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Reported latex allergy in dental patients
Reported latex allergy in dental patients Eustachio Nettis, MD,a Maria Cristina Colanardi, MD,a Antonio Ferrannini, MD,b and Alfredo Tursi, MD,b Bari, Italy UNIVERSITY OF BARI
Objective. The purpose of this study was to alert doctors of dental surgery to the possibility of latex sensitivity in both outpatients and inpatients. Study design. The study involved 2 groups: group A was composed of 21 subjects with a history of immediate reaction in dental environment; group B was composed of 24 healthy individuals. Patients underwent skin prick tests with common inhalant allergens, with latex cross-reacting foods, with a commercial extract of nonammoniated latex, and the incremental challenge test with local anesthetics. Specific IgE to latex and to latex cross-reacting foods were measured with the fluorescent enzyme immunoassay. Results. All patients in group A and none in group B were latex-allergic. Subjects who were latex-allergic were significantly more likely to be atopic and had positive IgE test to cross-reactive foods. Conclusions. Dentists and people working in a dental surgery environment must obtain detailed patient history to help identify individuals at risk of latex allergy or those actually allergic to latex. If an allergy exists, equipment used should be made of alternative materials. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:144-8)
The use of latex gloves by doctors of dental surgery for the prevention of disease transmission is taken for granted by most patients these days,1 but many are unaware of a potentially serious side effect of this important routine means of infection control. Regular exposure to latex-containing products, not only gloves as shown in Table I, in a dental environment can cause both adverse allergic and nonallergic reactions among dental practitioners and their patients. Irritant dermatitis is the most common reaction to latex, and it is due to friction between gloves and the skin. Immunologic reactions to latex may vary from IgEmediated reactions to delayed cell-mediated reactions.2 The full spectrum of IgE-mediated symptoms ranges from localized urticaria and rhinoconjunctivitis to asthma and anaphylaxis.3 Delayed dermatitis is a type IV allergic reaction; symptoms include swelling, redness, itching, cracking, and blistering. These result from exposure to chemicals, including antioxidants, antidegradants, and antizonants (eg, thiuram mixes, carbamate mixes, mercapto mixes).4 To the list of type IV allergens, latex can be added.
aDepartment of Medical Clinic, Immunology and Infectious Diseases, Division of Allergy and Clinical Immunology, University of Bari, Italy. bProfessor, Department of Medical Clinic, Immunology and Infectious Diseases, Division of Allergy and Clinical Immunology, University of Bari, Italy. Received for publication Jun 11, 2001; returned for revision Aug 6, 2001; accepted for publication Sep 27, 2001. Copyright © 2002 by Mosby, Inc. 1079-2104/2002/$35.00 + 0 7/13/120805 doi:10.1067/moe.2002.120805
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Identified risk factors for latex allergy are the following: 1. History of atopy5 2. Irritant or allergic hand eczema (skin barrier is disrupted with possibility of increased invasion by latex protein)6,7 3. Spina bifida or other disorders necessitating repeated surgery or instrumentations8,9 4. Food allergy: there is a clinical condition called “Latex-fruit syndrome” based on cross reactivity between latex allergens and fruit/vegetable allergens, particularly avocado, banana, chestnut, and kiwi.10 This study describes 21 cases of latex type I hypersensitivity in patients undergoing dental procedures and investigates the significance of some risk factors.
METHODS Two groups of subjects were enrolled in the study. Group A consisted of 21 subjects (9 males, 12 females; aged 11-47 years [mean = 28.4 years]) with a history of immediate reaction in dental environment; group B, the control group, consisted of 24 healthy individuals (10 men, 14 women; aged 27-43 years [mean = 33.7 years]) with referred occasional contact with latex and no latex-associated symptoms. All subjects were referred to the Allergology and Clinical Immunology Service of the Policlinico Hospital in Bari, Italy. A complete history was obtained to point out relevant clinical symptoms, history of personal atopy (including rhinitis, reactive airway disease, childhood dermatitis, food allergy, and drug allergy), previous surgical procedures, and previous reactions to products containing latex.
