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Hepatitis Dental Implications

The dental personnel while treating a person with Hepatitis should take the following precautions.

  • The universal infection control protocol should be followed while treating a patient with Hepatitis.
  • Use personal protective equipments like gloves, face masks, head caps, protective eye wear and protective clothing.
  • Maintain proper infection control for clinical contact surfaces, house keeping surfaces, dental hand pieces and other devices, saliva ejectors, dental radiology etc.
  • Maintain proper infection control for the water units.
  • Sterilization and disinfection of the patient care items. Proper storage of the sterilized instruments.
  • Use disposable items.
  • Prepare operatory prior to the appointment, infection control during the clinical sessions, infection control between patient appointments.


Hepatitis B

A full course of Hepatitis B immunization consists of 3 injections, the 2nd dose, 1month and the 3rd dose, 6 months after the initial dose. All 3 injections are needed for maximum protection and antibody response should be checked 3 to 6 months after the final injections. If a sufficient antibody titre has not been achieved a 4th injection of Hepatitis B vaccine may sometimes be necessary.

All clinical staff must be immunized against Hepatitis B with a single booster, 5yrs after a primary course. Protection in indicated by HbsAb>100mlU/ml. Antibody levels < 10mlU/ml indicate a non responder. Poor responders have an antiboby level of 10-100mlU; it is not clear what protection is afforded by this level of response so an annual booster is recommended. You must keep documentary evidence of immunization.

Vaccination should be instituted for the following:-

  1. Prior to commencement of clinical work in the dental health care sector.
  2. After a sharp injury.
  3. After regular testing indicates warning antibody levels.
Hepatitis A
Type of vaccine Inactivated, given by the intramuscular route
Number of doses Two
Schedule Second dose 6–18 months after first (timing varies with manufacturer)
Booster May not be necessary; manufacturers propose at 10 years
Contraindications Hypersensitivity to previous dose
Adverse reactions Mild local and systemic reactions
Special precautions Not protective before one year of age

Which diseases of significance may be transferred by needlestick injury?

Most infectious diseases can be transmitted by needle stick injury but the main concerns are Hepatitis B, Hepatitis C and HIV infection.

What would you do immediately?

Encourage bleeding at the injury site and wash it-with either 70% alcohol, antiseptic handwash or soap and water. Do not scrub the injury.

What is the most urgent priority and why?

The most urgent priority is to assess whether there is a significant risk of transmission of HIV infection. Post exposure prophylaxis with antiretroviral drugs can significantly reduce the chance of transmission of HIV, but for maximum effectiveness it is recommended that it is administered within 1 hour.

What is the risk of transmission of Hepatitis B by this needlestick injury?

This should be minimal because all members of the dental team should be vaccinated against Hepatitis B and their antibody titre should be checked regularly and revaccination should be provided as necessary. However, if the recipient is not immune, the risk of transmission has been estimated at 30% if the patient is 'E' antigen positive. Infection can follow transmission of as little as 0.1 ul of blood. Hepatitis B is so infectious that the degree of injury is almost immaterial. If recent evidence of the effectiveness of the recipient's vaccination is not available, the recipient should have their antibody titre checked.

Does this mean you have to give blood even if you know that your Hepatitis B vaccination is successful?

Yes. You must ensure that your serum is stored, because you may need to show that infection was not present at the time of the injury.

How can you determine whether the patient is infectious for Hepatitis B?

The blood taken from the patient should be screened for Hepatitis B antigens and antibodies (Table below) in order to assess the risk of transmission. The exact tests performed in the screen vary between hospitals.

