- Email: [email protected]
Local anesthetic sensitivity
Local anestheticsensitivity Report of a case
Rocco J. Latronica, D.D.S.,* Allen Fred Goldberg, D.D.S.,” and John R. Wightman, D.D.S.,“* Hines, Ill. VETERANS
ADMINISTRATION
HOSPITAL
A
45-year-old man was admitted to Veterans Administration Hospital in Hines, Illinois, on Dec. 13,1968, for treatment of a duodenal ulcer. In accordance with hospital policy, the patient was examined by the dental clinic within 48 hours following his admission. Physical and radiographic examination revealed restorable carious teeth and rather severe periodontal disease involving most of the maxillary molars. The patient’s oral hygiene was observed to be chronically inadequate. A treatment plan consisting of removal of the maxillary molars, treatment of the generalized periodontal disease, and restoration of the carious teeth was prescribed. Subsequent evaluation for prosthetic replacement of missing teeth was to be based on the patient’s response to therapy. The physical examination and laboratory work-up revealed nothing remarkable when viewed with respect to the reason for hospitalization. The patient had a history of severe angioneurotie edema of the face, airway, and hands following injection of intravenous pyelogram contrast media. In addition, he was allergic to tetracycline, grapes, strawberries, and procaine. After a coordination of treatment objectives with the assigned physician, the patient was given an appointment with the oral surgery clinic. At the time of this initial appointment, the proposed treatment plan was explained to the patient, with an explanation of possible operative and postoperative complications that could conceivably occur. During this appointment the patient related that on several past occasions, while under treatment by various private dental practitioners, he had experienced the occurrence of transient skin rashes, itching symptoms, and “hives” following the administration of local anesthetic agents and had concluded from *Staff Dentist, Oral Surgery **Intern, Dental Service.
Section.
439
440
Latrokca,
O.S.,O.M. & OP.
Goldberg, a,jd IVightnm)~
September,
1969
this that he was allergic to them. He also recalled being told that he was “allergic to Novocain.” To determine the possible sensitivity to lidocaine, intradermal testing was performed at this time. The local anesthetic solution most prevalently used in our dental clinic is a lidocaine solution supplied in a 1.8 ml. Carpule containing a total of 36 mg. of lidocaine hydrochloride, 0.018 mg. of epinephrine (1 :lOO,OOOdilution), and methylparaben (preservative), 1.8 mg. Approximately 0.1 ml. of 2 per cent lidocaine with methylparaben was injected intradermally into the patient’s forearm, and an equal quantity of normal saline solution was similarly injected in an adjacent area as a control. Thirty minutes after the initial injection a positive reaction at the lidocaine injection site was evidenced by the presence of erythema and wheel formation. The site of the lidocaine injection was inflamed 24 hours after injection, while the control site appeared normal. On the following day, the test was repeated with a solution containing mepivacaine hydrochloride (20 mg, per milliliter) and no preservative. Observation at both 30 minutes and 24 hours shows no reaction to this agent. During the next 30 days the prescribed surgical procedures were performed, with a 2 per cent mepivacaine solution without preservative used for regional anesthesia. At no time during this period were any adverse reactions to the injected solution observed or reported by the patient. After completion of the surgical phase of treatment, the patient was retested for lidocaine sensitivity. The intradermal skin test was repeated with a 2 per cent solution of lidocaine without preservative. Observation 30 minutes and 24 hours following injection showed no reaction to the anesthetic agent at the test injection site. DISCUSSION
Local anesthetics may be classified into two separate categories: (1) the aminobenzoic acid esters (para-amino, meta-amino, para-ethoxybenzoic, benzoic) , which are all chemically related, and (2) the anilides (nonesters), which may or may not be individually chemically related. Common examples of each type are shown here, followed by their proprietary brand name in parentheses. The benzoic acid ester group includes procaine (Novocain, Ethocaine, Neocaine) , tetracaine (Pontocaine) , 2chloroprocaine (Nesacaine) , and butethamine (MonoCaine). The anilide group includes lidocaine (Xylocaine, Octocaine) , mepivaCaine (Carbocaine) , prilocaine (Citanest) , dibucaine (Nupercaine), and phenaCaine (Holocaine) . Methylparaben is an organic compound occurring as a white crystalline powder or as small colorless crystals. It is used as a preservative in some local anesthetics, and it is very commonly used as a preservative and fungistatic agent in the preparation of hydrophilic ointments. Its empirical formula is CsHsO,. Its structural formula bears a marked resemblance to that of para-amino benzoic acid : NH,
COOH @
PABA
HO
COOCHa
0 Methylparaben (Methyl p-hydroxybenzoa)
Volume Number
Local anesthetic
28 3
sensitivity
441
The aminobenzoic-acid-derived local anesthetics possess the acid radical figure that is evident in the structure of several compounds of highly antigenic quality. It is this structural resemblance to which cross reaction among esters of aminobenzoic acid is commonly attributed There is also evidence that reactions to first application of a local anesthetic may occur by virtue of a cross sensitization from exposure to other compounds with a similar chemical configuration. Allergic and contact dermatitis following exposure to creams and lotions containing paraben compounds as preservatives have recently been rep0rted.l Methylparaben is a compound whose configuration is chemically related to paraamino benzoic acid. Although skin testing alone does not give the total answer to whether a patient is sensitive to a certain drug, it is usually assumed that patients cannot safely receive the drugs to which they specifically react. For this reason, intracutaneous skin testing was of practical value in the treatment of our patient and should be considered in the treatment of any patient with a history of sensitivity to local anesthetic drugs. Considering the possibilities of methylparaben sensitivity, it is necessary to use solutions without preservatives, as the presence of these agents can lead to false assumptions of sensitivity.’ SUMMARY
A patient with a history of sensitivity to local anesthetic agents may also be sensitive to the preservative commonly used in these solutions. The distinction between the two must be kept in mind if patients are to be treated rationally. REFERENCES
1. Gaul, L. E.: Cross Sensitization Anesthesiology 16: 606, 1955. 2. Aldrete, J. A., and Johnson, D. A.:
From Allergy
Para-aminobenzoate to Local
Anesthetics,
in
Sunburn
J.A.M.A.
Preventives,
207: 356, 1969.
Rocco J. Latronica, D.D.S.,* Allen Fred Goldberg, D.D.S.,” and John R. Wightman, D.D.S.,“* Hines, Ill. VETERANS
ADMINISTRATION
HOSPITAL
A
45-year-old man was admitted to Veterans Administration Hospital in Hines, Illinois, on Dec. 13,1968, for treatment of a duodenal ulcer. In accordance with hospital policy, the patient was examined by the dental clinic within 48 hours following his admission. Physical and radiographic examination revealed restorable carious teeth and rather severe periodontal disease involving most of the maxillary molars. The patient’s oral hygiene was observed to be chronically inadequate. A treatment plan consisting of removal of the maxillary molars, treatment of the generalized periodontal disease, and restoration of the carious teeth was prescribed. Subsequent evaluation for prosthetic replacement of missing teeth was to be based on the patient’s response to therapy. The physical examination and laboratory work-up revealed nothing remarkable when viewed with respect to the reason for hospitalization. The patient had a history of severe angioneurotie edema of the face, airway, and hands following injection of intravenous pyelogram contrast media. In addition, he was allergic to tetracycline, grapes, strawberries, and procaine. After a coordination of treatment objectives with the assigned physician, the patient was given an appointment with the oral surgery clinic. At the time of this initial appointment, the proposed treatment plan was explained to the patient, with an explanation of possible operative and postoperative complications that could conceivably occur. During this appointment the patient related that on several past occasions, while under treatment by various private dental practitioners, he had experienced the occurrence of transient skin rashes, itching symptoms, and “hives” following the administration of local anesthetic agents and had concluded from *Staff Dentist, Oral Surgery **Intern, Dental Service.
Section.
439
440
Latrokca,
O.S.,O.M. & OP.
