Dverse Reactions To Latex Products
Content
Advers Adve rse e Rea React ctio ions ns to La Late tex x Pr Prod oduc ucts ts:: Pr Prev even enti tive ve an and d Therapeutic Strategies for Oral Healthcare Settings Michaell A. Huber, DDS; Géza T. Terézhalmy, DDS, MA Continuing Education Units: 2 hours
Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce81/ce81.aspx
Disclaimer: Participants
must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
This course is based on a review of the literature and presents the etiology and epidemiology of adverse reactions to latex products, clinical manifestations of adverse reactions to latex products, and strategies for the prevention and treatment of adverse reactions to latex products.
Conflict of Interest Disclosure Statement • •
Dr. Huber reports no conflicts of interest associated with with this course. Dr. Terézhalmy has done consulting work for Procter & Gamble and is a member of the dentalcare.com Advisory Board.
ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp http://www.ada.org/cerp
Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to 7/31/2017. Provider ID# 211886
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Overview Evidence-based infection control/exposure control practices are evolutionary in nature. Elements of 1 historical note were first recorded with the suggestions of Lister for guidelines on aseptic procedures. Others, like Semmelweis, promoted the practice of hand washing by medical students and physicians prior 2 to leaving autopsy suites and before entering the labor and delivery areas of hospitals. Halstead is credited 3 with being the first to use surgical gloves in a clinical setting. While the use of latex surgical gloves became routine by the end of World War I, it wasn’t until the adoption of universal precautions by the Centers for Disease Control and Prevention in 1987 that the use of gloves was officially expanded to cover virtually 4 all aspects of patient care. Since then the ubiquitous ubiquitous use of latex gloves gloves and other latex products in healthcare has resulted in a parallel increase in latex-associated adverse reactions. To provide for a safe environment for both oral healthcare workers (OHCWs) and patients alike, clinicians must understand the basis for latex-related adverse reactions, recognize associated signs and symptoms, and initiate appropriate preventive and therapeutic strategies. The recommendations for preventing or minimizing latex-related adverse reactions in the oral healthcare setting are based on current knowledge and a common sense approach to the problem.
Learning Objectives Upon completion of this course, the dental professional should be able to: • Discuss the etiology and epidemiology of adverse reactions to latex products. products. • Recognize the clinical manifestations manifestations of irritant contact dermatitis, allergic contact dermatitis, and and immediate allergic reactions. • Discuss diagnostic diagnostic issues related to adverse reactions to latex latex products. products. • Establish strategies strategies for the prevention prevention of adverse reactions to latex latex products. • Implement strategies for for the treatment of adverse reactions to latex products.
Course Contents
Etiology and Epidemiology
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Etiology and Epidemiology Clinical Manifestations Irritant Contact Dermatitis Dermatitis Allergic Contact Dermatitis Immediate Allergic Reactions Urticaria Angioedema Allergic Rhinoconjunctivitis and Asthma Anaphylaxis
Latex is a product of the Brazilian Hevea brazilienses rubber rubber tree harvested mainly in 5-6 Malaysia, Indonesia, and Thailand. A milky sap flows in lactifers under the surface of the bark, which is collected by making diagonal cuts in the bark of the tree. Once collected, ammonia ammonia is added to the sap to prevent autocoagulation 5,7,9 and bacterial contamination of the latex. There are two types of ammonia-latex concentrates:
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Diagnosis Medical History Labora Laboratory tory Testing Skin-p Skin-patch atch Testing Skin-puncture Testing Testing (SPT) Radioallergosorbent Test Test (RAST) Glove Provocation Testing (GPT) Preventive Strategies for the Oral Healthcare Setting Treatment Strategies Conclusion Course Test Previe Preview w References About the Authors
high ammonia-latex concentrate (0.7% ammonia by weight) and low ammonia-latex concentrate (0.2-0.3% ammonia by weight). While the higher ammonia concentration is more effective in stabilizing the latex, it also increases the 7,10 incidence of irritant contact dermatitis.
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Natural rubber latex contains cis-1,4polyisoprene (the major component), proteins, lipids, carbohydrates, and numerous inorganic constituents such as potassium, manganese, 11 copper, zinc, and iron. Over 250 proteins have been identified in latex and, depending on the source; the overall protein content varies from
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formers. Donning powder (typically cornstarch) cornstarch) is recognized as a major vector for the development 8,14,16-26 of latex sensitivity sensitivity.. Free extractable proteins not removed during the glove manufacturing process may be adsorbed by the cornstarch. During the donning, use and removal of these gloves, the cornstarch-protein complexes come in direct contact with skin and mucosal surfaces or become suspended in the air (aeroallergens) for up to six hours.27 Following direct direct contact, mucosal surfaces appear to absorb latex proteins much more readily than intact skin and exposure to aeroallergens is considered the predominant method of inducing latex sensitization in 18.19,25,28 healthcare workers. While an allergy to cornstarch is rare, evidence exists that it may act as an immunoadjuvant further increasing the risk 7,18,29 of latex-induced allergic reactions.