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Table I. Dental surgery products containing latex Amalgam carriers Anesthetic carpules (plunger and stopper) Bandages and tapes Bite blocks Bulbs on medication droppers Endodontic filling materials Evacuation tubing Facemask fasteners Gloves Impression materials Irrigator tubing Mask Mixing bowls Orthodontic rubber bands and elastics Polishing disks Prophy cups Rubber dams Suction tips Syringes (rubber plunger covered with silicone)
After their histories were taken, patients underwent the following examinations: 1. Skin prick test (SPT)* with a commercial extract of nonammoniated latex (Stallergènes, Paris, France) 2. SPTs* with common inhalant allergens including Dermatophagoides pteronyssinus and farinae, Parietaria officinalis, grass pollen, olive pollen, cypress pollen, Artemisia vulgaris, Alternaria tenuis, dog dander, and cat dander (Bayropharm DHS, Milan, Italy) 3. SPTs* with latex cross-reacting foods, including the following: avocado, kiwi, apricot (Stallergènes, Paris, France); banana, apple, peach, tomato, potato, melon, celery (Bayropharm DHS); and chestnut and pineapple (Lofarma, Milan, Italy) 4. Specific IgE to latex and cross-reacting foods were measured with fluorescent enzyme immunoassay (Pharmacia CAP System) according to the manufacturer’s instructions. 5. To rule out a possible role of local anesthetics in adverse reactions, the incremental challenge test with mepivacaine (Carbocaine 3%, 2-mL vials; Astra Farmaceutici, Milan, Italy) without adrenaline was performed in 7 subjects. Tests were performed as previously reported.11 Informed written consent was obtained from all subjects, and resuscitation equipment was available at all times during all tests. Proportions were compared by means of the Fisher exact test (1-tailed), and means were compared by means *In
all SPTs, histamine hydrochloride (10 mg/mL) was used as positive control and physiologic saline was a negative control. A prick test was considered positive if the wheal size (mean diameter) was 3 mm larger than the wheal of the negative control.
Table II. Relative risk No. with risk factors No. without risk factors Total
Cases
Controls
α γ α+γ
β δ β+δ
Relative risk = αδ/βγ.
of the Student t test. Probability (P) values less than .05 were considered significant. Relative risk for independent samples was calculated as shown in Table II.
RESULTS One patient from group A had an allergic reaction while she was in the waiting room; the remaining 20 patients had reactions in the course of dental procedures. Seven subjects experienced reactions after anesthesia. The adverse events described by patients from group A included contact urticaria in all cases, generalized urticaria in 6 cases, dyspnea in 6 cases, rhinitis in 5 cases, conjunctivitis in 5 cases, and anaphylactic shock in 1 case (Table III). All reactions were easily controlled by administration of antihistamines and corticosteroids. Epinephrine administration was necessary for 1 patient. Six patients in group A had only a positive SPT to latex, 2 patients had only a positive latex CAP fluorescent enzyme immunoassay, and 13 patients were positive for both tests. With regard to group B, tests did not show the presence of specific IgE to latex allergens. The diagnosis of natural rubber latex (NRL) allergy was made when the patient had a definite history of reactions to NRL exposure and exhibited an SPT reaction to NRL or NRL-specific IgE in serum, or both. On the basis of these criteria, all 21 patients in group A were considered latex-allergic and no patient in group B was considered latex-allergic. Sixteen (76.2%) subjects in group A reported a positive history of atopic disease, whereas 16 (76.2%) subjects showed a positive SPT to at least 1 inhalant. Five (28.3%) subjects in group B had a positive history of atopic disease, whereas 3 (12.5%) showed a positive SPT to at least 1 inhalant. Patients were classified as atopic when they had a history of atopic disease or had at least 1 immediate SPT reaction to common inhalants, or both. By definition, a total of 19 (90.5%) and 6 (25%) subjects from groups A and B, respectively, were atopic. A comparison of the prevalence of atopics in patients who had latex allergies with those who did not have latex allergies showed a strongly significant association between atopy and latex allergy (P < .001; relative risk = 28.5). When comparing SPT and radioallergosorbent test (RAST) results, a difference among 2 groups of
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Table III. Characteristics of enrolled patients
No.
Sex
Age (y)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
F F F‡ F F F M F M M F F M M M M M M F
26 43 11 36 36 27 16 47 22 22 32 35 23 23 25 22 27 22 22
20 21
F F
43 37
History of atopy*
Clinical symptoms during dental surgery procedures†
RAD, R, FA CU, GU, R, C, D Neg CU, GU, R, C, D A, R CU, GU, R, D R CU, GU, R, C RAD, R CU, AS R, FA CU Neg CU, C Neg CU, R, D Neg CU FA CU RA, R, FA CU RAD CU, GU RAD, R, FA CU, D RAD, R CU RAD, R CU R, FA CU Neg CU RAD, R CU RAD, R, DA, FA CU R DA, FA
CU, C, D, GU CU
No. of surgical operations
Positivity for latex SPT
Positivity for latex RAST
1 0 2 4 0 0 0 0 0 0 0 0 2 1 0 1 1 1 0
Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes
Yes Neg Yes Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes Neg Neg Neg Neg Yes
1 0
Yes Yes
Yes Yes
SPT positivity for common inhalant allergens§
SPT and/or RAST positivity for cross-reacting foods
DF, DP Banana Neg Kiwi Neg Neg DF, DP, CD, P Pineapple, chestnut DF, DP Kiwi, banana O, P Chestnut, avocado CD Neg Neg Neg DF, DP Neg O, G, P, C Neg DF, DP Banana, avocado Neg Avocado G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg DF, DP, G, CD Neg G, O Chestnut, pineapple, peach DF, DP, P Peach, potato Neg Neg
*A and RAD, Reactive airway disease; R, rhinitis; FA, food allergy; Neg, negative; DA, drug allergy. †CU, Contact urticaria; GU, generalized urticaria; R, rhinitis; C, conjunctivitis; D, dyspnea; AS, anaphylactic shock. ‡Spina bifida. §O, Olive pollen; G, grass pollen; C, cypress pollen; A, Alternaria tenuis; P, Parietaria officinalis; DP, Dermatophagoides pteronyssinus; DF, Dermatophagoides farinae; CD, cat dander.
