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Rubber latex allergy and the endodontic patient
0099-2399/98/2411-0760503.00/0 JOURNALOF ENDODONTICS Copyright © 1998 by The American Association of Endodontists
Printed in U.S.A.
VOL. 24, No. 11, NOVEMBER1998
Rubber Latex Allergy and the Endodontic Patient Kenneth I. Knowles, DDS, MS, Jos~ L. Ibarrola, DDS, MS, Marvin O. Ludlow, DDS, MS, John R. Anderson, DDS, and Bruce E. Newcomb, BS
Increasingly, patients with rubber latex allergy are being seen in dental offices. Health care workers, persons allergic to certain foods and those with certain medical histories are potentially latex-sensitive. This article presents the case of a patient with a history of severe rubber latex allergy and the associated management of an endodontically involved tooth. The possibility of the latex allergic patient being sensitive to gutta-percha obturation material is also raised.
The following case report describes the endodontic treatment of acute irreversible pulpitis of a maxillary molar in a patient with a history of severe latex allergy.
CASE R E P O R T Because of her self-reported severe allergy to rubber latex products, the patient, a 33-yr-old female registered nurse, was referred to the adult clinic at Creighton University School of Dentistry for endodontic therapy. The maxillary right first molar presented symptoms of acute pulpitis, and diagnostic procedures confirmed that this condition was irreversible. In her medical history, the patient reported the following symptoms of allergic reaction as a result of contact with natural rubber latex products: dermatitis, pruritus, urticaria, bronchospasms, and anaphylaxis. She also related an allergy to bananas, avocados, and chestnuts. No other significant medical history was reported, including no history of genitourinary anomalies (frequent urinary catheterization) or spina bifida. She denied any history of atopy or serious childhood surgical procedures. The patient stated that the initial dermititis on her hands was not diagnosed as latex allergy until after the first anaphylactic reaction. This dermatitis occurred while at her hospital workplace, but was originally considered to be a result of construction materials associated with a remodeling project. At the time of the initial anaphylactic reaction, the patient was injected with 0.3 mg of epinephrine and was stabilized. She had since had 28 episodes of anaphylactic reaction, including two times that required a ventilator for resuscitation. After her initial severe allergic reaction, she was examined by her physician, a pulmonologist, and an allergist. Allergy to latex rubber products was confirmed using skin patch tests, skin prick tests, and serologic testing. This patient was employed at a local hospital in the adult critical care unit. She had been in nursing for the past 11 yr and had first come in contact with rubber latex gloves in nursing school during 1984. A result of her allergy, she carries two Epi-Pens (Center Labs., Port Washington, NY) of 0.3 mg of epinephrine, injectable Benadryl (Park-Davis, Morris Plains, NJ), and a Proventil (Schering Corp., Kenilworth, N J) inhaler with her at all times. She states she knows when a reaction is about to occur and self-injects to combat the impending episode. The patient's physician recommended premedication with prednisone, Benadryl, and Claritin before each treatment appointment. Accordingly, 2 days before treatment, the patient was premedi-
Current Occupational Safety and Health Administration infection control guidelines and the use of "universal precautions" in the~ health care setting have resulted in increased use of rubber gloves that in turn have resulted in an increased number of patients and health care workers being exposed to natural rubber latex (NRL). With this increased exposure, more cases of latex allergy and hypersensitivity have been identified, especially in workers routinely exposed to NRL. Numerous studies have documented significant percentages of latex sensitization in the overall population: in oral health care workers, 12% (1); in registered nurses, 8.9% (2); and in latex doll manufacturing employees, 9.1% (3). In addition to frequent contact with the NRL, increased risk of latex sensitization has been correlated with several medical conditions and cross-allergenicities to certain foods. Medical patients that seem to be predisposed to developing latex hypersensitivity include those who have experienced multiple surgical operations during childhood, such as patients with spina bifida (4), and patients with certain disorders requiring repeated urinary catheterization (5). Cross-reacting IgE antibodies have been discovered that associate latex allergies with banana allergies (6). Other food allergies placing individuals at a higher risk for latex sensitivity include chestnut, avocado, and kiwi fruit (7). During treatment of known hypersensitive individuals, certain precautions must be followed. Nonlatex materials and barriers should be available in every dental office. For some severely hypersensitive individuals, direct contact with NRL is not necessary to invoke an allergic reaction. Phosphated cornstarch, used to prevent latex gloves from sticking together, can act as a vehicle for the airborne transport of the latex allergen (8). This warrants removal of all latex products from the operatory and scheduling latex-sensitive patients first in the morning, before latex dust has accumulated in the office (7).