1-1.8%. These proteins are involved in numerous processes of biosynthesis and defensive, 9 structural, and housekeeping functions. While about 30-60 latex proteins are believed to be responsible for virtually all of the immediate hypersensitivity reactions (Gell and Coombs Type I), only 13 of these proteins have been classified and labeled by the International Nomenclature 5,11,12 Committee of Allergens.
Improvements in the manufacturing of latex gloves includes the use of enzymatic processes to breakdown raw latex proteins; increased centrifugation of the raw latex liquid to separate out more latex proteins; refined leaching protocols; and chemical deproteinization during 8 the leaching process. In addition the use of oat starch in lieu of cornstarch as a donning powder appears to be associated with reduced 25 aeroallergen formation. An increasing number of latex-free alternatives are also becoming available; however, residual chemicals associated with the manufacturing of non-latex gloves may 8 also induce delayed hypersensitivity reactions.
Gloves are produced by one of two processes: 8 coagulant dipping or straight dipping. In coagulant dipping a destabilizing chemical is deposited on the formers, while in straight dipping no destabilizing agent is used. After dipping, the latex product on the former is washed (leached) to remove residual chemicals and proteins. In order to enhance elasticity, strength, and stability it is then subjected to the process of vulcanization (heating in the presence of sulfur). To reduce the time and temperature required for vulcanization, numerous “accelerators” and
The incidence of latex allergy in the general 30 population is 1 to 2 percent. Patients with spina bifida, because of repeated exposure of mucous membranes to latex during various medical/
“promoters” (thiurams, mercaptobenzothiazoles, and carbamates) are added. After vulcanization, post-cure leaching further removes residual chemicals and proteins. Residual chemicals are primarily responsible for allergic contact dermatitis associated with latex glove use (Gell and Coombs 7,9,10,13-15 Type IV).
surgical procedures, are at highest risk of latex allergy with a prevalence rate that ranges from 30 20 to 67 percent. Healthcare workers workers have the second highest risk of developing latex allergy with sensitization rates that are three times higher 30,31,32 than in the general population. Healthcare workers who are exposed to latex products on a regular basis are at higher risk than those who are 7 not routinely exposed. There is also a positive correlation between the risk of latex allergy and 33 the length of employment in healthcare. Finally, exposure to powdered gloves appears to be associated with symptoms of asthma, allergic 7,30,32 rhinitis, conjunctivitis, and angioedema.
If the gloves are destined to be free of donning powder, another washing followed by chlorination and further washing is undertaken to reduce 8 the inherent tackiness of latex. Alternatively, donning powder may be added by dipping the gloves into slurry prior to removal from the
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Clinical Manifestations
natural rubber latex during harvesting, processing, 5,7,9,10,13,15,24,35,39 or manufacturing. Many of these processing chemicals are also utilized in the 15 manufacturing manufactur ing of nitrile and neoprene gloves. ACD is a T cell-mediated cell-mediated immune immune response. It is characterized by a papular, pruritic rash; redness; and itching, which usually begin 24 to 48 hours after contact with offending products and may progress to oozing vesicles and blisters and spread to areas of skin untouched by latex 15,41,42 (Figure 1). The reaction is similar similar to those caused caused by nickel and poison ivy. A skin rash may be the first sign of allergy to latex and more serious reactions could occur with continued exposure. Since the clinical signs and symptoms of ACD are similar to ICD, it is necessary to confirm the allergic nature of the reaction in order to avoid further sensitiza sensitization. tion. The most frequently cited allergen for glove-related ACD is the accelerator 5,43 thiuram. ACD can develop upon re-exposure re-exposure to 7 an antigen many years after initial exposure.
Adverse reactions following exposure to latex products may be categorized as: (1) irritant contact dermatitis, (2) allergic contact dermatitis, or (3) immediate hypersensitivity reactions (urticaria, angioedema, allergic rhinitis, asthma, or 5,7,10,14,34 anaphylaxis).
Irritant Contact Dermatitis The most common reaction to latex products, specifically to latex gloves, is irritant contact dermatitis (ICD). ICD, characterized by dry dry,, cracked, itchy, irritated areas of the skin (usually of the hands) is not an allergy. The time of onset is gradual (over several days) and may result from abrasion and maceration from wearing gloves constantly, repeated hand washing and drying, incomplete hand drying, the use of cleaners and sanitizers, exposure to powder added to gloves, and exposure to other workplace 5,7,10,35 products and chemicals. These signs and symptoms are similar to those associated with allergic contact dermatitis, which can only be ruled out by allergy testing. In one study, only 9 percent of healthcare workers who reported symptoms of allergic contact dermatitis actually 36 had a latex allergy; the remainders had ICD. In a study of dental students, of the 10 percent who reported reactions to latex, only 1 percent had 31 confirmed diagnosis of latex sensitization. Other studies suggest that 80 percent of the cases 34,37 of hand dermatitis are a result of ICD. It is important to note that ICD increases the potential 9,20,30,35-40 for allergic sensitization.
Immediate Allergic Reactions The risk of progression from ACD to more serious reactions is unknown, but at least some patients initially develop ACD; then urticaria; then allergic rhinitis, sneezing, scratchy throat, conjunctivitis, angioedema, wheezing, asthma (coughing, difficulty breathing); and, rarely, anaphylaxis. Immediate allergic reactions are all 24,34 IgE mediated.
