Pharmacotherapy

Safe and effective medications remain the cornerstone of treatment for most allergic conditions. Non-sedating antihistamines, topical (inhaled, intranasal, or cutaneous) corticosteroid preparations, bronchodilators (asthma rescue inhalers), and various other medical therapies can be safely and effectively used to control most allergy and asthma symptoms.

Early, appropriate and regular use of appropriate controller or anti-inflammatory medications for asthma, allergic rhinitis, and atopic dermatitis have been shown to dramatically reduce symptoms, improve quality of life, and decrease long-term complications from these common and often life-long conditions

Your Snö allergy team shares your goal: the least amount of medication required to adequately and appropriately control your condition. It is important to understand that as much as we would all love to eliminate your need for treatment, there is no “cure” for most allergic conditions, and it is possible you or your child will require medication for a long time. Your allergist will work with you to ensure a safe and effective treatment plan, which will be continually reassessed and adjusted over time

Immunotherapy

Also known as Allergen “immunotherapy” (IT) is the oldest treatment for allergic conditions, first described more than 100 years ago.

There are 3”, primary forms of allergen immunotherapy, subcutaneous (injection) IT, sublingual (under the tongue) IT, and oral (swallowed) IT.

Subcutaneous (injection) immunotherapy, also known as SCIT or “allergy shots”,s the oldest and most familiar approach. SCIT is often used for environmental allergies such as tree, grass or weed pollen, dust mites, or furred animals. SCIT is the only appropriate treatment to prevent stinging insect or venomallergies, and can be considered a life-saving treatment for this very serious condition.

SCIT involves injecting small and gradually increases amounts of the allergen into the fatty tissue in the upper arm, usually every week until eventually achieving a target monthly “maintenance” dose, which has been proven to result in protection against the allergic exposure and long-term benefit in decreasing the allergic response. SCIT has the potential to “cure” an allergy in some cases, with 3-5 years of treatment usually resulting in long-term immunologic benefit

SCIT has a long record of safety and efficacy, however this treatment does carry a risk of anaphylaxis, with as many as 1/6 patients receiving high-dose IT suffering a systemic reaction along the way. Your Snö allergy team has extensive training and experience in determining your need for SCIT, and in the safe administration of such therapy.

Sublingual immunotherapy (SLIT) is a newer approach, common in Europe for the past 20 years, with either drops or dissolvable tablets of allergen placed under the tongue on a daily basis. This has been most commonly used for environmental allergies, including tree, grass & weed pollen, dust mites, and furred animals, and there are currently approved SLIT tablets for grasspollen, ragweed pollen, and dust mites, with even more on the way. SLIT offers the convenience of home dosing, with a very low risk of reaction, and may also have similar long-term immunologic benefits like SCIT.

Oral immunotherapy (OIT) is a newer and evolving approach to food allergies. Studies have shown that OIT can be very effective for children with milk, egg, and peanut allergies, and may be able to “cure” a food allergy over time, allowing the child to enjoy a normal diet. While a promising approach for some children, OIT carries a risk for anaphylaxis, and your allergist will help determine if this is an appropriate option for your child.

Education and avoidance

Your Snö allergy team places a premium on patient education, and will spend a great deal of time explaining your diagnosis, management plan, therapeutic options, and prognosis.We will always take the time to answer your questions and make sure that you are comfortable with your treatment plan.

Whenever possible, your allergy team will help you determine strategies to avoid your allergic triggers. Although it is usually fairly easy to avoid allergenic foodsor medications, it may be a lot harder to effectively avoid environmental allergens. Your allergist will work with you to determine if changes to your environment will be worthwhile.

Biological therapies

There have been tremendous advances in targeted biological therapies for asthma and allergies over the past 20 years, and your Snö team has experience and expertise in determining if any of these may be appropriate for you or your child.

Anti-IgE therapy (omalizumab)

Omalizumab is a monoclonal antibody therapy proven effective for moderate-to-severe asthma in patients > 6 years of age, or for patients with chronic urticaria (hives) > 12 years of age. It has also shown promising results in patients undergoing OIT for food allergies. This biological agent has been in wide use for nearly 20 years, and your allergist will be able to determine if this is a good option for you.

Anti-IL5 therapies (mepolizumab, reslizumab, benralizumab)

These newer biological anti-IL5 or anti-eosinophil agents have been shown to be particularly effective in severe difficult-to-control allergic or eosinophilic asthma. They each have their own potential advantages, and your allergist will be able to help decide if one of these agents is right for you.

