1. Loma Linda University Curt Hamann, M.D. February 2009 Allergic to Infection Control? Unforgettable lessons on how to sleuth & solve occupational allergies

2. hamann@smarthealth.com

3. SURVEY 1. According to NIOSH, occupational skin disease is the ______ most common type of occupational disease. A) fourth B) tenth C) firstD) fifth 2. What is the most common allergen in dentistry? A) latexB) disinfectants C) methacrylatesD) glove powder

4. SURVEY 3. The best thing to do if you suspect you have a latex allergy is: A) get an accurate diagnosis B) change to non-latex gloves right away C) get rid of all powdered gloves D) use a barrier cream to protect yourself

6. Course Objectives: Occupational Allergies o Review common allergies in dentistry and their role in occupational skin disease o Understand difference between allergy and irritation o Discuss practical strategies to avoid or manage these allergies

7. Occupational Injuries and Illnesses, NIOSH 2004

8. Why Are Allergies Relevant to Dental Professionals?  Occupational skin disease is the second highest cause of work-related disease in the U.S.  Contact dermatitis accounts for 86-97% of occupational skin disease.  Annual costs of contact dermatitis are high, totaling nearly $2 billion in the U.S. alone. The Burden of Skin Diseases, 2005 Report

9. Chronic skin disease develops in 75% of workers with occupational skin disease Serious consequences from damaged skin!  HIV and HCV transmission to healthcare worker with “cracked, abraded and lacerated” skin and inadequate barrier precautions Beltrami et al.; AJIC May 2003 Why Are Allergies Relevant to Dental Professionals?

10. Broken skin encourages pathogen transfer:  ~50% of dental patients developed herpes simplex virus (Manzella et al., 1994)  Osteomyelitis developed in finger as a result of chronic glove-related dermatitis (Duplechain & Lorio, 1998)  8.6% of sternotomy patients developed Pseudomonas aeruginosa infections (McNeil et al., 2001) Why Are Allergies Relevant to Dental Professionals?

11. Materials and methods Hand Eczema (HE) patients: n=50 Hand Eczema (HE) patients: n=50 Healthy controls: n=52 Healthy controls: n=52 3 visits were planned for all HE patients (follow-up for 6 months) 3 visits were planned for all HE patients (follow-up for 6 months) Examination: Examination: –bacterial swabs (hands and nose) –severity assesment Hand Eczema Severity Index - score (HECSI) –patch test – spa -typing of S.aureus Treatment with emollients atopical corticosteroids and UV- light was accepted Treatment with emollients atopical corticosteroids and UV- light was accepted Agner T, European Society Contact Dermatitis Abstracts, May 28-31, 2008

12. Hand Eczema Severity Index (HECSI) HECSI includes scoring of morphological symptoms (score 0-3) morphological symptoms (score 0-3) ✓ erythema ✓ infiltration ✓ vesicles ✓ fissures ✓ scaling ✓ edema Affected area (fingertips, fingers, palms, back of hand and wrist), (score 0-4) Affected area (fingertips, fingers, palms, back of hand and wrist), (score 0-4) Minimum points = 0, maximum points = 360 Minimum points = 0, maximum points = 360 Held E, Skoet R, Johansen JD, Agner T, British Journal of Dermatology, 2005; 152 (2), 302–307

13. Distribution of S.aureus among patients and controls at visit 1 Patients Controls Agner T, European Society Contact Dermatitis Abstracts, May 28-31, 2008

14. Bacteriology Results Spa -typing on 57 isolates from 30 HE-patients and 13 isolates from 11 controls spa -typing was performed on isolates from both hand and nose in 8 patients: spa -typing was performed on isolates from both hand and nose in 8 patients: – Spa -type identical hand/nose in all cases spa -typing obtained from 17 patients from more than one visit spa -typing obtained from 17 patients from more than one visit –15 patients had the same spa -type at both/all visits –2 patients changed spa -type, which did not influence the severity of HE Many different subtypes of S.aureus among the patients Many different subtypes of S.aureus among the patients Agner T, European Society Contact Dermatitis Abstracts, May 28-31, 2008

15. Severity of HE in patients with and without S.aureus at first visit * * Significantly more severe HE in patients with S.aureus at first visit (p>0.01) HECSI Agner T, European Society Contact Dermatitis Abstracts, May 28-31, 2008

