Dental Practice

Natural rubber latex (NRL) products may impact on dental healthcare workers (ie dentists, nurses, hygienists) because:

They are at increased risk of developing NRL allergy through the frequent use of NRL gloves.
They may need to manage NRL-sensitive patients, which may be either known in advance or previously undiagnosed.
They have a statutory responsibility to reduce risk of sensitisation in themselves, their colleagues and their patients.

Ensure you have and are familiar with the following:

A written policy on action to protect staff from developing NRL allergy
A written policy on the management of NRL-sensitive members of staff
A written policy for the safe dental management of patients with known or suspected NRL allergy

Prevention of NRL Allergies
All staff to be screened and monitored before and during employment. All staff to be educated about NRL allergy, its recognition and management.

It is important that you protect yourself against breaches of the skin barrier which can result from frequent use of skin cleansers and occlusive glove-wear, especially if you have an atopic background (asthma, hay fever or flexural eczema) where damage to the skin from irritants is more common. A compromised skin barrier will increase your chances of developing Type IV rubber chemical or Type I NRL allergy.

Observe the following hand care protocols

Do not wear jewellery (e.g. rings); keep nails short & do not wear false nails or extensions
Wash and disinfect hands at the beginning and end of each session, as well as between each glove change;
Use cool/tepid water when washing, to keep hand temperature down;
Use hand-wash agents sparingly & rinse thoroughly to remove all traces;
Pat skin dry rather than rubbing it, use soft towels (disposable);
Ensure hands are dry before putting on gloves;
NRL gloves should only be used where there is an operational need
Only non-powdered gloves with low levels of NRL proteins (<50 micrograms /g) and residual chemicals to be used; non NRL gloves to be available;
Chose the right size of gloves;
Minimise contact with other potential irritants/allergens in the surgery (eg acrylic powders / anti-microbial solutions)
At end of session, wash hands to remove traces of NRL, apply aqueous based handcream;
Outside work, don’t forget to protect hands when gardening/doing household chores etc.

Management of a patient with Type 1 NRL allergy

All patients to be screened.
At risk groups: Spina bifida patients ( 67% chance of latex allergy); Healthcare professionals; Patients with urogenital anomalies; atopic patients; patients with history of multiple surgical procedures; Latex industry workers
Check history for above, plus: Allergy to foods especially banana, kiwi, avocado; Elastoplast; latex products; Lips / tongue swelling following GA, dental treatment or blowing up balloons; Asthma, problems with eyes, breathing etc at work (especially healthcare workers).

Patients with NRL allergy have often been treated in a General Dental Practice without significant problems when adjustments have been made by the dental team to manage the patient’s allergy. However if the dentist is in doubt or lacks confidence (eg managing a highly reactive patient), the patient may need to be referred for appropriate management, possibly in a community CDS or PDS or in a hospital setting.

Pre-treatment

All team members to be aware of and understand implications
Latex-free items to be available and stored away from latex products
Appointment to be first of session
Signs to indicate 'latex free zone in operation'; patient’s notes marked appropriately
Fresh protective clothing, face masks with paper ties, wash hands well
Latex free resuscitation drugs and equipment to be readily available and stored away from latex products
Be practised at resuscitation

During treatment

Wear latex free gloves
Use Dentsply Citanest with Octapressin local anaesthetic cartridges
Use latex free plastic medical syringes eg Discardit II for other medication
Dental and medical equipment to be latex free or covered to prevent skin contact, eg suction tubes, blood pressure apparatus, stethoscopes
Use non NRL IV tubing, cannulae, airways, anaesthetic masks, adhesive tape
Use non NRL prophy cups, rubber dam, orthodontic elastics
Laboratory work to be handled with non NRL gloves – mark the lab sheet
For the more reactive patient or member of staff, other items should be checked for their latex content eg mixing bowls, spatula, chip syringes, needle guards, dappens pot.