Allergic Contact Dermatitis Allergic contact dermatitis (ACD) is a delayed hypersensitivity hypersensitivit y reaction (Gell and Coombs
Urticaria Urticaria (local or generalized) is the most common presentation of a type I hypersensitivity reaction to latex (Figure 2). It likely reflects an IgE-mediated immediate hypersensitivity reaction in response to contact with latex proteins, although not all cases
Type IV) caused primarily by the accelerators, promoters, and antioxidants antioxidants that are added to
are associated with detectable latex-specific IgE antibodies. Symptoms usually occur within 10 to
Figure 1. Allergic contact dermatitis characterized by rash, redness, and itching, which began about 24 hours after dental treatment under a rubber dam.
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Figure 2. Acute urticaria characterized by pruritic, red wheals that range from 1.5 to 3.0 cm in diameter, which began about an hour after exposure to latex gloves.
Figure 3. Angioedema characterized by localized, well-circumscribed, non-pitted swelling affecting the lips.
15 minutes of direct contact and is characterized by itching, redness, and wheal and flare reaction at the site of contact. Urticaria may represent a transitional stage in the progression from ACD to immediate hypersensitivity. hypersensitivity. Reactions that occur within 60 minutes of exposure to a latex product are highly suggestive of IgE-mediated allergy, while delayed or persistent urticaria is suggestive 44 of delayed hypersensitivity.
proteins) on the mucosal surfaces of the eyes and upper respiratory tract initiate the IgE-mediated allergic response. If sufficient sufficient aeroallergens penetrate below the level of the glottis, the 22 allergic response progresses to include asthma. An estimated 2.5% of healthcare workers are susceptible to asthma induced by exposure to 21 latex aeroallergens.
Anaphylaxis Anaphylaxis is the most severe manifestation of a type I hypersensitivity reaction. Latex proteins interact with IgE antibodies found on tissue mast cells and peripheral blood basophiles. A massive
Angioedema Angioedema may be a feature of urticaria. It is characterized by episodes of localized, wellcircumscribed, nonpitting swelling commonly affecting the lips (Figure 3), face, limbs, trunk, abdominal viscera, and larynx. When edema affects the larynx, upper airway obstruction can be severe and life threatening. Involvement of the gastrointestinal tract is associated with severe pain.
release of histamine and other mediators initially results in weakness, dizziness, and cutaneous symptoms such as flushing and urticaria. Anaphylaxis progresses rapidly and sequentially to include laryngeal edema (resulting in stridor), bronchospasm (resulting in wheezing); followed by hypotension, tachycardia, and vascular collapse as a result of decreased systemic vascular resistance 45 (Figure 4). While anaphylaxis is seldom the first sign of latex allergy, latex exposure is estimated to account for 12 to 40 percent of anaphylactic 30,46,47 reactions that occur during adult surgery. In oral healthcare settings, anaphylactic reactions to latex products have been reported to occur with
Allergic Rhinoconjunctivitis and Asthma Nasal congestion, sneezing, rhinorrhea, watery eyes, and an itching sensation of the oropharyngeal mucosa are clinical symptoms of a type I hypersensitive reaction known as allergic 22 rhinoconjunctivitis. It is generally accepted that deposits of aeroallergens (in this case latex
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Figure 4. Anaphylactic reactions to latex allergens in the oral healthcare setting characterized by angioedema of the lips and oropharynx associated with stridor, wheezing, hypotension, and tachycardia.
exposure to gloves, dental rubber dams, and 7 exposure to latex-related aeroallergens. Rapid detection of signs and symptoms with immediate intervention is necessary to prevent serious 10,48 complications and death.
known to have allergens that cross-react with 30,36 latex. Many latex proteins, collectively called pathogenesis-related (PR) proteins, serve to protect the rubber tree from a variety of environmental threats such as infections (fungal, bacterial, and viral), wounding, and chemical 50 insults. These same proteins are also expressed 51,52 in numerous other plant species. For example,
Diagnosis The diagnostic algorithm for latex allergy entails obtaining a thorough medical history history, , skin-patch for diagnosing type IV testing delayed hypersensitivity,, i.e., allergic hypersensitivity contact dermatitis; serum IgE measurement to confirm suspected severe latex allergy,, i.e., type I immediate allergy hypersensitivity; and glove provocation testing when the patient’s clinical 7,29,49 history is incongruent with IgE results.
the latex protein β-1,3-glucanase shares high association with the β-1-3-glucanase proteins found in avocado, banana, chestnut, and kiwi. Other latex PR proteins share moderate association with analogous proteins in apple, carrot, celery, melon, papaya, tomato, and potato. Low or undetermined association exists between still other latex PR proteins and many other 53 fruits and vegetables, e.g., turnip and zucchini. It is estimated that a patient with a history of fruit allergy has an 11% risk of concurrent latex 59 allergy. Conversely, up to 50% of patients with latex allergy are hypersensitive to some plant5,30,54 derived foods.
