trigger allergic reactions in some people have no affect on others. Family history seems to be the single most important predisposing factor. Yet many suffering from allergies have no known family history.
Food allergies can be pervasive and potentially life-threatening. Our understanding of food-induced allergic reactions has increased dramatically in recent years. Food allergies in the United States were previously estimated at 2 percent of the population; more current estimates show the incidence closer to 4 to 6 percent. In the past decade, studies indicate that the prevalence of peanut allergy in children has doubled.
A food allergy is an adverse reaction to a food or food component involving the immune system. Toxic reactions are not related to individual sensitivity, but occur in anyone who ingests a sufficient quantity of trigger food. There are adverse reactions to food that involve the body’s metabolism but not the immune system. These are considered food intolerances. Table 1 shows some conditions related to food intolerances.
True allergic reactions to food are either IgE-mediated or nonIgE-mediated. As with most allergies, IgE-mediated antibodies are produced with exposure to a food protein binding with mast cells and other cells in body tissue and to basophils circulating in the blood stream. Though the reactions are the same, the pathogenesis of nonIgE-mediated reactions is not clear, but we do know that T-cells and macrophages play a role.
Many people are confused about food allergies, and myths abound. Some common myths include:
- Food allergy is a myth. This is fiction. Food allergy is a well-understood medical problem that causes a clearly defined set of symptoms.
- Food allergy is hard to diagnose because you never know when you are going to react to food. This is fiction because in a true allergy, the allergic person will react every time.
- People with food allergy are allergic to so many foods that they couldn’t eat if they avoided all of them. Studies have shown that a vast majority of people with food allergy are allergic to one or two foods.
- Food allergy is diagnosed by food allergy testing. This is true and false. Most of the time it is diagnosed by medical history. Food allergy blood tests can be helpful but may give a false positive. The double-blind controlled food challenge remains the gold standard for diagnosis of food allergies.
- Food allergy can be treated by desensitization shots or drops. This is unfortunately not the case. The only treatment is to completely avoid the problem food.
- Food allergy is rarely life-threatening. False. Food allergy remains a major cause of anaphylaxis treated in emergency rooms.
Though there are a number of promising therapeutic modalities being researched, the only proven therapy for food allergies is avoidance. This includes reading labels, avoiding high-risk situations such as buffets, and asking about ingredients. Some people think that picking an offending item out of a dish makes a food safe. This is incorrect. For someone like my sister, removing a crouton from a salad still puts her at high risk for a reaction. Reactions can occur from aerosolized food protein in the steam of cooking the food, particularly boiling seafood.
Not all reactions to food are a direct allergy to that food. An oral allergy syndrome may bring on sensitivity to foods in the same classification, in a cross-reaction manner. This can occur in a person with no known food allergies. A person with a ragweed allergy might react to fresh melons and bananas. People with grass pollen allergy might develop symptoms after eating raw tomatoes. A person allergic to birch pollen might react after eating raw potatoes, carrots, celery, apples, pears, hazelnuts, or kiwi.
The Food Allergen Labeling and Consumer Protection Act (FALCPA) became effective in January 2006. It ensures that people can easily and accurately identify ingredients that may cause a reaction. Under this law, allergen declarations must be in plain English. Though more than 160 foods have been identified as triggering food allergies, this law is limited to the eight major food allergens which account for 90 percent of food allergies in the United States. These are milk, eggs, fish (e.g., bass, flounder, cod), crustacean shellfish (e.g., crab, lobster, shrimp), tree nuts (e.g., almonds, pecans, walnuts), wheat, peanuts, soybeans, or any ingredient that contains a protein derived from one of these foods.
While some allergic reactions to food are mild, food-allergic individuals can experience severe reactions. Generalized anaphylaxis caused by food allergies accounts for at least one-third to one-half of the anaphylaxis cases seen in hospital emergency departments. Anaphylaxis is the dramatic multi-organ reaction associated with IgE-mediated hypersensitivity. Fatal food-related anaphylaxis appears to be more common in patients with underlying asthma. Symptoms usually appear rapidly, sometimes within minutes of exposure. Immediate medical attention is necessary.
