The cross-infection control guidelines of all the major Dental Associations now recommend that dentists wear protective gloves for all operative procedures.1,2 It is possible therefore that some recent graduates face forty years of glove wearing. The recommendation for glove wearing has been made to protect both the operator and the patient from cross-infection. The routine use of gloves should protect the dental team from blood borne viruses such as hepatitis B, C and HIV. The use of gloves does bring other problems, some of which are still not properly understood.
Gloves, Gloves and Gloves
There are now a plethora of gloves on the market. The gloves are chiefly made from latex vinyl or plastic. These gloves, in addition to containing chemicals such as accelerators, cross-linking agents, are often dusted on their surface with donning agents to facilitate putting them on. There is therefore a possibility of close opposition of these agents to skin for prolonged periods of time. The effect of this can be irritation or hypersensitivity.2,3
The simple effect of deleterious substances from gloves can be irritant contact dermatitis (ICD).3 This is a non-specific inflammatory reaction to irritant chemicals being put in contact with the skin. Surveys have shown that about a third of dentists suffer from it.4 ICD can also be caused or exacerbated by poor handwashing techniques which leave pools of hyperosmotic detergents on the hands. Non-removal of rings or watches can cause stagnation areas underneath them which can also result in ICD; this can be manifested by so called ring dermatitis.
The Powder Problem
Gloves and hands have routinely been dusted with a variety of agents usually in powder form. The powders are either starch or other agents which absorb sweat and also aid the donning or removal of the glove from the hand. Starch powder can be used by the skin flora as a growth nutrient and this may predispose to skin irritation.5 When left in surgical wounds it can cause granulomas which can be misdiagnosed as neoplasms. Residues of starch can also cause peritonitis and delayed wound healing.6,7 It is preferable therefore to use non-starch powder gloves.
Other agents are used to aid the donning of gloves; these include cetyl pyridium chloride (CPC). The use of CPC avoids all the deleterious problems of starch and also has other advantages. CPC is a mild disinfectant and kills some bacteria and viruses, it could therefore act as `microbial' barrier beneath gloves.
The other type of dermatitis is the allergic dermatitis (AD).8 This type of dermatitis is rare but may be due to delayed or immediate hypersensitivity.
Delayed hypersensititivy2 is a Type IV or cell-mediated hypersensitivity reaction. It slowly evolves usually taking 24-48 hours to cause swelling, erythema, pruritis, vesiculation and cracking of the skin. A variety of chemicals can induce delayed hypersensitivity including the thiurams, dithiocarbamates, phenols, peroxides, organic pigments. This type of dermatitis is cured by removing the stimulus (i.e. the glove), and the use of topical steroids in severe cases.
Immediate hypersensitivity type 1 reactions to gloves is a serious reaction which is fortunately quite rare. It is caused by prior exposure to a glove antigen which has got into the circulation and caused the generation of IgE antibodies. These antibodies bind with the antigen on repeat exposure. The antigen-antibody complex binds to mast cells or basophils and trigger a severe immune reaction and in some cases anaphylaxis. There is usually intense swelling, itching, wheals on the skin and there may be cardiac arrhythmia and difficulty in breathing. The most common antigen to cause these problems are low molecular weight latex proteins.9
Natural latex contains numerous species of proteins. The proteins present in latex have been studied in detail in the last few years as they appear to be related to allergy. The proteins from natural latex have molecular weights of 5, 14, 29 and 46 KDa these are ammoniated during stabilisation of the latex. The protein content of latex examination gloves can vary from 0.17 to 4001ęg/g latex. The proteins in gloves are water soluble but in some surgical gloves are almost totally removed. Exposure to these proteins is not good for health-care workers as Type 1 allergies may develop.
The prevention of problems for health care with gloves demands a systematic approach to handcare. Good handwashing techniques, the use of emollient creams and powder and protein-free gloves are necessary to avoid hand problems.
1 Glenwright H D, Martin M V. Cross infection control in dentistry. British Dental Association, 1993, London.
2 Field E A, King C K. Skin problems associated with the routine wearing of protective gloves in dentistry Br. Dent. J. 1990: 168: 281-285
3 Fray M F. Hand dermatitis: the role of gloves Aorn Journal 1981; 54 :3
4 Burke F J T, Wilson N H F, Cheung S W. Factors associated with skin irritation of the hand experienced by dental practitioners Contact Dermatitis. In press.
5 Ellis H. Pathological changes produced by surgical dusting powders Ann R Coll Surg Engl 1994: 76: 5-8
6 Glerchksky K E, Quist H, Gierchksky T, Warbe T, Nesland J M. Multiple glove powder granulomas masquerading as peritoneal carcinomatosis.
7 Khan M A, Brow J L, Logan K V, Hayes R I. Suture contamination by surface glove powders on surgical gloves.
8 Heese A, Van Hintzenstern J, Peters K P, Koch J, Hornstein O P. Allergic and irritant reactions to rubber gloves in medical health services.
9 Beezhold D, Beck W C. Surgical glove powders bind lated antigens Arch Surg 1992; 127: 1354-1357.