Contact Dermatitis and Latex Allergy

What is contact dermatitis?
What is latex allergy?
What are the categories of glove-associated skin reactions?
What are some considerations if dental health care personnel are allergic to latex?
Why are powder-free gloves recommended?
What are some considerations for providing dental treatment to patients with latex allergy?
References

What is contact dermatitis?

Occupationally related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use. Contact dermatitis is classified as either irritant or allergic. Irritant contact dermatitis is common, nonallergic, and develops as dry, itchy, irritated areas on the skin around the area of contact. By comparison, allergic contact dermatitis (type IV hypersensitivity) can result from exposure to accelerators and other chemicals used in the manufacture of rubber gloves as well as from exposure to other chemicals found in the dental practice setting. Allergic contact dermatitis often manifests as a rash beginning hours after contact and, like irritant dermatitis, is usually confined to the areas of contact.

What is latex allergy?

Latex allergy (type I hypersensitivity to latex proteins) can be a more serious systemic allergic reaction. It usually begins within minutes of exposure but can sometimes occur hours later. It produces varied symptoms, which commonly include runny nose, sneezing, itchy eyes, scratchy throat, hives, and itchy burning sensations. However, it can involve more severe symptoms including asthma marked by diffcult breathing, coughing spells, and wheezing; cardiovascular and gastrointestinal ailments; and in rare cases, anaphylaxis and death.

What are the categories of glove-associated skin reactions?

	Irritant Contact Dermatitis	Allergic Contact Dermatitis (Type IV [delayed] Hypersensitivity)	*Latex Allergy (Type I [immediate] Hypersensitivity or NRL protein allergy)**
Causative Agents	Toxic chemicals (e.g., biocides, detergents); excessive perspiration; irritating chemicals used in hand products and in glove manufacture	Accelerators and other chemicals used in glove manufacture; sterilants and disinfectants (e.g. glutaraldehyde); bonding agents (e.g. methracrylates); local anesthetics	Latex proteins from Hevea brasiliensis (rubber tree)
Reactions	Skin reactions usually confined to the area of contact	Skin reactions usually confined to the area of contact	Skin and systemic reactions can occur as soon as 2�minutes, or as long as several hours after skin or mucous membrane contact with the protein allergens
	Acute: Red, dry, itchy irritated areas	Acute: Itchy, red rash, small blisters	Acute: Hives, swelling, runny nose, nausea, abdominal cramps, dizziness, low blood pressure, bronchospasm, anaphylaxis (shock)
	Chronic: Dry, thickened skin, crusting, deep painful cracking, scabbing sores, peeling	Chronic: Dry thickened skin, crusting, scabbing sores, vesicles, peeling (appears 4� hours after exposure)	Chronic: As above, increased potential for extensive, more severe reaction
Diagnosis	By medical history, symptoms, and exclusion of Type IV and Type I hypersensitivity Not an allergic reaction	By medical history, symptoms, and skin patch test	By medical history, symptoms, and skin-prick or blood test

* NRL=natural rubber latex
American Dental Association, 1999.

Dental health care personnel experiencing contact dermatitis or latex allergy symptoms should seek a definitive diagnosis by an experienced health care professional (e.g., dermatologist, allergist) to determine the specific etiology and appropriate treatment for their condition, as well as to determine what work restrictions or accommodations may be necessary.

What are some considerations if dental health care personnel are allergic to latex?

Dental health care personnel who are allergic to latex will need to take precautions at work and outside the workplace since latex is used in a variety of other common products in addition to gloves. The following recommendations are based on those issued by the National Institute for Occupational Health and Safety (NIOSH):

If definitively diagnosed with allergy to natural rubber latex (NRL) protein:

Avoid, as far as feasible, subsequent exposure to the protein and only use nonlatex (e.g., nitrile or vinyl) gloves.

Make sure that other staff members in the dental practice wear either nonlatex or reduced protein, powder-free latex gloves.

Use only synthetic or powder-free rubber dams.