16. Summary S.aureus significantly more frequent on hands in HE- patients than in controls S.aureus significantly more frequent on hands in HE- patients than in controls Same frequency of S.aureus in nose in HE-patients and controls Same frequency of S.aureus in nose in HE-patients and controls Same subtype of S.aureus in hand and nose, and over time, in each HE-patient Same subtype of S.aureus in hand and nose, and over time, in each HE-patient Many different subtypes of S.aureus among HE-patients Many different subtypes of S.aureus among HE-patients Presence of S.aureus related to the severity of HE Presence of S.aureus related to the severity of HE S.aureus present at first visit seem to indicate more severe HE at follow-up S.aureus present at first visit seem to indicate more severe HE at follow-up Agner T, European Society Contact Dermatitis Abstracts, May 28-31, 2008

17. Many Health Care Professionals Assume NRL And Glove Powder Are Still #1 Dental Allergens

18. Non Fatal Occupational Injuries and Illnesses, NIOSH 2007 4,002,700 Total 4,002,700 Total 50% Required time off work 50% Required time off work 9 daysMedian time off work 9 daysMedian time off work 202,700 (5%) Illnesses 202,700 (5%) Illnesses 3,802,565 (95%)Injuries 3,802,565 (95%)Injuries

19. Illnesses Skin Disease- Skin Disease- –#1 single cause of occupational illness

20. Injuries 333,760 (29%) of all workplace injuries 333,760 (29%) of all workplace injuries requiring time away from work in 2007 were requiring time away from work in 2007 were Musculoskeletal disorders (MSDs) Musculoskeletal disorders (MSDs) muscles, nerves, tendons, joints, cartilage, or spinal discsmuscles, nerves, tendons, joints, cartilage, or spinal discs injuries or disorders caused by slips, trips, falls, motor vehicle accidents, or similar incidents are not MSDs.injuries or disorders caused by slips, trips, falls, motor vehicle accidents, or similar incidents are not MSDs. Median Time Off Work= 10 Days Median Time Off Work= 10 Days

21. Many Health Care Professionals Assume NRL And Glove Powder Are Still #1 Dental Allergens 0% 20% 40% 60% 80% 2003 DW 2003 Ed 2005 DW 2006 DW 2005 Derm LatexPowder

22. Different Reactions to Dental Materials Allergic contact dermatitis - type IV immune response to chemicals or small haptens - delayed onset; skin localized Irritant dermatitis - physical, non-immunologic - rapid onset; skin localized Type I allergy - immune response to proteins or large haptens - rapid onset; systemic

23. Allergic Contact Dermatitis (Type IV) to Chemicals Used in Dentistry Accelerators and antioxidants in NRL and synthetic rubbers: thiurams, carbamates Dental bonding agents: methyl methacrylates Disinfectants & preservatives: glutaraldehyde, formaldehyde, thimerosal

24. allergEAZE Dental Materials SubstancePercentageVehicle (2-hydroxyethyl)-methacrylate1petrolatum 1,3-butandiol-dimethacrylate2petrolatum 2-hydroxy-ethylacrylate0.1petrolatum 2-hydroxypropyl-methacrylate2petrolatum amalgam alloy metals (Ag 8.2%, Cu 5.6%, Sn 6.2%)20petrolatum amalgam, non gamma 2 (53% alloy/47% Hg)5petrolatum ammoniated mercury1petrolatum ammonium tetrachloroplatinate0.25petrolatum benzoyl peroxide1petrolatum BIS-GMA2petrolatum bisphenol A1petrolatum bisphenol-A-dimethacrylate2petrolatum copper sulphate1water diurethane-dimethacrylate2petrolatum

25. allergEAZE Dental Materials SubstancePercentageVehicle ethyleneglycol-dimethacrylate2petrolatum N,N-dimethyl-p-toluidine2petrolatum palladium chloride1petrolatum potassium dicyanoaurate0.002petrolatum sodium thiosulfoaurate (gold)0.25petrolatum tetracaine-HCl1petrolatum tin (II) chloride0.5petrolatum triethyleneglycol-dimethacrylate2petrolatum methyl methacrylate2petrolatum eugenol1petrolatum

26. Allergic Contact Dermatitis From Dental Allergens: Skin Response 4. Localized skin inflammation: - Hapten recognition - Cytokine release - Mast cells, histamine - Itching, burning  1. Skin exposure to chemical/hapten 3. T cells: - Activation, production - T cell migration to skin 2. LC & dermal DC: - Process hapten; MHC binding - LC migration to lymph nodes - Hapten-MHC binds to T cell receptor

