Respiratory and Pulmonary Allergic Emergencies in Dental and Periodontal Surgery: A Systematic Review of Identification, Management, and Prevention Strategies

Maryam Kazem Pour(PubMed)(Google Scholar)

Mehdi Shokri (PubMed)(Google Scholar)

Introduction

Allergic responses to dental treatment, although often localized, can evolve to life-threatening respiratory complications such as anaphylaxis or bronchospasm. Local anesthetics, latex, and dental instruments are the most common offenders, and IgE-mediated reactions are the most dangerous [1-5]. IgE-mediated (Type I) hypersensitivity reactions are particularly risky, as they bring with them the risk of immediate mast cell degranulation, histamine release, and subsequent bronchoconstriction and airway edema, resulting in widespread impairment of oxygenation [3, 5]. On the other hand, non-IgE-mediated allergic-like reactions, such as those caused by preservatives of anesthetics (i.e., sodium metabisulfite), may also have severe respiratory compromise but through varied inflammatory mechanisms [2]. Because of the significant risk of these emergencies, prompt identification, quick intervention, and preventive strategies are essential to risk minimization and better patient outcomes during dental procedures [6-8].

The epidemiological significance of allergic emergencies in dental clinics cannot be overstated. While there is limited worldwide data, studies show that major allergic reactions, including anaphylaxis, are seen following 1 in 1,000 to 1 in 10,000 dental procedures, with a mortality rate as high as 1–3% if left untreated [9, 10]. Local anesthetics and latex are the most frequent triggers mentioned, causing over 60% of cases [11]. These statistics highlight the need for greater caution and preparedness in dental practice to prevent unnecessary death.

Despite the widely publicized risk of anaphylaxis and airway complications in the dental setting, there are relevant research gaps. Firstly, no systematic review specifically of respiratory and pulmonary allergic emergencies in dental and periodontal surgery exists. Although most reviews available report on general anaphylaxis management, none of them emphasize dental-specific allergens, airway management, or the late effects on the respiratory system of such reactions [12, 13]. Second, practitioner preparedness remains insufficient, as questionnaires indicate that the majority of dentists do not receive adequate training in anaphylaxis management protocols, airway stabilization algorithms, or proper epinephrine injection [14, 15]. Third, there is a serious shortage of standardized prevention protocols. Although allergy testing, premedications, and material substitution strategies are being used, there is a lack of consensus on best practices for preventing allergic respiratory disasters in dental surgery [16]. To cover these gaps, this systematic review attempts to synthesize and review existing studies to provide a comprehensive overview of the diagnosis, emergency management, and prevention of respiratory allergic complications of dental and periodontal surgical procedures.

The central purpose of this systematic review is to critically evaluate the diagnosis, management, and prevention of pulmonary and respiratory allergic emergencies in dental and periodontal treatment. More precisely, the review seeks to outline the frequent allergens that have been implicated in these reactions, including local anesthetics, latex, antiseptics, and dental restoratives, and contrast their clinical patterns, differentiating IgE- and non-IgE-mediated reactions. In addition, it will present current emergency management guidelines, such as first-line pharmacologic therapy of allergies (e.g., epinephrine, bronchodilators) and stabilization of the airway methods, and address preventive measures such as preoperative allergy testing, premedication, and material substitution. Furthermore, this review will identify gaps in practitioner preparedness and provide evidence-based recommendations to further prepare dental practitioners with information and response abilities in allergic airway emergencies.

This systematic review contributes to clinical and academic practice by combining evidence from diverse case reports, cohort studies, and systematic reviews to yield a systematic, detailed information source for the treatment of respiratory allergic emergencies in dental surgery. It discusses best practice in the diagnosis of genuine allergic emergencies versus mimicking presentations, such as vasovagal attacks or sulfite-induced bronchospasm, to optimize diagnostic performance in high-risk situations. Additionally, it points out areas of dentist preparedness and advocates for tangible reforms in training and protocol administration to enhance emergency response. By informing preventive models of preoperative patient assessment, this review can potentially reduce the risk of allergic complications by way of proactive screening, material substitution, and premedication protocols. Finally, it fulfills the need for clinical standardization by studying existing guidelines and condensing guidelines for enhanced dental surgical practice for enhanced safety, ultimately leading to better patient outcomes and safety in this vital area.

Methods 

This is a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) systematic review [17]. We systematically search, screen, and synthesize the existing evidence on respiratory and pulmonary allergic emergencies of dental and periodontal surgery, from their identification to emergency management and prevention.

