The purpose of this report is to present a rare case of allergic chelitis
secondary to latex in an elderly diabetic patient. There are very few
reported cases of allergic cheilitis in literature. Most of the reported
cases of allergic chelitis were secondary to cosmetics, tooth pastes or
impression materials. Few cases of rubber dam induced allergic cheilitis and
stomatitis reported.
Methods
Since the patient was diabetic on insulin therapy and belonged to the elderly
age group, utmost caution was observed while performing diagnostic tests and
treatment procedures. The use test was performed to detect the allergen
(latex) because of short contact time to the skin surface.
Results
The patient was followed-up for a period of eight months, complete healing of
the lesions was witnessed. The patient has not reported of any lesions
later.
Conclusions
Appropriate diagnostic test and interdisciplinary approach in consultation
with medical specialists would be ideal for the management of allergic
cheilitis especially in diabetic elderly patients.
cheilitisallergic contact dermatitislatex hypersensitivityelderlydental care for ageddiabetic complications.INTRODUCTION
Latex is derived from the fluid contained in tissue beneath the bark of the rubber
tree, Hevea Brasiliensis. William Halstead introduced latex surgical gloves in 1890.
A century passed by when Nutter reported the first case of latex allergy in 1979
[1]. Since then, latex allergy although
rare has become an emerging and serious phenomenon that has implications not just
for health care providers, but also for society. Natural rubber latex is found in
over 40,000 products that are used in healthcare settings as well as in the home
[2]. Latex hypersensitivity in dental
patients and practitioners has significantly increased since the introduction of
universal precautions for infection control over 20 years ago and will undoubtedly
rise in future [3,4]. The most frequent risk of population for the latex allergy
includes children with spina bifida, people with a family or personal history of
allergy (atopy), those exposed to latex through occupational or surgical means,
latex-fruit syndrome, healthcare workers, spinal cord injuries, congenital
urogenital abnormalities and patients undergoing repeated surgical procedures or
internal examinations [3,5]. Latex fruit syndrome is a condition wherein some latex
allergens cross react with plant derived food allergens [6,7].
The prevalence of latex allergy in general population though not accurately
documented is believed to be very low. The American Dental Association conducted a
study as a part of their annual health screening wherein they found that 6.2% of the
participants comprising of dentists, dental hygienist, and dental assistants, tested
positive for type I hypersensitivity to latex proteins [1]. The latex allergy reactions could vary from localized
stomatitis to life threatening airway compromise [8].
Allergic cheilitis occurs most commonly due to cosmetic products, especially
lipsticks and fragrance mixes [9-15] or toothpaste [16,17]. Rare cases of
allergic cheilitis secondary to use of rubber dam (latex and non latex types) [18,19]
and dental materials [20] have also been
reported.
CASE DESCRIPTION AND RESULTS
A 61 year old female patient reported to the Department of Oral and Maxillofacial
Radiology, AB Shetty Memorial Institute of Dental Sciences, Nitte University,
Deralakatte, Mangalore, Karnataka, India with complaint of ulceration on the lower
lip since four days. The patient visited a local dentist six days ago for dental
prosthesis. The dentist performed impression procedures and recalled her after two
days. Two days after the impression procedure, the patient noticed multiple erosions
and ulcerations on both upper and lower lips. The erosions were associated with
bleeding and severe burning sensation. The patient also stated that there was severe
itching and mild redness on the skin which reduced within few hours. There was no
history of such oral eruptions or allergic reactions to the drugs, food or cosmetic
products in the past. Patient's medical history revealed that she was diabetic since
20 years and was on regular medication (insulin injections - 12 units/day
subcutaneously). Patient resided in a rural area but did not practice any
deleterious habits. No other co-morbid medical factors were reported.
Intraoral examination revealed ulcerated and eroded areas on the lower lip (Figure 1A). The lesion was extending from the
right angle of the mouth to the left side, superiorly from the vermilion border of
the lip to 2 mm from the cutaneous margin of the lip (Figure 1B). The surface of the lesion was a mixture of
ulcerated eroded and crusted areas, the lip was swollen throughout. The lower
anterior teeth had gingival recession and deposits of the calculus (Figure 1C), which was in close approximation
with the lesion. Other areas of the oral mucosa were normal. A diagnosis of allergic
chelitis was made and the dental surgeon's gloves or the impression material was
thought to be the possible allergen. The impression material would have caused
intraoral lesions rather than lip lesions, so the gloves were thought to be the
cause for the allergic reaction. Erythema multiforme, exfoliative chelitis and
actinic chelitis were the other possible differential diagnosis which could be ruled
out based on the fact that the lesion was acute in nature and absence of any history
of the skin reactions to sunlight. Viral eruptions could be ruled out due to the
lack of other symptoms. On further enquiry the local dentist revealed that latex
gloves containing natural latex powdered with bio-absorbable cornstarch and fast
setting alginate material were used during impression procedure.
