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Type I latex allergy diagnosis ends career of Florida dental assistant.

Ronna Williams, a former dental assistant from Brandon, Florida, had no idea that the chronic contact dermatitis she suffered in the 1980s, would later be diagnosed as symptoms of latex allergies.

Williams, who began her career as a dental assistant shortly after high school graduation in 1971, also experienced "respiratory attacks at home," a condition she mistakenly attributed to "something in the house." Unable to pinpoint the cause of these "strange reactions," she sought the medical help of Dr. Alan Halsey, an allergist from Valrico, FL, who diagnosed her condition as a type I allergy to NRL.

"I didn't know what it could be until I was diagnosed with respiratory problems related to my latex allergies in 1992," she said.

Placed on a regimen of steroids, Williams continued to work for her employer, a general dentist in Apollo Beach, FL. However, repeat exposure to NRL on the job, particularly to latex gloves, jeopardized her health. Shortly after her latex allergy diagnosis, Williams suffered her first episode of anaphylactic shock while working--an allergy attack so severe it ended her career on the spot.

"I was cleaning up after patients and all of a sudden my eyes went blurry and I couldn't breathe. I went up to the reception desk and collapsed. I felt like I was going to die. They threw me in an ambulance and I heard them say, 'Don't touch her. She's allergic to latex,'" she recalled.

What Are Latex Allergies?

Latex allergies represent an antigenic response to the complex compounds known as proteins found in NRL. More than a dozen proteins identified in NRL can cause allergic reactions, though which one(s) remains uncertain. Latex proteins react with the body's IgE antibodies, a group of structurally related human serum proteins responsible for allergies, to produce a host of unpleasant symptoms. These include sneezing, wheezing, watery eyes and skin rashes to anaphylaxis, a condition characterized by breathing difficulties and low blood pressure that can cause shock or even death. (1)

The three recognized reactions to latex include nonallergic irritant contact dermatitis, type IV cell-mediated allergies and type I IgE-mediated allergies. Nonallergic irritant contact dermatitis, a skin rash, is the most common reaction affecting regular wearers of powdered and nonpowdered latex gloves. Symptoms include dry, crusted patches in the glove area also caused by certain types of cleaners, repeated hand washing and incomplete hand drying. (2)

Type IV cell-mediated allergies, the most common immune system reaction to latex, affect 82 percent of individuals allergic to rubber products. (3) Type IV latex allergies represent a delayed hypersensitivity to one or more of the 300-plus chemicals used to manufacture latex and cause allergic contact dermatitis within 48 to 96 hours of exposure. Continued exposure puts individuals with a type IV allergy at risk of developing the antibodies that can trigger a type I latex allergy. (4)

Type I IgE-mediated allergies represent an immediate hypersensitivity to actual latex proteins and include two subgroups. The first causes hives, itchy and watery eyes, runny nose, sneezing, wheezing, asthma, abdominal pain, nausea, diarrhea and skin rashes. The second and more serious causes anaphylaxis.

Latex Allergies Rise

The incidence of latex allergies ha risen dramatically over the past 20 year for several reasons. The introduction c universal precautions--including the use of latex gloves to prevent the spread of bloodborne diseases such as AIDS, HIV and hepatitis B--primarily contributed to the rise seen after 1979. Increased awareness and reporting c latex allergies also revealed a higher prevalence of this hypersensitivity. (5)

Manufacturers, that failed to adequately wash latex gloves, inadvertently may have contributed to the increase in latex allergies. In 1991, the FDA outlined to manufacturers a two step washing process, the first to occur during leaching and the second after product completion, to better remove allergenic proteins from latex. (6)

In addition to her latex allergies Williams also suffers from "bad reactions to bananas, avocados and ware chestnuts." Latex allergies often trigger food cross-reactions because certain plant products--including bananas avocados, kiwis, plums, peaches, cherries, apricots, figs, papayas, tomatoes, potatoes and chestnuts--contain the same allergy-producing proteins a NRL. Latex-sensitive individual should avoid the aforementioned fruits, vegetables and nuts as well a genetically engineered fruits and vegetables that contain the same DNA markers as latex. (7)

Treating and Preventing Latex Allergies

Though no cure exists, nonallergic skin rashes can be treated with doctor prescribed or over-the-counter ointments, creams or jellies. Petroleum jelly should not be applied before glove use since petroleum product can destroy the barrier of protection provided by latex.