subjects with respect to the presence of specific IgE to latex cross-reacting foods was evident. IgE test positivities were more frequent in patients with latex allergy than in those without latex allergy (9/21 [42.8%] versus 2/24 [8.3%], respectively; P < .01; relative risk = 20.1). The mean number of surgical procedures was higher—yet not significantly so—among patients with latex allergies than in subjects without latex allergies (0.7 versus 0.3, respectively; P > .05). Two (9.5%) subjects reported previous mild reactions to NRL products (one to gloves and the other to gloves and a balloon). Three (14.3%) subjects had a positive clinical history of latex exposure, and 1 (4.8%) reported the ingestion of chestnuts after the appearance of NRL allergy in dental environment. The main characteristics of enrolled patients are shown in Table III. None of the incremental challenge tests was positive, so none of the patients experienced an allergic reaction to local anesthetics during dental procedures.
DISCUSSION This description of latex allergies in the dental environment addresses the need to alert doctors of dental surgery of the possibility that severe reactions in latexsensitive dental patients may arise.
The majority of reactions described in this study occur on contact between NRL products and mucous membranes or blood, but reactions could also occur from inhalation of airborne allergens (allergic airborne reactions).12,13 Mucosal exposure, as occurs during dental surgery procedures, may result in more severe reactions than those following cutaneous exposure because greater amounts of latex protein are absorbed into the systemic circulation.14 There is also a risk of inhalation exposure because latex proteins become airborne when they adhere to powders used to make wearing and taking off gloves easier.12,13 Numerous glove changes during the day send proteins out into the air. Inhalation of aerosolized particles may produce respiratory symptoms predominantly, but progression to full anaphylaxis with generalized hives may follow. Conjunctivitis may be a possibility because dentistry involves working in the close proximity of eyes, so that airborne particles may easily make contact with conjunctiva. A previous study15 demonstrated that latex aeroallergen in a dental practice setting is primarily generated by the use of a glove, whereas fabric upholstery and carpeting can serve as important aeroallergen repositories; in the absence of any other control measures,
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airborne latex may in fact become undetectable (<5 ng/m3) with exclusive use of nonpowdered latex gloves (in absence of control measure levels ranging from 6 to 25 ng/m3). Because many patients are unaware that they may be latex-sensitive, dental professionals must obtain a detailed patient history to help them identify individuals at risk of latex allergy and all patients should be screened for conditions such as spina bifida and recurrent surgical procedures, history of atopy (not only because atopy per se is a risk factor but also because of the possible cross-reactivity between latex and some pollens),16-18 cross-reactive food allergy (ie, banana, avocado, kiwi, and chestnuts, which may sensitize allergic patients to latex exposure), and previous reactions to NRL products. Questions such as the following should be routine in the collection of a patient’s medical history: • Do you have a history of hay fever, asthma, eczema, allergies, or rashes? • Do you experience rash, oral itching, swelling, or wheezing when exposed to any foods, especially bananas, avocados, kiwi, or chestnuts? • Are you exposed to any products that contain latex, including gloves, at work and have you ever had an allergic reaction to something in your work environment? • Have you ever had swelling, itching, hives, shortness of breath, cough, or other allergic symptoms during or after blowing up a balloon, undergoing a dental procedure, using condoms or diaphragms, or following a vaginal or rectal examination? • Have you ever had an allergic reaction of unknown cause, especially during a medical or dental procedure? • Have you ever had surgery? If so, what kind? • Do you have spina bifida or any urinary tract problem that required surgery or catheterizations? If a patient appears to have risk factors for latex allergy or is allergic to latex, then all equipment that comes in intimate patient contact, including gloves used during a dental surgery procedure, should be made of synthetic or nonlatex substitutes such as teflon, silicon, vinyl, tactylon, or nitrile.19 It is necessary to avoid the handling of nonlatex products while wearing latex gloves or with unwashed hands to prevent the transfer of latex allergens on nonlatex products. In addition, nonlatex products should not be stored with other NRL products, dental materials, or instruments to be used on patients with latex allergies because these nonlatex products must not be exposed to airborne allergens, which could cause contamination. At present, vinyl or alternative-material gloves are used whenever possible, even if their use may involve
performance limitation in terms of features such as grip, flexibility, comfort, and cost, as well as barrier protection (studies have shown that vinyl gloves are generally more permeable to blood and water than latex gloves).20 For added protection of latex allergic patients, the ideal time to schedule dental appointments is preferably at the beginning of a working session in the morning or after a vacation when the office has been closed. The reason for this is to minimize exposure to airborne latex, which can remain airborne for several hours.21 Another good time for appointments is after a cleaning crew has vacuumed the drapes, blinds, carpets, and so on, to remove latex-tainted cornstarch.