Epinephrine has long been the treatment of choice for acute anaphylaxis. Even when epinephrine is used promptly, it is not always effective in severe cases. People with diagnosed food allergies should have epinephrine prescribed and carry it with them at all times. They should also wear an identification bracelet describing the allergy. Oral health professionals need to be aware of the location and use of the patient’s epinephrine, and that it must be given intermuscularly, not intravenously or subcutaneously.
The American Academy of Allergy, Asthma, and Immunology’s The Use of Epinephrine advocacy statement says: “Epinephrine must also be available in many first aid situations for use by trained personnel who can evaluate the scene, the indication, benefit, and risk of treatment with epinephrine in individual cases. These efforts could significantly reduce the annual death rate associated with sting and food anaphylaxis.”
This statement emphasized the need for personnel trained in first aid. Most practice acts require hygienists to maintain current CPR certification. CPR certification courses are not the same as and do not always include first aid training. In November 2005, the American Heart Association (AHA) and the American Red Cross (ARC) came together to review the scientific literature and publish the 2005 Guidelines for First Aid, which updated the previous guidelines. (Note: These first aid guidelines are in addition to the 2005 AHA guidelines for CPR.) Topics that are new to the 2005 guidelines include use of oxygen, use of inhalers, use of epinephrine auto-injectors, wounds and abrasions, dental injuries, snakebites, and cold emergencies. These were added to the coursework on seizures, bleeding, burns, musculoskeletal trauma, and poisoning.
An Internet search on dentistry and allergy lists numerous hits on latex sensitivity and reactions to dental anesthetics. Though latex and anesthetic sensitivity are important, they are not the only situations in which an allergic reaction can occur. Could a food allergic reaction or anaphylaxis occur in the dental office? Possibly, because dental health professionals often do not know what the products they use contain. Even trace amounts of seemingly innocuous ingredients could put someone at risk. Unless we have a full understanding of the life-threatening possibilities of allergy, early symptoms might not be recognized. Every dental health professional should enroll in a first aid training course, as well as maintain CPR certification.
It is my hope that with the research on promising therapeutic modalities, improved product labeling, and training in first aid along with a heightened awareness, my sister and others can rest better knowing that help will be there when they need it, particularly from their oral health providers.
Epilogue: It took several hours and multiple medications at the hospital to stabilize my sister. It took another several months to get her system back on track. Unfortunately, she has had more reactions that have sent her the hospital. She has committed to a campaign to increase public and professional awareness. RDH
Author’s note: Thank you to Dr. Greg Sharon for his assistance on this article. Greg Sharon, MD, is chairman of the Department of Medicine and Medical Education at Glen Oaks Hospital in Glendale Heights, Ill. He has practiced allergy/immunology in both multi-specialty and single-specialty practices. He is involved in drug allergy, asthma treatment, and psychoneuroimmunobiology, and has worked with Lyme disease, chronic fatigue, fibromyalgia, and addictive medicine patients.
1 Advocacy statement - the use of epinephrine in the treatment of anaphylaxis. American Academy of Allergy, Asthma, and Immunology. November 2002 www.aaaai.org/media/resources/academy_statements/advocacy_statements/ps26.asp.
2 American Heart Association and American Red Cross release joint Guidelines on First Aid. American Heart Association. November 2005 http://camclstc.org/lstc/instructor/pdf/instructor/TNUpdate2005GL1.pdf#search=%22American%20Heart%20Association%20and%20American%20Red%20Cross%20release%20joint%20Guidelines%20on%20First%20Aid%22.
3 Food allergies and asthma. International Food Information Counsel. May 2004 http://ific.org/food/allergy/index.cfm.
4 Guidelines for first aid. American Red Cross/American Heart Association. November 2005 https://www.instructorscorner.org/ViewDocument.aspx?DocumentId=2271.
