Frances Dean Wolfe
OSHA guidelines were developed to protect employees ... yet the mandate of universal precautions - to wear gloves - has resulted in the potential risk of latex sensitivity to those same healthcare workers. For example, the article on page XX describes a hygienist whose life has been changed forever by a latex allergy.
The emphasis on employee protection has brought about significant changes in the dental office. It has mandated that personal protective equipment, especially gloves, eyewear, and masks be worn as protective measures for the employee. According to Dr. Robert Runnells, of the University of Utah, "Gloves are the single most important factor in preventing cross-contamination in the dental office."
This transition from wet- to glove-fingered dentistry has brought an unnecessary evil to the dental office: a growing number of allergic reactions resulting from the residual manufacturing-related proteins left inside latex exam gloves contacting the skin. Following is the latest information on latex allergies and what hygienists can do to protect themselves from the effects.
How prevalent is latex sensitivity?
Contact dermatitis and sensitization to latex following prolonged exposure are the two most common latex-allergy reactions in health-care workers. Symptoms can range from itchiness and redness to respiratory distress and, occasionally, fatal anaphylaxis! More than 100,000 people in the United States are at risk, most of whom work in the health-care field and contact latex on a daily basis. It is estimated that from 8 to 17 percent of them risk developing latex allergies, either by inhaling the particles from the gloves that carry latex proteins in the air or by wearing latex gloves.
How serious is latex sensitivity and why all the fuss?
That`s what RDH asked Dr. Lauren Charous, director of the Allergy and Respiratory Care Center, Milwaukee Medical Center, and chairman of the American College of Allergy and Immunology`s task force on latex hypersensitivity. He responded, "Since 1990, more than 1,500 reports of allergic reactions to medical devices or equipment containing natural rubber latex have been reported to the U.S. Food and Drug Administration." According to Dr. Charous, latex-allergic responses may be significantly under-reported because the FDA`s reporting system is a voluntary one.
Dr. John Molinari, professor and chairman of the Department of Biomedical Sciences, University of Detroit Mercy, says, "In the past 15 years, hand asepsis has improved with the use of latex gloves. But unfortunately, adverse reactions, such as localized and systemic hypersensitivity, have been associated with the use of latex gloves."
Latex-allergy exposure develops from three sources:
- gloves worn by dental health-care workers (DHCWs)
- air breathed by the DHCWs
- direct tissue exposure
According to sources contacted by RDH, approximately one-third of all health-care workers who regularly use latex gloves report some type of dermatitis. NIOSH estimates 10 to 15 percent of those individuals occupationally exposed to latex eventually develop some form of latex allergy.
What causes latex sensitivity?
The problem starts with a white, milky substance harvested from the tropical tree, Hevea brasilienis, whose proteins provide the essential "stretch" to many products used in the dental profession - including latex gloves.
The specific culprit linked to latex allergies originates in the manufacturing process. Ammonia is added to the latex sap to preserve it and keep it hydrated during transportation from the forest to the manufacturing plant. Researchers now believe the ammonia causes an estimated 240 proteins to change and degrade, creating protein allergens. Centrifugation, a subsequent latex manufacturing process, removes some of the proteins, but, unfortunately, not all of them.
Gloves are manufactured using porcelain molds coated with a coagulating salt. Then, they are dipped into a vulcanized latex concentrate. After drying, the gloves are washed, coated with lubricating powder, and removed from the molds. Cornstarch powder is the most common glove lubricant and is associated with reactions due to the absorption of antigens to the cornstarch particles, producing aerosolized latex antigen. Powder-free gloves are preferred by some sensitive DHCWs - however, the powder is not the cause of latex allergy.
CPC (cetyl pyridium chloride) is another agent used to facilitate the donning of gloves. It avoids all the deleterious problems associated with starch and also acts as a mild disinfectant, killing some bacteria and viruses and providing a microbial barrier under gloves.
"We assume that more [glove] washing will make the latex safer," says Orhan H. Suleiman, Ph.D., chairman of the FDA`s latex sensitivity task group.
What adverse immunological reactions do dental health-care workers experience?
According to Dr. Curtis P. Hamann, president and CEO of SmartPractice, Phoenix, Ariz., "The increase in reported cases of natural rubber latex (NRL) hypersensitivity, especially in health care, appears to coincide with the increased demand for personal protection in response to the AIDS crisis. Increased frequency and duration of exposure to natural rubber latex-containing devices, such as examination and surgical gloves, has led to an increase in the prevalence of both occupational and non-occupational cases of reported NRL allergy."