CONCLUSION Dental care providers have a responsibility to their patients: to recognize the signs and symptoms of latex hypersensitivity. Patients displaying any evidence of sensitivity should be advised to consult an allergist immediately to evaluate management strategies. If, during a dental visit, a patient develops itching around the mouth or lips, swelling of the lips or tongue (not to be confused with the feeling of swelling that comes from local anesthesia), a rash around the mouth or on the face, itching or swelling around the eyes, tightness in the throat, or congestion to shortness of breath, elevated pulse rates, or low blood pressure, dentists need to recognize these allergy symptoms and medical equipment has to be available. Whereas mild irritant reactions can be treated with immediate removal of the offending rubber object and antihistamine, systemic reactions require immediate treatment with more potent drugs, such as adrenaline, and may necessitate emergency resuscitation measures if their severity intensifies. In conclusion, this study may raise awareness of latex hypersensitivity in dental health professionals and should encourage them to take an active role in identification of patients at risk by submitting a detailed questionnaire to patients and avoiding the use of products containing latex. We thank Dr Giovanni F. M. Strippoli for his expert cooperation. REFERENCES 1. Harwood SE. Federal regulations for implementing infection control policies to reduce health-care workers’ risks. Occup Med 1989;4:115-6. 2. Zak HN, Kaste LM, Schwarzenberger K, Barry MJ, Galbraith GMP. Health-care workers and latex allergy. Arch Environ Health 2000;55:336-46. 3. Jaeger D, Kleinhans D, Czuppon AB, Baur X. Latex-specific proteins causing immediate-type cutaneous, nasal, bronchial, and systemic reactions. J Allergy Clin Immunol 1992;89:759-68.
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4. Yunginger JW. Latex allergy in the workplace: an overview of where we are. Ann Allergy 1999;83:630-3. 5. Moneret-Vautrin DA, Beaudounin E, Widmer S, Mouton C, Kanny G, Prestat F, et al. Prospective study of risk factors in natural rubber latex hypersensitivity. J Allergy Clin Immunol 1993;92:668-77. 6. Nieto A, Estornell F, Mazon A, Reig C, Nieto A, Garcìa-Ibarra F. Allergy to latex in spina bifida: a multivariate study of associated factors in 100 consecutive patients. J Allergy Clin Immunol 1996;98:501-7. 7. Hunt LW, Fransway AF, Reed CE, Miller LK, Jones RT, Swanson MC, et al. An epidemic of occupational allergy to latex involving health care workers. J Occup Environ 1995;37:12049. 8. Slater JE, Mostello LA, Share C. Rubber-specific IgE in children with spina bifida. J Urol 1991;146:578-9. 9. Porri F, Pradal M, Lamière C, Birnbaum J, Mege JL, Lanteaume A, et al. Association between latex sensitization and repeated exposure in children. Anesthesiology 1997;86:599-602. 10. Brehler R, Theissen U, Mohr C, Luger T. Latex-fruit syndrome: frequency of cross-reacting IgE antibodies. Allergy 1997;52:40410. 11. Nettis E, Napoli G, Ferrannini A, Tursi A. The incremental challenge test in the diagnosis of adverse reactions to local anesthetics. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:402-5. 12. Bauer X, Ammon J, Chen Z, Beckmann U, Czuppon AB. Health risk in hospital through airborne allergens for patients presensitized to latex. Lancet 1993;342:1148-50. 13. Tomazic VJ, Shamparni EL, Lamanna A, Withrow TJ, Adkinson NF Jr, Hamilton RG. Cornstarch powder on latex products is allergen carrier. J Allergy Clin Immunol 1994;93:751-8.