Medical History Obtaining a complete medical history is the first step in diagnosing latex allergy. OHCWs and patients who relate a history of papular,
Laboratory Test Testing ing There is no standardized testing protocol for diagnosing latex allergy and screening for latex allergy in the general population has not been 7,55 found useful and is not indicated. However, testing may be helpful in high-risk patients (e.g., patients with a high number of previous surgical procedures, a history of atopy, and a history of 28,47,56 adverse reaction to latex).
pruritic rash of the skin; rhinitis; conjunctivitis; urticaria (local or generalized); angioedema; and coughing, shortness of breath, or wheezing; and/ or a drop in blood pressure following exposure to latex should be suspected of latex allergy. As noted earlier, certain patient populations (i.e., those with neural tubal defects and occupational exposure) are at higher risk for latex allergies than the general population. Other risk factors include a history of atopy (persons predisposed to multiple allergies such as those with a familial history of hay fever, asthma, dry skin, or eczema), multiple surgeries, previous hand dermatitis of any kind, and allergies to foods
Skin-patch Test Testing ing Skin-patch testing is a sensitive test for diagnosing type IV delayed hypersensit hypersensitivity ivity reactions to rubber additives (e.g., chemical accelerators accelerators,,
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CA, USA], ImmunoCAP [Phadia AB, Portage, MI, USA], CLA Allergen-Specific IgE Assay [Hitachi Chemical Diagnostics, Mountain View, CA, USA], and HY TECH-288 [Hycor Biomedical Incorporated, Garden Grove, CA, USA] licensed by the FDA. Their sensitivity and selectivity is variable, ranging from 50 to 90 percent and 80 to 30 87 percent, respectively respectively..
Glove Provocation Testing (GPT) GPT is useful when the patient’s clinical history is 30 inconsistent with IgE results. During the test, the patient wears one finger of a latex glove while the physician watches for a reaction. If there is no urticarial reaction after 15 minutes, the exposed surface area is increased. The test concludes when an urticarial response is identified (i.e., a positive provocation test), or when the patient is able to wear the full glove for 15 minutes with 7,30 no reaction (i.e., a negative provocation test). Because of variations of latex content in gloves, this test has varied sensitivity and could be 7 unsafe in highly sensitized persons.
antioxidants) and helps to differentiate ACD from ICD. It is performed performed by applying allergen allergen samples to intact skin and covering them with a dressing. The patient is checked for skin reaction at 30 7,30 minutes, 24 hours, and 48 hours. Swelling, redness, or blistering characterize a positive test. If the test is negative, the site is reexamined again at 72 and 96 hours because weak reactions may appear later. A refinement of the technique, the thin layer rapid use epicutaneous (TRUE) test (Allerderm, Petaluma, Petaluma, CA, USA), has been licensed by the FDA and is available commercially. The test consists a pre-prepare pre-prepared d testing strip TRUE containing 24 of theofmost common contact allergens, including four rubber screening mixes 9 and mercaptobe mercaptobenzothiazole. nzothiazole.
Preventive Strategies for the Oral Healthcare Setting To prevent cross-contamination, oral healthcare workers must perform proper hand hygiene (work practice controls) and wear gloves (engineering controls) during the treatment of all patients and when cleaning and disinfecting instruments, 58,59 dental units, and environmental surfaces. Sterile surgical gloves are used during surgery. Non-sterile examination gloves are used for routine examinations, restorative procedures, and preventive care and thick utility gloves are used during cleaning procedures. Most available glove types contain latex proteins in variable
Skin-puncture Testing (SPT) The skin-puncture test (SPT) is the most sensitive testing method for diagnosing type I immediate 30,36,55,57 hypersensitivity reactions. A minute quantity of allergen, sufficient to react with IgE antibodies fixed in cutaneous mast cells, is introduced into the epidermis at a single point. After 15 minutes, a wheal formation equal to or larger than half the 30 control signifies a positive response. However, SPT should only be performed at medical centers with staff experienced and equipped to manage severe IgE-mediated immediate hypersensitivity reactions and an FDA-approved latex skinpuncture testing reagent is not available in the 30,42 United States.
amounts, as well as processing chemicals that are responsible for precipitating type I or type IV allergic reactions, respectively respectively.. The proteins responsible for latex allergies fasten to the powder (cornstarch) used as a donning lubricant in some some gloves. While cornstarch is an extremely rare sensitizing agent, when powdered gloves are used, more latex proteins reach the host. During donning, use, and removal, removal, the water-soluble cornstarch/latex protein particles become airborne. These aerosols can be inhaled and absorbed systemically systemically,, causing conjunctivitis, rhinitis, and asthma. Work areas,
Radioallergosorbent Test (RAST) The radioallergosorbent test (RAST), a quantitative measurement of allergen-specific IgE antibodies, is considered to be the safest testing method for confirming suspected severe latex 30 allergy because there is no risk of anaphylaxis. There are a number of assays (e.g., Alastat [Diagnostic Products Corporation, Los Angeles,
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where only powder-free gloves are used, show low or undetectable levels of allergy-causing 4,9,21,23,24 latex proteins. Consequently Consequently,, low-protein, powder-free gloves; or latex-free gloves provide a 32,60-62 primary prevention of latex l atex allergy.
by following the recommendations of the National Institute for Occupational Safety and Health 28 (Figure 5).