Three distinct reactions directly attributed to NRL products are:
- immediate hypersensitivity (type I)
- delayed hypersensitivity (type IV) and
- irritant dermatitis (ID)
Type I (immediate hypersensitivity) - Immediate hypersensitivity (Type I) is a cutaneous anaphylactic response caused by induction of the host humoral immune system to synthesize IgE antibodies against latex proteins. The resultant wheal and flare reaction is an immediate hypersensitivity response that develops within minutes of contacting the user, either by direct contact or carried airborne by powdering agents contained in some NRL products. Potentially the most severe (even life-threatening), Type I reactions may involve the skin, respiratory tract, gastrointestinal tract, or the cardiovascular system.
The prevalence of Type I hypersensitivity in health-care workers ranges from 5 to 10 percent, depending upon the testing methodology used and the study participants. Prevalence for high-risk groups, such as spina bifida patients, has been reported as high as 68 percent.
According to Dr. Hamann, "In the U.S. alone, there are an estimated 1.4 million health-care workers. If the prevalence of Type I allergies is approximately 7 percent of the population, immediate hypersensitivity affects approximately 98,000 health-care workers, not including approximately 112,500 of 450,000 (25 percent) of health-care workers potentially affected by the other two types of reactions due to NRL exposure."
Adds Dr. Molinari: "An even more severe manifestation of Type I hypersensitivity can develop in some subjects who are challenged with airborne allergens. NRL proteins also can adhere to cornstarch powder particles during glove manufacture. These proteins can subsequently remain suspended in the air bound to powder for prolonged periods. Respiratory and conjunctival exposure of sensitized persons to NRL protein can stimulate more systemic anaphylactic symptoms."
The University of Colorado`s Marjory Bernstein, a latex-allergic nurse and state representative for ELASTIC (East Coast Latex Allergy Support Team and Information Coalition) confirms this. "Even in operating rooms where laminar air-flow devices are used, latex aeroallergens remain present in high quantities from the donning and discarding of powdered latex gloves." She notes that aeroallergens are carried throughout the hospital environment by ventilation air-exchange systems, as well as by settling on clothing and equipment.
Those who develop immediate-type allergy symptoms experience eye watering, nasal congestion, sneezing, coughing, wheezing, shortness of breath, decreased blood pressure, and dizziness within minutes of being exposed to latex. Severity can range from mild itching, irritation, and allergic conjunctivitis to a brief period of difficulty in breathing to life-threatening anaphylaxis. Affected dental health-care workers often find that their hands begin to burn and itch soon after donning latex gloves. After removing the gloves, they also may notice rapid appearance of hives and localized edema, usually within 20 minutes after exposure to the protein antigens.
"Obtaining a definitive diagnosis of an immediate hypersensitivity to NRL presents yet another challenge for the [dental] health-care worker," says Dr. Hamann.
The two options currently available for diagnosing a Type I allergy are the skin-prick test (SPT), currently the most convenient and accurate diagnostic method for screening individuals with Type I allergy. It often is used in conjunction with the CAP RAST (Pharmacia) test to quantitate the amount of specific IgE antibodies present in serum. The FDA has approved the newer AlaSTAT (Diagnostic Products Corporation) test method for marketing.
According to Dr. Hamann, who has overseen skin-prick latex tests on more than 8,000 individuals in clinical and screening situations, "Letting a sensitized, but undiagnosed, individual to continue NRL glove use and other NRL exposures on a daily basis may be very dangerous and clearly indicates the importance of identifying NRL-allergic individuals, providing synthetic alternatives, and effectively managing the environment."
Type IV (delayed hypersensitivity) - Like Type I, this is an acquired immune reaction but mediated by sensitized T-lymphocytes and other leukocytes infiltrating into epithelial tissues that harbor their target allergen. Type IV is most commonly caused by the residual processing chemical found in NRL products (thiurams, carbamates, and mercaptobenzothiazoles). "The primary sensitizing additives in NRL are the accelerators added as catalysts during the compounding phase of glove production to shorten vulcanization and to help control the uniformity of the product," Dr. Hamann reports.
Subjects with Type IV hypersensitivity develop lesions slowly with a several-hour delay in the onset of symptoms, reaching maximal appearance in 24 to 48 hours.
"Historically," says Dr. Molinari, "Type IV latex hypersensitivity has been found to be the most common NRL allergy." Symptoms include diffuse or patchy eczema on the contact area often accompanied by itching, redness, and vesicles and, later, by dry skin, fissures, and sores often confined to the contact area. "A classic example," says Dr. Molinari, "is that of glove dermatitis showing a sharp delineation where the [latex] glove cuff ends."