760
Vol. 24, No. 11, November 1998
cated with 20 mg of prednisone/day for 2 days and 60 mg on the day of the appointment. In addition, 2 hours before the treatment appointment, she was given 50 mg of Benadryl and one tablet of Ctaritin (Schering Corp., Kenilworth, NJ). Treatment was performed in a small isolated room for better control of rubber latex products, latex aerosols, and supplies. The room was prepared using routine infection control procedures. Great care was taken to avoid rubber latex products. Vinyl examination gloves (General Medical Corp., Richmond, VA) were used by both the assistant and the treating dentist. Regional anesthesia was administered, and the tooth was isolated with a nonlatex rubber dam material (Hygienic Corp., Akron, OH). Access was gained through a porcelain crown, and routine cleansing and shaping procedures were performed to prepare the canals for obturation. An interim restoration was then placed and the patient was reappointed. All precautions taken during the first visit were observed for the obturation appointment, including premedication. The patient stated that the tooth was now symptom-free and comfortable. Upon re-entry into the tooth, all canals were irrigated, the apices "cleared" with the final instrumentation, and the gutta-percha cones (Brassler USA, Savannah, GA) were fit. The canals were then obturated with gutta-percha and sealer (Sulton Chemists, Englewood, N J) using lateral condensation. The access preparation was restored using a base of glass ionomer cement (Ketac-Chem, Norristown, PA), followed by TPH composite restorative material (Dentsply, Milford, DE). At no time during the endodontic treatment appointments did the patient experience any allergic type symptoms or reactions. The patient's endodontically treated tooth remained asymptomatic, and 2 wk after obturation, she returned to her private dentist for the fabrication of a new crown restoration. During this treatment procedure, she came into contact with a rubber handgrip device on a dental instrument and immediately experienced another anaphylactic reaction. This episode required three injections of 0.30 mg of epinephrine, 125 mg of Solumedrol (Upjohn, Kalamazoo, MI) intravenously, 50 mg of Benadryl intramuscularly, and two Proventil (Schering Corp.) aerosol treatments. In addition, she was placed on 20 mg of prednisone/day for 1 wk.
DISCUSSION The patient's medical background and history profiled an individual at risk for reactions to NRL products. These indicators should be warning signals to the dental treatment team to take precautions to prevent further harm to the patient. With increasing numbers of the population becoming allergic to NRL products, especially among the health care professionals, it is of paramount importance that the dental treatment team be aware of these sensitivities and be prepared to provide appropriate care for these patients. Guidelines for the care of latex allergic patients appeared in the Office Safety and Asepsis Procedures (OSAP) Monthly Focus (9) and recommend that these patients be treated in an environment with latex presence as low as is reasonably achievable. These patients should be the first patients of the day, and there should be no latex in the room. The treatment room should be closed to entrance, and personnel setting up the room should wear nonlatex gloves. Likewise, instruments should be handled only with nonlatex gloves. Anyone having worn latex gloves that day should be prohibited from entering the treatment room before and during treatment.