Treatment Strategies Once an individual becomes allergic to latex, special precautions are needed to prevent exposure at home, at work, and during medical and dental care. They should also be aware of common natural rubber latex products, as 30 well as foods with cross-reactive proteins. Pretreatment with antihistamines, corticosteroids, and bronchodilators do not predictably prevent latex or other IgE-mediated anaphylactic reactions, consequently, complete latex avoidance is the 26 most effective approach to this problem. While symptoms of latex allergy resolve quickly with avoidance, elevated IgE levels can remain detectable for more than 5 years after exposure, suggesting the importance of long-term 65 avoidance. OHCWs and patients with a history of type I hypersensitivity to latex should wear a Medic Alert bracelet and carry epinephrine for emergency
The amount of latex exposure to produce sensitization or symptoms of an allergic reaction is unknown. However, reductions in exposure to latex products have been reported to be associated with decreased sensitization and 19,24,36,44,63 symptoms. Table 1 contains some of the products used in dentistry that contain latex and a 52 list of alternative products. Practitioners should routinely check with their suppliers to stay current on the availability of latex-free substitutes. The cost of latex alternatives and non-latex gloves has been analyzed, and it was found to be less expensive when compared to the disability and liability costs associated with exposure to latex 6,64 products. Allergic reactions to latex products in the
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healthcare setting can be minimized or prevented
use. Strategies for the management of emerging 52
Table 1. Dental products that frequently contain latex and alternatives.
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adverse reactions to latex are presented in 66,67 Figure 6.
Reductions in exposure to latex products have been reported to be associated with decreased sensitization and symptoms, consequently, a reasonable reduction of latex products in the oral healthcare setting should be considered for the protection of both OHCWs and the patient. Lowprotein, powder-free gloves, or latex-free gloves provide a primary prevention of latex allergy.
Conclusion Adverse reactions to latex products in the oral healthcare setting can result in potentially serious health problems; however, such adverse reactions can be minimized or prevented.
Figure 5. Strategies for the prevention of adverse reactions to latex products.
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Figure 6. Strategies for the treatment of allergic reactions to latex products.
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Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to: www.dentalcare.com/en-us/dental-education/continuing-education/ce81/ce81-test.aspx
1.
Naturally occurring proteins found in latex are believed believed to be responsible responsible for inducing what type of allergic reaction? a. Type I b. Type II c. Type III d. Type IV
2.
The process process in in which which latex is heated in the presence of sulfur is termed: a. Leaching b. Vulcanization c. Autocoagulation d. Chlorination
3.
The most commonly used donning powder is ____________. a. talcum b. baby powder c. cornstarch d. oat starch
4.
During the donning process, donning powder may become suspended in the air for up to __________. a. 10 minutes b. 1 hour c. 6 hours d. 24 hours
5.
Residual chemicals associated with the manufacturing of non-latex gloves may also induce delayed hypersensitivity reactions. a. True b. False
6.
The most common form of adverse reaction to latex glove use is ____________. a. irritant contact contact dermatitis dermatitis b. allergic contact dermatitis c. immediate hypersensitivity reaction
7.
Factors contributing to irritant contact dermatitis include: a. Frequent hand washing b. Constant wearing of gloves gloves c. Exposure to donning powder d. All of the above.
8.
Allergic contact dermatitis is ____________. a. delaying hypersensitivity hypersensitivity reaction reaction b. caused by latex proteins c. caused by accelerators, promoters and antioxidants antioxidants added during glove manufacturing d. A and C
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9.
One of your assistants develops a hand rash while working in the office. She relates that the rash only occurs when she wears brand X, but not brand Y. Y. She is most likely describing what type of adverse reaction? a. Irritant contact dermatitis b. Allergic contact dermatitis c. Immediate hypersensitivity reaction
10.
The most common presentation presentation of a type I hypersensitivity hypersensitivity reaction is: a. Asthma b. Angioedema c. Urticaria d. Allergic rhinitis
11.
Type I hypersensitivity reactions are mediated by: a. IgA b. IgD c. IgE d. IgM
12.
The most serious manifestation manifestation of a type I hypersensitivity hypersensitivity reaction is: a. Anaphylaxis b. Asthma c. Angioedema d. Allergic rhinitis
13.
The diagnostic diagnostic algorithm for latex allergy include _______________. a. obtaining a thorough medical medical history b. skin-patch testing for diagnosing type IV IV delayed hypersensitivity and serum IgE measurements measurements to confirm type I immediate hypersensitivity c. glove provocation testing when patient’s clinical history is incongruent with IgE IgE results d. All of the above.
14.
Historical clues to to a possible latex latex sensitivity sensitivity include: a. Signs and symptoms of an allergic response after exposure to latex b. Atopy c. Multiple surgical exposures d. All the the above.
15.
The risk of latex latex allergy in an individual with with a fruit allergy is estimated estimated to be ______. a. 1% b. 11% c. 20% d. 50%
16.
Patch testing is diagnostic of a: a. Type I hypersensitivity reaction b. Type II hypersensitivity reaction c. Type III hypersensitivity hypersensitivity reaction d. Type IV hypersensitivity reaction
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17.
