Rubber Trouble by Lesley Longman

Lesley Longman

Liverpool University Dental Hospital and School of Dentistry

NRL and Dentistry:the issues

adverse reactions to NRL staff and pts

prevention of allergy management of pts with:

NRL allergy allergic reactions to NRL during treatment

management of dental HCWs with NRL allergy

Epidemiology of NRL allergy

30 fold discrepancy amongst reported studies

General population 1.0%

Health Care Workers 3-12%

history of repeated mucosal

exposure to NRL 18-60%

Dental HCWs – why increased risk of NRL allergy ?

Low quality NRL gloves - often powdered

Prolonged use of gloves

NRL allergy: Clinical governance implications

morbidity and mortality tostaffPatient

2005 survey eng ad Wales by NPSA 40% trusts had no policy addressing NRL allergy

Policy on the use and management of latex products: all NHS trusts to

Substitute, control or eliminate NRL where appropriate and possibleEnsure staff are aware of and have access to the NRL-free alternativesIdentify and protect sensitised patientsRaise awareness about latex sensitivity –pts and staffEnsure that NRL-free alternatives do not replace the risk of reaction to NRL with another risk ???? National Patient Safety Agency

National Patient Safety Agencywww.npsa.nhs.uk

Useful contacts

Latex allergy Support Group www.lasg.co.uk

National Patient Safety Agency www.npsa.nhs.uk

The Health and Safety Executive www.hse.gov.uk/latex/pdf/patientinfosheet.pdf

http://www.lasg.co.uk/

http://www.npsa.nhs.uk/

NRL is a plant protein – milky Sap of the rubber tree mainly cis-1, 2-polyisoprene but other proteins present NRL has >200 polypeptides. Regular tapping

Pathogenesis – defense related proteins Selective breeding Hormone treatment

Hevea brasiliensis

Working Party for the Faculty of General Dental Practitioners (FGDP)

NRL: adverse reactions:

irritant contact dermatitis*

allergic contact dermatitis

NRL allergy

* Non-immunological

Routes of exposure

Cutaneous Mucosal Inhalation Inoculation

Irritant contact dermatitismost common form of hand eczema

non-immunological inflammation

“chapping”, drying, erythema, thickening, fissuring even papules of skin.

Allergic contact dermatitis (Type IV)

delayed- type response

not life threatening,

accelerators used in manufacturing process

carbamates, thiurams, mercaptobenothiazoles

presents as hand eczema

patch testing can be undertaken

Allergic contact dermatitis

patchy or sharply delineated band of eczema

skin may be scaly or vesicular and weeping

Type I, Immediate hypersensitivity to NRL

IgE – mediated

30-60 minutes

Life threatening

Skin: contact urticaria



Contact urticaria

nettle rash appearance



Upper and lower airways

- tingling, itching, sneezing, rhinorrhoea

- angioedema (swelling of oropharyngeal

tissues)



Upper and lower airways

Anaphylaxis

Hypotension, bronchospasm

NRL allergy: predisposing factors

history of atopyhistory of repeated mucosal exposure to NRL (eg multiple operations for spina bifida and urethral dilation)

health care workers (HCW)

history of food sensitivities (shared

antigens with NRL).

Some foods reported as cross-reacting with NRL

Avocados Bananas Chestnuts Kiwi fruit Figs Melons Pineapples

Some evidence that hand eczema may predispose to

Type 1 immunological responseto NRL

Prevention of NRL allergy&

Identification of high risk individuals

Diagnosis of latex allergy

Clinical history

medical history

serology

dermatological tests.

HCWs “Hay fever-like” symptoms Diagnosis of latex allergy

clinical history

medical history

Sp Bif, bladder probs, Problems after gynae examinn

HCWs be aware if hay-fever type symptoms


clinical history

medical history

adverse reactions to GA, LA

allergies: Marigolds, rubber

gloves, elastic bands, blow up

balloons, wellingtons,

condoms, diaphragms.

General products that contain NRL

balloons, hot water bottles, bath-mats, bath toys tyres envelope seals, glues, adhesives carpets and mats mattress covers clothing


clinical history

medical history

serology : RAST test to

latex (serum specific IgE

immunoassay)


clinical history

medical history

serology

dermatological tests: skin

prick test by specialist

A Letter:- a cautionary tale We investigated this lady for latex

sensitivity. She gets pinking of her lips

when blowing up balloons, has problems

with intercourse which may be related to

condom exposure. I could see no point in

re-prick testing her.