Irritant dermatitis (ID) - Irritant dermatitis may be caused by the numerous irritants commonly present in the health-care setting (acrylates, soaps, disinfectants, metals, lotions, improper hand drying, excessive scrubbing of the hands, solvents, vapors, etc.), as well as by surgical and examination gloves. Irritant dermatitis, however, is not an immunologic event.
When linked with glove use, the ID reaction most often is due to the residual processing chemicals, donning lubricants or the user`s perspiration inside of the glove. Some chemicals, such as acrylates, disinfectants and resins, have the ability to penetrate NRL and other glove materials, causing hand eczema or paresthesia. Irritant dermatitis reactions often are attributed to the gloves, rather than to the actual offending agents. If clinically mismanaged or left untreated, irritant dermatitis may cause permanent skin damage.
What glove alternatives are available for the hygienist?
Atopic health-care workers with chronic eczema should avoid natural-rubber latex if at all possible. Premedication with corticosteriods or antihistamines may help. Cotton glove-liners or barrier creams also may be helpful for some hygienists.
A number of alternatives to latex gloves currently are available, including vinyl and decreased allergenicity gloves, which have helped alleviate the symptoms suffered by many dental health-care providers. Be aware, however, that gloves labeled hypoallergenic may not always prevent adverse reactions. The FDA recently implemented changes in advertising claims of glove manufacturers to provide labeling aimed that better informs health-care providers and corrects manufacturing misconceptions.
Frances Dean Wolfe is the pen name of a long-time dental author whose career in the dental profession spans three decades.
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How can a hygienist combat allergic responses?
1. Switch to non-latex gloves. (Vinyl gloves are an acceptable alternative, although they have less elasticity and offer less protection against hepatitis B virus and HIV.)
2. Look for low protein content on glove boxes. The Food and Drug Administration has suggested that lowering protein levels in gloves may significantly reduce the risk and incidence of problems associated with latex sensitivity. As a result, many glove manufacturers are improving processes to ensure lower protein content.
3. If your practice uses latex dental dams, consider switching to a non-latex product.
4. Avoid coming into contact with other dental products containing latex, such as rubber bite blocks, banana flavored topical, latex prophy cups, amalgam carriers with rubber tips (use ones with Teflon®), liquid droppers or rubber stoppers on bottles, orthodontic elastics, suction tips, etc.
5. Remember that products labeled "hypoallergenic" may not be allergy-free. Check all new FDA-required package labeling for content.
6. Be alert to the possibility of an allergic reaction whenever devices containing latex are used in the dental office, especially when the latex will contact the oral mucosa.
7. Advise all patients of a possible latex sensitivity, should they develop signs and symptoms following a dental appointment.
8. Stress to all latex-sensitive patients that they should inform all their health-care providers about their latex sensitivity.
Does your practice screen patients?
Because all chairside dental team members are required to wear gloves to perform invasive procedures, they are advised to screen their patients (new ones, as well as patients of record) about possible NRL sensitivity.
If your health history form does not have a question about possible latex sensitivity, you can print your own, using the following questions:
1. Are you allergic to latex or rubber?
2. Have you ever had surgery?
3. Have you ever experienced any complications during surgery or a medical procedure requiring resuscitation?
4. Have you ever worked in an environment that brought you into constant contact with latex products?
5. Have you experienced wheezing, difficulty in breathing, coughing, rashes, swelling, hives, itching, or watery eyes when coming into contact with rubber items, such as balloons?
6. Are you allergic to bananas, avocados, chestnuts, kiwi, passion fruit, potatoes, or other foods?
7. Do you have a history of asthma, hay fever, eczema, or dermatitis?
8. Does maintaining your health require frequent mucous membrane exposure to products containing latex?
9. Have you ever experienced swelling of the mouth or other adverse symptoms after dental procedures or with denture wear?
10. Do you frequently wear rubber gloves at home?
If patients respond affirmatively to any of the above questions, they may have experienced an allergic reaction to NRL or may be sensitive to products containing it. If so, report this to the dentist.
How latex allergies changed my life
(A personal nightmare)
Working as a dental hygienist for approximately 26 years in a profession that I loved came to an abrupt halt one evening in May 1997 when I was diagnosed with Type III latex allergy. I was further warned that returning to work one more time, could be - and probably would be - life threatening. Disbelief was my first reaction. A simple blood test called the RAST test made a positive diagnosis of latex allergy.
I had returned to hygiene in 1989, following OSHA`s mandated use of gloves, eyewear, and masks for the safety of health-care workers. Some of the more expensive masks, I learned, are made with latex to filter out bloodborne pathogens.