To reduce latex exposure, when performing routine routine restorative dentistry which which of the the following is not recommended? a. Use only properly sized surgical gloves. b. Use reduced protein, protein, powder-free gloves. c. When possible, use latex-free latex-free products d. Practice proper hand hygiene
18.
When managing a patient who has a confirmed type I hypersensitivity to latex, which which of the following is not recommended? a. Premedicate the patient with an antihistamine antihistamine one hour prior to the appointment. appointment. b. Schedule the patient for the first appointment of the day. day. c. Schedule the patient for the last available appointment appointment of the day. day. d. A and C
19.
The most effective medication medication available available to manage allergic contact dermatitis dermatitis is ____________. a. Epinephrine b. Benadryl c. A topical corticosteroid corticosteroid d. An oral H1 receptor antagonist
20.
Which of the following following medication medication is most critical critical for managing anaphylaxis? anaphylaxis? a. Epinephrine b. c. Benadryl An inhaled beta2-adrenergic agonist d. An oral H1 receptor antagonist
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Newsom SWB. Pioneers in infections control control – Joseph Lister. Lister. J Hosp Infect Infect 2003;55:246-253. 2003;55:246-253. Trampuz A, Widmer AF AF.. Hand hygiene: A frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79:109-116. Ownby DR. A history of latex allergy. allergy. J Allergy Clin Immunol Immunol 2002;110(2 2002;110(2 Suppl):S27-S32. Centers for for Disease Control and Prevention. Recommendations for prevention of HIV transmission transmission in health care setting. MMWR Morb Mortal Wkly Rep 1987;36(suppl):35-185. Ahmed SM, AW TC, Adiseh A. Toxicological Toxicological and immunological aspects of occupational latex allergy. Toxicol Toxicol Rev 2004;23:123-134. Phillips V, V, Goodrich M, TJ S. Health Care Worker Disability Due to Latex Allergy and Asthma: A Cost Analysis. Am J Public Health 1999;89:1024-1028. Woods J, Lambert S, Platts-Mills TA, et al. Natural Rubber Latex Allergy: Spectrum, Diagnostic Approach, and Therapy. J Emerg Med 1997;15:71-85. Yip E, Cacioli P. P. The manufacture of gloves from natural rubber latex. J Allergy Clin Immunol 2002; 110(2 110( 2 Suppl):S3-S14. Ahmed DD, Sobczak SC, Yunginger JW. Occupational allergies caused by latex. Immunology Allergy Clin North Am 2003;23:205-19. Spina A, Levine H. Latex allergy: A review for the dental professional. Oral Surg Oral Med Oral Pathol Oral Rad Endod 1999;87:5-11. Sussman GL, Beezhold DH, Kurup VP. Allergens and natural natural rubber proteins. J Allergy Clin Immunol 2002;110(2 Suppl):S33-S39. International Union of Immunological Societies. List of Allergens. Accessed February 22, 2010. Farrell AL, Warshaw Warshaw EM, Zhao Y, Y, et al. Prevalence and methodology of evaluation for latex allergy among allergists in the United States: results of a cross-sectional survey. Am J Contact Dermat 2002;13:183-189. Hamann CP, CP, Turjanmaa K, Rietschel R, et al. Natural rubber latex hypersensitivity. hypersensitivity. Incidence and prevalence of type I allergy in the dental professional. J Am Dent Assoc 1998;129:43-54. Hamann CP, CP, Rodgers PA, Sullivan KM. Allergic contact dermatitis in dental professionals. Effective diagnosis and treatment. J Am Dent Assoc 2003;134:185-194. Tomazic-Jezic VJ, Lucas AD. Protein and allergen assays for natural natural rubber latex products. J Allergy Clin Immunol 2002;1 2002;110(2 10(2 Suppl):S40-S46. Weissman DN, Lewis DM. Allergic and latex-specific sensitization: Route, frequency, frequency, and amount of exposure that are required to initiate IgE production. J Allergy Clin Immunol 2002;110(2 Suppl): S57-S63. Barbara J, Santais MC, Levy DA, et al. Immunoadjuvant properties properties of glove cornstarch powder in latex-induced hypersensitivity. Clin Exp Allergy 2003;33:106-1 2003;33:106-112. 12. Baur X, Chen Z, Allmers H. Can a threshold limit value for natural rubber latex airborne allergens be defined? J Allergy Clin Immuno 1998;101(1 Part 1):24-27.