27. Type I Allergy to Plant NRL Proteins ALLERGENS: ~17 characterized PROTEINS from Hevea: >250 Cornstarch powder Skin & mucosa Respiratory Percutaneous Ingestion EXPOSEEXPOSE

28. Type I NRL Protein Allergy from Immune System Response To Plant Proteins 17 Allergens in Products PROTEINS from Hevea: >250 NRL Protein in HCWs GlovesPowder Hev b 1 50%Y** Hev b 2 >60%Y Hev b 5 > 60% Y**** Hev b 6.01-3 80%Y* Hev b 13 60%Y** Hev b 3 < 33% Hev b 4 39% Hev b 7 <45% * * *

29. Food & Grass Proteins Cross-React to NRL FRUITS: peach, pear, melon, banana, papaya, apple, orange, tomato, kiwi passion fruit, pineapple, mango, avocado, sweet pepper NUTS: peanut, chestnut GRASSES, ETC: Timothy, birch, mugwort Melon profilin 3-D structure

30. Summary of Allergy Symptoms Respiratory: asthma sneezing, runny nose Respiratory: asthma sneezing, runny nose Hives (urticaria) Hives (urticaria) Itching, burning Itching, burning Red, itchy eyes Red, itchy eyes Gastrointestinal Gastrointestinal Cardiovascular Cardiovascular Rash Rash Respiratory: asthma sneezing, runny nose Respiratory: asthma sneezing, runny nose Hives (urticaria) Hives (urticaria) Itching, burning Itching, burning Red, itchy eyes Red, itchy eyes Gastrointestinal Gastrointestinal Cardiovascular Cardiovascular Rash Rash Itching Itching Redness Redness Rash Rash Dryness Dryness Fissures, cracks Fissures, cracks Hyperkeratosis Hyperkeratosis Edema Edema Type IV Allergy: Type I NRL Allergy:

31. Potential Allergens & Reactions SUBSTANCE TYPE I ACD Natural rubber latex protein X(rarely) Methacrylates (in bonding agents)* ( asthma) ( asthma)X Thiurams *, carbamates *, thiazoles, thiorueas X Glutaraldehyde ( asthma) X Formaldehyde * XX EugenolXX Metals (gold, nickel, platinum, etc) * X AnestheticsXX Epoxies, resins X Fragrances, flavorings * X Chlorhexadine gluconate X IodophorsX * Chemicals also found in over-the-counter consumer products infection control

32. Comparison of Risk Factors Repeat exposure to NRL Repeat exposure to NRL Myelodysplasia Myelodysplasia Multiple childhood surgeries Multiple childhood surgeries History of allergies History of allergies Previous reactions to NRL Previous reactions to NRL Unexplained severe allergic reactions Unexplained severe allergic reactions Dermatitis Dermatitis Prior skin reactions to rubber or chemicals Prior skin reactions to rubber or chemicals Repeat exposure to chemical Repeat exposure to chemical History of allergies History of allergies Chronic eczema Chronic eczema Type I NRL Allergy: Type IV Allergy:

33. NRL Type I Protein Allergy Is Decreasing Compared To Type IV Allergies Glutaraldehyde Methacrylates Thiurams 0% 5% 10% 15% 20% 1999200020012002200320042005 U.S. ADA dentists (n=3,181) U.S. ADA hygs/assts (n=797) ( Hamann et al., unpublished data) Allergies to: NRL Type I Protein Allergy