14. Oei DH, Tjiook SB, Chang KC. Anaphylaxis due to latex allergy. Allergy Proc 1992;12:95-102. 15. Chaorus BL, Schuenemann PJ, Swanson MC. Passive dispersion of latex aeroallergen in a healthcare facility. Ann Allergy Asthma Immunol 2000;85:285-90. 16. Heiss S, Fischer S, Muller W-D, Weber B, Hirschwerh R, Spitzauer S, et al. Identification of a 60 kd cross-reactive allergen in pollen and plant-derived food. J Allergy Clin Immunol 1996;98:938-47. 17. Achatz G, Oberkofler H, Lechenauer E, Simon B, Unger A, Kandler D, et al. Molecular cloning of major and minor allergens of Alternaria alternata and Cladosporium herbarum. Mol Immunol 1995;32:213-27. 18. Crameri R, Faith A, Hemmann S, Jaussi R, Ismail C, Menz G, et al. Humoral and cell-mediated autoimmunity in allergy to Aspergillus fumigatus. J Exp Med 1996;184:265-70. 19. Hamann B, Hamann C, Taylor JS. Managing latex allergies in the dental office. CDA J 1995;23:45-50. 20. Field EA, Fay MF. Issues of latex safety in dentistry. Oral Health 1996;68:7-16. 21. Heilman DK, Jones RT, Swanson MC, Yunginger JW. A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol 1996;98:325-30. Reprint requests: Eustachio Nettis, MD Cattedra di Allergologia e Immunologia Clinica Padiglione Chini – Policlinico Piazza Giulio Cesare 70124 Bari, Italy [email protected]
CALL FOR LETTERS TO THE EDITOR A separate and distinct space for Letters to the Editor was established by Larry J. Peterson, editor in chief of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics in his Editorial in the January 1993 issue. Dr Peterson also encouraged brief reports on interesting observations and new developments to be submitted to appear in this letters section as well as letters commenting on earlier published articles. Please submit your letters and brief reports for inclusion in this section. Information for Authors for the Journal appears in this issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. We look forward to hearing from you.
Objective. The purpose of this study was to alert doctors of dental surgery to the possibility of latex sensitivity in both outpatients and inpatients. Study design. The study involved 2 groups: group A was composed of 21 subjects with a history of immediate reaction in dental environment; group B was composed of 24 healthy individuals. Patients underwent skin prick tests with common inhalant allergens, with latex cross-reacting foods, with a commercial extract of nonammoniated latex, and the incremental challenge test with local anesthetics. Specific IgE to latex and to latex cross-reacting foods were measured with the fluorescent enzyme immunoassay. Results. All patients in group A and none in group B were latex-allergic. Subjects who were latex-allergic were significantly more likely to be atopic and had positive IgE test to cross-reactive foods. Conclusions. Dentists and people working in a dental surgery environment must obtain detailed patient history to help identify individuals at risk of latex allergy or those actually allergic to latex. If an allergy exists, equipment used should be made of alternative materials. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:144-8)
The use of latex gloves by doctors of dental surgery for the prevention of disease transmission is taken for granted by most patients these days,1 but many are unaware of a potentially serious side effect of this important routine means of infection control. Regular exposure to latex-containing products, not only gloves as shown in Table I, in a dental environment can cause both adverse allergic and nonallergic reactions among dental practitioners and their patients. Irritant dermatitis is the most common reaction to latex, and it is due to friction between gloves and the skin. Immunologic reactions to latex may vary from IgEmediated reactions to delayed cell-mediated reactions.2 The full spectrum of IgE-mediated symptoms ranges from localized urticaria and rhinoconjunctivitis to asthma and anaphylaxis.3 Delayed dermatitis is a type IV allergic reaction; symptoms include swelling, redness, itching, cracking, and blistering. These result from exposure to chemicals, including antioxidants, antidegradants, and antizonants (eg, thiuram mixes, carbamate mixes, mercapto mixes).4 To the list of type IV allergens, latex can be added.
aDepartment of Medical Clinic, Immunology and Infectious Diseases, Division of Allergy and Clinical Immunology, University of Bari, Italy. bProfessor, Department of Medical Clinic, Immunology and Infectious Diseases, Division of Allergy and Clinical Immunology, University of Bari, Italy. Received for publication Jun 11, 2001; returned for revision Aug 6, 2001; accepted for publication Sep 27, 2001. Copyright © 2002 by Mosby, Inc. 1079-2104/2002/$35.00 + 0 7/13/120805 doi:10.1067/moe.2002.120805
144
Identified risk factors for latex allergy are the following: 1. History of atopy5 2. Irritant or allergic hand eczema (skin barrier is disrupted with possibility of increased invasion by latex protein)6,7 3. Spina bifida or other disorders necessitating repeated surgery or instrumentations8,9 4. Food allergy: there is a clinical condition called “Latex-fruit syndrome” based on cross reactivity between latex allergens and fruit/vegetable allergens, particularly avocado, banana, chestnut, and kiwi.10 This study describes 21 cases of latex type I hypersensitivity in patients undergoing dental procedures and investigates the significance of some risk factors.
METHODS Two groups of subjects were enrolled in the study. Group A consisted of 21 subjects (9 males, 12 females; aged 11-47 years [mean = 28.4 years]) with a history of immediate reaction in dental environment; group B, the control group, consisted of 24 healthy individuals (10 men, 14 women; aged 27-43 years [mean = 33.7 years]) with referred occasional contact with latex and no latex-associated symptoms. All subjects were referred to the Allergology and Clinical Immunology Service of the Policlinico Hospital in Bari, Italy. A complete history was obtained to point out relevant clinical symptoms, history of personal atopy (including rhinitis, reactive airway disease, childhood dermatitis, food allergy, and drug allergy), previous surgical procedures, and previous reactions to products containing latex.