Hepatitis B antigen and antibodies
Type Found where Significance for infectivity
HBs (surface) antigen or Australia Antigen Becomes detectable in late incubation and is present during the acute Hepatitis. Declines over 3- 6 months but persists in carriers, whether asymptomatic or with chronic active Hepatitis. Indicates infectivity though not necessarily a high infectivity.
Antibody to HBs Antigen Seen in recovery reflex immunity against the virus. Also found in those immunised against Hepatitis B. Probably indicates no risk of infection. Denotes past exposure and immunity (including by active vaccination) to the virus and a possible need to further determine infectivity.
HBc (core) Antigen Only present in liver. Not used for determining infectivity.
Anitbody to HBc Antigen. Found in acute diseases, recovery and in carriers, weather asymptomatic or with chronic active Hepatitis. Indicates past infection but a high level indicates infection risk.
HBe Antigen HBe Antigen Indicates acute infection or a carrier state of high infectivity.
Antibody to HBe Antigen Sometimes persists in chronic asymptomatic carriers. Indicates either recovery from acute infection or a carrier state of low infectivity.

What is the risk of contracting Hepatitis C?

The risk of contracting Hepatitis C (HCV) through a needlestick injury is 3% if the donor is infected. This risk is therefore higher than for HIV infection and the consequences can be severe. As many as 85% of individuals who become infected will become chronic carriers and of these, virtually all will develop chronic Hepatitis. As many as 20% of patients go on to develop cirrhosis in the first decade or two of HCV infection.

How can you determine whether the patient is infectious for Hepatitis C?

The routine test is for anti-Hepatitis C antibody. Presence of antibody could indicate immunity rather-than infectivity, but if the result is positive the individual has an 85% chance of being a carrier. If positive, infectivity is assumed and further tests are indicated. Detecting the virus in blood by polymerase chain reaction (PCR) can distinguish immunity from chronic infection but this is not a first-line test.

Is prophylaxis against Hepatitis C available?

No active or passive immunizations were possible at the time of writing and no post exposure drug regimen appears effective.

How may the risk of needlestick or sharps injury in the dental setting be minimized?

Needlestick-type injuries do not always result from needles. Burs, broken plastic and hand instruments and other contaminated sharps all constitute a risk. You should:-

  • Ensure that all the dental team are trained in the disposal of sharps.
  • Identify and dispose of needles and other sharps immediately after use.
  • Always pass instruments with the sharp end pointing away from any person.
  • Remove burs and ultrasonic tips from hand pieces immediately after use.
  • Pick up instruments individually.
  • Never resheath a needle holding the sheath in a hand: use a one- handed technique or dispose of the needle immediately.
  • Dispose of sharps into a solid container.
  • Ensure that sharps are disposed of by incineration and by an authorized person registered to collect such waste.
  • Use heavy-duty gloves when cleaning instruments prior to autoclaving.
  • Keep your working area well organized and uncluttered, with sharps in a separate area.
  • Do not place waste material such as swabs or tissues over instruments.


Although transmission of blood-borne pathogens (e.g. HBV, HCV and HIV) in dental health-care settings can have serious consequences, such transmission is rare. Exposure to infected blood can result in transmission from patient to dental professionals, from dental professionals to patient and from one patient to another. The opportunity for transmission is greatest from patient to dental professionals, who frequently encounter patient blood and blood-contaminated saliva during dental procedures.

Hepatitis transmission from dental professionals to patients has not been reported. The majority of dental professionals infected with a blood-borne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission.

Hepatitis transmission from dental professionals to patients has not been reported. The majority of dental professionals infected with a blood-borne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission.

  1. be viremic (i.e. have infectious virus circulating in the bloodstream);
  2. be injured or have a condition (e.g. weeping dermatitis) that allows direct exposure to their blood or other infectious body fluids and
  3. enable their blood or infectious body fluid to gain direct access to a patient's wound, traumatized tissue, mucous membranes or similar portal of entry. Although an infected dental professional might be viremic, unless the second and third conditions are also met, transmission cannot occur.

The risk of occupational exposure to blood-borne viruses is largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure. The risk of infection after exposure to a blood-borne virus is influenced by inoculum size, route of exposure and susceptibility of the exposed dental professional.

