Latex allergy: implications for oral health care professionals.
In recent years, physicians have documented an increase among health care providers in contact dermatitis, sinusitis, itchy watery eyes, congestion, and other allergic symptoms. The implementation of universal precautions and stringent infection-control guidelines has resulted in widespread use of latex gloves. As a result, health care workers are experiencing hypersensitivity reactions to latex in gloves and the work environment.
Allergy: A subspecialty of immunology, allergies are acquired hypersensitivity, the clinical sign of an immediate hypersensitivity reaction (Table I). Allergens, such as dust, pollen, and latex, cause allergic reactions, such as dermatitis, sneezing, and asthma--a spastic contraction of the smooth muscle in the bronchioles of the lungs that results in difficult breathing. Allergic reactions can range from a simple runny nose to systemic allergic reactions (Table II). Life-threatening anaphylaxis is the most severe form of allergic reaction to an allergen. It can cause shock, respiratory or cardiovascular failure, or a combination thereof. Allergic reactions involve all the components of the immune and inflammatory responses that are common to all hypersensitivity reactions.
Table I. General Allergy Symptoms Type I (IgE mediated) runny nose shortness of breath sneezing coughing nasal itching chest tightness nasal congestion wheezing sinusitis asthma skin reactions dyspnea urticaria (hives) headaches dermatitis(**) itching(**) rash(**) pruritis rhinoconjunctivitis ocular itching and/or swelling angioedema
(**) most common latex allergy symptoms
Table II. Systemic Allergy Symptoms urticaria/hives rhinoconjunctivitis rhinorrhea/clear discharge angioedema (swelling) ocular itching edema (organ specific) flushing/facial redness shortness of breath facial swelling coughing fainting asthma shock wheezing stridor laryngeal edema Cardiovascular tachycardia hypotension arrhythmia Gastrointestinal nausea vomiting diarrhea abdominal cramping/pain
IgE and the Role of Antibodies
Immunoglobulin E (IgE) is one of five general classes of antibodies: IgE, IgA, IgD, IgM, and IgG. These gamma globulins of the immunoglobulin family of proteins have a molecular weight of 160,000 to 970,000 and compose about 20 percent of all plasma proteins. All immunoglobulins contain light and heavy polypeptide chains. IgE is the antibody primarily involved in allergic reactions. Attached to the surface of mast cells, it can remain dormant for years, sensitizing the cells. IgE-specific receptors are present on mast cells, basophils, neutrophils, eosinophils, macrophages, and platelets. They attach to mast cells, triggering them to expel their contents, such as histamine, prostaglandin, and leukotriene. Immediate hypersensitivity and antibodymediated cellular toxicity, or allergic reaction, ensues.
Atopy: A genetic predisposition to develop an allergy but not to a specific allergen. Atopic individuals have many circulating IgE antibodies that remain dormant for years. For example, a woman who is allergic to ragweed may have children with the tendency to develop an allergy, but not necessarily to the same allergens.
Allergic reaction: A chain of events triggered by contact with an allergen, such as hay fever (a misnomer) from inhaling grass pollen. The body perceives the allergen as a foreign invader and lymph tissues release IgE antibodies into the bloodstream. IgE attaches to mast cells that line the skin, nose, mouth, throat, eyes, and lungs, causing them to release histamine. This and other chemical mediators react with tissues, resulting in allergic symptoms, depending on the tissue in which the chemical mediator is released. For example, chemical mediators expelled in the nose, results in rhinitis; in the lungs, asthma. Reactions also can be delayed. Histamine causes an engorgement of blood vessels, making them swell. This inflammatory reaction causes a more prolonged response, lasting from a few days to as long as one month from a single allergen exposure. This prolonged type of inflammatory response is part of the chronic allergic problem.
The four types of hypersensitivity reactions can be subdivided into additional categories. The following is a synopsis of the revised Gell and Coombs classification system.
Type I (IgE, mast-cell mediated): An immediate hypersensitive reaction occurs when mast cells or basophil mediators are released to create an immediate and delayed (4 to 8 hours) reaction to sensitizing allergens. Type Ia (anaphylactic) reactions need IgE antibodies to attach to IgE receptors on mast cells in order to trigger the chain of events, as in allergic rhinitis to ragweed pollen or anaphylaxis to penicillin. Type Ib (anaphylactoid) responses result in an antibody-antigen reaction at the surface of the sensitized cells, triggering the release of other mediators through degranulation of mast cells or basophil cells. Even though not involved in the immediate reaction, cells are attracted to the site of reaction by specific chemotactic factors. This contributes to ongoing inflammatory responses. At least four cell types (mast, basophil, eosinophil, neutrophil) share in the full expression of the immediate hypersensitivity reaction. These cells are programmed to secrete significant quantities of mediators that contribute to the general state of inflammation. Those mediators include histamine, prostaglandin, leukotriene, and platelet activating factors (PAF) in conditions such as chronic sinusitis and asthma.