20. Charous BL, Blanco C, Tarlo Tarlo S, et al. Natural rubber latex latex allergy after 12 years: recommendations recommendations and perspectives. J Allergy Clin Immunol 2002;109:31-4. 21. Charous BL, Schueneman PJ, Swanson MC. Passive dispersion of latex aeroallergen in a healthcare facility. Ann Allergy Asthma Immunol 2000;85:285-290. 22. Fish JE. Occupational asthma asthma and rhinoconjunctivitis induced by natural rubber latex exposure. J Allergy Clin Immunol 2002;1 2002;110(2 10(2 Suppl):S75-S81. 23. Hunt LW, LW, Kelkar P, P, Reed CE, et al. Management of occupational allergy to natural rubber latex in a medical center: The importance of quantitative latex allergen measurement and objective follow-up. J Allergy Clin Immunol 2002;1 2002;110(2 10(2 Suppl):S96-S106. 24. Pershall KE. Contact and chemical sensitivities in the hospital environment. Otolaryngol Otolaryngol Clin North Am. 2003;36:1021-1034. 25. Swanson MC, Ramalingam M. M. Starch and natural rubber allergen interaction in the production of latex gloves: a hand held aerosol. J Allergy Clin Immunol 2002;110(2 Suppl):S15-S20. 26. Yunginger JW. JW. Latex-associated anaphylaxis. Immunol Immunol Allergy Clin North Am 2001;21:669-677.
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27. Haeberle HA, Lupic D, Midoro-Horiuti T, T, et al. Role of cross-allergies to to latex in clinical routine of anesthesia. J Clin Anesth 2003;15:495-504. 28. Centers for Disease Control and Prevention. National Institute of Occupational Safety and Health. Preventing allergic reactions to natural rubber latex in the workplace. Cincinnati, Ohio: U.S. Depaertment of Health and Human Services; 1997. NIOSH publication no. 97-135. Accessed February 15. 2010. 29. Fisher AA. Contact Contact urticaria and anaphylactoid reactions to corn starch surgical glove powder. powder. Contact Dermatitis 1987;16:224-225. 30. Taylor JS, Erkek E. Latex allergy: diagnosis and management. Dermatol Ther 2004;17:289-301. 31. Schmid K, Cristoph BH, Niklas D, et al. Latex sensitization in dental students using powder-free gloves low in latex protein: a cross sectional study. Contact Dermatitis 2002;47:103-108. 32. Bousquet J, Flahault A, Vandenplas Vandenplas O, et al. Natural rubber latex allergy among health care workers: a systematic review of the evidence. J Allergy Clin Immunol 2006;118:447-454. 33. Larese Filon F, F, Bosco A, Fiorito A, Negro C, Barbina P. P. Latex symptoms and sensitisation in health care workers. Int Arch Occup Environ Health. 2001 Apr;74(3):219-223. 34. Reines HD, Seifert PC. Patient safety: latex allergy. allergy. Surg Clin N Am 2005;85:1329-1340. 35. Antezana M, Parker F. F. Occupational contact dermatitis. Immunol Allergy Clin North Am 2003; 23:269-290. 36. Nettis E, Assennato G, Ferrannini Ferrannini A, et al. Type Type I allergy to natural rubber latex and type IV allergy to rubber chemical in healthcare workers with glove-related skin problems. Clin Exp Allergy 2002;32:441-447. 37. Del Savio B. Is allergic contact dermatitis dermatitis being overlooked? Arch Fam Med 1994;3:537-543. 38. Saary MJ, Kanani A, Alghadeer H, et al. Changes in rates of natural natural rubber latex sensitivity among
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dental school students and staff members after changes in latex gloves. J Allergy Clin Immunol 2002;109:131-135. Zak HN, Kaste LM, Schwarzenberger K, et al. Health-care workers and latex allergy. allergy. Arch Environ Health 2000;55:336-346. Ruëff F, F, Kientz A, Schöpf P, P, et al. Frequency of natural rubber latex allergy in adults is increased after multiple operative procedures. Allergy 2001;56:889-894. Hamilton RG. Diagnosis of natural rubber latex allergy allergy.. Methods 2002;23:22-31. 2002;23:22-31. Hamilton RG, Peterson EL, Ownby DR. Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy allergy.. J Allergy Clin Immunol 2002;110(2 2002;110(2 Suppl):S47-S56. Jacob SE, Steele T. T. Allergic contact contact dermatitis: early recognition and diagnosis of important allergens. Dermatol Nurs 2006;18:433-439, 446. Charous BL, Tarlo Tarlo SM, Charous MA, et al. Natural rubber latex allergy in the occupational occupational setting. Methods 2002;27:15-21. Neugut AI, Ghatak AT AT,, Miller RL. Anaphylaxis in the United States. An investigation into its epidemiology. Arch Intern Med 2001;161:15-21.
46. Lieberman P. P. Anaphylactic Anaphylactic reactions during surgical and medical procedures. J Allergy Clin Immunol Immunol 2002;110(2 2002;1 10(2 Suppl):S64-S9. 47. Porri F, F, Lemiere C, Birnbaum J, Guilloux Guilloux L, et al. Prevalence of latex sensitization in subjects attending health screening: implications for a perioperative screening. Clin Exp Allergy. 1997 Apr; 27(4):413-417. 48. Pumphrey RSH, Duddridge M, Norton J. Fatal latex allergy. allergy. J Allergy Clin Immunology 2001; 107:558. 49. Wakelin SH, White IR. Natural rubber latex allergy. allergy. Clin Exp Dermatol. 1999 Jul;24(4):245-248. Jul;24(4):245-248. 50. Breiteneder H, Ebner C. Molecular and biochemical biochemical classification of plant-derived plant-derived food allergens. J Allergy Clin Immunol 2000;106:27-36. 51. Sicherer SH. Clinical implications of cross-reactive food allergens. J Allergy Clin Immunol 2001; 108:881-890. 52. American Latex Allergy Association. Latex-free medical/dental products. Accessed February 24, 2010).