Hepatitis A Virus
  • HAV is not a significant infection risk in dentistry as the route of transmission is the faeco-oral route. Close contact with saliva may transmit infection as saliva can contain HAV. Rarely infection has been transmitted by needle stick injury. Universal infection control measures are enough to prevent transmission in dental practice.
Hepatitis B Virus
  • HBV is a well-recognized occupational risk for dental professionals. HBV is transmitted by percutaneous or mucosal exposure to blood or body fluids of a person with either acute or chronic HBV infection. Persons infected with HBV can transmit the virus for as long as they are HBsAg-positive. The risk of HBV transmission is highly related to the HBeAg status of the source person. In studies of HCP who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical Hepatitis if the blood was positive for both HBsAg and HBeAg was 22-31%; the risk of developing serologic evidence of HBV infection was 37-62%. By comparison, the risk of developing clinical Hepatitis from a needle contaminated with HBsAg-positive, HBeAg- negative blood was 1-6% and the risk of developing serologic evidence of HBV infection, 23-37% .

Blood contains the greatest proportion of HBV infectious particle titers of all body fluids and is the most critical vehicle of transmission in the health-care setting. HBsAg is also found in other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat and synovial fluid. However, the majority of body fluids are not efficient vehicles for transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg. The concentration of HBsAg in body fluids can be 100-1,000 fold greater than the concentration of infectious HBV particles.

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among HCP.

Hepatitis C Virus
  • Hepatitis C virus appears not to be transmitted efficiently through occupational exposures to blood. A history of unintentional needlesticks was the only occupational risk factor independently associated with HCV infection. The risk of transmission from HCV- infected DHCP to patients is limited. Transmission from HCV-infected surgeons, can occur during performance of invasive procedures; the overall risk for infection averaged 0.17%.
Hepatitis D Virus
  • An estimated 4% of persons with acute HBV infection are also infected with Hepatitis Delta virus (HDV). Discovered in 1977, HDV is a defective blood-borne virus requiring the presence of HBV to replicate. Patients coinfected with HBV and HDV have substantially higher mortality rates than those infected with HBV alone. Because HDV infection is dependent on HBV for replication, immunization to prevent HBV infection, through either pre- or post exposure prophylaxis, can also prevent HDV infection.

Dental Treatment in Hepatitis

Upto 60% of the patients with chronic Hepatitis will develop some form of liver damage and experience symptoms that include oral health problems. All the members of the dental health team need to be aware of the precautions needed to be taken while treating a patient with Hepatitis C. Knowledge of preventive programme to reduce dental pathology and maximise oral health for those infected is also important.

here are increased incidences of dry mouth or  xerostomia in patients with Hepatitis C which leads to difficulty in talking, eating and swallowing; halitosis; dental decay and tooth sensitivity.

Cirrhosis is a common problem in patients suffering with Hepatitis C.

These patients have a common problem of prolonged bleeding following dental procedures, caused by lack of coagulation factors and thrombocytopenia.

Consequently any invasive dental treatment (extraction surgery or any surgical treatment) should be undertaken under consultation of an appropriate medical specialist. Simple treatments can be carried out utilising agents to establish local control of bleeding (e.g. topical transexemic acid mouth wash).


In addition to medical complications arising from liver disease, problem is delivering dental care also exists for those undergoing anti viral therapy.

Drugs such as interferon, ribavirin and corticosteroids may lower resistance to infection and cause bleeding, so non urgent invasive treatment should be postponed until therapy has ceased. Urgent dental treatment needs to be undertaken in consultation with the appropriate medical specialists.

The use of topical fluorides, oral hygiene instructions dietary counselling and regular recall should be combined into a comprehensive treatment protocal for patients with  Hepatitis C infection.


There is a small but significant risk for patients suffering from Hepatitis with cirrhosis, that drug interactions and toxicity, will burden an already stressed liver.

In such cases:-

Drugs such as metronidazole, tetracycline, erythromycin and paracetamol are contraindicated as they may lead to liver failure.

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