NRL sensitivity & allergy

NRL sensitivity presence of specific antibodies to NRL allergens ~ does not imply the presence of symptoms

NRL allergy elicitation of type 1 allergy symptoms

Prevention of NRL allergy

Desensitisation and immunotherapy are generally not available

Prevention of NRL allergy

education hand care regimen protective gloves

powder free !!! low residual proteins (< 50µg

protein/gram of rubber) low chemical residue NRL free gloves ?

The dental management of pts with NRL allergy

Problems

• Surgery environment

• Patient

Management of NRL allergic pts

Dedicated

environment

Creation of a “protected / safe” treatment

environment

…. where and how to treat NRL allergic patients

…..treat NRL allergic pts first on the list ?

…. different levels of precautions ~ severity of allergy history ?

Consensus

latex …free ? …controlled ?

…safe ?

Consensus

latex - screened

ALARP principle

LATEX-SCREENED SURGERY

No Unauthorised Entry


Dedicated environment – Awareness - notice on the door

pre-treatment preparation of surgerycheck-list prepared dental team


Dedicated environment

pre-treatment preparation of surgery

treatment phasecheck-liststaff to wash hands and face and change clothes if they have been contaminated by latex before entering designated area ?

Team approach to managementof the unit

Radiography

Phlebotomy

Technical work

Domestic staff

Management of the Patient

NRL – free alternative products


gloves

dental dam, endodontic

stoppers, rubber polishing

cup

K Martin. MV Martin. A Birss. EA Field.1997. J Dent. 25:347-50

The protein content of dental rubber dams


gloves

dental dam, endodontic

stoppers, rubber polishing

cup

orthodontic elastics,

headgear straps

NRL – free alternative products gloves

dental dam, rubber polishing cup,

rubber endodontic stoppers

orthodontic elastics, headgear straps

bunsen burner tubing

adhesive tapes and bandages

first aid box


LA cartridges (bungs &

seals/diaphragms)

Dentsply

Xylocaine – NRL

Lignostab-A, Xylotox dry latexCitanest 4%

Septodont

Lignospan, scandanest, septanest - dry latex

Latex free preparations:

Espestesin 1.7ml articaine —

3M Espe

Prilocaine with felypressin 1.8 ml

Dentsply

Gutta Percha

anecdotal case report linking GP allergy to NRL allergy- localised reaction

no IgE antibodies to GP found

2 case reports documenting safe GP root fillings in NRL allergic pts.

No reliable scientific evidence

which should restrict the use of GP in NRL allergy pts


resuscitation equipment

drug vials, syringes &

needle sheaths

Special considerations

general anaesthesia

Case study (not dental)

Julia, 45 y, had NRL allergy, was planned for elective surgery under GAWas recorded in pts case notesJulia rang up hospital to remind them Julia had severe anaphylactic reaction in theatre from equipment containing latex

Special considerations

sedationIV cannulae

BP cuff and tubing

Pulse oximeter probes

RA machine – tubing,

reservoir bag

Management of Type 1 reactions to NRL during treatment

Resuscitation equipment

hypodermic syringes, IV cannulae tourniquets airways non-elastic retainers on face masks resuscitation manikins bag, valve mask, tubing and connectors to oxygen cylindersIndependently powered suction

Non-NRL delivery of drugs

adrenalineAurum Min-I-jetGlass ampoules



glucagonGlucagen kit



glucagonGlucagen kit

salbutamolGTNaspirin

glucose powder/gel

midazolam

chlorphenamine

hydrocortisone

Case 1

19 year old dental studentAtopic eczema, asthma and hayfever

Case 1

Erythema & swelling immediately after application of rubber dam.

Case 1

19 year old dental studentAtopic eczema, asthma and hayfeverAllergy to peanutsItching and tingling of hands within minutes of donning gloves.

Case 2

INDIRECT LATEX CONTACT

Anaphylaxis

36 year old female atopic history

Case 2

Post-coital anaphylaxis Emergency Room—adrenaline NRL-allergy Source?

Rubber Trouble by Lesley Longman

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