British Journal of Dermatology 2001; 145: 32±37.

Protective gloves in Swedish dentistry: use and side-effects

Ê RD,§
K.WRANGSJOÈ,*² L-M.WALLENHAMMAR,*² U.OÈ RTENGREN,³ L.BARREGA
È
H.ANDREASSON,³ B.BJO RKNER,¶ S.KARLSSON,³ B.MEDING*²
*Occupational and Environmental Dermatology, Department of Medicine, Karolinska Institutet and Stockholm County Council,
Norrbacka, Karolinska Sjukhuset, 17176 Stockholm, Sweden
²Occupational Dermatology, National Institute for Working Life, Stockholm, Sweden
³Department of Prosthetic Dentistry/Dental Materials Science, GoÈteborg University, Sweden
§Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, GoÈteborg, Sweden
¶Department of Occupational and Environmental Dermatology, University Hospital, MalmoÈ, Sweden

Date accepted for publication: 2 March 2001

Summary Background During the 1980s routine wearing of gloves in dentistry was recommended by health
authorities in several countries. However, prolonged glove use is associated with side-effects of
irritant and allergic origin.
Objectives To investigate the extent of glove use and self-reported glove intolerance reactions
among Swedish dentists, and to examine how far IgE-mediated allergy to natural rubber latex (NRL)
occurs in subjects who report rapid itching when in contact with protective gloves.
Subjects/methods A postal questionnaire was answered by 3083 of 3500 licensed dentists, a
response rate of 88%. Of the dentists who reported rapidly occurring itching of the hands from
gloves, 131 of 170 attended a clinical examination including a skin prick test (SPT) and a
serological examination (RAST) for IgE-mediated allergy.
Results Seventy-three per cent of the dentists reported daily glove use of more than 2 h, 48% more
than 6 h a day, and 6% reported no use. NRL gloves were used most frequently (P , 0´001) and
were the main material that elicited symptoms (P , 0´001). Female dentists reported more
frequent glove use than males, as did young dentists (P , 0´001) compared with older ones.
Females also preferred vinyl gloves. Glove intolerance reactions were reported by 723 (23%)
dentists, [females 28%, males 21% (P , 0´001)] and were more common in younger dentists. Of
the 417 dentists with reported hand eczema during the previous year, 54% reported glove
intolerance, compared with 20% of the dentists without hand eczema (P , 0´001). A logistic
regression analysis including hand eczema, age, sex and atopy showed that all these factors
contributed significantly to the risk of glove intolerance, and that hand eczema was a stronger factor
than atopy. In 15 of 131 (11%) dentists examined for reported glove-related itch, latex allergy was
verified by SPT and/or RAST. Glove-related conjunctivis, rhinitis and asthma, in contrast to skin
symptoms, showed a significant association with IgE-mediated allergy to NRL.
Conclusions Swedish dentists show good compliance with the recommendations for routine glove
use. Intolerance reactions are frequently reported, especially by dentists with hand eczema, which
emphasizes the need for preventive skin care programmes. Glove-related symptoms from mucous
membranes showed a higher association with IgE-mediated allergy to NRL than reported itching of
the skin, a fact that should be considered when composing screening questionnaires for NRL
sensitization
Key words: allergy, dentist, gloves, hand dermatitis, natural rubber latex

Correspondence: Karin WrangsjoÈ, Department of Occupational and

Environmental Dermatology, Norrbacka, Karolinska Sjukhuset,
171 76 Stockholm, Sweden.

32 q 2001 British Association of Dermatologists

 PROTECTIVE GLOVES IN SWEDISH DENTISTRY 33

Continuous glove use is more common in dentistry Subjects, materials and methods
than in most other occupations. The gloves should offer
Study population
protection against blood-borne infections, wet work
and skin-irritating and allergenic chemicals. During the From the register of licensed dentists (n ˆ 10,621) at
1980s routine wearing of gloves was recommended by the Swedish National Board of Health and Welfare,
health authorities in several countries1 and, since 3500 dentists, under 65 y old and licensed between
1986, in Sweden.2 Compliance with these recommen- 1965 and 1995, were randomly selected. A postal
dations differs between countries3±7 and over time.1 questionnaire was sent to these in 1996. After three
Non-sterile medical gloves for single use are commonly reminders, 3083 answers were received, giving a
chosen. The most frequently used materials in response rate of 88%. The female : male ratio was
such gloves are and have been natural latex rubber 1464 : 1619 and the mean age of the responders was
(NRL), and polyvinylchloride (vinyl), powdered or non- 45 y (range 25±64 y). Forty-seven per cent were
powdered. There is now, however, a rapid development employed in public dentistry and 38% in private
of new materials, e.g. synthetic rubber materials, practice. They had worked in dentistry for 17 y
coming on the market. (range 0±39 years) on average.13
The function of gloves depends on several factors In the Stockholm, GoÈteborg and MalmoÈ areas, 170
such as quality, thickness and the material used. The dentists (103 females and 67 males), who reported
barrier against blood-borne infections seems effective rapid onset of itching of the hands from skin contact
as long as the gloves are free from holes and other with protective gloves, were invited to a clinical
mechanical damage.8 The barrier against acrylates examination. Eighty of them had also reported hand
used in dentistry in bonding and composite materials eczema during the past 12 months. In total 131
is often insufficient to prevent penetration of the attended, 69 of 80 with hand eczema and 62 of 90
glove.9 without. In addition, 80 dentists in the Stockholm,
Hand eczema is recognized as an occupational GoÈteborg and MalmoÈ areas who had reported hand
hazard in dentistry. In previous epidemiological ques- eczema during the past 12 months, but denied rapid
tionnaire studies during the 1990s on dentists' self- onset of itching from gloves, were examined. The Ethics
reported hand eczema, prevalence figures between 20 Committees of the Karolinska Institute, and of GoÈteborg
and 30% were found,10±12 exceeding those in the and Lund Universities approved the study.
general population.13 Dentists with hand eczema have
a special need for skin protection because of their
defective skin barrier. Questionnaire
Gloves offer skin protection, but prolonged use is
The postal questionnaire included questions on the
also associated with side-effects. Irritant contact
use of protective gloves, types of glove used and glove
dermatitis caused by occlusion and glove chemicals is
intolerance reactions, and previous and current symp-
considered to be the main problem.14 Gloves, especially
toms of hand eczema and atopy. In this study, atopy
those of rubber, can also provoke allergic reactions in
was defined by reports of childhood eczema, and/or
personnel and patients. Chemicals added to rubber
allergic rhinitis and/or asthma. Other questions covered
glove materials during manufacturing can elicit allergic
exposure to certain contact allergens, in particular
contact dermatitis, becoming apparent as hand
methacrylate-based dental materials; these have been
eczema.15,16
reported previously.13
The second type of allergy is IgE-antibody mediated
allergy, caused by allergenic proteins derived from
NRL.17,18 In sensitized individuals, contact with NRL
Clinical examination and skin prick test
may elicit contact urticaria, allergic rhinoconjunctivitis,
asthma and even serious generalized allergic reactions. The clinical examination in 1997±99 was performed
The aims of this study were to investigate the extent by experienced dermatologists (BM, KW, L-MW, BB). A
of glove use and self-reported glove intolerance reac- standardized interview was followed by the recording of
tions among Swedish dentists, and to examine how far objective signs of current hand eczema. Skin prick tests
IgE-mediated allergy to NRL occurs in subjects who (SPT) were performed on the forearm, with a commercial
report the rapid onset of itching when in contact with NLR extract (StallergeÁnes SPT reagent, Antony, Cedex,
protective gloves. France). Histamine dihydrochloride 10 mg mL21 and

q 2001 British Association of Dermatologists, British Journal of Dermatology, 145, 32±37

34 K.WRANGSJOÈ et al.

saline were used as positive and negative controls. SPT

responses were regarded as positive if the weal mean
diameter was at least half of the histamine weal and
there was no reaction to the negative control. The
reactions were scored in accordance with the European
Guidelines, with histamine chloride corresponding to
1 1 1 as a reference.19 The dentists with hand
eczema were also patch tested with a standard patch
test series and a dental screening series, as reported
previously.20