Research Questions

1. Which are the most common system allergens and risk factors of respiratory and pulmonary allergic emergencies in dental and periodontal treatment?
2. What are the clinical characteristics of these emergencies, and how do IgE-mediated events compare with non-IgE-mediated events?
3. What are the optimal acute emergency measures in management of respiratory allergic reactions (e.g., anaphylaxis, bronchospasm, airway obstruction) in the dental office?
4. What are the best pharmacologic and non-pharmacologic treatment modalities (e.g., epinephrine, corticosteroids, oxygen administration)?
5. What allergy testing protocols (e.g., skin testing, screening medical history) are applicable to patients who are to receive dental surgeries?
6. How effective are prophylactic premedications (e.g., antihistamines, bronchodilators) in preventing respiratory allergic complications?
7. What training and preparedness demands need to be implemented to be instituted in order to maximize emergency handling of anaphylaxis and other respiratory allergic complications in dentists?

Databases and Search Strategy

A comprehensive literature search was conducted in the following scientific databases to give a thorough overview of the available evidence:

1. PubMed (MEDLINE)
2. Scopus
3. Web of Science
4. Cochrane Library
5. Embase

Additionally, further searches were also carried out in Google Scholar for grey literature and ClinicalTrials.gov for current studies. The search strategy utilized a combination of keywords and MeSH terms to maximize the recall of studies of relevance. Search terms and strategies are provided in Supplementary File 1 in detail.

Inclusion and Exclusion Criteria

Inclusion criteria

• Study Design: Clinical trials (case report, case series, cohort study, cross-sectional survey, randomized controlled trial), systematic reviews, and reviews by experts based on guidelines.
• Study Population: Patients who had nasal or oral intubation during dental or periodontal surgery and exhibited respiratory and pulmonary allergic reactions to surgical allergens (e.g., anesthetics, latex, antiseptics).
• Outcome Measures: Risk factors and allergens Identification of respiratory allergic symptoms (airway obstruction, bronchospasm, anaphylaxis) Methods utilized in emergency management (premedications, interventions) Preventive protocols instituted (premedications, screening tests, allergy history).
• Time Frame: Papers published between 2000–2025 to ensure pertinence to current dental procedures.
• Language: English-language articles only.

Exclusion Criteria

• Irrelevant Medical Contexts: Allergies to drugs that are irrelevant to dental or periodontal therapy, general dermatological/mucosal allergies without respiratory involvement.
• Non-Allergic Respiratory Events: Papers on drug adverse reactions in dentistry that are not immune-mediated mechanisms of allergy.
• Non-Surgical Contexts: Studies on general dentistry with no reference to dental/periodontal surgeries or procedural allergens.
• Animal or In Vitro Studies (except with direct relevance to clinical implications).

Study Selection

1. Title and Abstract Screening: The titles and abstracts will be independently screened for relevancy by two reviewers.
2. Full-Text Review: Filtered full-text pre-selected articles will be screened based on inclusion and exclusion criteria.
3. Inter-Reviewer Agreement: Disagreements in decision-making shall be resolved by consensus or referral to a third reviewer.
4. PRISMA Flow Diagram: Study selection will be documented using a flowchart.

Data Extraction and Synthesis

Data will be extracted using a standardized data extraction form. Information to be extracted includes:

• Study Characteristics: Authors, publication year, study type, Geographic location, and patient demographics.
• Allergenic Causes Identified: Local anesthetics, Latex Dental materials, Other procedural allergens.
• Clinical Presentation: Anaphylaxis (immediate hypersensitivity), airway obstruction; delayed or chronic respiratory allergic reactions.
• Emergency Management Strategies: Medications (epinephrine, antihistamines, corticosteroids, bronchodilators), Airway Support Strategies (oxygen therapy, intubation, resuscitation). Results of emergency intervention.
• Preventive Practices: Patient screening and recording allergy history, pre-medication and desensitization protocols, Dental practitioner preparedness, training, and protocol adherence.

Quality and Risk of Bias Assessment

For strict screening for bias, all studies included will be assessed by two independent reviewers with validated tools based on study design:

• Case-Control & Cohort Studies: Newcastle-Ottawa Scale (NOS) for evaluating selection, comparability, and outcome/exposure.
• Randomized Controlled Trials (RCTs): Cochrane Risk of Bias 2 (RoB 2) tool, covering randomization, deviations, missing data, outcome measurement, and reporting.
• Cross-Sectional Surveys: Joanna Briggs Institute (JBI) Critical Appraisal Checklist, covering sampling, measurement validity, and statistical analysis.
• Systematic Reviews & Guidelines: AMSTAR-2 to evaluate methodological quality, including protocol adherence and meta-analysis quality.

For case reports and series, an abbreviated checklist will assess follow-up records, intervention data, and diagnostic confirmation (e.g., confirmatory allergy tests).

Inter-rater reliability will be estimated by Cohen’s kappa (κ), with resolution of disagreements by consensus or third-reviewer adjudication. High-risk of bias studies will be flagged, and their impact investigated with sensitivity analyses (e.g., exclusion or subgroup comparisons).

Results

Our database search findings gave us a total of 1200 articles. After eliminating 450 duplicate articles that we found, we were left with 750 articles to further assess. Using our inclusion and exclusion criteria, we omitted 300 articles based on the following grounds:

• Not published in English: 50 articles
• Unrelated to our study: 250 articles

Following these exclusions, 450 articles remained. An additional title and abstract screen eliminated a further 200 articles, and a full-text screen eliminated another 203 articles. This ultimately resulted in a final list of 47 relevant articles from the database search (Figure 1).

Figure 1. Flowchart of Article Selection Process: Identification, Screening, Eligibility, and Inclusion in the Systematic Review.

Data extraction included 47 studies of respiratory and pulmonary allergic emergencies during dental and periodontal surgery, identification, management, and prevention. Supplementary File 2 documents the complex findings from extraction in an unambiguous, tabulated manner. The table includes a concise overview of evidence for each study in a readable format to facilitate an in-depth examination of the surveyed literature.

Common Allergens and Risk Factors Leading to Respiratory and Pulmonary Allergic Emergencies in Dental and Periodontal Surgeries

Table 1 synthesizes the primary allergens and associated risk factors identified in studies review, focusing on their relationship with respiratory and pulmonary allergic emergencies in dental and periodontal surgeries.

Clinical Manifestations of Respiratory and Pulmonary Allergic Emergencies in Dental and Periodontal Surgeries, and Differentiation Between IgE- and Non-IgE-Mediated Reactions

Table 2 summarizes the primary respiratory and pulmonary allergic manifestations observed in dental and periodontal surgeries, clearly differentiating IgE-mediated (allergic) responses from non-IgE-mediated mechanisms such as chemical irritants, toxicity reactions, and pharmacologic side effects.

Best Practices for Acute Emergency Management of Respiratory Allergic Reactions in Dental Settings

Table 3 systematically identifies best-practice emergency management strategies for allergic airway complications in dental settings, based on a review of relevant studies.

Pharmacological and Non-Pharmacological Interventions for Respiratory Allergic Emergencies in Dental Settings

Table 4 is based on article review and synthesizes pharmacological and non-pharmacological strategies for emergency intervention in respiratory allergic complications during dental procedures.

Allergy Assessment Protocols for Patients Undergoing Dental Surgeries

Table 5 outlines the recommended allergy assessment protocols for patients undergoing dental surgeries, based on a review of relevant studies.

Effectiveness of Preventive Premedications in Reducing Respiratory Allergic Complications in Dental Surgeries

Table 6 findings are based on article review, focusing on the effectiveness of premedications in preventing respiratory allergic complications during dental procedures.

Training and Preparedness Measures for Dental Professionals to Respond to Anaphylaxis and Allergic Respiratory Emergencies

Table 7 outlines key training and preparedness measures that can better equip dental professionals to respond to anaphylaxis and allergic respiratory emergencies.

Discussion

The point of discussion is current allergens, clinical presentation, emergency management protocols, preventive measures, and the preparedness of dental practitioners in handling such life-threatening conditions.

The most frequently seen allergens in dental clinics are local anesthetics (particularly lidocaine), latex, antiseptics (e.g., chlorhexidine), sulfite preservative additives in anesthetics, and dental restorative materials (e.g., methacrylates, persulfates) [3, 15, 18, 19, 21, 22, 25]. Local anesthetic hypersensitivity is held to account for a large proportion of anaphylactic and respiratory responses reported, with the drug most commonly incriminated being lidocaine [3, 14, 18, 21]. Though true IgE-mediated reactions to local anesthetics are uncommon, sodium metabisulfite, used as an added preservative in certain anesthetics, has been identified as a cause of non-IgE-mediated hypersensitivity reactions that produce respiratory distress [15]. Latex allergy remains a generally accepted risk factor, particularly in those with an atopic background or a history of latex allergy [25]. Powdered latex fine particles can cause bronchospasm or anaphylaxis and require strict latex-free protocols in high-risk individuals [25]. Hypersensitivity to chlorhexidine, not as well characterized, has resulted in cases of anaphylaxis in the dental setting [48]. Risk indicators for such reactions include a history of drug allergies, asthma, atopic disorders, multiple previous exposures to anesthetics, and mast cell disorders in the systemic system [5, 20, 22]. Patients with asthma are particularly susceptible to bronchospasm and airway occlusion following exposure to an allergen and may require special precautions during dental treatment [34, 35].

Dental office presentations of respiratory allergic emergencies include laryngeal edema, bronchospasm, wheezing, stridor, cyanosis, and respiratory distress, typically in a few minutes following exposure to the allergen [5, 18, 20]. Full-blown presentations progress to airway obstruction and cardiovascular collapse that require urgent treatment [1, 6, 36]. IgE-mediated anaphylaxis is characterized by rapid onset (within minutes), urticaria, angioedema, hypotension, and airway compromise secondary to histamine release from mast cell degranulation [14, 36]. Serum tryptase levels can also be increased, confirming mast cell activation [5, 33]. But non-IgE-dependent hypersensitivity reactions (e.g., NSAID or sulfite hypersensitivity, MRGPRX2-mediated mast cell activation) can produce the same symptoms regardless of histamine activity [15, 21, 26]. Negative serum tryptase and late onset of symptoms (e.g., sulfite reaction causing bronchospasm within minutes to hours) can differentiate these reactions.

There has always been a focus in studies on the need for immediate diagnosis and prompt intramuscular epinephrine administration as the initial treatment for anaphylaxis in a dental setting [1, 4, 6, 36]. Adjuncts include airway management, oxygen therapy, and antihistamines/corticosteroids, but are not to delay administration of epinephrine [36, 48]. For edema of the larynx and airway obstruction, prompt identification and escalation to emergency airway management (e.g., intubation, cricothyrotomy when required) is required [5, 18, 20]. Mild bronchospasm (e.g., dyspnea, wheezing) is managed with rapid-acting bronchodilators (e.g., salbutamol inhalers) along with epinephrine [34, 35]. Dental practitioners should also stimulate EMS, position the patient supine, observe vital signs at regular intervals, and arrange for immediate transfer to a hospital [1, 36].

Treatment of choice for anaphylaxis is intramuscular epinephrine (0.3-0.5 mg IM for adults, 0.01 mg/kg in children), which is the standard for anaphylaxis treatment [1, 36]. Second-line therapies, including antihistamines (e.g., diphenhydramine, cetirizine) and corticosteroids (e.g., hydrocortisone, methylprednisolone), control secondary symptoms but don’t substitute for epinephrine [34, 36]. Bronchodilators such as salbutamol (albuterol) inhalers also work well to relieve allergic bronchospasm, particularly in asthmatic individuals [34]. Fluid resuscitation and high-flow oxygen are also important to reverse shock and hypoxia [18, 36]. Non-pharmacologic interventions, such as the provision of a latex-free environment, minimization of preservatives in anesthetics (e.g., avoidance of sodium metabisulfite wherever possible), and provision of an emergency airway kit in clinics, play a significant role in the prevention and treatment of allergic reactions [25, 32].

Extensive screening for medical history, including drug allergies in the past, atopy, asthma, and prior episodes of anaphylaxis, is crucial for risk stratification before dental treatment [1, 16, 22]. Skin testing and intradermal testing for hypersensitivity to local anesthetics, especially in reaction-prone individuals who have a history of reactions to lidocaine, is recommended [16, 21]. Pre-surgical screening for serum-specific IgE against latex, chlorhexidine, and anesthetic allergens should be part of high-risk scenarios [25]. Oral or intravenous challenge testing under controlled settings may affirm the safety of anesthetics in equivocal skin tests [10, 22].

Preventative premedications such as corticosteroids (e.g., prednisone, methylprednisolone) and antihistamines (e.g., cetirizine, diphenhydramine) can be employed to prevent mild allergic reactions in drug-sensitive patients but fail to prevent anaphylaxis [2, 34]. Preoperative bronchodilators (e.g., salbutamol) increase airway stability and are helpful in reducing the risk of bronchospasm in asthma sufferers [34, 35]. Preventive strategies such as the application of preservative-free anesthetics and non-latex gloves remain the optimal methods of preventing allergic reactions rather than solely relying on drugs [15, 25, 32].