Individuals with type IV allergies car use the aforementioned treatments to relieve skin irritations. They also should avoid the latex gloves or rubber products suspected of causing the dermatitis. (8)

Those with type I allergies must avoid latex exposure altogether. This requires them to wear vinyl or nonlatex gloves and work in areas that prohibit powdered glove use. (9)

In 1991, the U.S. Occupational Safety and Health Administration issued a bloodborne pathogen standard stating that "Glove liners, powderless gloves, or other alternatives must be readily accessible to employees who are allergic to the gloves normally provided." (10) Latex-sensitive individuals should be aware that the use of powder-free gloves does not guarantee a safe environment. Under current government standards, gloves labeled as "powder-free" can contain up to two milligrams of powder per glove, enough to trigger allergic reactions in sensitized individuals.

Detecting Latex Allergies

Methods include skin prick, skin patch and radioallergosorbent (RAST) tests screen for latex allergies. To perform the skin prick test, an allergist-immunologist injects the latex proteins suspected of causing allergic reactions under the skin or to a scratch or puncture wound on the patient's arm or back. These proteins produce a small, raised, red area within 15 minutes of injection among allergic patients. Skin prick tests, which can induce anaphylactic shock, should be performed only under the supervision of an allergy specialist and with appropriate emergency backup equipment on hand. (11)

Skin patch tests use the patient's glove or latex product to screen for an immediate or delayed hypersensitivity and to evaluate the cause of the skin irritation Use of the latex product in question helps to ensure an accurate diagnosis since no standardized patch test exists.

The PAST test, which identifies specific IgE antibodies to latex in the blood, can accurately diagnose an NRL allergy. The diagnostic success of this test approaches 100 percent.

The current unavailability of a standard by which to benchmark the skin prick, skin patch and PAST tests can produce inconclusive results, such as false positives and negatives. These inconsistencies may require further testing or a diagnosis to be made based on a patient's medical history. The Food and Drug Administration (FDA) is expected to approve a serum for a standardized skin prick test soon.

Latex Allergies and Dental Workers

According to a survey in the January 1996 issue of the Journal of the American Dental Association, about 12 percent of dental workers suffer from latex allergies. Latex abounds in dental offices where it can be found in items such as dental dams, suction lines, chair coverings and gaskets.

The January 2001 issue of In Control, a supplement published by the U.S. Air Force Dental Investigation Service, states that nonlatex or powder-free gloves represent "the most important latex-reduction method." The supplement, which covers "issues in infection control and occupational health and safety in dentistry," published the following precautions to help dental workers avoid developing work-related latex allergies.

I. Reduce the use of gloves in the general population.

II. Urge manufacturers to wash allergens out of latex gloves.

III. Suggest to healthcare providers that they schedule latex-sensitive patients as the first case of the day because latex is an aeroallergen and stays in the air for at least an hour after latex gloves are used.

IV. Emphasize to patients that they need to tell physicians, dentists, employers, school officials, etc., about their latex allergy. Patients with latex allergies should be advised to wear a medical alert bracelet.

V. Emphasize to hospitals and clinics that questions about latex sensitivity should be included in all patient histories and that clear, visible signs be placed on doors to patient and procedure rooms when there is a latex-sensitive patient present.

VI. Due to the risk of anaphylaxis, emphasize the need for latex-safe resuscitation equipment.

VII. Advise patients to carry auto-injectable epinephrine and to avoid foods that cross-react with latex, such as bananas, kiwis, and avocados.

VIII. Distribute information about latex allergies to all healthcare employees, students, ancillary personnel and patients and encourage them to read labels to identify latex-containing items.

Converting to Latex-Safe Practices

Many dentists convert their practices to "latex-safe" to reduce the incidence of latex allergies. Latex-safe, an environmental standard intended to eliminate significant direct and indirect risk factors that cause latex allergies, should not be confused with latex-free, a term that describes products that do not contain NRL.

Dr. Jeffrey S. Harris, who owns the Chadds Ford Center for Cosmetic and Restorative Dentistry in Chadds Ford, PA, converted his practice to latex-safe in 1996 after he developed contact dermatitis from a face mask and his dental assistant suffered allergies to latex gloves. The conversion, which took about a year and a half, included replacing the carpeting, heating, ventilation and air conditioning (HVAC) duct work, cleansing the walls and floors, inventory analysis and a professional air-filtration vacuuming.