Management of allergic reactions during dental treatment
Ensure that NRL-free emergency equipment and medicines are readily available to treat any allergic reaction from mild (eg urticaria and asthma) to severe (ie laryngeal oedema / bronchospasm / cardiovascular collapse from anaphylaxis) and that staff are fully trained in resuscitation techniques. Mild reactions require avoidance of NRL, reassurance and perhaps topical or oral antihistamines with appropriate advice / monitoring / supervision. More severe reactions will require adrenaline / oxygen / paramedical support and hospitalisation.*

Management of sensitised workers
Report any problems with skin / hands to line manager. You may need a referral to a dermatologist or immunologist via your GP or the PCT’s Occupational Health Physician so that this can be appropriately investigated as soon as signs and symptoms develop. If you are found to be NRL-sensitive, then it is essential that your work environment is adapted as soon as possible to avoid unnecessary exposure to NRL, which would increase your sensitivity and put you at risk of more severe reactions.

Type I NRL allergy
If you are diagnosed with Type I allergy, it may be possible for you to continue to work in the clinical environment, although this depends on the severity of reactions you experience. It is important that you learn to avoid NRL proteins in consumer and medical products both at home and at work. As gloves are the main cause of allergic reactions to NRL, it is essential that you replace NRL gloves with suitable NRL-free gloves for yourself. In some severe cases, your colleagues will also need to wear non NRL gloves. It is recommended that you wear a Medic-Alert® bracelet. If you have been advised to carry adrenaline for self-administration (eg Epipen® or Anapen®), colleagues should be instructed on how to use it.

Type IV allergy
If you are diagnosed with Type IV allergy to a rubber chemical, then you need to find a glove that does not contain the chemical to which you are allergic. The Dermatologist who has diagnosed this should be able to help you with appropriate glove selection.

Reporting
Employers have a duty to report incidences of occupational dermatitis and asthma attributable to NRL to the Health and Safety Executive under the RIDDOR (or Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995 requirements).

Reporting agencies for adverse reactions to Natural Rubber Latex products

Health and Safety Executive
National Patient Safety Agency - Government agency designed to improve patient safety.
The Medicines and Healthcare Products Regulatory Agency (MHRA) has a voluntary reporting system for reporting cases of NRL sensitisation in both patients and staff.

Resources
For the British Dental Association fact sheet, click here.
For Resuscitation Council (UK) guidance on emergency medical treatment of anaphylactic reactions, click here.

Examples of dental equipment that may contain latex and NRL-free alternatives

Examples of Dental Equipment that may contain NRL	NRL-Free alternative	Manufacturer
Amalgam Carriers	Teflon amalgam carriers	Austinell
Aspirators:	Yankeur plastic wide-bore	Tyco-Healthcare Durr
Bunsen burner tubing	Heating device
Dental Dam	Roeko Flexi-dam Hygenic Non Latex	FE Cardozo Ltd. Coltene/Whaledent
Hygenic Wedjets (dental dam stabilising cord)	Not currently available
Endodontic*Stops	Silicone stops	QED
Elastics (Orthodontic)	GAC ELF Latex Free elastics	Orthocare TOC(The Orthodontic Co)
Mixing bowls** eg alginate Bowls	NRL-free bowls	Dentsply
Polishing equipment	Prophy cups, prophy heads Disposable Prophy Angle to be used on nosecone of doriot-style handpiece	Young Dental W+H Dental (UK) Ltd
	Enhance Polishing Cups	Dentsply
	Shofu Greenies & Brownies polishing points	Minerva
Temporary crowns and matrices	Directa crowns (polycarbonate) Odus cervical matriza Odus-Pella Crown Form	Tower Dental Hawes Neos Austinall
It has been suggested that gutta percha may have the potential to exhibit cross allergenicity with NRL, however, there is no reliable scientific evidence to confirm this * Please check mixing bowls that are purchased individually or are included with a product; for example the mixing bowl in the Tokuyami Soft kit contains NRL.

Some items (eg “rubber based” impression materials) are free from latex proteins. However manufacturers cannot be 100% certain that the product did not come into contact with any NRL during production.

N.B. Manufacturing processes are constantly changing and it is essential to check with the company, that supplies dental equipment that their products are NRL-free.