Abstract
A 29-year-old Japanese man with food-dependent exercise-induced anaphylaxis (FDEIA) underwent tooth extraction under general anesthesia. FDEIA is a rare condition in which anaphylaxis occurs due to exercise load or oral administration of NSAIDs after ingestion of allergens. Wheat is often the cause in FEDIA, defined as wheat-dependent exercise-induced anaphylaxis (WDEIA). It is an allergy that is not well known in the dental field. Patients may ingest the causative food on a regular basis because they do not develop without factors such as exercise. Post extraction period was uneventful as the patient was instructed not to ingest wheat before the treatment or while he was taking NSAIDs. We were able to safely extract teeth without causing anaphylaxis.
Keywords: Tooth extraction, Food dependent exercise induced anaphylaxis, Wheat dependent exercise induced anaphylaxis, NSAIDs
Introduction
Food-dependent exercise-induced anaphylaxis (FDEIA) is a relatively rare allergic condition in which symptoms appear due to exercise load following ingestion of the causative food. Herein, we report the case of a patient with FDEIA who underwent tooth extraction under general anesthesia.
Case Report
A 29-year-old Japanese man presented with horizontally impacted mandibular third molars bilaterally. The patient was referred by a general dentist for tooth extraction under general anesthesia. At 14 years of age, he experienced an episode of dyspnea due to exercise following consumption of bread. Following this, allergic symptoms such as rash and dyspnea appeared on playing musical instruments; he was therefore diagnosed with wheat-exercise-induced allergy. Furthermore, he had a medical history of tricuspid valve insufficiency and ventricular septal defect; at age 17 years, he had undergone radical surgery for ventricular septal defect and tricuspid valve closure.
Immediately after the allergy onset, he was prescribed a restricted diet, eliminating wheat completely, and antihistamines. However, he was not on a restricted diet when he reported to our department. Anaphylaxis had not recurred because he was careful to avoid wheat intake before exercise.
On the panoramic radiograph, the mandibular wisdom teeth appeared horizontally impacted within the bone (Fig. 1). Tooth extraction was performed under general anesthesia on the day of hospitalization, after administration of 2 g of ampicillin to prevent infective endocarditis. Additionally, wheat was not provided during hospitalization, and excessive exercise load was not applied during extraction. The patient was discharged the next day with no record of any adverse events. Acetaminophen was prescribed for pain management; however, as the pain was severe, non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed. The patient was advised to maintain a wheat-free diet when using NSAIDs, and anaphylaxis was not observed.
Fig. 1.
Panoramic radiograph showing horizontally impacted wisdom teeth bilaterally in close proximity to the mandibular canal and the crown covered by bone
Discussion
The incidence of immunoglobulin E (IgE)-medicated wheat allergy in children is estimated to be 0.2–1.3% in the European Union and 0.4% in the US [1, 2]. According to the European Union guidelines, FDEIA is more common in adults than in children [3], Manabe et al. reported an incidence of 0.047% in 170,000 elementary -school students and 0.018% in 76,000 junior-high school students [4]. It is a special type of food allergy, wherein the associated symptoms are induced by additional cofactors, such as exercise and oral administration of NSAIDs after the ingestion of causative food [5]. Although the etiopathogenesis of FDEIA is not clearly understood, exercise has been suggested to lower the threshold for allergies [6]; therefore, ingestion of causative food 4 h before exercise should be avoided [7]. FDEIA-related symptoms do not usually appear after ingestion of causative food alone; however, they are induced by exercise load after ingestion of the allergen. Moreover, the patients themselves are often unable to recognize the allergens, and there is lack of clarity regarding the effects of exercise load on the allergic reaction. In this case, the patient was aware of the allergen and was careful to avoid exercise after wheat ingestion. In this way, some patients who are aware of the FDEIA regularly consume the causative food by taking precautionary measures. Hence, it is important to confirm the circumstances under which the symptoms appear if there is a food allergy. If FDEIA is suspected, it is important to ask the patient to avoid the causative food before dental treatment or oral surgery and when using NSAIDs. Inomata et al. reported that etodolac, a selective COX-2 inhibitor, does not allergic reactions in FDEIA [8]. Hence, we should prescribe acetaminophen or etodolac as analgesics for patients with FDEIA. However, in the present case, as acetaminophen was ineffective, we prescribed NSAIDs and instructed the patient to avoid wheat. Routine dental treatment in patients with FDEIA does not require general anesthesia. However, third molar extractions are quite invasive, and apart from the epinephrine in the anesthetic solution, the stress-induced epinephrine release during an exercise load. Thus, dentists should be aware of FDEIA and should exercise when treating patients with known history. Tsuda et al. performed maxillary median transection surgery under local anesthesia for tooth extraction and under general anesthesia in patients with FDEIA. Olopatadine was administered orally 2 weeks before the treatment, and treatment under general anesthesia was uneventful [9]. However, such measures are not always necessary if such patients are placed on restricted diet and NSAIDs. Finally, because of the lack of clarity on the equivalence of the amount stress caused by an invasive dental treatment to that during an exercise load, an epidemiological investigation of FDEIA in dental treatment or oral surgery is necessary in the future.
Funding
The authors have no relevant financial or non-financial interests to disclose.
Declarations
Conflict of interests
The authors declare that they have no conflict of interest.
Ethics Approval
This article does not contain any studies with animals performed by any of the authors.
Informed Consent
Informed consent has been obtained from the patient for this publication.
Footnotes
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