Type II (antibody mediated-non IgE): The five categories involve IgG, IgM, and IgA. Three are destructive in nature, such as phagocytic cell destruction of antibody-coded platelets, inducing thrombocytopenia. Two are nondestructive: one involving target cell stimulation, and the other, negative signaling or ligand blockage, as seen in insulin-resistant diabetes mellitus.
Type III (immune complex): Involves IgG and IgM antibodies, activated complement components, and neutrophils. Strong immune responses in genetically predisposed individuals with certain antigens result in an immune injury. An example is the combined early allergic reaction and later immune complex reaction to an antigen, such as the drug penicillin.
Type IV (cell mediated): Involves T-cells (lymphoid stem cells that remain in the thymus gland) or natural killer cells (large granular lymphocytes; NK) in an antibody-independent mechanism. This reaction is broken down into three categories: Type IVb, which responds to viruses; Type IVc reactions, part of immune surveillance against tumor cells; and Type IVa immune response, the delayed hypersensitivity reaction. This last reaction is considered allergic, even though it is CD4+ T-cell-mediated rather than IgE-mediated. It includes contact dermatitis, such as to poison ivy, and is the most common allergic reaction to latex antigens.
Latex is a milky liquid also known as natural rubber latex (NRL), derived exclusively from the milky sap of the Hevea Brasiliensis tree. Raw sap contains approximately 33 percent rubber as well as cis-1,4-polyisoprene, water-soluble proteins, lipids, amino acids, nucleotides, and other chemical and heat-resistant substances.[9,11] Ammonia and other preservatives are added to prevent degradation.[1,7] Chemical additives, including the accelerators thiurams and carbamates; and antioxidants, such as phenylenediamine, are added to obtain desired properties. The physical versatility of latex allows for multiple applications, Latex is contained in many products, such as balloons, condoms, exam gloves, carpet backing, computer terminals, and adhesives.
Latex allergy is a hypersensitivity reaction to natural rubber latex proteins. In 1933, Downing reported only seven cases of latex glove dermatitis. But from 1988 to 1992, the FDA received 1, 118 reports of latex allergy and 15 deaths. Currently, researchers believe that latex allergy manifests as a Type 1, IgE-mediated,[11,14-19] and/or Type IV hypersensitivity reaction.[15-17]
The initial symptoms of latex allergy are insidious, and the individual may not be aware of what could result from exposure to latex antigens. Symptoms are usually dermatitis, rash, and itching.[11-20] Dermatitis is a Type IV cell-mediated delayed hypersensitivity reaction commonly considered to be CD4+T-cell-mediated, not IgE-mediated. Type IV hypersensitivity reactions to latex result in various skin eruptions, which can be immediate or delayed (Table III).
Table III. Skin Reactions to Latex Reaction Response Irritation Contact Dermatitis red, chapped hands (rapid--minutes to hours) blistering burning or itching dry skin reaction limited to contact area Allergic Contact Dermatitis (ACD)(*) eczema Type IV Hypersensitivity Reaction severe itching (delayed--6 to 48 hours) vesicles/blisters dryness cracking crusting desquamation reaction may extend beyond glove area (up the arm) (*) appearance similar to irritant contact dermatitis; difference is the extent (within or beyond glove border) of the reaction (*) chemical sensitivity falls within this type of reaction Immediate Allergic Urticaria itching Type I Hypersensitivity Reaction urticaria (immediate-minutes to 1 hour) erythema edema pruritis swelling
Skin reactions can be affected by other factors. Hand creams can deteriorate the latex by changing the physical characteristics of the glove. This can increase the amount of latex protein transferred from glove to hand and allows transfer to other surfaces, especially if hands are not washed thoroughly after wearing gloves. When hands sweat inside gloves, more protein is dissolved in the powder and a more prominent reaction occurs--known as leaching. Latex-allergic individuals may first notice erythema, rash, pruritus, or comparable hand problems--immediate or delayed. The trouble with identifying and diagnosing latex allergy is that most people initially deal with such symptoms by ignoring or enduring them, or by applying steroidal creams to their hands, allowing the body to build even greater levels of antibodies to the latex proteins. The immunologic response escalates if the individual continues to ignore the symptoms. Dental hygienists who are occupationally exposed to latex should not ignore the early warning signs. Researchers believe that, as exposure to latex continues, sensitivity increases. Many people do not realize they are highly sensitive to latex until a serious reaction occurs. Physicians report that an individual with developed hay fever who is continuously exposed to latex could develop chronic, severe asthma.
