Latex and Nickel Allergy

Michelle M. Klinek, M.D.

Family Center

for Allergy and Asthma

York, PA

Overview of Latex Allergy

Latex Allergy is a growing health problem and concern in the U.S. Medical Providers need to be Aware Of and Prepared For the appearance of Latex Allergy in their patients and staff.

Overview (con't)

On March 29, 1991, the USFDA released a Medical Alert Warning that a number of deaths and anaphylactic reactions had occurred due to latex exposure.

• From 1989-1993 the FDA received >1100 reports of latex injury and 15 deaths.
  • all deaths due to latex containing barium enema catheters which have been recalled.

Overview (con't)

FDA has recommended that all patients be questioned for potential latex allergies. Latex allergy should become a part of the medical and dental history.

Definitions

• Allergy= The clinical manifestation of symptoms that occur from an IgE mediated or Type I process.

Sensitization= Development of immunologic memory by exposure to a given antigen or protein ie. latex. It is not known what level of protein is required to sensitize and individual.

Definitions (con't)

• Sensitivity= This occurs after sensitization. In other words, the immune system is now armed to respond.

Immunologic Processes Caused by Latex

• IgE Mediated or Type I
  • Exposure to latex antigen results in the production of IgE receptors that attach to the mast cell or basophil
  • Reexposure results in an Immediate Hypersensitivity reaction due to crosslinking of the IgE receptors.
  • The ability to produce IgE in response to certain proteins appears to be genetically linked.

Type I Mediators

• 1. Histamine - released immediately a
  • causes sneezing, itching, wheezing, nausea
• 2. Inflammatory Chemicals - slow release, Leukotrienes
  • Causes recruitment of cells leading to congestion, swelling and inflammation.
  • Late phase reaction 6-8hrs later.
• Anaphylaxis Can Occur

Immunologic Processes Caused by Latex

• Delayed Type Hypersensitivity or Type IV
  • Involves the release of chemicals from T Cells and Macrophages.
  • Symptoms usually occur in 72 hrs
  • Examples: PPD, Poison Ivy, and Nickel Allergy

What is Latex?

• Natural Rubber (cis 1,4 polyisoprene) is a processed plant product.
  • 99% derived from the latex or milky sap of the rubber tree, Hevea brasiliensis found in Africa and Southeast Asia.

Vulcanization is a process by which latex is heated in the presence of sulfur. This improves the elasticity and thermostability.

What is Latex? (con't)

• Ammonia and other preservatives are used to disrupt rubber particles and prevent coagulation.
• Vulcanized latex is poured into molds or coat products.
  • Dipped products include gloves, balloons, condoms, adhesives foam and carpet backing.

What is Latex? (con't)

In dipped products the latex proteins migrate to the surface of the molds. Gloves are removed by stripping them wrong side out, placing the highest concentration of protein next to the skin.

What is Latex? (con't)

• Natural rubber cannot be identified visually. Any rubber like object can be made out of natural or synthetic material.

Latex is not synonymous with natural rubber. Latex paint and caulking are usually synthetic and not a danger for latex allergy patients.

Who is at Risk?

• Prevalence of Type I Latex Allergy in the General Population is 2-3%.
• High Risk Groups
  • 1. Spina Bifida - up to 67%
  • 2. Genitourinary Tract Abnl
  • 3. Health Care Professionals - up to 20%
    • >400, 000 known to be latex allergic presently

Who is at Risk?

• 4. Atopic Individuals - 6.8% - 36%
• 5. Multiple Surgeries - 6.5%
• 6. Latex Industry Workers - 11%
• 7. Food Allergies - Bananas, Avocado, Chestnut, Kiwi

Latex Sensitivity in Dental Students and Staff

Among students at the University of Toronto, an increase number of positive latex skin tests correlated with number of years of dental study. (n=203)

• YR 1=0% YR 2=0% YR 3=6% YR 4=10%
• After this study the school changed to nonpowdered, low protein latex gloves.
  • JACI Vol. 99 No. 3 March 1997, PP 396-400

Case Report - Latex

• Dental Student's Perspective
  • Childhood: unable to wear tights due to itching and rashes, lip and tongue swelling from blowing up balloons

Dental School: fluid filled bumps on hands and face during gross anatomy , hives and presumed impetigo from band-aids, reaction to condoms

Case Report - Latex (con't)

• Unwilling to change professions
• Frustrated by overall ignorance and lack of change in dental community for latex allergic patients and staff.
  • Latex Allergy News by Suzanne Rimmer

Factors that Contribute to Latex Allergy

• 1. Increased latex glove use since 1987 with the introduction of universal precautions

2. Increased demand for latex gloves resulted in a change of manufacturing process. This has led to highly allergenic products due to shorter wash and shelf time.

