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 
 . 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 
 . 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 . 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 . latex fruit syndrome is a condition wherein some latex 
 allergens cross react with plant derived food allergens . 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 . the latex allergy reactions could vary from localized 
 stomatitis to life threatening airway compromise . allergic cheilitis occurs most commonly due to cosmetic products , especially 
 lipsticks and fragrance mixes [ 9 - 15 ] or toothpaste . rare cases of 
 allergic cheilitis secondary to use of rubber dam ( latex and non latex types ) 
 and dental materials   have also been 
 reported . 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 . two days after the impression procedure , the patient noticed multiple erosions 
 and ulcerations on both upper and lower lips . 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 ) . 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 . 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 . 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 ) . 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 . latex , used as the raw material for natural rubber , sometime induces immediate and 
 delayed hypersensitivity reactions . 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 . rare cases of the allergic stomatitis 
 secondary to orthodontic rubber bands have also been reported . 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 . recently , the cases of immediate , systemic allergic 
 reaction due to rubber dam have been reported . 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 . 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 . 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 . 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 . 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 . 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 . contact dermatitis and type iv allergy may be managed with topical corticosteroids 
 and antihistaminics as it was in reported case . 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 . 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 . 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 ] . 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 .
abstractbackgroundthe 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.methodssince 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.resultsthe 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.conclusionsappropriate diagnostic test and interdisciplinary approach in consultation 
 with medical specialists would be ideal for the management of allergic 
 cheilitis especially in diabetic elderly patients .