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53. Pareira C, Tavares Tavares B, Loureiro G, et al. Turnip and zucchini: new foods in the latex-fruit syndrome. Allergy 2007;62:452-453. 54. Sanchez-Monge R, Blanco C, Lopez-Torrejon Lopez-Torrejon G, et al. Differential Differential allergen sensitization patterns in chestnut allergy with or without associated latex-fruit syndrome. J Allergy Clin Immunol 2006; 118:705-s10. 55. Suli C, Lorini M, Mistrello G, Tedeschi A. Diagnosis of latex hypersensitivity: comparison of different methods. Eur Ann Allergy Clin Immunol 2006;38(1):24-30. 56. Sapan N, Nacarkucuk E, Canitaz Y, Saglam H. Evaluation of the need for routine preoperative latex allergy tests in children. Pediatr Int 2002;44(2):157-162. 57. Hamilton RG, Adkinson NF Jr. Diagnosis of natural rubber latex allergy: multicenter latex skin testing efficacy study. Multicenter Latex Skin Ski n Testing Testing Study Task Force. J Allergy Clin Cl in Immunol. 1998 Sep;102(3):482-490. 58. Centers for Disease Control and Prevention. Guidelines for hand hygiene hygiene infection in health-care settings. MMWR Recomm Report 2002;51(No. RR-16). 59. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care health-care settings-2003. MMWR Recomm Report 2003;52(No. RR-17). 60. Allmers H, Schmengler J, Skudlik C. Primary Primary prevention of natural natural rubber latex allergy in the German health care system through education and intervention. J Allergy Clin Immunol. 2002 Aug; 110(2):318-323. 61. Allmers H, Schmengler J, John SM. Decreasing incidence of occupational occupational contact urticaria caused by natural rubber latex allergy in German health care workers. J Allergy Clin Immunol. 2004 Aug; 114(2):347-351. 62. LaMontagne AD, Radi S, Elder DS, Abramson MJ, Sim M. Primary prevention of latex related
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About the Authors Michaell A. Huber, DDS Associate Professor Head, Oral Medicine Division Department of Dental Diagnostic Science The University of Texas Health Science Center at San Antonio, Dental School Dr. Huber is an Associate Professor, Head, Division of Oral Medicine, Department of Dental Diagnostic Science, the University of Texas Health Science Center at San Antonio, Dental School, San Antonio, Texas. Dr. Huber received his DDS from the University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas in 1980 and a Certificate in Oral Medicine from the National Naval Dental Center, Bethesda, Bethesda, Maryland in 1988. He is certified by the American Board of Oral Medicine as an
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officer of the Dental Corps, United States Navy. Navy. Dr. Huber’s assignments included numerous ships and shore stations and served as Chairman, Department of Oral Medicine and Maxillofacial Radiology and Director, Graduate Program in Oral Medicine, National Naval Dental Center, Bethesda, Maryland. In addition he served as Specialty Leader for Oral Medicine to the Surgeon General of the United States Navy, Washington, Washington, DC; and Force Dental Officer Officer,, Naval Air Force Atlantic, Norfolk, Virginia. He has many professional affiliations and over the past 24 years, he has held a variety of positions in professional organizations. Since joining the faculty in 2002, Dr. Huber has been teaching both pre-doctoral and graduate dental students at the University of Texas Texas Health Science Center Dental School, San Antonio, Texas, Texas, and is the Director of the school’s Oral Medicine Tertiary Tertiary Care Clinic. He is currently serving as the Public Affairs Chairman for the American Academy of Oral Medicine. Dr. Huber has accepted invitations to lecture before many local, state, and national professional organizations. He has been published in numerous journals including: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology ; Dental Clinics of North America , Journal of the American Dental Association , and Quintessence International . Email: [email protected]
Géza T. Terézhalmy, DDS, MA Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Dr. Terézhalmy Terézhalmy is Professor and Dean Emeritus, School of Dental Medicine, Case Western Reserve University. University. In addition, he is a Consultant, Naval Postgraduate Postgraduate Dental School, National Naval Medical Center; and Civilian National Consultant for Dental Pharmacotherapeutics, Department of the Air Force. Dr. Terézhalmy Terézhalmy earned a B.S. degree from John Carroll University; a D.D.S. degree from Case Western Reserve University; an M.A. in Higher Education and Human Development from The George Washington University; and a Certificate in Oral Medicine from the National Naval Dental Center. Dr. Terézhalmy is certified by the American Board of Oral Medicine and the American Board of Oral and Maxillofacial Radiology (Life). Dr. Terézhalmy has many professional affiliations and over the past 40 years, has held more than 30 positions in professional societies. He has served as editor or contributing contributing editor for several publications, co-authored or contributed chapters for several books and has had over 200 papers and abstracts published. Dr. Terézhalmy Terézhalmy has accepted invitations to lecture before many local, state, national, and international professional societies. Email: [email protected]
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