Studies recognize significant deficits in knowledge and preparedness among dentists regarding the management of anaphylaxis [42-44, 47, 48]. Findings of questionnaires reveal that the majority of dental practitioners are not adequately trained in epinephrine dosing, airway management, and recognizing anaphylaxis [43, 47]. Acceptable training measures are simulation training to enhance emergency response competence and reduce reluctance to administer epinephrine [43, 46]. Emergency preparedness guidelines with standard procedures like the availability of a well-stocked emergency kit containing epinephrine, oxygen, antihistamine, corticosteroids, and bronchodilators must be uniformly adopted [36, 42]. BLS and advanced airway management courses must be made mandatory as part of dental professional education [1, 6, 18, 47]. Also critical are compulsory continuing education sessions on anaphylaxis and the treatment of respiratory emergencies [42, 43, 46].

Lastly, respiratory allergic emergencies in dentistry are most often caused by local anesthetics, latex, and antiseptics and are at higher risk in asthmatics, atopics, or individuals with a history of allergic reactions [3, 18, 21, 25]. IgE-mediated anaphylaxis is still the most severe manifestation, with immediate epinephrine injection and airway control [1, 6, 36]. Precautions such as preoperative allergy testing, premedication with medications (antihistamines, corticosteroids, bronchodilators), and avoidance of allergen exposures decrease risks but cannot completely avoid severe anaphylactic episodes [1, 22, 34]. With the substantial dentist readiness gaps in perspective, regular simulation-based training and standardized emergency response algorithms must be encouraged in an attempt to improve outcomes in dental allergic emergencies [42, 43, 46-48]. Thus, while effective emergency algorithms do exist, increased training, preoperative risk stratification, and preventive measures must be implemented universally in dental practice in an attempt to optimize patient safety in managing allergic respiratory complications.

This systematic review has several drawbacks, including reliance on case reports and retrospective analyses, thereby limiting generalizability and bias. Self-reported data on preparedness among dentists don’t always translate to clinical skill, and it is inadequately studied whether chronic respiratory complications arising from allergic emergencies in the dentist’s office do occur. Inconsistency in investigation protocols for allergies and the absence of uniform application of standardized diagnostic tests make comparison more difficult. Geographical biases decrease worldwide generalizability significantly, with a majority of individuals included studies being from high-income regions—most notably North America (42%), Western Europe (33%), and East Asia (15%)—with underrepresented regions being Africa (<2%), Latin America (3%), and South Asia (5%). The bias may be a consequence of variations in healthcare delivery, publishing facilities, or geographic variations in allergen exposure (for instance, latex vs. anesthetic prevalence). Furthermore, much is not understood concerning hypersensitivity to newer dental materials, such as methacrylates and other anesthetics. Prospective study, standardized diagnosis, long-term follow-up, and prolonged training evaluation are recommended in future studies to enhance the prevention and treatment of respiratory allergic emergencies in dental practice.

Declaration

Ethics Approval and Consent to Participate: In accordance with the research policies of Ilam University of Medical Sciences, this study was exempt from ethical review because it is a systematic review of existing literature and does not involve primary data collection from human or animal participants.

Consent for Publication: As the corresponding author and on behalf of all authors, I provide the journal with full publication rights to this journal.

Conflict of Interests: No competing interests were disclosed.

Declaration of generative AI: During the preparation of this work, the authors used ChatGPT version 4 to enhance grammar, spelling, and clarity, and to improve sentence structure and overall readability. The AI tool was not used for generating original scientific content, designing experiments, performing data analysis, or drawing conclusions. All ideas, interpretations, and conclusions in this work are solely those of the authors. The authors have thoroughly reviewed and verified all AI-assisted edits to ensure accuracy and integrity of the final manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Funding: No institutional funding was gained for this article.

Authors’ contributions: MK: was responsible for the study’s conception and design, prepared the first draft of the manuscript and revised the manuscript, analyzed the results, made critical revisions to the paper for important intellectual content, and supervised the study; MS: searched the relevant databases and included the appropriate articles according to the study objective, and prepared the first draft of the manuscript and revised the manuscript; BFM: revised the manuscript; FS: supervised the whole study. All authors read and approved the final manuscript.

Acknowledgments: Not applicable.