I had trouble wearing the gloves because of a rash that would appear shortly after donning them. I informed my employer, who offered to provide me with different gloves. After the problem continued, I sought medical attention and was given steroid creams for the dryness, itching, and burning sensations on my hands. I was free of the rash for a while and continued doing what I loved to do: treat patients.
Shortly after that, I developed coughing bouts. They were slight at first and I thought I had a cold. The symptoms increased, sounding like an asthmatic cough. I continued to get worse, especially at work. Again I sought medical advice and was told, "You have occupational asthma."
I was given an inhaler, which I only used when I absolutely needed it. Months passed and the cough worsened, but only at work! I was using the inhaler every four hours at work and had several episodes when I had to go to the emergency room because the coughing had progressed into an asthmatic attack.
Occasionally, I experienced unexplained hives on my neck and face and what I thought was pinkeye. Although I washed my hands every time I took off my latex gloves, I realized that minute particles of the powder in the gloves (which contained the latex protein) were left under my fingernails. The tiniest bit of latex protein is enough to trigger a surface reaction in a latex-sensitive person.
I was advised: "Avoid latex as much as possible! Each exposure to latex sensitizes you more!" Latex is everywhere! All underwear and bathing suits have latex. Elastic in the sleeves of shirts and pants is made of latex. Sit in a cushioned chair and you`re sitting on latex. Talk on the phone, the cord has latex. Sit at the computer, the mouse pad has latex.
Go into anaphylaxis from latex and someone calls an ambulance. The EMT personnel switch to the latex-free gloves and take your blood pressure, listen to your respiration and start an IV. Guess what the blood pressure cuff, stethoscope, and IV line are made of? Latex! Guess what`s in the ambulance and hospital emergency room? Latex proteins by the millions!
Not until I was diagnosed with latex allergy did I correlate the constricted feeling in my throat when I ate bananas or kiwi. It turns out that they are only a few of the foods cross-reactive to latex allergy. All pitted fruits, bananas, kiwi, avocados, peaches, plums, pears, pineapple, cantaloupe, honeydew, watermelon, and tomatoes can be life-threatening to a latex-sensitive individual. Macadamia and hazel nuts have been known to be the cause of death in health-care professionals with latex sensitivity.
Even though there are many foods that don`t cross-react to latex allergies, the preparation of them can be dangerous! If you eat in a restaurant that uses powdered latex gloves for food preparation, there are latex proteins in the food. I have experienced situations in which I started to cough and had trouble breathing while waiting for my food to arrive or after eating a few bites of the meal in a restaurant.
Food shopping has become a nightmare for me. Most grocery stores have a section with balloons (made of latex), a deli, bakery, meat department, and seafood department where the employees wear latex gloves.
Because there is no way to escape contact with latex in our everyday lives, the least I can do is raise the awareness of the effects of latex allergy and alert others to the way it can change your life forever. If you think you may be latex-sensitive, take the symptoms seriously and seek medical attention early.
(Hygienist`s name withheld due to pending Workman`s Compensation and Social Security benefits appeal.)
Skin cream helps curb allergies
So what can a hygienist with latex sensitivity do to combat the side effects associated with wearing gloves? Columbia-Presbyterian University has developed and licensed a zinc formulation cream called Allergy Guard, which will be marketed by Virasept Pharmaceuticals.
According to lead researcher Dr. Shanta Modak, "Use of the cream may reduce heath-care workers` risk of being sensitized to latex after continued exposure and may help the tens of thousands of health-care workers who suffer daily with chronic irritant dermatitis." She is quick to point out that the cream cannot cure the advanced stages of latex reaction.
According to Dr. Modak, the new hand cream provides a protective coating over the intact skin by reacting and bonding with the soluble latex proteins and other irritants to prevent latex allergies for up to four hours when applied before putting on gloves.
The Feds and other legal issues
Latex-exposure reactions should be reported to the U.S. Food and Drug Administration MedWatch Program. The FDA encourages health-care professionals to report any incident associated with a medical device. All reporting is confidential and can be faxed to (800) FDA-0178. For further information, call or write: MedWatch, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20852-9789; phone: (800) FDA-1088.
The FDA will also require warning labels on products containing latex, and manufacturers will be discouraged from labeling latex gloves as "hypoallergenic."
Glove manufacturers are monitoring legal actions arising from latex allergies. In Milwaukee last February, a jury awarded a hospital technician $1 million for health problems related to latex sensitivity. The latex product liability case was expected to motivate more companies to redesign manufacturing processes that lead to higher protein contents in gloves.