Factors that Contribute to Latex Allergy (con't)

• 3. Increased awareness and therefore recognition of Latex Allergy

Natural History of Latex Allergy

• Review of Symptoms

1. Irritant Contact Dermatitis - a nonallergic skin rash characterized by redness, swelling, and cracking. May be due to sweating or friction from gloves.

2. Allergic Contact Dermatitis - Type IV process that present with similar symptoms to above. Caused by chemical additives to the latex processing.

Natural History of Latex Allergy (con't)

• Dermatitis can result in skin barrier breakdown, allowing latex allergens access to the bloodstream, leading to sensitization.
• Type I process or Immediate Allergic Reaction.

Progression of Occupational Symptoms

• Cutaneous - Rhinoconjunctivitis - Bronchospasm - Anaphylaxis.

The presence of Latex Specific IgE in the bloodstream precedes the development of clinical symptoms by months or years. The more you are exposed the more likely you are to eventually demonstrate symptoms.

Testing for Type I Reaction

• The processing of latex has made identification of specific proteins difficult. To date no standardized test exists.

Skin Testing involves eluting latex protein by soaking different latex gloves in saline. The extract is then first tested via the percutaneous route and then if (-) intradermally. A positive test reveals a hive reaction, signaling histamine release.

Skin Testing for Type I

• Sensitivity 100%
• Specificity 99%
• Negative Predictive Value 100%
• Positive Predictive Value 80%
  • Lagier et. al. Prevalence of Latex Allergy in OR Nurses. JACI 90;1992, p.319-322.

Testing for Type IV Reaction

• Patch Testing

The various chemicals involved in latex processing are placed in a holding device (ie. patch) on the back. The test is read in 48-72 hours.

Latex Products Commonly Used in the Dental Office

• 1. Gloves
• 2. Polish teeth - Use of disposable prophy angle with rubber cup.
• 3. Pre-filled anesthetic capules
• 4. Bite Blocks
• 5. Orthodontic Rubber Bands
• 6. Rubber Dams
• 7. Syringe with rubber plunger

Treatment

• No therapies are yet available to cure latex allergy
• Best treatment is Prevention of Exposure

Treatment (con't)

• Be prepared for Anaphylaxis with Emergency Medicines
  • Epinephrine 1:1000 0.01cc/kg
    • Adults 0.3cc SQ
    • Children less than 15kg 0.15cc SQ
  • Benadryl 1mg/kg, PO/IM
  • Prednisone 1-2mg/kg
  • Albuterol Nebulization 0.5cc

Treatment (Con't)

• Need Trained Personnel
• Supplemental Oxygen and Mask or Nasal Cannula
• IV Equipment with Fluids

Treatment Goals

• 1. People already sensitized be protected from latex exposure
• 2. Prevent the development of new cases of latex allergy, especially among the high risk groups.

Identification of those with Latex Allergy

• 1. Questionnaire on Latex Allergy for staff and patients.

2. Refer high-risk staff with work related allergy symptoms for evaluation, particularly those with hand dermatitis and existing allergies.

• 3. Identify Latex containing dental products and their alternatives.

Establish Policies for Recognition of Latex Reaction

• 1. Sneezing, watery eyes, rhinitis, contact rash, hives, itching
• 2. Wheezing, stridor chest tightness
• 3. Nausea, vomiting, abdominal cramps, diarrhea
• 4. Anaphylaxis - skin flushing, hypotension, bronchospasm, edema

Development of Policies to Protect Latex Allergic Pts.

• 1. Schedule patient early in day to prevent aerosolized latex particles from treatment of other patients.
• 2. Organize for latex free items to be in room.

Avoidance of Latex

• Abolish the use of Powdered Latex Gloves.

Cornstarch powder adsorbs and carries latex proteins. One study showed 208 ng/ul of latex protein in an OR and ICU. It only takes 4.0ug/ml of ragweed pollen to induce symptoms

• Hypoallergenic gloves are NOT latex-free

Avoidance of Latex (con't)

Use of Powder-Free, Low Allergen content gloves will help decrease the chance of sensitization. However, in known latex allergic patients and staff, Latex-Free Gloves Must Be Used to prevent symptoms.

Avoidance (con't)

"It is no longer acceptable to buy a glove only because it costs less or an individual believes it feel better. The price will eventually be paid in the form of workman's compensation, disability and litigation for not taking measures to limit an individual's exposure to a sensitizing agent." Ansell

Avoidance (con't)

Brigham and Women's Hospital spent hundreds of thousands of dollars in hospital renovations to control latex allergy, realizing that this expenditure would be outweigh by a savings in worker's compensation and malpractice litigation.