A = Erosions and crusted areas on the lower lip. B = Erosions on the upper
lip. C = Supragingival calculus and stains on the lower anterior teeth.
The blood sugar levels, both fasting and post prandial were within the normal range.
Immunological blood tests could not be performed because of the lack of facility in
our institution. After consulting a medical specialist an allergen test (use test)
was performed using cut glove finger tip (same brand of gloves was used), dipped in
saline applied on the patient's forearm for 15 minutes (Figure 2A). Erythematous areas were noticed at the site of
application (Figure 2B). The patient was
admitted to the hospital and administered oral antihistaminic (pheniramine maleate
25 mg thrice daily), topical corticosteroid (triamcinolone acetonide 1% thrice
daily) over the lesion and amoxicillin 500 mg orally thrice daily for 5 days to
prevent any secondary infection. Thorough scaling was performed after six days using
polythene gloves to prevent secondary infection. The patient was reviewed and
discharged after 7 days (Figure 3A).
Considerable healing of the lip lesions was noticed at the time of her discharge.
The patient was reviewed after 8 months and complete healing of the lesion was noted
(Figure 3B).
A = The allergen test performed using cut glove finger tip on the patient's
forearm. B = Erythematous areas noticed at the site of application.
A = Healing of the lesion at the time of discharge. B = Complete healing of
the lesion after 8 months.
DISCUSSION
Latex, used as the raw material for natural rubber, sometime induces immediate and
delayed hypersensitivity reactions [1,3]. There has been a rise in the latex induced
allergic reaction in the recent years in a dental team as well as in the patients
possibly due to the increased use of latex gloves and rubber dam [21]. Rare cases of the allergic stomatitis
secondary to orthodontic rubber bands have also been reported [22]. Patient, presented here was subjected to the repeated
latex gloves contact during the impression procedures. There are 3 types of
reactions to the latex products: irritant contact dermatitis, allergic contact
dermatitis, and immediate allergic reactions [4,5]. Our patient exhibited
allergic contact cheilitis. Recently, the cases of immediate, systemic allergic
reaction due to rubber dam have been reported [21]. Allergic contact dermatitis is a delayed type IV hypersensitivity
mediated by T cells. Lesions generally appear 48 - 96 hours after exposure;
similarly time duration was reported by our patient. Clinical manifestations include
pruritis, scales, crusts, scabs, papules and vesicles [23,24]. Our patient also
reported with lip ulcerations two days after the latex contact. Oral mucosal
involvement is relatively rare due to 2 reasons: primarily saliva washes off the
sensitizers thus not allowing adequate contact time, secondarily abundant
vasculature aids in rapid clearing of the allergens [6]. This could possibly explain the lack of oral mucosal lesions in
presented patient. No single diagnostic test is 100% accurate and there is still no
"gold standard" for diagnosing allergy to the latex. The most common tests used are
patch test, use test and the skin prick test. They are relatively quick, inexpensive
but they also carry higher risks for potentially serious systemic reactions during
the testing [25-27].
The use test is performed with a fingertip cut from a latex glove and moistened with
saline solution. The latex is applied to the skin of a patient for 15 minutes.
Urticarial pruritis or erythema shows a positive result. If no reaction occurs, an
entire saline-soaked surgical glove can be applied to patient's hand until a
reaction occurs or for a maximum of 15 minutes [1]. The same test was used in our case because prevention is better than
cure. Use of the latex-free gloves and equipments in high-risk patients are
suggested. Cotton liners and barriers may also be effective. Polythene gloves during
the treatment and scaling procedures were used in the present case. Some authors
suggest administering prophylactic antihistamines, such as diphenhydramine, or
corticosteroids, such as prednisone, before the dental treatment to those at known
risk [28].
Contact dermatitis and type IV allergy may be managed with topical corticosteroids
and antihistaminics as it was in reported case [1,29]. The American Society of
Anesthesiologists Task Force of Latex Sensitivity recommends that patients who are
latex allergic have a surgical procedure performed as the first case in the morning,
when the levels of latex aeroallergens are the least [30]. A strategy was developed for the management of latex
allergic patients that consists of a collection of information on medical equipment
including latex-free and latex-containing items and latex-containing items that
could be used with modification [31].
Minimizing latex exposure is the most effective strategy when treating latex
sensitive patients. Latex alternatives (vinyl, nitrile or silicone) and powder-free
gloves should be used in the dental clinic to prevent the sensitization of patients
and personnel [30-33].
CONCLUSIONS
Although old age and diabetes do not have any proven link to allergic reaction,
special care is required to prevent secondary wound infection due to
immunocompromised state. Case reports pertaining to allergic chelitis secondary to
the latex in elderly diabetics are sparse, making the presented case unique.
Application of a relatively simple use test for detection of suspected latex
allergen and comprehensive management of an immunocompromised allergic patient are
also highlighted in the present case.
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS
The authors declare that they have no conflict of interests.
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