34. International Studies Suggest Type I NRL Protein Allergy May Be Decreasing UK: None reported in dental students Jones et al., 2004 UK: None reported in dental students Jones et al., 2004 Germany: Increase from 9% (1991) to 17% (2001) in dental students Schmid et al., 2002 Decrease by 80% in HCW (1998-2002) Allmers et al., 2004 Germany: Increase from 9% (1991) to 17% (2001) in dental students Schmid et al., 2002 Decrease by 80% in HCW (1998-2002) Allmers et al., 2004 Canada: Decrease from 10% (1995) to 3%(2000) in dental students Saary et al., JACI 2002 Canada: Decrease from 10% (1995) to 3%(2000) in dental students Saary et al., JACI 2002 U.S.: Dentists - Decrease from 6.2% (1994-5) to ~3% (2004) C. Hamann et al., unpublished data Hygienists - Decrease from 10% (1994-5) to ~4% (2004) C. Hamann et al., unpublished data U.S.: Dentists - Decrease from 6.2% (1994-5) to ~3% (2004) C. Hamann et al., unpublished data Hygienists - Decrease from 10% (1994-5) to ~4% (2004) C. Hamann et al., unpublished data Japan: in 2004, 4.5% in dentists; 6.6% in hygienists; currently monitoring Nakajima et al., IADR 2005 Japan: in 2004, 4.5% in dentists; 6.6% in hygienists; currently monitoring Nakajima et al., IADR 2005 UK: None reported in dental students Jones et al., 2004 UK: None reported in dental students Jones et al., 2004 Germany: Increase from 9% (1991) to 17% (2001) in dental students Schmid et al., 2002 Decrease by 80% in HCW (1998-2002) Allmers et al., 2004 Germany: Increase from 9% (1991) to 17% (2001) in dental students Schmid et al., 2002 Decrease by 80% in HCW (1998-2002) Allmers et al., 2004 Canada: Decrease from 10% (1995) to 3%(2000) in dental students Saary et al., JACI 2002 Canada: Decrease from 10% (1995) to 3%(2000) in dental students Saary et al., JACI 2002 U.S.: Dentists - Decrease from 6.2% (1994-5) to ~3% (2004) C. Hamann et al., unpublished data Hygienists - Decrease from 10% (1994-5) to ~4% (2004) C. Hamann et al., unpublished data U.S.: Dentists - Decrease from 6.2% (1994-5) to ~3% (2004) C. Hamann et al., unpublished data Hygienists - Decrease from 10% (1994-5) to ~4% (2004) C. Hamann et al., unpublished data Japan: in 2004, 4.5% in dentists; 6.6% in hygienists; currently monitoring Nakajima et al., IADR 2005 Japan: in 2004, 4.5% in dentists; 6.6% in hygienists; currently monitoring Nakajima et al., IADR 2005

35. Potential reasons for decreased occurrence of NRL allergy Increased use of ‘low protein’ NRL gloves NRL glove protein standard encouraged reduced NRL allergen NRL glove protein standard encouraged reduced NRL allergen Lower glove protein lowers aerosolized protein Lower glove protein lowers aerosolized protein Increased use of synthetic gloves (nitrile, vinyl) and powder-free NRL gloves Decreased powder on NRL gloves Glove powder standard changes Glove powder standard changes Increased processing reduces NRL protein Increased processing reduces NRL protein

36. Other Allergies May Occur More Often Rubber Processing Chemicals Thiurams and carbamates: Thiurams and carbamates: - 4% and 3% in tested HCWs, respectively (Nettis et al., Clin Exp Allergy 2002) - 20% and 12% in HCWs with occupational ACD, respectively (Nettis et al., Contact Dermatitis 2002) - 15% and 3% in those tested with occupational ACD, respectively (Geier et al., Contact Dermatitis 2003) Mercaptobenzothiazoles (MBT): Mercaptobenzothiazoles (MBT): - 1- 3% of tested workers (Nettis, 2002 ; Geier, 2003; Wallenhammar Contact Dermatitis 2000)

37. Percentage of positive patch-tested ADA Health Screening participants with allergic reactions to rubber chemicals: ThiuramsCarbamatesMBT 11% (14 of 130 positives) 17% (17 of 112 positives) 0.8% (1 of 130 positives) From Hamann et al., unpublished data of dentists and dental hygienists (1997-2004)

38. Percent of ADA Health Screening participants with allergic reactions to these substances: AllergenReactionsPrevalence (published) MMA5% (6 of 130 positives) 5-23% EGDMA11% (14 of 130 positives) 5-23% HEMA (2004 only) 6% (1 of 17 positives) 5-23% Glutaraldehyde3% (4 of 130 positives) 6-18% Thimerosal31% (40 of 130 positives) 4-10% Nickel18% (23 of 130 positives) 14-22% Gold7% (9 of 130 positives) 8-30% Mercury (NH4) 3% (4 of 130 positives) 10-13% From Hamann et al., unpublished data of dentists and dental hygienists (1997-2004)

39. How Do Irritant Reactions Develop? Irritant reactions may account for nearly half of occupational skin problems IRRITATE ABRADE Water (handwashing) Heat & perspiration Metals & jewelry Detergents & soaps Disinfectants Excessive scrubbing LotionsOintmentsSolvents

40. Symptoms of Irritant Reactions Drying Drying Peeling Peeling Cracking Cracking Burning Burning Itching Itching Redness Redness Soreness Soreness Photo from the collection of Donald V. Belsito, M.D.