5 Hahn M, McKnight M. Answers to frequently asked questions about FALCPA. The Food Allergy and Anaphylaxis Network. 2004 http://www.foodallergy.org/Advocacy/FALCPAFaQ14.html.
6 Sampson H. Update on food allergy. J Allergy Clin Immunol May 2004; 113(5):805-19; quiz 820.
7 Sicherer S. Manifestations of food allergy: evaluation and management. American Family Physician. Jan. 15, 1999. http://www.aafp.org/afp/990115ap/415.html.
8 The connection between food allergies and asthma. The Cleveland Clinic. January 2005 www.clevelandclinic.org/health/health-info/docs/2200/2209.asp?index=8956.
9 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.
10 Trends in allergic disease. American Academy of Allergy, Asthma, and Immunology. 2006 www.aaaai.org/media/resources/media_kit/trends_in_allergic_disease.stm.
11 Wasserman R. Food allergy: separating the fact from the fiction. American Academy of Allergy, Asthma, and Immunology. Winter 2005. www.aaaai.org/patients/advocate/2005/winter/foodallergy.stm.
Aquafresh Toothpaste ...A representative from GlaxoSmithKline has provided the following statement:
“We were recently contacted by several consumers requesting information about the possibility of trace amounts of peanut oil in our Aquafresh toothpaste products. It was our belief that trace amounts of peanut oil could be present in certain flavor blends purchased by Aquafresh from external flavor suppliers. Consequently, we responded to those consumers that there was a possibility that trace amounts of peanut oil may be present in some Aquafresh products.
“Subsequently, we have contacted our flavor suppliers to confirm this information. We are pleased to learn that all of the flavor blends currently used to manufacture Aquafresh toothpaste contain no peanuts, no peanut oil, and no peanut derivatives.
“Until we were able to validate our flavor blend information, we chose to err on the side of caution and told consumers that the products may contain trace amounts of peanut oil. In light of how serious some allergies can be, we felt that was the right thing to do. As an additional assurance, we are arranging to have independent tests of our toothpaste conducted.
“We apologize if this has caused any confusion or concern among our loyal customers. If consumers have additional questions, they may contact us toll free at (800) 897-5623.”
Conditions Related to Food Intolerance: Non-immunologic Adverse Reactions to Food
• Gastrointestinal disorders
• Structural abnormalities: hiatal hernia, pyloric stenosis, Hirschprung’s disease, tracheoesophageal fistula
• Disaccharidase deficiencies: lactase, sucrase-isomaltase complex, glucose-galactose complex
• Pancreatic insufficiency, cystic fibrosis
• Gallbladder disease
• Peptic ulcer disease
• Metabolic disorders
• Pharmacologic-related conditions
• Jitteriness (caffeine)
• Pruritis (histamine)
• Headache (tyramine)
• Disorientation (alcohol)
• Psychological disorders
• Neurologic disorders
• Gustatory rhinitis
• Auriculotemporal syndrome (facial flush from tart food)
Manifestations of Food Allergy: Evaluation and Management. American Family Physician Jan, 15, 1999 www.aafp.org/afp/990115ap/415.html.
Anaphylaxis = Killer Allergy*
Who is at risk?
Anyone, especially those allergic to foods such as peanut, tree nut, seafood, fin fish, milk, egg, and wheat, or to insect stings or bites, natural rubber latex, or medications.
When can it happen?
Within minutes, anytime the allergic person comes in contact with his or her trigger.
How do we know?
Several symptoms occur at the same tie, such as itching, hives, flushing, difficulty breathing, vomiting, diarrhea, dizziness, confusion, and shock.
Where can it happen?
Anywhere - home, restaurant, school, child care, sports facility, summer camp, car, bus, airplane, or dental office.
What should we do?
Inject epinephrine, call 911 or your local emergency number, and notify the individual’s family - in that order. Act quickly. Anaphylaxis can be mild or fatal.
*Adapted from Simmons FER, Anaphylaxis, killer allergy: long-term management in the community. Journal of Allergy and Clinical Immunology 2006; 117: 367-377.