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Table I. Dental surgery products containing latex Amalgam carriers Anesthetic carpules (plunger and stopper) Bandages and tapes Bite blocks Bulbs on medication droppers Endodontic filling materials Evacuation tubing Facemask fasteners Gloves Impression materials Irrigator tubing Mask Mixing bowls Orthodontic rubber bands and elastics Polishing disks Prophy cups Rubber dams Suction tips Syringes (rubber plunger covered with silicone)
After their histories were taken, patients underwent the following examinations: 1. Skin prick test (SPT)* with a commercial extract of nonammoniated latex (Stallergènes, Paris, France) 2. SPTs* with common inhalant allergens including Dermatophagoides pteronyssinus and farinae, Parietaria officinalis, grass pollen, olive pollen, cypress pollen, Artemisia vulgaris, Alternaria tenuis, dog dander, and cat dander (Bayropharm DHS, Milan, Italy) 3. SPTs* with latex cross-reacting foods, including the following: avocado, kiwi, apricot (Stallergènes, Paris, France); banana, apple, peach, tomato, potato, melon, celery (Bayropharm DHS); and chestnut and pineapple (Lofarma, Milan, Italy) 4. Specific IgE to latex and cross-reacting foods were measured with fluorescent enzyme immunoassay (Pharmacia CAP System) according to the manufacturer’s instructions. 5. To rule out a possible role of local anesthetics in adverse reactions, the incremental challenge test with mepivacaine (Carbocaine 3%, 2-mL vials; Astra Farmaceutici, Milan, Italy) without adrenaline was performed in 7 subjects. Tests were performed as previously reported.11 Informed written consent was obtained from all subjects, and resuscitation equipment was available at all times during all tests. Proportions were compared by means of the Fisher exact test (1-tailed), and means were compared by means *In
all SPTs, histamine hydrochloride (10 mg/mL) was used as positive control and physiologic saline was a negative control. A prick test was considered positive if the wheal size (mean diameter) was 3 mm larger than the wheal of the negative control.
Table II. Relative risk No. with risk factors No. without risk factors Total
Cases
Controls
α γ α+γ
β δ β+δ
Relative risk = αδ/βγ.
of the Student t test. Probability (P) values less than .05 were considered significant. Relative risk for independent samples was calculated as shown in Table II.
RESULTS One patient from group A had an allergic reaction while she was in the waiting room; the remaining 20 patients had reactions in the course of dental procedures. Seven subjects experienced reactions after anesthesia. The adverse events described by patients from group A included contact urticaria in all cases, generalized urticaria in 6 cases, dyspnea in 6 cases, rhinitis in 5 cases, conjunctivitis in 5 cases, and anaphylactic shock in 1 case (Table III). All reactions were easily controlled by administration of antihistamines and corticosteroids. Epinephrine administration was necessary for 1 patient. Six patients in group A had only a positive SPT to latex, 2 patients had only a positive latex CAP fluorescent enzyme immunoassay, and 13 patients were positive for both tests. With regard to group B, tests did not show the presence of specific IgE to latex allergens. The diagnosis of natural rubber latex (NRL) allergy was made when the patient had a definite history of reactions to NRL exposure and exhibited an SPT reaction to NRL or NRL-specific IgE in serum, or both. On the basis of these criteria, all 21 patients in group A were considered latex-allergic and no patient in group B was considered latex-allergic. Sixteen (76.2%) subjects in group A reported a positive history of atopic disease, whereas 16 (76.2%) subjects showed a positive SPT to at least 1 inhalant. Five (28.3%) subjects in group B had a positive history of atopic disease, whereas 3 (12.5%) showed a positive SPT to at least 1 inhalant. Patients were classified as atopic when they had a history of atopic disease or had at least 1 immediate SPT reaction to common inhalants, or both. By definition, a total of 19 (90.5%) and 6 (25%) subjects from groups A and B, respectively, were atopic. A comparison of the prevalence of atopics in patients who had latex allergies with those who did not have latex allergies showed a strongly significant association between atopy and latex allergy (P < .001; relative risk = 28.5). When comparing SPT and radioallergosorbent test (RAST) results, a difference among 2 groups of
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Table III. Characteristics of enrolled patients
No.
Sex
Age (y)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
F F F‡ F F F M F M M F F M M M M M M F
26 43 11 36 36 27 16 47 22 22 32 35 23 23 25 22 27 22 22
20 21
F F
43 37
History of atopy*
Clinical symptoms during dental surgery procedures†
RAD, R, FA CU, GU, R, C, D Neg CU, GU, R, C, D A, R CU, GU, R, D R CU, GU, R, C RAD, R CU, AS R, FA CU Neg CU, C Neg CU, R, D Neg CU FA CU RA, R, FA CU RAD CU, GU RAD, R, FA CU, D RAD, R CU RAD, R CU R, FA CU Neg CU RAD, R CU RAD, R, DA, FA CU R DA, FA
CU, C, D, GU CU
No. of surgical operations
Positivity for latex SPT
Positivity for latex RAST
1 0 2 4 0 0 0 0 0 0 0 0 2 1 0 1 1 1 0
Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes
Yes Neg Yes Yes Yes Yes Neg Yes Yes Yes Yes Yes Yes Yes Neg Neg Neg Neg Yes
1 0
Yes Yes
Yes Yes
SPT positivity for common inhalant allergens§
SPT and/or RAST positivity for cross-reacting foods
DF, DP Banana Neg Kiwi Neg Neg DF, DP, CD, P Pineapple, chestnut DF, DP Kiwi, banana O, P Chestnut, avocado CD Neg Neg Neg DF, DP Neg O, G, P, C Neg DF, DP Banana, avocado Neg Avocado G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg G, DF, DP, O, C, P, CD, A Neg DF, DP, G, CD Neg G, O Chestnut, pineapple, peach DF, DP, P Peach, potato Neg Neg
*A and RAD, Reactive airway disease; R, rhinitis; FA, food allergy; Neg, negative; DA, drug allergy. †CU, Contact urticaria; GU, generalized urticaria; R, rhinitis; C, conjunctivitis; D, dyspnea; AS, anaphylactic shock. ‡Spina bifida. §O, Olive pollen; G, grass pollen; C, cypress pollen; A, Alternaria tenuis; P, Parietaria officinalis; DP, Dermatophagoides pteronyssinus; DF, Dermatophagoides farinae; CD, cat dander.
subjects with respect to the presence of specific IgE to latex cross-reacting foods was evident. IgE test positivities were more frequent in patients with latex allergy than in those without latex allergy (9/21 [42.8%] versus 2/24 [8.3%], respectively; P < .01; relative risk = 20.1). The mean number of surgical procedures was higher—yet not significantly so—among patients with latex allergies than in subjects without latex allergies (0.7 versus 0.3, respectively; P > .05). Two (9.5%) subjects reported previous mild reactions to NRL products (one to gloves and the other to gloves and a balloon). Three (14.3%) subjects had a positive clinical history of latex exposure, and 1 (4.8%) reported the ingestion of chestnuts after the appearance of NRL allergy in dental environment. The main characteristics of enrolled patients are shown in Table III. None of the incremental challenge tests was positive, so none of the patients experienced an allergic reaction to local anesthetics during dental procedures.
DISCUSSION This description of latex allergies in the dental environment addresses the need to alert doctors of dental surgery of the possibility that severe reactions in latexsensitive dental patients may arise.
The majority of reactions described in this study occur on contact between NRL products and mucous membranes or blood, but reactions could also occur from inhalation of airborne allergens (allergic airborne reactions).12,13 Mucosal exposure, as occurs during dental surgery procedures, may result in more severe reactions than those following cutaneous exposure because greater amounts of latex protein are absorbed into the systemic circulation.14 There is also a risk of inhalation exposure because latex proteins become airborne when they adhere to powders used to make wearing and taking off gloves easier.12,13 Numerous glove changes during the day send proteins out into the air. Inhalation of aerosolized particles may produce respiratory symptoms predominantly, but progression to full anaphylaxis with generalized hives may follow. Conjunctivitis may be a possibility because dentistry involves working in the close proximity of eyes, so that airborne particles may easily make contact with conjunctiva. A previous study15 demonstrated that latex aeroallergen in a dental practice setting is primarily generated by the use of a glove, whereas fabric upholstery and carpeting can serve as important aeroallergen repositories; in the absence of any other control measures,
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airborne latex may in fact become undetectable (<5 ng/m3) with exclusive use of nonpowdered latex gloves (in absence of control measure levels ranging from 6 to 25 ng/m3). Because many patients are unaware that they may be latex-sensitive, dental professionals must obtain a detailed patient history to help them identify individuals at risk of latex allergy and all patients should be screened for conditions such as spina bifida and recurrent surgical procedures, history of atopy (not only because atopy per se is a risk factor but also because of the possible cross-reactivity between latex and some pollens),16-18 cross-reactive food allergy (ie, banana, avocado, kiwi, and chestnuts, which may sensitize allergic patients to latex exposure), and previous reactions to NRL products. Questions such as the following should be routine in the collection of a patient’s medical history: • Do you have a history of hay fever, asthma, eczema, allergies, or rashes? • Do you experience rash, oral itching, swelling, or wheezing when exposed to any foods, especially bananas, avocados, kiwi, or chestnuts? • Are you exposed to any products that contain latex, including gloves, at work and have you ever had an allergic reaction to something in your work environment? • Have you ever had swelling, itching, hives, shortness of breath, cough, or other allergic symptoms during or after blowing up a balloon, undergoing a dental procedure, using condoms or diaphragms, or following a vaginal or rectal examination? • Have you ever had an allergic reaction of unknown cause, especially during a medical or dental procedure? • Have you ever had surgery? If so, what kind? • Do you have spina bifida or any urinary tract problem that required surgery or catheterizations? If a patient appears to have risk factors for latex allergy or is allergic to latex, then all equipment that comes in intimate patient contact, including gloves used during a dental surgery procedure, should be made of synthetic or nonlatex substitutes such as teflon, silicon, vinyl, tactylon, or nitrile.19 It is necessary to avoid the handling of nonlatex products while wearing latex gloves or with unwashed hands to prevent the transfer of latex allergens on nonlatex products. In addition, nonlatex products should not be stored with other NRL products, dental materials, or instruments to be used on patients with latex allergies because these nonlatex products must not be exposed to airborne allergens, which could cause contamination. At present, vinyl or alternative-material gloves are used whenever possible, even if their use may involve
performance limitation in terms of features such as grip, flexibility, comfort, and cost, as well as barrier protection (studies have shown that vinyl gloves are generally more permeable to blood and water than latex gloves).20 For added protection of latex allergic patients, the ideal time to schedule dental appointments is preferably at the beginning of a working session in the morning or after a vacation when the office has been closed. The reason for this is to minimize exposure to airborne latex, which can remain airborne for several hours.21 Another good time for appointments is after a cleaning crew has vacuumed the drapes, blinds, carpets, and so on, to remove latex-tainted cornstarch.