41. + How Are These Conditions Diagnosed? Medical & occupational history with worker’s symptom and exposure records Symptom Assessment type I allergy type IV allergy Consider other tests if symptomatic + - - + Avoid products with those chemical allergens Patch test with relevant occupational allergens SPT or blood (RAST) tests AVOID NRL

42. Diagnosing Type I Allergy to NRL Type I Allergy to NRL proteins: Type I Allergy to NRL proteins: – Serologic (common blood test) : ImmunoCap, AlaStat – Skin prick test: - better, but less common - skin reaction to NRL source –Provocation test with NRL - not recommended Type I Allergy to NRL proteins: Type I Allergy to NRL proteins: – Serologic (common blood test) : ImmunoCap, AlaStat – Skin prick test: - better, but less common - skin reaction to NRL source –Provocation test with NRL - not recommended

43. Diagnosing Type IV Allergy to Dental Chemicals: Patch Testing Standard guidelines Standard guidelines Wear patches for 1-2 days Wear patches for 1-2 days Reactions read for several days after patch removal Reactions read for several days after patch removal Used for suspected allergies to rubber-based chemicals, methacrylates, disinfectants, metals, etc. Used for suspected allergies to rubber-based chemicals, methacrylates, disinfectants, metals, etc.

44. Obtaining Accurate Diagnosis Requires Perseverance Dermatologists: 17% test for NRL allergy - Over 60% use RAST and/or “use” testing - 83% likely to patch test ( Warshaw & Nelson, AJCD 2001) Allergists: 95% test for NRL allergy ~ 60% use RAST testing first ~ 40% use prick testing first (most use glove soln.) But only half patch test for type IV (Farrell et al., AJCD 2002) Cortisone or barrier creams are not sufficient!

45. Managing Skin Disease Requires Reduced Exposure Improved ventilation for airborne allergens (e.g NRL proteins, glutaraldehdye, acrylates) Improved ventilation for airborne allergens (e.g NRL proteins, glutaraldehdye, acrylates) Allergen isolation, removal or substitution - Cleaning can reduce contamination and symptoms - Shifting staff to powder-free NRL gloves - Improving sterilant/disinfectant containment - Use different technique with bonding agents Allergen isolation, removal or substitution - Cleaning can reduce contamination and symptoms - Shifting staff to powder-free NRL gloves - Improving sterilant/disinfectant containment - Use different technique with bonding agents Education is critical - without it, symptoms likely to continue - training needed about MSDS, labels, cross-reactivity Education is critical - without it, symptoms likely to continue - training needed about MSDS, labels, cross-reactivity

46. Allergen reduction programs in dentistry: Prevalence of type I NRL allergy decreased to < 3% in dental school staff & student ( Saary et al., JACI 2002 ) Prevalence of type I NRL allergy decreased to < 3% in dental school staff & student ( Saary et al., JACI 2002 ) Airborne NRL allergen dropped below detection with use of low allergen NRL gloves ( Charous et al, Ann Allergy Asthma Immunol 2000 ) Airborne NRL allergen dropped below detection with use of low allergen NRL gloves ( Charous et al, Ann Allergy Asthma Immunol 2000 ) Thorough cleaning and change in glove products reduced allergen load in dental office (Reiter, JE JACI 2002) Thorough cleaning and change in glove products reduced allergen load in dental office (Reiter, JE JACI 2002) Dental professional learned to avoid 11 contact allergens and healed after 10 years (Hamann et al., JADA 2003) Dental professional learned to avoid 11 contact allergens and healed after 10 years (Hamann et al., JADA 2003) Reducing Exposure Equals Success!

47. Allergic Contact Dermatitis from Formaldehyde Textile Resins in Surgical Uniforms and Nonwoven Textile Masks Dermatitis, Vol 18, No 1 (March), 2006: pp 40-44

48. Burning lips syndrome Contact Dermatitis 2007: 57: 344-346

49. www.allerderm.com

50. Questions and Answers STOP

51. SURVEY ANSWERS 1. According to NIOSH, occupational skin disease is the ______ most common type of occupational disease. A) fourth B) tenth C) first D) fifth   2. What is the most common allergen in dentistry? A) latexB) disinfectants A) latexB) disinfectants C) methacrylatesD) glove powder C) methacrylatesD) glove powder

52. SURVEY ANSWERS  3. The best thing to do if you suspect you have a latex allergy is: A) get an accurate diagnosis B) change to non-latex gloves right away C) get rid of all powdered gloves D) use a barrier cream to protect yourself