In addition, some reactions can progress from a Type IV to a Type I, which is IgE mediated. In some cases, a Type I reaction may occur without a Type IV, in which the release of mast-cell or basophil mediators creates immediate and delayed (four to eight hours) responses (Table I). Rhinitis, urticaria, conjunctivitis, dyspnea, and systemic reactions have been reported in patients--92 percent of whom were health care workers. Respiratory symptoms have been reported in employees of latex companies. Although symptoms usually are mild and local (Table II), if respiratory and circulatory problems develop, they could result in anaphylactic shock.
Methods of Exposure
There are three routes of latex exposure: mucosal contact, glove wearing, and via airborne latex particles in powder. Mucosal contact occurs during surgical and dental procedures or multiple medical procedures, such as catheterization. Frequent exposure can sensitize an individual to latex. Donning gloves results in both physical contact and the latex allergen becoming airborne.[12,22-24] Tomazic et al., demonstrated that cornstarch powder binds latex proteins and supports the causative relationship between reactions and sensitivity as well as exposure to airborne particles. Inhaling latex proteins can account for 80 percent of exposure. A person doesn't have to be the wearer for exposure to occur. Most particles become airborne when gloves are donned or removed.
Swanson et al., reported that latex is re-suspended from clothing or settled dust in a room where gloves were used. Once re-suspended, these reservoirs of settled dust contribute to the aero-allergen content, and levels fell to four percent 2.5 hours after procedures were completed. More than one mg was found on a laboratory coat that had been used for a week. Upper surfaces of the room also held large amounts. A large of portion (20 percent) of particles carrying allergen are seven microns, which are breathable and capable of causing asthma. Beezhold et al. reported that airborne latex proteins bind to latex glove powder, making it a vector for an inhalation antigen. Also, proteins settled among surgical tissue, instruments, and other surgical supplies.
Assessing the incidence of latex allergy is difficult because there is no national surveillance, and its prevalence among the general population is unknown. However, Ownby et al. reported that 2.5 percent of 1,000 volunteer Red Cross blood donors from the general population were seropositive to latex. Slater et al., demonstrated that as much as 34 percent of children with spina bifida have evidence of rubber-specific IgE. Latex sensitivity was reported to be 21 percent among perioperative nurses in a survey by the Centers for Disease Control and the Association of Operating Room Nurses. In a survey of periodontists, dental hygienists, and dental assistants, 42 percent reported reactions to occupational materials--mostly hand dermatitis. More severe reactions were by atopic persons. Another study involving oral health care workers in a hospital setting showed 38 percent were sensitized to latex, even though only 12 percent tested positive to a skin-prick test. Employees of the Mayo Medical Center reported symptoms suggestive of latex allergy, and 30 percent were found to be latex allergic. In a recent study by the Center for Devices and Radiological Health and the Consumer Product Safety Commission, only 5.5 percent of individuals tested positive for latex-specific IgE. However, 52 percent reported experiencing at least one symptom when using latex gloves. Many other studies report latex hypersenSitiVity.[33-34]
Atopy is another risk factor for developing latex allergy.[1,15,33,34] Reinheimer et al. confirmed that 62 percent of latex-positive individuals are atopic. Other factors that could impact on glove reaction include the use of hand cream prior to donning gloves, hand perspiration during glove use, and use of antibacterial soap or scrubbing.
Populations at Risk
Many groups are identified as high risk for developing latex allergy, including spina bifida patients, health care workers,[28-33,36] and rubber plant employees. Other groups beginning to display adverse reactions are hair dressers, food handlers, and housekeeping employees, especially those who are atopic or with multiple allergies.[1,15,33,34] The fastest growing group with mild or severe latex allergy is health care employees--who are exposed occupationally to latex. Oral health care professionals may have the highest reactions because they wear gloves 40 to 50 hours a week and are exposed to latex in the environment.
Historically, latex allergy diagnosis has been based upon a patient's clinical history and physical exam. A patch test applied by a dermatologist for 48 hours may differentiate chemical-sensitivity from latex allergy dermatitis. Skin-prick and intradermal tests also have been performed. In a skin-prick test, an antigen is placed on the skin and a lancet is used to prick the skin. An intradermal test injects an antigen just below the dermis. Both tests use a control agent and observe the testing site. A positive response is a wheal-and-flare reaction. However, the possibility of severe reactions raises concern over the safety of the intradermal method for latex. Such testing should be done cautiously and only by experienced personnel with emergency equipment available. Blood tests have been developed to measure the circulating levels of IgE specific to latex. AlaStat (Diagnostic Products Corp., Los Angeles, California) and Rast (radioallergosorbant) are latex sensitivity tests.
