Cross-Infection Control Protocol Continued Latex

LATEX ALLERGIES and DENTAL PROCEDURES

Since the late 1980s, there has been a significant increase in the number of allergic reactions to natural rubber latex. This rise may be attributed to a ten-fold increase in the use of latex gloves. While only 1-6% of the general population is allergic to latex, the prevalence in healthcare workers and others whose occupations involve exposure to rubber products is around 10%. Children and adolescents with spina bifida also have an increased incidence because of their frequent exposure to latex products from birth.

Natural rubber latex (NRL) is manufactured from the sap of the Havea brasiliensis rubber tree. Some individuals are allergic to the proteins found in this natural rubber. During the production of commercial latex, several chemicals are added to the natural rubber. These chemicals also cause some individuals to have allergic reactions to latex products.

Three types of reactions can occur with the use of natural rubber latex. Irritant contact dermatitis is the most common reaction to latex products. It is caused by the chemicals added to NRL during manufacturing. The chemicals directly injure the skin resulting in redness, swelling, dryness, itching and burning. This reaction can also occur from the powder added to latex gloves. Irritant contact dermatitis is not a true allergy and the symptoms disappear within several hours after removal of the stimulus. Allergic contact dermatitis is a delayed type of immunological response resulting from the chemicals used in the manufacture of the latex product. The chemicals penetrate the skin resulting in an allergic reaction. Symptoms such as redness and swelling occur between 24-48 hours after exposure and can last for several days. This delayed type of allergic response accounts for approximately 80% of the true allergic reactions to latex. Latex allergy is an immediate hypersensitivity response to proteins found in natural rubber latex. The response begins within minutes of exposure to the allergen (protein) and can take the form of an urticaria (hives) if exposure is through the skin, or respiratory symptoms (wheezing, runny nose, sneezing) if the allergen is inhaled. In some cases, an anaphylactic reaction (facial swelling, difficulty in breathing, and a severe drop in blood pressure) may occur if the protein is introduced directly into the blood. This immediate type of hypersensitivity or true allergic reaction to NRL is most likely to be found in those individuals who have multiple allergies and are frequently exposed to NRL products. Because of a similarity of proteins, individuals allergic to latex may also be sensitive to foods such as chestnuts, bananas, kiwi fruit and avocados. Patients should be informed of this potential cross allergenicity.

As a result of the chemical similarity between natural rubber and gutta-percha, the material used in filling the root canal, questions have arisen concerning its use in patients with a history of natural rubber latex. To date, there’s only one report of a supposed allergic reaction to gutta-percha. There is, however, no definitive proof that the patient had a true allergic reaction to the gutta-percha. In patients with a true immediate hypersensitivity to natural rubber latex, a consultation with the patient’s physician should be made prior to initiating the obturation phase of treatment. The contents of dental gutta-percha and the technique to be used should be discussed with the physician.

A complete medical history and dental history should include identifying patients with a history of latex allergy or those at high risk for being allergic. Precautions must be taken to safely treat these patients. "Hypoallergenic" gloves and rubber dams in which the manufacturer has removed allergy causing chemicals can be substituted. If, however, the patient has an immediate type of allergy to the proteins found in natural latex, vinyl or nitrile rubber gloves and dams must be used. In addition, thought should be given to treating the patient as the first appointment in the day in order to minimize exposure to airborne particles of latex.

Patients with a history of latex allergy or a high risk for being allergic can be identified through their medical and dental history. Patients should notify their dentists of their medical condition prior to their appointment, especially if there is potential for an allergic reaction to latex. Endodontists use gloves and rubber dams to ensure safe and successful endodontic treatment. These products often contain latex. Precautions can and must be taken to safely treat patients with latex allergies. Special gloves and rubber dams from which the manufacturer has removed allergy-causing chemicals can be substituted. If, however, the patient has an immediate type of allergy to natural latex proteins, the endodontist must use vinyl or nitrile rubber gloves and dams instead.

