Dr. SHABIN UL HASSAN
Hepatitis and Dental Professionals
In a dental office, infections can be expedited through several routes, including direct contact with blood, oral fluids, or other secretions; indirect contact with contaminated instruments, operatory equipment, or environmental surroundings; or contact with airborne contaminants present in either droplet splatter or aerosols of oral and respiratory fluids. HBV is the major causative agent of acute and chronic liver infection, cirrhosis, and primary hepatocellular carcinoma worldwide. There are more than 300 million carriers of the virus globally, and about 90% of these live in developing countries. Among the global carriers, 75% are from the Asian continent; where between 8% and 15% of the population carries the virus. It has been documented that HBV infection is the most important infectious occupational hazard in the dental profession.
A number of reports suggest the following:
- A significantly higher incidence of HBV infection among dental staff
- A higher rate of HBV infection especially among oral surgeons, periodontists, and endodontists.
Vectors of infection with HBV in periodontal practice are blood, saliva, and nasopharyngeal secretions. Intraorally, the greatest concentration of hepatitis B infection is in the gingival sulcus. Also, periodontal disease, severity of bleeding, and bad oral hygiene are said to be associated with the risk of HBV.
Blood is very often found in the aerosols produced by the dental equipments such as an ultrasonic scaler or other high-speed equipments. Ultrasonic scaling is obviously associated with increased air contamination levels, confirming the results reported by several other studies showing that this procedure is the main executor of airborne contaminants in dentistry.
Previous research demonstrated that rinsing with an antiseptic mouthwash produced a 94.1% reduction in airborne contaminants, compared to the non-rinsed controls. Hence, high-volume suction evacuators and pre-procedural oral rinses would prevent the air contamination.
Patients with periodontal disease showed higher detectability rate of surface antigen of HBV (HBsAg), anti-HBc, anti-HCV, or both anti-HCV and anti-HBc in whole unstimulated saliva than the controls. No undisputed case of HCV salivary transmission has been documented. However, the existence of other routes of transmission is possible. HCV-RNA has been detected in the saliva and salivary glands of patients with sialadenitis. Most HCV patients (77%) had higher HCV RNA levels in their gingival sulcus than in their saliva, and HCV-RNA was found in toothbrushes of hepatitis C patients. Sharing these objects by their household members could be a theoretical risk of infection.
Prevention and Management of Hepatitis in Dental Clinic
To decrease the burden of hepatitis in dental health care workers, it is recommended that the dental professionals should receive immunization against hepatitis virus or booster doses if required and should use individual protective equipments such as gloves, head caps, and masks. Each dental health care facility should develop a comprehensive written program for preventing and managing occupational exposures. This should focus on the following:
- Dental health care provider should receive three doses of hepatitis B vaccination
- Describe the type of blood exposures that may place dental health care personnel (DHCP) at risk of infection.
- Outline the procedures for promptly reporting and evaluating such exposures
- Resource should be available that permits rapid access of exposed DHCP to clinical care, testing, counseling, and post-exposure prophylaxis (PEP) and the testing and counseling of source patients.
Exposure that might place a dentist at risk of hepatitis infection includes the following:
- Percutaneous injuries (needlestick or cut with a sharp object)
- Contact with potentially infectious blood, tissues, or other body fluids
- Mucus membranes of the eye, nose, or mouth or non-intact skin (exposed skin that is chapped, abraded, or afflicted with dermatitis).
Percutaneous injuries pose a greater risk of transmission. The majority of exposures in dentistry are preventable, and methods to reduce the risk of blood contacts have included use of standard precautions and engineering controls and modifications of work practice. These approaches might have contributed to the decrease in percutaneous injuries among dentists during recent years. However, needle sticks and other blood contacts continue to occur, which is a concern because percutaneous injuries pose the greatest risk of transmission.
When a patient enters a dental clinic, his/her medical history should be recorded. All patients with a history of hepatitis must be managed as they are potentially infectious. Whether or not an individual becomes a chronic carrier of hepatitis B depends on geographic, socioeconomic, immunologic, and genetic factors. A high carrier rate is found among patients with the following:
- Lepromatous leprosy.
- Patients on chronic renal dialysis.
- Down syndrome.
- Patients receiving immunosuppressive drugs.
- Drug abusers having history of hepatitis.
- Tattooed patients.
The following are the guidelines for treating hepatitis patients:
- No dental treatment other than urgent care should be rendered for a patient with acute viral hepatitis.
- Hepatitis B is of primary concern to the dentist. Individuals still carry the virus up to 3 months after the symptoms have disappeared, so any patient with a recent history of hepatitis B should be treated for dental emergency problems only.
- For patient with a past history of hepatitis, consult the physician to determine the type of hepatitis, course and length of the disease, mode of transmission, and any chronic liver disease or viral carrier state.
- For recovered HAV or HEV, perform routine periodontal care.
- For recovered HBV and HDV, consult with the physician and order HBsAg and HBs laboratory tests.
- If HBsAg and anti-HBs tests are negative but HBV is suspected, order another HBs determination.
- Patients who are HBsAg positive are probably infective (chronic carriers); the degree of infectivity is measured by an HBsAg determination.
- Patients who are anti-HBs positive may be treated routinely.
- Patients who are HBsAg negative may be treated routinely.
- If a patient with active hepatitis, positive-HBsAg (HBV carrier) status, or positive HCV status requires emergency treatment, use the following precautions.
- Consult the patient's physician regarding status.
- If bleeding is likely during or after treatment, measure prothrombin time (PT) and bleeding time. Hepatitis may alter coagulation; change treatment accordingly.
- All personnel in clinical contact with the patient should use full barrier technique, including masks, gloves, glasses or eye shields, and disposable gowns.
- Use as many disposable covers as possible, covering light handles, drawer handles, and bracket trays. Headrest covers should also be used.
- All disposable items (e.g., gauze, floss, saliva ejectors, masks, gowns, gloves) should be placed in a lined wastebasket. After treatment, these items and all disposable covers should be bagged, labeled, and disposed of, following proper guidelines for bio-hazardous waste.
- Aseptic techniques should be followed at all times. Minimize aerosol production by not using ultrasonic instrumentation, air syringe, or high-speed handpieces. Remember that saliva contains a distillate of the virus. Pre-rinsing with chlorhexidine gluconate for 30 s is highly recommended.
- When the procedure is complete, all equipments should be scrubbed and sterilized. If an item cannot be sterilized or disposed of, it should not be used.
- All working surfaces and environmental surfaces should be wiped with 2% activated glutaraldehyde.
- Work practice controls are an important adjunct for preventing blood exposures. They are as follows.
- Using a one-handed scoop technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, or an engineered sharp injury protection device (e.g., needles with re-sheathing mechanisms) for recapping needles between uses and before disposal.
- Not bending or breaking needles before disposal.
- Avoid passing a syringe with an unsheathed needle.
- Removing burs before disassembling the handpiece from the dental unit.
- Using instruments rather than fingers to grasp needles, retract tissue, and load/unload needles and scalpels.
- Placing used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were used.
- Giving verbal announcements when passing sharps.
(To be continued…)
(Author is Dental Surgeon, BioDentis Dental Clinic Magarmal Bagh, Srinagar. Email: firstname.lastname@example.org)