Determination of total and specific IgE

Blood samples were collected and total IgE was measured
in the Pharmacia CAP system FEIA (Pharmacia & Figure 1 Percentage use of gloves in relation to age reported by 3031
Upjohn, Uppsala, Sweden), with results given in kU Swedish dentists
L21. Levels below 120 kU L21 were considered as
normal according to the instructions of the manufac-
(P , 0´001), but females favoured vinyl gloves
turer. Measurements of specific IgE antibody to NRL were
(Table 2). Use of NRL gloves dominated in dentists
made (CAP RAST k 82, Pharmacia). Specific IgE con-
older than 35 y (NRL 41%, vinyl 35%), in contrast to
centrations of $ 0´35 kU L21 were regarded as positive.
the younger dentists who preferred vinyl gloves (NRL
34%, vinyl 44%) (P , 0´001).
Statistical methods Skin symptoms from gloves. In the questionnaire, both
Differences between groups were generally assessed unspecified skin symptoms and immediate itching from
using Fisher's exact test and the Mantel-Haenszel x2 gloves were asked about. Any type of glove intolerance
technique. Multivariate analysis of the impact of several reaction was reported by 723 (23%) dentists, [females
variables on reported glove intolerance was performed 28%, males 21% (P , 0´001)] and reactions were
using logistic regression analysis. more common in younger dentists. Rapidly developing
itching from gloves was reported by 437 (14%) dentists
[females 19%, males 12% (P , 0´001)]. NRL was the
Results main material that elicited symptoms (Table 3). Thirty-
seven per cent of the responding dentists had a history
Questionnaire study
of atopy. Glove intolerance was reported by 31% of the
Glove use routines. Forty-eight per cent of the dentists atopics and by 20% of the non-atopics (P , 0´001). Of
reported glove use more than 6 h daily, and 6% the 417 dentists with hand eczema during the past
reported that they never used protective gloves. Female year, 54% reported glove intolerance, compared with
dentists reported more frequent glove use than their 20% reported by the 2666 dentists without hand
male colleagues (Table 1). Young dentists used gloves eczema (P , 0´001). In a logistic regression analysis
more than older ones (P , 0´001) (Fig. 1). including hand eczema, age, sex and atopy all of these
Types of glove used. The dentists generally knew which factors contributed significantly to the risk of glove
glove material they used; only 2% were unaware of the intolerance, and hand eczema was a stronger factor
material. NRL gloves were used most frequently than atopy.

Table 1. Reported use of gloves by gender Table 2. Types of glove used by gender
Femalesa Males Total Femalesa Males Total
Glove use, % n ˆ 1436 n ˆ 1595 n ˆ 3031 Types of glove, % n ˆ 1345 n ˆ 1449 n ˆ 2794
Never 4 8 6 NRL 33 46 40
, 2 h day21 14 27 21 Vinyl 42 30 36
2±6 h day21 28 23 25 Both types 23 21 22
. 6 h day21 54 42 48 Ignorant 2 3 2
a a
Females reported more frequent glove use than males (P , 0´001). Females favoured vinyl gloves (P , 0´001).

q 2001 British Association of Dermatologists, British Journal of Dermatology, 145, 32±37

 PROTECTIVE GLOVES IN SWEDISH DENTISTRY 35

Table 3. Reported skin symptoms related to glove materials Table 5. Glove-related symptoms reported at examination in 131
Type of reaction, % NRL Vinyl Both types dentists who had noted rapidly developing itching from gloves in the
postal questionnaire
Any type of intolerance reaction 73 8 19
(n ˆ 723) Glove-related Sensitized to Not sensitized to
Rapid onset of itching 81 6 13 symptoms, % NRL, n ˆ 15 NRL, n ˆ 116
(n = 437) Conjunctivitis 27 7 P , 0Š´05
Difference between glove materials statistically significant Rhinitis 13 3 P ˆ 0Š´08
(P , 0´001). Asthma 13 0 P ˆ 0Š´01
Contact urticaria 33 18 NS
Itching 93 94 NS
Clinical examination Redness 87 83 NS
Dry skin 40 47 NS
In 15 of 131 (11%) dentists (8 females, 7 males) who Eczema 40 44 NS
had reported the rapid onset of itching from gloves and NS ˆ Not statistically significant.
were examined, the diagnosis of latex allergy was
verified by SPT and/or RAST. The mean age was 47
years (range 36±50). Twelve were atopics with mucous ones. Among those who reported rapid onset of itching
membrane symptoms and five also had a history of but without diagnosed latex allergy (n ˆ 116), NRL
atopic dermatitis. Eleven reported hand eczema, eight was also the main symptom-giving material, 96%
of them during the past 12 months. The results of SPT, having symptoms from NRL, and 21% from vinyl. Eight
serum-IgE and RAST are presented in Table 4. of the 15 latex-allergic dentists were patch tested for
The symptoms of glove intolerance as reported at hand eczema. Two of them had positive reactions to
examination of the 131 dentists who had reported rubber chemicals, one to thiuram-mix (1 1) and one
rapid onset of itching from gloves in the questionnaire to mercapto-mix (1 1).
are shown in Table 5. Contact urticaria and symptoms Among the 80 dentists who in the questionnaire
from the mucous membranes were somewhat more denied the rapid onset of itching from gloves but were
frequent among the dentists sensitized to NRL. The examined for their reported hand eczema, two had
differences according to mucous membrane symptoms positive RAST in low titres to NRL but negative SPT and
were statistically significant. No significant differences one had a positive SPT but negative RAST to NRL. At
were shown with respect to the various skin symptoms. examination two of them admitted itching from NRL
All 15 NRL-sensitized individuals reported NRL as gloves. None of these three dentists were patch-test
the material eliciting symptoms, though three of them positive to rubber chemicals.
also reported symptoms from vinyl gloves. All con-
tinued to use gloves in their daily work, mainly vinyl
Discussion
Table 4. Results of skin prick test (SPT) to latex extract, IgE and The recommendations for routine glove use in den-
radioallergosorbent test (RAST) in the latex-sensitized dentists who tistry, given in the 1980s, aimed at efficient cross-
reported hand eczema (n ˆ 15) infection control. The use of gloves is, however, also
Hand RAST Total serum IgE known to introduce new health hazards, and it is only
Age Sex eczema SPT kU L21 kU L21
partially understood how glove intolerance reactions
50 Šf Š± Š1 1 1 Š1´7 Š 140 are associated with routines of use, properties of glove
40 Šf Š1 Š 11
1 Š ´8
0 Š 90
50 Š m 1
Š Š 11
1 ŠNTa ŠNTa materials and individual vulnerability of the user.
47 Šm Š± Š1 1 Š0´4 Š 220 In the questionnaire part we investigated the extent
42 Šf Š± Š1 1 Šneg Š 38 of glove use and self-reported glove intolerance reac-
46 Šf Š1 Š1 1 Šneg Š 45 tions among Swedish dentists. The large random
38 Šm 1
Š Š1 1 Š3´7 Š 73
48 Š m Š 1 Š 1
1 Š0´5 Š 130 sample and the high response rate (88%) should
37 fŠ Š± Š1 Šneg Š 130 make the results representative for all Swedish dentists.
36 Šm Š± Š1 Š0´9 Š 360 The recommendation for routine glove use seems to
48 Šf Š1 Š1 Šneg Š 46 be followed by the majority of dentists, with almost half
41 fŠ 1
Š Š 1 Šneg Š 46
46 Š m Š± Š± Š1´1 Š1600 of the dentists using gloves for more than 6 h per
44 fŠ Š± Š± Š0´4 Š 74 working day, and almost three-quarters for more than
40 Š m Š 1 ŠNTa Š7´7 Š 170 2 h. Only 6% reported no glove use. The actual findings
a
not tested. correspond well with internationally reported figures,

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36 K.WRANGSJOÈ et al.

from England, 81±88%1,4 and from Australia 85%.3 hand eczema and poor tolerance to gloves underscores
Females reported more frequent glove use than did the importance of efficient skin care programmes in
males, as did the younger dentists. This glove use pattern dentistry.
has also been recognized in previous studies.3,4,12 A questionnaire investigation alone cannot determine
These findings strongly indicate that there will be the prevalence of IgE-mediated allergy to NRL, since
increased demand for functional, low-risk gloves by only a limited proportion of reported glove intolerance is
younger dentists. caused by IgE-mediated reactions to NRL.23,24 Rapid
NRL was the commonest glove material, but there onset of itching and even contact urticaria from gloves
was a significant trend in females and young dentists to may be provoked by several mechanisms, such as
prefer vinyl. In Sweden the recognition of allergic irritating chemicals and dermographism.25,26
reactions to NRL medical gloves resulted in a switch The design of the present study did not permit
to non-NRL gloves during the 1990s. The female accurate calculation of the prevalence of allergy to NRL
preference for vinyl was also noted in a previous among Swedish dentists. In the clinical part, the aim
Swedish study.12 A more marked dominance for NRL was to examine how far IgE-mediated allergy to NRL
gloves in dentistry can be seen in the studies from explained the rapid onset of itching from gloves. The
England and Australia.1,3 It is, however, difficult to diagnosis of IgE-mediated allergy to NRL was estab-
analyse the reasons for differences in patterns of use for lished in only 11% of the dentists examined who had
different glove materials. Local traditions, marketing reported the rapid onset of itching from gloves. In the
and initiatives from health authorities differ over time smaller group of dentists, with hand eczema but
and between countries. During the past few years new without rapid-onset itching, who were examined, the
synthetic rubbers, mainly in the form of nitrile rubber, prevalence of latex allergy was 4%. We had expected a
have also been introduced on the medical glove market. higher rate in these two risk groups for latex allergy,
They offer better elasticity and tensile strength than since the overall prevalence in dentists in general, in
vinyl gloves, and are free from the allergenic proteins of several studies is around 5±10%.7,27,28 The prevalence
NRL. It is possible that these types of glove will partly of latex allergy in symptomatic groups of health care
replace NRL and vinyl in dental care, even if progress is workers has in previous studies ranged from 30 to
made in the development of NRL and vinyl gloves as 70%.29 Our low figures, with only 11% dentists allergic
well. to latex among those reporting glove-related itching,
There is much literature on self-reported glove may have several explanations. The itching from gloves
intolerance reactions in medical and dental care. The reported by dentists with actual hand eczema, may be
investigations have been initiated by the attention given generated from the occlusive effect of glove use on the
to IgE-mediated allergic reactions to NRL during the dermatitis, without any superimposed IgE-mediated
past two decades. Highly varying figures are presented, allergy to NRL. The prevalence of latex allergy may also
ranging between 12% and 56%.21 The prevalence of be low in our group of dentists, compared with previous
self-reported glove intolerance among dentists in our studies. We used a commercial NRL extract, which has
study (24%), agrees well with the figures previously previously shown good sensitivity.30 Preventive measures
reported by dentists in studies from Sweden, 33%7 and such as using non-latex or `low-allergenic' non-powdered
England, 29±32%.1,4 Females reported significantly NRL medical gloves prevent NRL sensitization among
more glove intolerance than males. Atopics reported students in dental schools.28 Possibly the frequent use
significantly more often than non-atopics, in accord- of non-NRL gloves or NRL gloves with low amounts of
ance with previous results.22 allergenic proteins may have improved the situation.
In the present study another and even more pro- The glove-related symptoms from mucous mem-
nounced association was found between glove intoler- branes: conjunctivis, rhinitis and asthma, showed an
ance and self-reported hand eczema during the association with IgE-mediated allergy to NRL, a fact
previous year. Hand eczema more than doubled the that should be considered when composing screening
risk of glove intolerance reactions, 54% vs. 20%. This questionnaires for NRL sensitization. This has also been
was not caused by over-reporting of hand eczema in clearly shown in Finland31 and deserves more atten-
dentists with glove intolerance, since clinical examina- tion. The fact that skin symptoms from NRL and vinyl
tion showed that 94% of dentists reporting hand gloves are reported by NRL-sensitized, as well as non-
eczema indeed received that diagnosis when examined sensitized dentists, indicates complex causes of the skin
by a dermatologist.20 The notable association between intolerance to gloves.

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 PROTECTIVE GLOVES IN SWEDISH DENTISTRY 37

In conclusion, Swedish dentists show good com- 12 LoÈnnroth E-C, Shahnavaz H. Hand dermatitis and symptoms from
pliance with the recommendations for routine glove the fingers among Swedish dental personnel. Swed Dent J 1998;
22: 23±32.
use, but glove intolerance reactions are frequently 13 OÈrtengren U, Andreasson H, Karlsson S et al. Prevalence of self-
reported, especially by dentists with hand eczema. How reported hand eczema and skin symptoms associated with dental
these difficulties when using gloves should influence materials among Swedish dentists. Eur J Oral Sci 1999; 107:
the recommendations for glove use is a delicate 496±505.
14 Wahlberg JE. Irritation and contact dermatitis from protective
question. Our findings emphasize the need for pre- gloves: an overview. In: Protective Gloves for Occupational Use
ventive skin care programmes in dentistry, which also (MellstroÈm G, Wahlberg JE, Maibach HI. eds). Boca Raton, FL:
include further development of glove materials with CRC Press, 1994: 215±19.
acceptable levels of irritant and allergenic ingredients. 15 von Hintzenstern J, Heese A, Koch HU et al. Frequency, spectrum
and occupational relevance of type IV allergies to rubber
chemicals. Contact Dermatitis 1991; 24: 244±52.
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17 Turjanmaa K, Alenius H, MaÈkinen-Kiljunen S et al. Natural
processing, and Karin Olsson, Margareta Sivertsson
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for Work Life Research (96±0503,97±1335), the allergy testing. Position paper. Subcommittee on Skin Tests of the
Swedish Foundation for Health Care Sciences and EAACI. Allergy 1989; 44 (Suppl. 10): 1±59.
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Karolinska Hospital, the Sigge Persson and Alice 2000; 43: 192±9.
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