Anti-IL4 therapy (dupilumab)

Dupilumab is a novel anti-IL4 antibody which has been proven effective for severe persistent atopic dermatitis (eczema), and has also shown promising results for severe asthma, both allergic/eosinophilic and not. The Snö Asthma & Allergy team will help determine if you are a candidate for this newer treatment option.

Root canal treatment (or not)

Toothaches can have many causes. You may experience pain even though the nerve of the tooth is gone (read more about pulp damage). But quite often the symptoms are obvious and a “root canal treatment” (root filling) is the best treatment. We gently remove the soft tissue inside the tooth (the pulp), clean it and seal it. Today this can be done completely pain-free. It is a common misconception that the best way to end toothaches is to remove the nerve. But without a nerve, the tooth loses its strength. At Snö, we believe it is always better to save the pulp, whenever possible.

There are basically four different scenarios depending how far the process has gone:

  • Pulp inflammation with chance for recovery
  • Pulp inflammation without chance for recovery
  • Pulp partially or fully infected with bacteria
  • Already root filled teeth with problems

Pulp inflammation with chance for recovery
If possible, we always begin by removing whatever causes trauma (eg caries) to the pulp. This is in order to save the pulp.

        
Above a schematic example of a healthy tooth (left) and one with a caries lesion (right) filled with bacteria that irritates the pulp.

The tooth is typically very sensitive, especially to cold. The inflammation creates pressure inside the pulp chamber making the nerve even more sensitive. The quick fix is to remove the pulp and do a root filling, but we do not believe that this is always necessary. In many cases, when most of the caries is removed and, more importantly, the cavity is sealed with a tight temporary filling, the pulp relaxes and the inflammation disappears. After a while (usually two months), if the tooth looks and feels better, it is an indication that we managed to save the pulp tissue. This also saves you the cost and trouble of a root filling. However, in some cases the inflammation is too widespread, making a root canal treatment necessary.

Unfortunately, dentists cannot easily tell which tooth will heal and which will not. Hence, many dentists play it safe by administering root canals. At Snö, we do not believe this is right, which is why we recommend a thorough exam (Snö Exam) and we carefully monitor your progress. 

Pulp inflammation without chance for recovery
When the symptoms are more severe and/or when we can diagnose an irreversibly damaged pulp, the two options are to remove the tooth, or try to save it with a root canal treatment. The latter is similar to the treatment for an infected tooth, but generally has a slightly better prognosis, and is sometimes faster.

Depending on the severity of your case, we will inform you of your prognosis and the alternatives.

Pulp partially or fully infected with bacteria
When bacteria gets into the pulp; eg, via a caries lesion, the infection spreads down through and out to the root canals, in close contact with the bone. Common symptoms at this stage are tenderness to touch and while chewing, discolouration of the tooth, swelling, pus drainage and tenderness in the lymph nodes, nearby bone and gum tissue. In some cases there may be no symptoms. To treat this, we remove the diseased and dead pulp tissue from the tooth with specially designed instruments.

This procedure is not painful as the area is numb and the tissue being removed is either dead or dying. Once the pulp, along with the nerves contained in it, is removed, the tooth itself can no longer feel pain. If there is an infection outside the root, it could cause some discomfort. But this will gradually dissipate. For particularly difficult cases we leave a special paste inside the tooth to fight bacterial build-up. But for most cases, we fill the tooth in the same session.

We then select root canal fillings (red above) that fit precisely into the freshly prepared canals. A rubber-like material called gutta-percha is used to fill the canal space. It is a thermoplastic material (“thermo” – heat; “plastic” – to shape) that is heated and then compressed into and against the walls of the root canals to seal it. Together with an adhesive cement (called sealant), the gutta-percha fills the prepared canal space. Sealing the canals is critically important to prevent them from becoming reinfected with bacteria. When the infection is gone, the bone will heal again (right), growing back into the cavity it created during the infection.

Your tooth will then need a permanent restoration — a filling or a crown — to replace lost tooth structure, and provide a complete seal for the top of the tooth. This step is of particular importance.

Already root filled teeth with problems
The prognosis for a root canal treatment depends on how thoroughly the treatment is carried out. If done quickly, without proper infection control and precision, the tooth could become reinfected. At Snö, we have the tools and expertise to guarantee thorough root canal treatments. 

However, some patients might have hidden canals or small fractures in the tooth/root leading to infections. In such cases, we can spot the problem and either do a cleaning/root filling procedure, or treat the root tip using microsurgery. The absolute last resort would be to remove the problematic tooth.

At Snö we prefer to give you pain-free options. You will always get all the information pertaining to your case, including all available scientifically proven techniques, alternatives, risks and prognoses. The Snö team is available to answer any questions you may have.