Because not all latex proteins have been identified, a false-negative blood test can occur. A recently identified 46/110-kd protein, is common among health care workers, as is the hevein preprotein. Epitopes in the hevein preprotein are recognized by latex-allergic individuals previously unidentified. Latex proteins must be identified before standardized skin test reagents can be implemented. A glove challenge known as a "use test" may be necessary if testing is negative. An allergist who is familiar with latex allergy should be consulted for identification of symptoms, diagnosis, and treatment.
Methods of treating allergies include avoidance, medication, immunotherapy, or a combination thereof. It is best to consult an allergist. Presently, the only safe treatment for latex allergy is avoidance.[1,11] This can be challenging since latex is airborne and a component of many products. In June 1996, the FDA proposed regulations to require labeling of all medical devices containing natural rubber latex that may directly or indirectly contact living human tissue. Taking medication prior to latex exposure (working near latex aeroallergens) can result in masking symptoms and increase exposure, ultimately resulting in more severe reactions. Clinical trials are under way to find ways to reduce sensitivity.
Once diagnosed with latex allergy, a person must avoid latex and take precautionary steps,[11,14] enforce it at work and home, and minimize it as a consumer and patient. This can be challenging since latex is in charts, gloves, supplies, drawers, prescription pads, ventilation systems, carpeting, computer terminals, telephone and alarm system buttons, shoes, toys, sports equipment, rubber bands, household gloves, tires, erasers, adhesives, undergarment elastic, bathing suits, and so forth. The most severe reactions result from dipped rubber products, such as exam gloves, balloons, or condoms. Sensitized individuals should wear medical alert badges, carry non-latex gloves,[11,14] and notify their health care professionals of their hypersensitivity. Physicians should prescribe auto-injectable epinephrine,[11,14] such as an Epi PenR (Center Laboratories, EM Industries, Inc., Port Washington, New York).
Cross-reactivity of latex proteins with certain foods has been reported,[41,42] including bananas, avocados, chestnuts, kiwi, potatoes, and tomatoes. Oral symptoms, such as itching, are normally the first sign of an allergic reaction to food. This cross-reactivity results from latex proteins being structurally homologous to the proteins or epitopes in these foods. Avoidance remains the best treatment for food allergy.
Creating a Minimal Latex Environment
De-latexing the work environment can decrease exposure and improve allergy symptoms. This can be accomplished by following some basic steps. First, any latex-containing products should be removed. In some cases, carpeting may need to be removed due to the latex aeroallergens that have settled in it. General housecleaning of the operatory minimizes latex particles on counters, cabinets, and chairs. Water removes settled particles. Use non-latex gloves when following infection-control policies. Also, latex aeroallergens have been found in ambient air. This can be cleaned by a HEPA filter--a high-efficiency particulate air filter that works by negative pressure, reversing the airflow to carry particles into the filter, collecting latex aeroallergens. If a facility is maintained latex-free, a HEPA filter may only be needed during the transition period.
Steps to be taken in the case of latex-allergic patients are listed in Table IV. Supplies must be latex-free, including gloves, prophy cups, x-ray film, and dams. Consult the original packaging and/or the manufacturer to assure that each item is latex-free. Although the FDA has proposed labeling, nothing has been mandated yet. However, some companies have begun voluntary labeling.
Table IV. Treating Latex-Allergic Patients * Identify the type of hypersensitivity reaction: (Type I or Type IV) * Work closely with the patient's allergist * Label the chart with an allergy alert sticker * Schedule the patient early in the day (aeroallergens are at a minimum) * Clear the counters, especially of any paper items * Prepare the operatory with non-latex gloves * If the room was disinfected using latex gloves, everything should be wiped with water, including counters, bracket table, hand piece hoses, chairs, x-ray unit, and so forth * Use non-latex gloves * Consult the manufacturer and/or product labeling to assure it is non-latex * List alternate latex products * Prepare a latex-free cart, including dental products and nonlatex gloves * Prepare a latex-free crash cart, including epinephrine and other emergency medications
Other dental products should be latex-free. Kodak[TM] (Eastman Kodak Company, Rochester New York) has latex-free film. During a dental prophylaxis, use latex-free prophy cups. Rite-Angle (Dentsply International, York, Pennsylvania) disposable prophy angle has a special synthetic prophy cup. However, Dentsply's Nupro[TM] Prophy Pak (teal) has a rubber cup. The G-U-M[R] Cup (JO Butler Co., Chicago, Illinois) is another latex-free prophy angle/cup. Other options include using a brush or air polisher.