Dental personnel can further reduce occupational exposure to NRL protein by taking the following steps:

Using reduced protein, powder-free latex gloves.

Frequently changing ventilation filters and vacuum bags used in latex contaminated areas.

Checking ventilation systems to ensure they provide adequate fresh or recirculating air.

Frequently cleaning all work areas contaminated with latex dust.

Educating dental staff on the signs and symptoms of latex allergies.

Why are powder-free gloves recommended?

Proteins responsible for latex allergies are attached to glove powder. When powdered gloves are worn, more latex protein reaches the skin. Also, when gloves are put on or removed, particles of latex protein powder become aerosolized and can be inhaled, contacting mucous membranes. As a result, allergic dental health care personnel and patients can experience symptons related to cutaneous, respiratory, and conjunctival exposure. Dental health care personnel can become sensitized to latex proteins after repeated exposure. Work areas where only powder-free, low-allergen (i.e. reduced-protein) gloves are used show low or undetectable amounts of allergy-causing proteins.

What are some considerations for providing dental treatment to patients with latex allergy?

Patients with a latex allergy should not have direct contact with latex-containing materials and should be treated in a "latex safe" environment. Such patients also may be allergic to the chemicals used in manufacturing natural rubber latex gloves, as well as to metals, plastics, or other materials used to provide dental care. By obtaining thorough patient health histories and preventing patients from having contact with potential allergens, dental health care professionals can minimize the possibility of patients having adverse reactions. Considerations in providing safe treatment for patients with possible or documented latex allergy include (but are not limited to) the following:

Screen all patients for latex allergy (e.g., obtain their health history, provide medical consultation when latex allergy is suspected).

Be aware of some common predisposing conditions (e.g., spina bifida, urogenital anomalies, or allergies to avocados, kiwis, nuts, or bananas).

Be familiar with the different types of hypersensitivity梚mmediate and delayed梐nd the risks that these pose for patients and staff.

Consider sources of latex other than gloves. Dental patients with a history of latex allergy may be at risk from a variety of dental products including, but not limited to, prophylaxis cups, rubber dams, and orthodontic elastics.

Provide an alternative treatment area free of materials containing latex. Ensure a latex-safe environment or one in which no personnel use latex gloves and no patient contact occurs with other latex devices, materials, and products.

Remove all latex-containing products from the patient's vicinity. Adequately cover/isolate any latex-containing devices that cannot be removed from the treatment environment.

Be aware that latent allergens in the ambient air can cause respiratory and or anaphylactic symptoms in people with latex hypersensitivity. Therefore, to minimize inadvertent exposure to airborne latex particles among patients with latex allergy, try to give them the first appointments of the day.

Frequently clean all working areas contaminated with latex powder/dust.

Frequently change ventilation filters and vacuum bags used in latex-contaminated areas.

Have latex-free kits (e.g., dental treatment and emergency kits) available at all times.

Be aware that allergic reactions can be provoked from indirect contact as well as direct contact (e.g., being touched by someone who has worn latex gloves). Hand hygiene, therefore, is essential.

Communicate latex allergy procedures (e.g., verbal instructions, written protocols, posted signs) to other personnel to prevent them from bringing latex-containing materials into the treatment area.

If latex-related complications occur during or after the procedure, manage the reaction and seek emergency assistance as indicated. Follow current medical emergency response recommendations for management of anaphylaxis.

Selected References and Additional Resources

Allmers H, Brehler R, Chen Z, Raulf-Heimsoth M, Fels H, Baur X. Reduction of latex aeroallergens and latex-specific IgE antibodies in sensitized workers after removal of powdered natural rubber latex gloves in a hospital. J Allergy Clin Immunol 1998;102:841�6.

American Dental Association Council on Scientific Affairs. The dental team and latex hypersensitivity. J Am Dent Assn 1999;130:257-264.

Baur X, Chen Z, Allmers H. Can a threshold limit value for natural rubber latex airborne allergens be defined? Journal of Allergy and Clinical Immunology 1998;101:24�.