Rubber Latex Allergy
761
With respect to endodontics, the focus for concern with the latex allergic patient primarily falls on the gloves and the rubber dam. Other potential sources of rubber that could come in contact with the patient are the rubber stoppers used for file measurement devices, the rubber plunger in the anesthetic syringe, rubber devices used for handgrips on instruments, and the gutta-percha. Chemically, gutta percha and natural rubber appear as isomers, with gutta-percha being trans-polyisoprene and natural rubber cis-polyisoprene. Both are high molecular weight polymers structured from the same basic building unit, the isoprene monomer (10). It seems possible that patients sensitive to NRL products could be allergic to gutta-percha as well. In 1994, a case was presented of a health care worker (a dental hygienist) who was rubber latex-sensitive and who required endodontic therapy on a maxillary molar. All precautions were taken to avoid latex products throughout the treatment procedure. During the obturation portion of the treatment, however, some of the gutta-percha cones were inadvertently extruded through the apex of the palatal root into the periradicular tissue. The patient reported immediate oral discomfort, lip and gingival swelling, a throbbing sensation around the tooth, and diffuse urticaria. Although 4 mg of dexamethasone were infiltrated around the tooth, oral discomfort and swelling persisted for > 4 wk. At that time, the gutta-percha was removed, and the patient experienced immediate relief (11). This case, coupled with the increased appearance of rubber latex-sensitive patients in the dental office, presents added concern for dentists providing endodontic therapy. Attempts were made after the 1994 case to identify specific gutta-percha allergy using an in vitro ELISA. Unfortunately, attempts to extract gutta-percha from pulverized material to prepare an antigen solution to bind the ELISA plate or for skin testing were unsuccessful and, as a result, the gutta-percha sensitivity could not be confirmed. The circumstances, conditions, and symptoms, however, remain highly suspicious of a rubber latex/gutta-percha allergy for that patient. From an endodontic standpoint, it would seem prudent to investigate the relationship further between the gutta-percha used in endodontic therapy and NRL allergies. Until more scientific evidence is available, the use of gutta-percha as an obturation material during endodontic therapy performed on NRL-sensitive patients requires extreme caution.
Dr. Knowles is associate professor, Dr. Ibarrola is assistant professor, and Dr. Ludlow is associate professor and chair, Department of Endodontics, Creighton University School of Dentistry, Omaha, NE. Dr. Anderson is a former student at Creighton University School of Dentistry, Omaha, NE, and he is currently a pediatric dentistry resident at the University of Nebraska Medical Center, Omaha, NE. Mr. Newcomb is a fourth-year student at Creighton University School of Dentistry, Omaha, NE. Address requests for reprints to Dr. Kenneth I. Knowles, Department of Endodontics, Creighton University School of Dentistry, 2500 California Plaza, Omaha, NE 68178.
References 1. Safadi GS, Safadi TJ, Terezhalmy GT, Taylor JS, Battisto JR, Melton AL Jr. Latex hypersensitivity: its prevalence among dental professionals. J Am Dent Assoc 1996;127:83- 8. 2. Grzybowski M, Ownby DR, Peyser PA, Johnson CC, Schork MA. The prevalence of anti-latex IgE antibodies among registered nurses. J Allergy Clin Immunol 1996;98:535-44. 3. Orfan NA, Reed R, Dykewicz MS, Ganz M, Kolski GB. Occupational asthma in a latex doll manufacturing plant. J Allergy Clin Immunol 1994;94: 826 -30.
762
Knowles et al,
4. Nieto A, Estornell F, Mazon A, Reig C, Nieto A, Garcia-lbarra 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. 5. Leger RR, Meeropol E. Children at risk: latex allergy and spina bifida. J Pediatr Nurs 1992;7:371-6. 6. Makinen-Kiljunen S. Banana allergy in patients with immediate-type hypersensitivity to natural rubber latex: characterization of cross-reacting antibodies and allergens. J Allergy Clin Immunol 1994;93:990-6. 7. Monthly OSAP Focus. Office Safety and Asepis Procedures Research Foundation. Annapolis, MD. February 1997.
Journal of Endodontics 8. Baur X, Ammon J, Chen Z, Beckmann U, Czuppon AB. Health risk in hospitals through airborne allergens for patients presensitized to latex. Lancet 1993;342:1148-9. 9. Ownby D. Care of latex allergic patients. Monthly OSAP Focus. Office Safety and Asepis Procedures Research Foundation. Annapolis, MD. February 1997:5. 10. Cohen S, Burns R. Pathways of the pulp. 6th ed. St. Louis: CV Mosby, 1994:401. 11. Boxer MB, Grammer LC, Orfan N. Gutta-percha allergy in a health care worker with latex allergy. J Allergy Clin Immunol 1994;93:943-4.
Printed in U.S.A.
VOL. 24, No. 11, NOVEMBER1998
Rubber Latex Allergy and the Endodontic Patient Kenneth I. Knowles, DDS, MS, Jos~ L. Ibarrola, DDS, MS, Marvin O. Ludlow, DDS, MS, John R. Anderson, DDS, and Bruce E. Newcomb, BS
Increasingly, patients with rubber latex allergy are being seen in dental offices. Health care workers, persons allergic to certain foods and those with certain medical histories are potentially latex-sensitive. This article presents the case of a patient with a history of severe rubber latex allergy and the associated management of an endodontically involved tooth. The possibility of the latex allergic patient being sensitive to gutta-percha obturation material is also raised.
The following case report describes the endodontic treatment of acute irreversible pulpitis of a maxillary molar in a patient with a history of severe latex allergy.
CASE R E P O R T Because of her self-reported severe allergy to rubber latex products, the patient, a 33-yr-old female registered nurse, was referred to the adult clinic at Creighton University School of Dentistry for endodontic therapy. The maxillary right first molar presented symptoms of acute pulpitis, and diagnostic procedures confirmed that this condition was irreversible. In her medical history, the patient reported the following symptoms of allergic reaction as a result of contact with natural rubber latex products: dermatitis, pruritus, urticaria, bronchospasms, and anaphylaxis. She also related an allergy to bananas, avocados, and chestnuts. No other significant medical history was reported, including no history of genitourinary anomalies (frequent urinary catheterization) or spina bifida. She denied any history of atopy or serious childhood surgical procedures. The patient stated that the initial dermititis on her hands was not diagnosed as latex allergy until after the first anaphylactic reaction. This dermatitis occurred while at her hospital workplace, but was originally considered to be a result of construction materials associated with a remodeling project. At the time of the initial anaphylactic reaction, the patient was injected with 0.3 mg of epinephrine and was stabilized. She had since had 28 episodes of anaphylactic reaction, including two times that required a ventilator for resuscitation. After her initial severe allergic reaction, she was examined by her physician, a pulmonologist, and an allergist. Allergy to latex rubber products was confirmed using skin patch tests, skin prick tests, and serologic testing. This patient was employed at a local hospital in the adult critical care unit. She had been in nursing for the past 11 yr and had first come in contact with rubber latex gloves in nursing school during 1984. A result of her allergy, she carries two Epi-Pens (Center Labs., Port Washington, NY) of 0.3 mg of epinephrine, injectable Benadryl (Park-Davis, Morris Plains, NJ), and a Proventil (Schering Corp., Kenilworth, N J) inhaler with her at all times. She states she knows when a reaction is about to occur and self-injects to combat the impending episode. The patient's physician recommended premedication with prednisone, Benadryl, and Claritin before each treatment appointment. Accordingly, 2 days before treatment, the patient was premedi-
Current Occupational Safety and Health Administration infection control guidelines and the use of "universal precautions" in the~ health care setting have resulted in increased use of rubber gloves that in turn have resulted in an increased number of patients and health care workers being exposed to natural rubber latex (NRL). With this increased exposure, more cases of latex allergy and hypersensitivity have been identified, especially in workers routinely exposed to NRL. Numerous studies have documented significant percentages of latex sensitization in the overall population: in oral health care workers, 12% (1); in registered nurses, 8.9% (2); and in latex doll manufacturing employees, 9.1% (3). In addition to frequent contact with the NRL, increased risk of latex sensitization has been correlated with several medical conditions and cross-allergenicities to certain foods. Medical patients that seem to be predisposed to developing latex hypersensitivity include those who have experienced multiple surgical operations during childhood, such as patients with spina bifida (4), and patients with certain disorders requiring repeated urinary catheterization (5). Cross-reacting IgE antibodies have been discovered that associate latex allergies with banana allergies (6). Other food allergies placing individuals at a higher risk for latex sensitivity include chestnut, avocado, and kiwi fruit (7). During treatment of known hypersensitive individuals, certain precautions must be followed. Nonlatex materials and barriers should be available in every dental office. For some severely hypersensitive individuals, direct contact with NRL is not necessary to invoke an allergic reaction. Phosphated cornstarch, used to prevent latex gloves from sticking together, can act as a vehicle for the airborne transport of the latex allergen (8). This warrants removal of all latex products from the operatory and scheduling latex-sensitive patients first in the morning, before latex dust has accumulated in the office (7).
760
Vol. 24, No. 11, November 1998
cated with 20 mg of prednisone/day for 2 days and 60 mg on the day of the appointment. In addition, 2 hours before the treatment appointment, she was given 50 mg of Benadryl and one tablet of Ctaritin (Schering Corp., Kenilworth, NJ). Treatment was performed in a small isolated room for better control of rubber latex products, latex aerosols, and supplies. The room was prepared using routine infection control procedures. Great care was taken to avoid rubber latex products. Vinyl examination gloves (General Medical Corp., Richmond, VA) were used by both the assistant and the treating dentist. Regional anesthesia was administered, and the tooth was isolated with a nonlatex rubber dam material (Hygienic Corp., Akron, OH). Access was gained through a porcelain crown, and routine cleansing and shaping procedures were performed to prepare the canals for obturation. An interim restoration was then placed and the patient was reappointed. All precautions taken during the first visit were observed for the obturation appointment, including premedication. The patient stated that the tooth was now symptom-free and comfortable. Upon re-entry into the tooth, all canals were irrigated, the apices "cleared" with the final instrumentation, and the gutta-percha cones (Brassler USA, Savannah, GA) were fit. The canals were then obturated with gutta-percha and sealer (Sulton Chemists, Englewood, N J) using lateral condensation. The access preparation was restored using a base of glass ionomer cement (Ketac-Chem, Norristown, PA), followed by TPH composite restorative material (Dentsply, Milford, DE). At no time during the endodontic treatment appointments did the patient experience any allergic type symptoms or reactions. The patient's endodontically treated tooth remained asymptomatic, and 2 wk after obturation, she returned to her private dentist for the fabrication of a new crown restoration. During this treatment procedure, she came into contact with a rubber handgrip device on a dental instrument and immediately experienced another anaphylactic reaction. This episode required three injections of 0.30 mg of epinephrine, 125 mg of Solumedrol (Upjohn, Kalamazoo, MI) intravenously, 50 mg of Benadryl intramuscularly, and two Proventil (Schering Corp.) aerosol treatments. In addition, she was placed on 20 mg of prednisone/day for 1 wk.
DISCUSSION The patient's medical background and history profiled an individual at risk for reactions to NRL products. These indicators should be warning signals to the dental treatment team to take precautions to prevent further harm to the patient. With increasing numbers of the population becoming allergic to NRL products, especially among the health care professionals, it is of paramount importance that the dental treatment team be aware of these sensitivities and be prepared to provide appropriate care for these patients. Guidelines for the care of latex allergic patients appeared in the Office Safety and Asepsis Procedures (OSAP) Monthly Focus (9) and recommend that these patients be treated in an environment with latex presence as low as is reasonably achievable. These patients should be the first patients of the day, and there should be no latex in the room. The treatment room should be closed to entrance, and personnel setting up the room should wear nonlatex gloves. Likewise, instruments should be handled only with nonlatex gloves. Anyone having worn latex gloves that day should be prohibited from entering the treatment room before and during treatment.
Rubber Latex Allergy
761
With respect to endodontics, the focus for concern with the latex allergic patient primarily falls on the gloves and the rubber dam. Other potential sources of rubber that could come in contact with the patient are the rubber stoppers used for file measurement devices, the rubber plunger in the anesthetic syringe, rubber devices used for handgrips on instruments, and the gutta-percha. Chemically, gutta percha and natural rubber appear as isomers, with gutta-percha being trans-polyisoprene and natural rubber cis-polyisoprene. Both are high molecular weight polymers structured from the same basic building unit, the isoprene monomer (10). It seems possible that patients sensitive to NRL products could be allergic to gutta-percha as well. In 1994, a case was presented of a health care worker (a dental hygienist) who was rubber latex-sensitive and who required endodontic therapy on a maxillary molar. All precautions were taken to avoid latex products throughout the treatment procedure. During the obturation portion of the treatment, however, some of the gutta-percha cones were inadvertently extruded through the apex of the palatal root into the periradicular tissue. The patient reported immediate oral discomfort, lip and gingival swelling, a throbbing sensation around the tooth, and diffuse urticaria. Although 4 mg of dexamethasone were infiltrated around the tooth, oral discomfort and swelling persisted for > 4 wk. At that time, the gutta-percha was removed, and the patient experienced immediate relief (11). This case, coupled with the increased appearance of rubber latex-sensitive patients in the dental office, presents added concern for dentists providing endodontic therapy. Attempts were made after the 1994 case to identify specific gutta-percha allergy using an in vitro ELISA. Unfortunately, attempts to extract gutta-percha from pulverized material to prepare an antigen solution to bind the ELISA plate or for skin testing were unsuccessful and, as a result, the gutta-percha sensitivity could not be confirmed. The circumstances, conditions, and symptoms, however, remain highly suspicious of a rubber latex/gutta-percha allergy for that patient. From an endodontic standpoint, it would seem prudent to investigate the relationship further between the gutta-percha used in endodontic therapy and NRL allergies. Until more scientific evidence is available, the use of gutta-percha as an obturation material during endodontic therapy performed on NRL-sensitive patients requires extreme caution.
Dr. Knowles is associate professor, Dr. Ibarrola is assistant professor, and Dr. Ludlow is associate professor and chair, Department of Endodontics, Creighton University School of Dentistry, Omaha, NE. Dr. Anderson is a former student at Creighton University School of Dentistry, Omaha, NE, and he is currently a pediatric dentistry resident at the University of Nebraska Medical Center, Omaha, NE. Mr. Newcomb is a fourth-year student at Creighton University School of Dentistry, Omaha, NE. Address requests for reprints to Dr. Kenneth I. Knowles, Department of Endodontics, Creighton University School of Dentistry, 2500 California Plaza, Omaha, NE 68178.
References 1. Safadi GS, Safadi TJ, Terezhalmy GT, Taylor JS, Battisto JR, Melton AL Jr. Latex hypersensitivity: its prevalence among dental professionals. J Am Dent Assoc 1996;127:83- 8. 2. Grzybowski M, Ownby DR, Peyser PA, Johnson CC, Schork MA. The prevalence of anti-latex IgE antibodies among registered nurses. J Allergy Clin Immunol 1996;98:535-44. 3. Orfan NA, Reed R, Dykewicz MS, Ganz M, Kolski GB. Occupational asthma in a latex doll manufacturing plant. J Allergy Clin Immunol 1994;94: 826 -30.
762
Knowles et al,
4. Nieto A, Estornell F, Mazon A, Reig C, Nieto A, Garcia-lbarra 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. 5. Leger RR, Meeropol E. Children at risk: latex allergy and spina bifida. J Pediatr Nurs 1992;7:371-6. 6. Makinen-Kiljunen S. Banana allergy in patients with immediate-type hypersensitivity to natural rubber latex: characterization of cross-reacting antibodies and allergens. J Allergy Clin Immunol 1994;93:990-6. 7. Monthly OSAP Focus. Office Safety and Asepis Procedures Research Foundation. Annapolis, MD. February 1997.
Journal of Endodontics 8. Baur X, Ammon J, Chen Z, Beckmann U, Czuppon AB. Health risk in hospitals through airborne allergens for patients presensitized to latex. Lancet 1993;342:1148-9. 9. Ownby D. Care of latex allergic patients. Monthly OSAP Focus. Office Safety and Asepis Procedures Research Foundation. Annapolis, MD. February 1997:5. 10. Cohen S, Burns R. Pathways of the pulp. 6th ed. St. Louis: CV Mosby, 1994:401. 11. Boxer MB, Grammer LC, Orfan N. Gutta-percha allergy in a health care worker with latex allergy. J Allergy Clin Immunol 1994;93:943-4.