Goldberg, a,jd IVightnm)~
September,
1969
this that he was allergic to them. He also recalled being told that he was “allergic to Novocain.” To determine the possible sensitivity to lidocaine, intradermal testing was performed at this time. The local anesthetic solution most prevalently used in our dental clinic is a lidocaine solution supplied in a 1.8 ml. Carpule containing a total of 36 mg. of lidocaine hydrochloride, 0.018 mg. of epinephrine (1 :lOO,OOOdilution), and methylparaben (preservative), 1.8 mg. Approximately 0.1 ml. of 2 per cent lidocaine with methylparaben was injected intradermally into the patient’s forearm, and an equal quantity of normal saline solution was similarly injected in an adjacent area as a control. Thirty minutes after the initial injection a positive reaction at the lidocaine injection site was evidenced by the presence of erythema and wheel formation. The site of the lidocaine injection was inflamed 24 hours after injection, while the control site appeared normal. On the following day, the test was repeated with a solution containing mepivacaine hydrochloride (20 mg, per milliliter) and no preservative. Observation at both 30 minutes and 24 hours shows no reaction to this agent. During the next 30 days the prescribed surgical procedures were performed, with a 2 per cent mepivacaine solution without preservative used for regional anesthesia. At no time during this period were any adverse reactions to the injected solution observed or reported by the patient. After completion of the surgical phase of treatment, the patient was retested for lidocaine sensitivity. The intradermal skin test was repeated with a 2 per cent solution of lidocaine without preservative. Observation 30 minutes and 24 hours following injection showed no reaction to the anesthetic agent at the test injection site. DISCUSSION
Local anesthetics may be classified into two separate categories: (1) the aminobenzoic acid esters (para-amino, meta-amino, para-ethoxybenzoic, benzoic) , which are all chemically related, and (2) the anilides (nonesters), which may or may not be individually chemically related. Common examples of each type are shown here, followed by their proprietary brand name in parentheses. The benzoic acid ester group includes procaine (Novocain, Ethocaine, Neocaine) , tetracaine (Pontocaine) , 2chloroprocaine (Nesacaine) , and butethamine (MonoCaine). The anilide group includes lidocaine (Xylocaine, Octocaine) , mepivaCaine (Carbocaine) , prilocaine (Citanest) , dibucaine (Nupercaine), and phenaCaine (Holocaine) . Methylparaben is an organic compound occurring as a white crystalline powder or as small colorless crystals. It is used as a preservative in some local anesthetics, and it is very commonly used as a preservative and fungistatic agent in the preparation of hydrophilic ointments. Its empirical formula is CsHsO,. Its structural formula bears a marked resemblance to that of para-amino benzoic acid : NH,
COOH @
PABA
HO
COOCHa
0 Methylparaben (Methyl p-hydroxybenzoa)
Volume Number
Local anesthetic
28 3
sensitivity
441
The aminobenzoic-acid-derived local anesthetics possess the acid radical figure that is evident in the structure of several compounds of highly antigenic quality. It is this structural resemblance to which cross reaction among esters of aminobenzoic acid is commonly attributed There is also evidence that reactions to first application of a local anesthetic may occur by virtue of a cross sensitization from exposure to other compounds with a similar chemical configuration. Allergic and contact dermatitis following exposure to creams and lotions containing paraben compounds as preservatives have recently been rep0rted.l Methylparaben is a compound whose configuration is chemically related to paraamino benzoic acid. Although skin testing alone does not give the total answer to whether a patient is sensitive to a certain drug, it is usually assumed that patients cannot safely receive the drugs to which they specifically react. For this reason, intracutaneous skin testing was of practical value in the treatment of our patient and should be considered in the treatment of any patient with a history of sensitivity to local anesthetic drugs. Considering the possibilities of methylparaben sensitivity, it is necessary to use solutions without preservatives, as the presence of these agents can lead to false assumptions of sensitivity.’ SUMMARY
A patient with a history of sensitivity to local anesthetic agents may also be sensitive to the preservative commonly used in these solutions. The distinction between the two must be kept in mind if patients are to be treated rationally. REFERENCES
1. Gaul, L. E.: Cross Sensitization Anesthesiology 16: 606, 1955. 2. Aldrete, J. A., and Johnson, D. A.:
From Allergy
Para-aminobenzoate to Local
Anesthetics,
in
Sunburn
J.A.M.A.
Preventives,
207: 356, 1969.