Dr. Larry C. Smedley converted his orthodonture practices in West Chester and Downington, PA, to latex-safe six years ago after his dental assistant developed "sensitivity and allergies to latex products." Smedley and his staff searched the offices "to find out what was made of latex" and "had the carpets cleaned to get the dust out."

He also switched to nonlatex gloves, a purchase Smedley says represents "an ongoing expense" for dental practices. He recalls that his dental assistants, accustomed to the feel of latex gloves, went through a period of adjustment after the switch.

"The first three or four months, the assistants didn't like the gloves. Because we rely on tweezers and don't use the tips of our fingers much, it (the switch to nonlatex gloves) was not a big deal," Smedley said.

Latex-Safe Benefits Patients/Dental Assistants

Harris believes the health benefits of a latex-safe dental practice far outweigh the cost and inconvenience of conversion. His conversion reaped a "ten-fold" return on his initial investment and expanded his practice to include latex-sensitive patients who come from as far away as Michigan and Florida to receive treatment.

Describing himself as "extremely proactive about latex allergies," Harris says the cost of nonlatex inventory and office items "is well within the budget of the average practitioner." He encourages dentists to practice latex-safe and learn about the dangers latex exposure poses to patients and staff members.

"Our profession as a whole does not truly and adequately understand latex allergies. Dentists think that if they substitute synthetic gloves for their latex-sensitive patients, they're doing enough," Harris said.

Smedley agrees that "there's a lack of awareness" among dental practitioners about the dangers of latex exposure. He attributes this to the non-invasive nature of their practices and the fact that most dentists and orthodontists "probably haven't had a lot of latex-sensitive patients cross their paths." Smedley notes that a latex-safe practice standard makes sense for his colleagues since "orthodontists see patients 15 to 20 times over a two-year period."

"In orthodonture, it (latex conversion) made sense because with the repeated exposure you could end up with a latex allergy. A lot of things we use, such as rubber bands, are made of latex," he said.

Ronna Williams, who must wear a surgical mask to enter medical centers and retail stores, supports efforts to reduce exposure to latex. Unable to work as a dental assistant, she now lobbies against the use of latex gloves in food service and educates the public about latex allergies.

"So many people link latex allergies to latex gloves and forget about everything else that contains latex. The worst place to enter is a shoe store because so many athletic shoes have rubber soles," she commented.

References

(1.) Tips to Remember: Latex Allergy. American Academy of Allergy, Asthma & Immunology 1996-2003. www.aaaai.org.

(2.) Dealing with latex allergies at work. Workers' Compensation Board of British Columbia Oct. 7, 2002: 4. www.worksafebc.com.

(3.) Dealing with latex allergies at work. Workers' Compensation Board of British Columbia Oct. 7, 2002: 5. www.worksafebc.com.

(4.) Sponselli C. Latex allergies still foe for many nurses. NurseWeek Dec. 1996.

(5.) Borel L. Latex Allergy: Are You at Risk? National Latex Allergy Network July 11, 2001: 5.

(6.) Stehlin D. When Rubber Rubs the Wrong Way. FDA Consumer Sept. 1992: 2.

(7.) Ganglberger E. Hev b 8, the Hevea Brasiliensis Latex Profilin, Is a Cross-Reactive Allergen of Latex, Plant Foods and Pollen. International Archives of Allergy and Immunology January 23, 2001: 217.

(8.) Q&A: Latex Allergies. American Academy of Allergy, Asthma & Immunology 1998. www.aaai.org.

(9.) Q&A: Latex Allergies. American Academy of Allergy, Asthma & Immunology 1998. www.aaai.org.

(10.) Chapter 720. Bloodborne Pathogens. Occupational Safety and Health Administration 1992. 700:2012.

(11.) Latex Allergies. Health Response Ability Systems 1993.

Chuck Mills, a Certified Registered Nurse Anesthetist and attorney, chairs the Occupational Safety and Hazard Committee for the American Association of Nurse Anesthetists in Park Ridge, IL. He maintains an anesthesia management consulting and healthcare law practice in Saunderstown, RI.
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Publication:The Dental Assistant
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Date:Nov 1, 2003
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