For isolation techniques, dental hygienists can use a non-latex dental dam (Hygenico; Coltene Whaledent Co., Mohwah, New Jersey), double-thickness headrest cover, or synthetic non-latex glove, which might work better because plastic tears easily. To achieve isolation, make an opening in the material with a heated instrument. Stretch the material over the frame, and follow standard procedures for dam placement. Nitrous oxide analgesia cannot be used unless the nosepiece, hoses, and reservoir bag are non-latex. For local anesthesia, use a glass ampule and draw up the medication immediately before administration. One reported allergic reaction to latex came from the stopper of a medication vial.
Caution should be exercised when endodontic treatment is necessary. Gutta percha, which contains 30 percent rubber, usually comes from the milky latex of the Palaquium tree in Southeast Asia The trans-polyisoprene, rubber-like gum is heated, coagulated, and transformed into a solid, then purified and softened. No preservatives or vulcanizing agents are added. Zinc oxide, barium sulfate, and pigment are added to the final product. Because gutta percha and natural rubber are derived from the same botanical family, there is cross-allergenicity. Alternative root-canaltilling materials should be identified and used by an endodontist.
Some older impression materials are rubber based. Alginates are safe. Other items in the office that contain latex are rubber bands, bite blocks, orthodontic bands, disposable gowns, stethoscope tubing, and blood-pressure cuffs. Dental hygienists should cover the arm with a cloth prior to placing the cuff.
An employee with Type IV hypersensitivity (contact allergic) who changes to low-protein, powder-free, non-latex gloves will notice a remarkable difference, and offices that do so will greatly reduce exposure. A HEPA filter could help during the transition period. An allergist and/or employee health representative should be consulted on methods to limit exposure in the workplace. Avoid "hypo-allergenic" gloves, which contain latex. For individuals who are Type I (systemic reaction), avoidance of latex is imperative. A latex-free environment should be implemented, meaning no use or direct contact with latex gloves or devices. Type I hypersensitivity is very serious, and can result in anaphylaxis with minimal exposure. Latex allergy and employment issues are somewhat controversial due to the unknown, differences of opinion among workers, employment settings, and so forth. Some latex-allergic persons have been forced into career changes.
Oral health care facilities can greatly reduce the incidence of latex allergy by using only low-protein, powder-free gloves, appropriately enforced, and worn only when necessary. Hands must be washed after gloves are removed to prevent latex antigens from transferring to other surfaces. Substituting nonlatex or vinyl gloves when possible, such as when placing x-ray film intra orally, will help. Charts should not be handled with gloves. Educational inservice programs for staff should include these preventive methods, and quality assurance programs to help monitor them.
Acquired hypersensitivity to a substance that normally would not cause a reaction can result in sneezing, watery eyes, itching, wheezing, shortness of breath, and anaphylaxis--a severe allergic reaction in which death can occur if appropriate emergency treatment is not administered. Due to the increased use of gloves, latex allergy is on the rise among health care workers, patients of spina bifida, and those who undergo multiple medical procedures, especially during infancy/early childhood. Symptoms can be immediate or delayed, with sensitization occurring over a period of time. People are exposed to latex via mucosal, physical, and airborne contact, and aeroallergens that can remain in the air for many hours. Early symptoms include erythema, rash, pruritis, or similar skin problems, which can lead to rhinitis; congestion; itchy, watery eyes; or shortness of breath. Continued exposure allows the body to build even greater levels of antibodies, and immunological symptoms to escalate. Persons who are occupationally exposed to latex should not ignore the early warning signs. Avoidance is necessary. De-latexing is imperative. The latex allergic patient always must be handled in a very careful manner. Oral health care professionals should make every effort possible to prevent latex sensitization.
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Kathryn Jean Falcone, RDH, AS, was a clinical dental hygienist until becoming latex sensitive. She provides community and professional educational programs, and volunteers with Education for Latex Allergy Support Team and Information Coalition, Inc. (ELASTIC). Diane O'Fee Powers, RDH, BS, was a clinical dental hygienist until becoming latex sensitive. She is an elementary school teacher in Philadelphia, Pennsylvania.
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|Author:||Falcone, Kathryn Jean; Powers, Diane O'Fee|
|Publication:||Journal of Dental Hygiene|
|Date:||Jun 22, 1998|
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