Baur X, Jager D. Airborne antigens from latex gloves. Lancet 1990;335:912.

Berky ZT, Luciano WJ, James WD. Latex glove allergy: a survey of the U.S. Army Dental Corps. J Am Dent Assn 1992;268:2695�97.

Bubak ME, Reed CE, Fransway AF, et al. Allergic reactions to latex among health-care workers. Mayo Clin Proc 1992;67:1075�79.

CDC. National Institutes of Occupational Safety and Health (NIOSH). NIOSH Alert: Preventing allergic reactions to natural rubber latex in the workplace. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, CDC, National Institute for Occupational Safety and Health, 1997. Accessed May 2004.

CDC. National Institutes of Occupational Safety and Health (NIOSH). Latex Allergy: A Prevention Guide. Questions and Answers about identifying and preventing latex allergy. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, CDC, National Institute for Occupational Safety and Health DHHS NIOSH Publication No. 98-113. Accessed May 2004.

CDC. National Institutes of Occupational Safety and Health (NIOSH). NIOSH Facts: Latex Allergy. US Department of Health and Human Services, Public Health Service, CDC, National Institute for Occupational Safety and Health, 1997. Accessed May 2004.

Hamann CP, Turjanmaa K, Rietschel R, et al. Natural Rubber Latex Hypersensitivity: incidence and prevalence of type I allergy in the dental professional. J Am Dent Assn 1998;129:43�.

Hamann CP, Rodgers PA, Sullivan K. Management of dental patients with allergies to natural rubber latex. Gen Dent 2003;50(6):526-536.

Hamann CP, Rodgers PA, Sullivan K. Allergic contact dermatitis in dental professionals: effective diagnosis and treatment. J Am Dent Assn 2003;134(2):185-194.

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�0.

Hermesch CB, Spackman GK, Dodge WW, Salazar A. Effect of powder-free latex examination glove use on airborne powder levels in a dental school clinic. J Dent Educ 1999;63:814�0.

Hunt LW, Fransway AF, Reed CE, et al. An epidemic of occupational allergy to latex involving health care workers. J Occup Environ Med 1995;37:1204�09.

Nash KD. How infection control procedures are affecting dental practice today. J Am Dent Assn 1992;123:67�.

Safadi GS, Safadi TJ, Terezhalmy GT, Taylor JS, Battisto JR, Melton AL Jr. Latex hypersensitivity: Its prevalence among dental professionals. J Am Dent Assn 1996;127:83�.

Smart ER, Macleod RI, Lawrence CM. Allergic reactions to rubber gloves in dental patients: Report of three cases. Br Dent J 1992;172:445�7.

Snyder H, Settle S. the rise in latex allergy: Implications for the dentist. J Am Dent Assn 1994;125:1089�97.

Swanson MC, Bubak ME, Hunt LW, Yunginger JW, Warner MA, Reed CE. Quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol 1994;94:445�1.

Tarlo SM, Sussman G, Contala A, Swanson MC. Control of airborne latex by use of powder-free latex gloves. J Allergy Clin Immunol 1994;93:985�9.

Trape M, Schenck P, Warren A. Latex gloves use and symptoms in health care workers 1 year after implementation of a policy restricting the use of powdered gloves. Am J Infect Control 2000;28:352�8.

Turjanmaa K, Reunala, Alenius H, Brummer-Korvenkontio H, Palosuo T. Allergens in latex surgical gloves and glove powder. Lancet 1990;336:1588.

Yassin MS, Lierl MB, Fischer TJ, O'Brien K, Cross J, Steinmetz C. Latex allergy in hospital employees. Ann Allergy 1994;72:245�9.

Zaza S, Reeder JM, Charles LE, Jarvis WR. Latex sensitivity among perioperative nurses. AORN Journal 1994;60:806�2.

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Page last reviewed: October 29, 2008
Page last modified: July 15, 2006
Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion