Are we numb to anaphylaxis?

UPFRONT COMMENT Letters to the editor Submit your Letters to the Editor via the online submission system: https://mts-bdj.nature.com/cgi-bin/main.plex. Letters must be less than 500 words including any references. Authors must sign the letter, which may be edited for reasons of space or clarity. Anaesthesiology Are we numb to anaphylaxis? We read with great interest the article by Mannion et al.1 on local anaesthetic (LA) allergy testing. We commend the authors for a well-designed study. In addition to LA skin infiltration and peripheral nerve blockade practised in dentistry, in anaesthesiology we also utilise intrathecal, epidural and intravenous routes of injection. As such, we would like to highlight some topics covered which may for some readers not explicitly differentiate a mild hypersensitivity reaction, anaphylaxis, and local anaesthetic systemic toxicity (LAST). One of the stated aims of the paper is to ‘describe the main characteristics of adverse drug reactions (ADRs) following LA application’ however despite ‘anaphylaxis’ being mentioned multiple times it is never described in detail beyond, ‘a severe and potentially life threatening, medical emergency that can occur in dental practice’ and ‘Immediate hypersensitivity – onset within one hour of exposure, including urticaria, angioedema, respiratory or cardiovascular symptoms’. Clarity around the types of allergic reaction is important for effective communication. The World Allergy Organization (WAO) recently published a 5-point grading system for systemic allergic reactions of which grades 3–5 are considered ‘anaphylaxis’.2 Clinical vigilance and observation over time are required to establish whether a reaction will ultimately be limited to grade 1–2 reaction or are just the first signs of an evolving anaphylactic reaction of grades 3–5. Whilst the authors note that in the absence of urticaria the likelihood of ‘anaphylaxis’ is low, the WAO anaphylaxis guidelines recognise the possibility of the presentation of anaphylaxis without typical skin involvement.3 We appreciated that due to the heterogeneity of presentation of anaphylaxis it is difficult to succinctly define or describe the condition, however, to best equip dentists to recognise anaphylaxis the WAO suggests a practical diagnostic framework (Box 1).3 It is important to appreciate that there is significant overlap in many of the ADR presentations including the two potentially life-threatening complications of local anaesthetic administration namely: anaphylaxis (type 1 immediate hypersensitivity [IgE mediated]) and LAST (high plasma concentrations). The mainstay of management of LAST differs from anaphylaxis in that it involves the early use of the use of ‘intralipid’.4 Detailed management guides on each condition are beyond the scope of this letter. However, of note, both anaphylaxis and LAST may evolve into a cardiac arrest scenario in which LAST management requires both intralipid and adrenaline. D. O’Reilly, R. Preston, Vancouver, Canada References 1. 2. Box 1 Amended criteria for the diagnosis of anaphylaxis Anaphylaxis is highly likely when any one of the following two criteria are fulfilled: 1. Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal tissue, or both (e.g., generalised hives, pruritus or flushing, swollen lips‑tongue‑uvula) AND AT LEAST ONE OF THE FOLLOWING: a. Respiratory compromise (e.g., dyspnea, wheeze‑bronchospasm, stridor, reduced PEF, hypoxemia) 3. 4. Mannion D, Conlon N, Pierse D, McCrea P, Alamin S. Are we numb to the facts? Our experience of local anaesthetic allergy testing in a tertiary hospital immunology department. Br Dent J 2025; DOI: 10.1038/ s41415-025-8921-y. Turner P J, Ansotegui I J, Campbell D E et al. Updated grading system for systemic allergic reactions: joint statement of the World Allergy Organization Anaphylaxis Committee and Allergen Immunotherapy Committee. World Allergy Organ J 2024; DOI: 10.1016/j. waojou.2024.100876. Cardona V, Ansotegui I J, Ebisawa M et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J 2020; DOI: 10.1016/j.waojou.2020.100472. Christie L E, Picard J, Weinberg G L. Local anaesthetic systemic toxicity. BJA Educ 2015; 15: 136–142. https://doi.org/10.1038/s41415-026-9892-3 b. Reduced BP or associated symptoms of end‑organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence) c. Severe gastrointestinal symptoms (e.g., severe crampy abdominal pain, repetitive vomiting), especially after exposure to non‑food allergens 2. Acute onset of hypotensiona or bronchospasmb or laryngeal involvementc after exposure to a known or highly probable allergend for that patient (minutes to several hours), even in the absence of typical skin involvement. PEF, Peak expiratory flow; BP, blood pressure. a. Hypotension defined as a decrease in systolic BP greater than 30% from that person’s baseline, OR i. Infants and children under ten years: systolic BP less than (70 mmHg + [2 x age in years]) ii. Adults and children over ten years: systolic BP less than <90 mmHg. b. Excluding lower respiratory symptoms triggered by common inhalant allergens or food allergens perceived to cause ‘inhalational’ reactions in the absence of ingestion. c. Laryngeal symptoms include: stridor, vocal changes, odynophagia. d. An allergen is a substance (usually a protein) capable of triggering an immune response that can result in an allergic reaction. Most allergens act through an IgE-mediated pathway, but some non-allergen triggers can act independent of IgE (for example, via direct activation of mast cells). Adapted from World allergy organization anaphylaxis guidance 2020.3 Dental public health Agricultural outlook data: a dental public health imperative Dental caries is the world’s most prevalent non-communicable disease, affecting 2.5 billion people; dietary free sugars are its principal aetiological agent.1 Despite a robust evidence base on effective sugarreduction policies, dental public health BRITISH DENTAL JOURNAL | VOLUME 240 NO. 10 | May 22 2026 © The Author(s) under exclusive licence to the British Dental Association 2026. 641  (...truncated)