CONCLUSION Dental care providers have a responsibility to their patients: to recognize the signs and symptoms of latex hypersensitivity. Patients displaying any evidence of sensitivity should be advised to consult an allergist immediately to evaluate management strategies. If, during a dental visit, a patient develops itching around the mouth or lips, swelling of the lips or tongue (not to be confused with the feeling of swelling that comes from local anesthesia), a rash around the mouth or on the face, itching or swelling around the eyes, tightness in the throat, or congestion to shortness of breath, elevated pulse rates, or low blood pressure, dentists need to recognize these allergy symptoms and medical equipment has to be available. Whereas mild irritant reactions can be treated with immediate removal of the offending rubber object and antihistamine, systemic reactions require immediate treatment with more potent drugs, such as adrenaline, and may necessitate emergency resuscitation measures if their severity intensifies. In conclusion, this study may raise awareness of latex hypersensitivity in dental health professionals and should encourage them to take an active role in identification of patients at risk by submitting a detailed questionnaire to patients and avoiding the use of products containing latex. We thank Dr Giovanni F. M. Strippoli for his expert cooperation. REFERENCES 1. Harwood SE. Federal regulations for implementing infection control policies to reduce health-care workers’ risks. Occup Med 1989;4:115-6. 2. Zak HN, Kaste LM, Schwarzenberger K, Barry MJ, Galbraith GMP. Health-care workers and latex allergy. Arch Environ Health 2000;55:336-46. 3. Jaeger D, Kleinhans D, Czuppon AB, Baur X. Latex-specific proteins causing immediate-type cutaneous, nasal, bronchial, and systemic reactions. J Allergy Clin Immunol 1992;89:759-68.
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14. Oei DH, Tjiook SB, Chang KC. Anaphylaxis due to latex allergy. Allergy Proc 1992;12:95-102. 15. Chaorus BL, Schuenemann PJ, Swanson MC. Passive dispersion of latex aeroallergen in a healthcare facility. Ann Allergy Asthma Immunol 2000;85:285-90. 16. Heiss S, Fischer S, Muller W-D, Weber B, Hirschwerh R, Spitzauer S, et al. Identification of a 60 kd cross-reactive allergen in pollen and plant-derived food. J Allergy Clin Immunol 1996;98:938-47. 17. Achatz G, Oberkofler H, Lechenauer E, Simon B, Unger A, Kandler D, et al. Molecular cloning of major and minor allergens of Alternaria alternata and Cladosporium herbarum. Mol Immunol 1995;32:213-27. 18. Crameri R, Faith A, Hemmann S, Jaussi R, Ismail C, Menz G, et al. Humoral and cell-mediated autoimmunity in allergy to Aspergillus fumigatus. J Exp Med 1996;184:265-70. 19. Hamann B, Hamann C, Taylor JS. Managing latex allergies in the dental office. CDA J 1995;23:45-50. 20. Field EA, Fay MF. Issues of latex safety in dentistry. Oral Health 1996;68:7-16. 21. Heilman DK, Jones RT, Swanson MC, Yunginger JW. A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol 1996;98:325-30. Reprint requests: Eustachio Nettis, MD Cattedra di Allergologia e Immunologia Clinica Padiglione Chini – Policlinico Piazza Giulio Cesare 70124 Bari, Italy [email protected]
CALL FOR LETTERS TO THE EDITOR A separate and distinct space for Letters to the Editor was established by Larry J. Peterson, editor in chief of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics in his Editorial in the January 1993 issue. Dr Peterson also encouraged brief reports on interesting observations and new developments to be submitted to appear in this letters section as well as letters commenting on earlier published articles. Please submit your letters and brief reports for inclusion in this section. Information for Authors for the Journal appears in this issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. We look forward to hearing from you.