In this article I discuss some of the unintended consequences of the extra focus on decontamination in dental practices following the publication of Health Technical Memorandum 01-05: Decontamination in primary care dental practices. In particular, I investigate some potential allergic reactions to the products and substances used for decontamination and allergies to infection control substances.

1. Endo essentials
Hazards of cleanliness
Amanda Atkin considers some of the allergic reactions arising from infection
control and decontamination
While the publication of Health Technical Memorandum 01- 2 – Hand-hygiene policy) is triclosan. The United States
05: Decontamination in primary care dental practices was Environmental Protection Agency (EPA) has a fact sheet on
understandably met with some grumbles – not least triclosan – which was actually first registered as a pesticide
because of the expense involved in re-equipping practices (in 1969). The EPA states: ‘Since the 2008 [risk] assessment,
– it did lay out quite clearly what procedures and protocols additional data on effects of triclosan on thyroid hormones
needed to be followed. and estrogen-related effects have also been made available
In addition, the Choice Framework for local Policy and from EPA’s Office of Research and Development (ORD).
Procedures (CFPP), published by the Department of Health, ORD studies on the thyroid and estrogen effects led EPA to
provides guidance on decontamination and infection determine that more research on the potential health
control in healthcare environments, including technical consequences of endocrine effects of triclosan is warranted.’
information on decontamination in primary care dental In August last year, The Telegraph ran a story under the
facilities. headline ‘Antibacterial soap may hinder muscle function:
There is similar guidance for the different countries study’ based on findings published in the Proceedings of the
within the United Kingdom – such as from the Scottish National Academy of Sciences. It quoted Bruce Hammock, a
Dental Clinical Effectiveness Programme (SDCEP). I shan’t study co-author and professor at the University of California
list them here, as no doubt readers will be familiar with the Davis’ department of entomology, as saying: ‘Triclosan can
guidance and requirements that apply to their practice. be useful in some instances, however it has become a
In this article I will discuss some of the unintended ubiquitous “value added” marketing factor that actually
consequences of this extra focus on decontamination – could be more harmful than helpful. At the very least, our
allergic reactions to the products and substances used. I’ll findings call for a dramatic reduction in its use.’
then consider allergies to infection control substances. Chlorhexidine is another ingredient in hand cleansers
given as an example on HTM 01-05 but I’ll discuss it later
Hand hygiene under the infection control heading.
Level two hand hygiene policy requires the use of approved
antibacterial hand cleansers. Increasingly popular in the Ozone
home as well as in healthcare environments, antibacterial Under the infection control heading, I’ll discuss the pros
cleaners are not without their drawbacks. According to the and cons of ozone therapy. Ozone is one of the most
Harvard Medical School Family Health Guide, ‘Just 30 seconds powerful disinfectants in the world and is three thousand
of simple hand washing with soap and water reduces the times more potent than chlorine. It has been used to purify
bacterial count on healthcare workers’ hands by 58%. And water for many centuries.
there is an even better way: alcohol-based hand rubs Ozonated water (ie, water containing significant levels
reduce counts by 83%.’ It continues: ‘…antibacterial soap is of ozone) is now being used as a very effective disinfectant
no better than ordinary soap, and the additives actually in dental practices. Drinking ozonated water is believed to
increase the risk of allergic reactions and other side effects.’ have health benefits and can actually help people with
However, the Alliance for the Prudent Use of Antibiotics allergies.
(APUA) – an international organisation with a ‘chapter’ in
the UK affiliated with the British Society for Antimicrobial Infection control
Chemotherapy – states: ‘Resistance to antibacterials has Within dentistry, we all know about latex allergy – more
been found where these agents are used continuously (as accurately, natural latex rubber (NRL) allergic reactions.
in the hospital and food industry); however, at the present However, I wonder if we know as much as we should?
time, this modest increase in resistance has not yet created In researching this article I came across the Latex Allergy
a clinical problem.’ Support Group (www.lasg.org.uk), which has a very
One of the ingredients in an approved antibacterial informative section for dental practices, including resources
hand cleanser given as an example in HTM 01-05 (Appendix for patients and for professionals. I found the patient
information leaflet and the sheet of labels for patients’
notes particularly useful (both of which are downloadable).
Amanda Atkin runs Atkinspire Ltd and offers practices support, training and Incidentally, according to the HSE, ‘Around one to six per
consultancy on information governance, CQC compliance, National Minimum cent of the general population is thought to be potentially
Standards and HTM 01-05. For further information please visit the website at
sensitised to NRL, although not all sensitised individuals
www.atkinspire.co.uk.
develop symptoms.’
34 February 2013 ENDODONTIC PRACTICE

2. Endo essentials
Chlorhexidine
In January of last year, the Medicines and Healthcare
products Regulatory Agency (MHRA) issued a Drug Safety
Ozone is one of the most
Update reminding medicine users that chlorhexidine –
widely used in mouthwashes – is known to induce
powerful disinfectants
hypersensitivity, including generalised allergic reactions
and anaphylactic shock. I know of two reported cases of
in the world and is three
dental patients in the UK suffering fatal allergic reactions to thousand times more
potent than chlorine.
chlorhexidine (in 2011).
According to the Anaphylaxis Campaign, ‘There is some
evidence of an increasing number of cases of allergy to
chlorhexidine, possibly due to its use in some brands of
mouthwash. It is thought that the true incidence of
anaphylaxis to chlorhexidine is likely to be underestimated It went on to say that a trial at Loughborough University
and also that it may be overlooked as the cause of exposed healthy people to fairly small doses of ozone and
anaphylaxis during surgery where it may also be used.’ that half of those studied showed a ‘significant’ reduction
According to the MHRA (Medical Device Alert 2012/075), in lung function.
chlorhexidine may also be present in dental implants.
At the beginning of December 2012, a paper by Dr Enhanced allergy precautions?
Michael Pemberton, a consultant in oral medicine at the The chance of a person visiting a medical or dental practice
University Dental Hospital of Manchester and School of with an allergy increases every day. All healthcare
Dentistry, was published in the British Dental Journal. The professionals need to know and be aware of potential
introduction states: ‘Immunological reactions to hazards and be competent to manage the situation
chlorhexidine, including allergy (type I hypersensitivity) effectively. Staff awareness is vital both from a personal
and allergic contact dermatitis/stomatitis (type IV perspective and for patients. Very often individuals are not
hypersensitivity), have been recognised for many years. aware they have an allergy or allergies.
This potential safety issue, however, is not well known Simple questions, such as, ‘Are you allergic to latex?’ or
within dentistry. The purpose of this paper is to alert ‘Do you have any allergies?’ are probably no longer
dentists and dental care professionals to the potential of sufficient. Patients (and staff ) should be asked more
chlorhexidine in causing hypersensitivity reactions and to probing questions such as:
consider this possibility if unexplained hypersensitivity • ‘Have you experienced wheezing, rashes, coughing, or
reactions occur.’ difficulty in breathing when handling items such as
balloons and rubber balls?’
Ozone therapy • ‘Have you experienced any of these symptoms after
Endodontists will be aware that since the early part of this contact with medical or dental products such as rubber
century ozone therapy has been promoted as an gloves or dental dams?’
antimicrobial. For example, in an article published in the • ‘Have you ever worked in a healthcare setting?’
Indian Journal of Dental Advancements in 2011, Sushma Das, • ‘Have you ever had surgery? How many times? Did you
senior lecturer at the department of periodontics, Vydehi ever experience any complications during surgery that
Institute of Dental Sciences, Bangalore, wrote: ‘Ozone is required resuscitation?’
one of the most powerful antimicrobial agents with
enormous advantages to reduce the number of Why is this problem growing?
microorganisms in the root canal’. There are many theories that attempt to explain the
However, he went on to point out the contraindications increasing prevalence of allergies. The main theory states
for its use: pregnancy, severe anaemia, hyperthyroidism, that the cause is increased exposure to substances such as
thrombocytopenia, severe myasthenia, acute alcohol latex due to the increased demand for personal protection
intoxication, recent myocardial infarction, haemorrhage equipment (PPE) in response to the HIV and other illnesses.
from any organ, glucose-6-phosphate-dehydrogenase Another theory is that increased demand for PPE has
deficiency and ozone allergy. created changes in the processing and manufacturing of
So, how common is ozone allergy? It has, in fact, hit the such equipment. These changes include, for example,
national headlines in recent years because of rising levels shorter wash and shelf times – which have increased the
of ozone in the workplace. A report on BBC News in 2001 amount of latex protein antigens in gloves and other
quoted the British Allergy Foundation (BAF) as warning products. Despite improvements to the manufacturing
that ozone, given off by office equipment such as process, high levels of extractable latex antigens are
photocopiers, computers, fax machines and printers, can currently still being found in latex gloves.
make office workers ill. The gas can make asthma and
allergies worse. And even people who are fit and well can
be affected.
36 February 2013 ENDODONTIC PRACTICE