Nonlatex Glove Options

• Vinyl Gloves
  • do not contain latex proteins or chemicals
  • they are plastic
  • do not provide as good a viral barrier as latex
  • economical, comparable cost to latex
  • decrease touch sensitivity

Nonlatex Glove Options

• Elastryn - styrene and butadiene
  • contain no latex protein
  • expensive compared to latex
  • decrease touch sensitivity
  • good barrier to bloodborne pathogens
  • contain a small amount of rubber accelerators

Nonlatex Glove Options

• Tactylon - styrene, ethylene, butadiene
  • contain no latex protein
  • expensive, 10x that of latex
  • good viral barrier
  • decrease touch sensitivity
  • no rubber accelerators
  • available in exam and surgical versions

Nonlatex Glove options

• Nitrile - acrylonitrile, butadiene
  • no latex proteins
  • 2x cost of latex gloves
  • good viral barrier
  • good touch sensitivity
  • small amount of rubber accelerator

Nonlatex Glove Options

• Neoprene - polychloroprene
  • no latex proteins
  • 6x cost of latex gloves
  • good viral barrier
  • good touch sensitivity
  • contains rubber accelerators
  • available as surgical gloves only

Nonlatex Supplies

• 1. Midwest Orthodontics Manufacturers 800-448-5594
• 2. Dental Dams - Hygenic Corp. 800-321-2135
• 3. Root Canal Fill ESPE-Premier Ketac Endo (glass ionomer) 800-344-8235
• 4. Syringes Norm-Jet (Luer Slip or Luer Lock) Air Tite 800-231-7762

Nonlatex Supplies

• 5. Mouth Props - nonlatex props
  • Patterson Dental Comp. 800-328-5536
• 6. Local Anesthetic
  • Bupivacaine, Lidocaine Glass ampules Astra 800-262-0460
  • Lidocaine with Epinephrine 1:100,000, MDV non-latex stopper ESI Wyeth 800-999-9384

Nickel Overview

• Used by the Chinese as an alloy with copper as early as 200 B.C.
• In mid 1800's nickel used as an undercoat for silver electroplating.
• Today almost all chromium plated articles are first nickel plated.

Allergic Nickel Dermatitis

• Type IV or Delayed Type Hypersensitivity
• One of the most common contact allergens today
• Incidence = 11% in the US as of 1973

Sources of Occupational Exposure

• Automechanics
• Cashiers
• Ceramic Makers
• Dyers
• Hairdresser

Oral Mucous Membrane Rxn

Until 1970, gold remained the most commonly used metal for dental prosthesis, but due to increased price, it has been progressively replaced by alloys.

Alloys and Nickel Content

• % Nickel
• NiTinol 60
• Elgiloy 15
• Stainless Steel 8-70

Pathophysiology

Corrosion of nickel containing alloys results in the release of nickel and its accumulation in adjacent tissues results in a hypersensitivity reaction.

• The release of nickel seems to be related to both the composition and the method of fabrication of the appliances.

Epidemiology

• Spain: Due to increasing number of pts. with oral contact reactions to dental prosthesis, study was organized.
  • Symptoms - erythema, papules, ulcers and lichen planus
  • Vilaplana et. al. Contact Dermatitis 30:1994 p. 80-84

Spanish Study (con't)

Epidemiology - Spanish Study

• Conclusion: Nickel Allergy is so common in Spain that the use of this metal in dental prosthesis should be circumspect.

Case Report

• 14yo male referred for orthodontic treatment for severe crowding.
  • 1/89: 1st molars banded, stainless steel brackets placed, NiTinol wires inserted.
    • in 2 wks severe burning and ulcerations of mouth and lips
    • removed wires and prescribed utility wax
  • 5/90: NiTinol wires used to finish alignment

Case Report (con't)

• In a few days severe erythematous lesions in oral cavity and lips.

• Patch Test
  • Positive for Nickel
• E.M.H. Al-Waheid, Quintessence International, 26:6 1995

Summary

• Latex Allergy is on the Rise
  • >100,000 health care workers may be at risk for developing this allergy
• Identification is Paramount in Preventing Reactions in both Patients and Staff
  • Remember symptoms can be Type I or Type IV
  • Consider Allergy referral if suspect latex allergy for testing

Summary (con't)

• Avoidance is the Only Known Treatment For Latex Allergy People
  • Avoid use of Latex Gloves - "hypoallergenic does not mean latex-free"
  • Be Prepared - have trained personnel to recognize allergy symptoms and medical equipment available to treat.

Summary (con't)

• Nickel Allergy is Common
  • Be Aware of Oral Mucous Membrane Reactions
  • If Suspect Allergy, Review Use of Materials Used for Their Nickel Content, and Consider Referral for Patch Testing.