Provided on behalf of the Quality Assurance Committee, ADA by Dr Michael J Aldred, Specialist in Oral Medicine and Oral Pathology

The universal adoption of the wearing of gloves in dentistry and other health professions has been accompanied by a rise in reports of allergy to natural rubber latex. Latex is also encountered in condoms and many household items. About 10% of dental health personnel may report reactions to latex products and many of these can be demonstrated to have Type I hypersensitivity to latex.

Latex can be encountered in the dental surgery in:

Latex is found in many items used in hospital clinics, wards and operating theatres. These items include:

Risk factors for latex allergy include:

Reactions to latex and, in particular, the wearing of gloves come under three categories:

Irritant contact dermatitis is not uncommon in health care workers and may be associated with frequent hand-washing and inefficient drying of the skin. This may increase the passage of latex allergens across the compromised skin barrier.

Type IV delayed type hypersensitivity reactions tend to appear 2-4 days after exposure to rubber products, producing erythema of tissues having been in direct contact with the material. The materials used in preparation of latex products are considered to be the major cause of a Type IV response.

Type I immediate hypersensitivity reactions are, as the name implies, immediate in their onset. The reactions can take the form of itching, a generalised rash, rhinitis, conjunctivitis, wheezing, palpitations, dizziness, laryngeal oedema and anaphylactic shock leading to death if not treated urgently. People who have Type I hypersensitivity to latex can develop anaphylactic reactions to latex simply on entering dental surgeries and operating theatres where there is a significant load of latex allergen.

Testing for latex allergy
Testing for latex allergy is problematic. Patch testing for Type IV reactions can be performed, but is difficult to standardise because of variations in the latex preparations used. Intradermal injection carries the risk of inducing anaphylactic shock. For patients with Type I reactions IgE radioallergosorbent testing (RAST) can be carried out, but false positives are not uncommon. It would be sensible to regard any person with symptoms of Type I hypersensitivity to latex (as outlined above) as being allergic.

Minimising latex allergy
The use of powdered gloves is a potent means of spreading an aerosol of latex into the environment. The latex protein binds to the corn starch used to powder the gloves and is then dispersed widely within a dental surgery or operating theatre. The use of unpowdered gloves is recommended to minimise spread of latex particles into the air and hence the general environment. "Low-allergen" latex gloves are available but there is little certainty that these offer any real benefit.

Dental treatment of patients with latex allergy
Non-latex (vinyl, neoprene, neolon, nitrile-based or polymer gloves) should be available in all dental practices. All patients claiming to be sensitised to latex should have their claims treated with due consideration.

To reduce cross-infection, gloves must be worn – latex allergy in a patient is not a reason to avoid wearing gloves. Patients with Type IV delayed hypersensitivity allergic contact dermatitis should not be treated with rubber gloves; other latex-containing materials and equipment should also be avoided. For endodontic treatment and other procedures normally carried out under rubber dam, an alternative dam can be fashioned from vinyl sheet or a vinyl glove.

Patients with Type I hypersensitivity reactions need to be treated with great care, adopting the measures referred to above. It is probably advisable that treatment not be offered in a surgery where powdered gloves are routinely used. It is mandatory to have appropriate emergency treatment available (adrenaline and oxygen) and staff should be trained in resuscitation techniques. Treatment at the beginning of the day is preferred, before environmental levels of latex allergens rise as activity in the surgery increases. Type I hypersensitivity patients should only be treated where the dentist and other staff are confident in their ability to manage patients who develop problems. If in any doubt, the patient should be referred for appropriate management, probably in a hospital setting.

Medico-legal and worker's compensation aspects The adoption of a policy of using non-powdered gloves to minimise exposure to latex allergens in the workplace should reduce the likelihood of an employer being sued if any employees develop latex allergy in the course of their work. Failure to act upon a patient's claim that they are allergic to latex would be difficult to defend.

Spina A M, Levine H J. Latex allergy: a review for the dental professional. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 5-11)

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