Prevention of Transmission of Hepatitis in Dental Practice

The oral cavity is increasingly becoming recognised as a window to general health. Hepatitis is a heterogeneous inflammatory liver disease which manifests in the oral cavity and has important implications in the dental setting. Dentists and oral health workers must be aware of the full spectrum of signs and symptoms, as well as how the disease is transmitted, in order to provide safe and effective dental care.

Hepatitis A, B and C (HVA, HBV and HCV, respectively) are separate entities each with unique disease characteristics and varying modes of transmission, pathogenesis, treatment and preventive measures. HVA is transmitted by faecal-oral route through contaminated food and water, shared drug equipment, sexual activity within the homosexual male community and poor hygiene and sanitation practices (1, 2). Therefore, thorough hand hygiene practices, avoidance of sharing food and drinks, provision of vaccinations for high risk groups and safe sex practice are preventive measures to reduce the risk of spreading the disease (1). While HVA has a low prevalence in Australia, it has a higher prevalence in countries where sanitation and hygiene are poor. Nevertheless, travelling to endemic areas is the highest risk factor for contracting the disease (3). Symptoms of HVA include fatigue, fever and jaundice (4). HBV is the most common liver infection and can lead to liver failure, cancer or cirrhosis if untreated (5). It is transmitted through bodily fluids such as blood, semen and breast milk, syringe-sharing and sexual intercourse (6). Preventive recommendations include vaccination, practicing safe sex and the use of more general infection control measures such as disposible PPE, sterilisation and hand hygiene (7). There is a higher incidence rate in children than in adults (8) and high-risk infections from population migration from endemic countries (9). Patients are often asymptomatic in the acute phase, however chronic infections may present with symptoms similar to HVA and may be prolonged and severe (8). HCV is transmitted through infected needles, contaminated medical equipment and sexual activity (10). Although there are no vaccinations for HCV, similar HAV and HBV prevention practices are used with special attention to the use of new and sterile syringes to decrease the risk of HCV (11). Infected patients may report flu-like symptoms, which can be followed by more specific hepatic or haematologic symptoms over the following years. If left untreated, it can lead to chronic disease, liver cirrhosis and hepatocellular carcinoma (8). Furthermore, HCV can induce insulin resistance, oxidative stress and liver steatosis (12).

In order to minimize liver damage and improve the quality of life of patients, early diagnosis is extremely important. Prevention methods, risk reduction of spread and vaccinations for higher risk populations are critical (13). Serology tests are non-invasive procedures used for diagnosis and are able to identify the specific viral strain (14). Coordination of care and effective communication between the full multidisciplinary healthcare team is paramount, to ensure the best patient outcome during both treatment and recovery. This is done through specific patient education on their own viral strain and risks and prevention methods to reduce the spread of the disease (15).

Sexual activity plays a significant role in the transmission of the hepatitis viruses, particularly hepatitis A and B. Oro-genital sex is common in both heterosexual and homosexual couples of all sexual orientations (16), and it is common for young people to consider oral sex safer than vaginal sex, however this is not entirely true. Oro-anal contact is likely the most important risk factor for transmission of hepatitis B from anus to mouth, and may occur from faeces or asymptomatic rectal bleeding in homosexual men (17, 18). Hepatitis B can also be transmitted through fellatio and cunnilingus and virus particles that are found in semen, stool, saliva and blood (19). Hepatitis A is an enteric pathogen and so it is unsurprising that it is more prevalent in homosexual males who report having oro-anal sex. Epidemic outbreaks of hepatitis A affecting homosexual men have been reported in the literature (19, 20). Sexual transmission of hepatitis C is uncommon and cofactors such as the presence of HIV and hepatitis B may be necessary for transmission (21, 22). Maintaining good oral health has an underestimated role in protecting at risk groups from oral transmission of hepatitis A and B infection. Limiting exposure to sexual fluids as well as maintaining good oral health - free from bleeding gums, broken skin, lip sores and cuts which serve as a gateway for entry of infection from oral cavity to circulation - markedly reduces the risk of infection during unprotected oral sex (23). Once trust and rapport have been established, dentists are in a unique position to reduce a patient’s risk of acquiring and transmitting hepatitis through the oral cavity by preventive treatments, education and health promotion.

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Oral health workers need to protect themselves adequately while maintaining a professional-patient relationship free from discrimination and prejudice. All patient’s body fluids must be treated as a potential portal to infection. Oral health practitioners are recommended to be vaccinated against HBV prior to performing dental treatment and to uphold appropriate standard precautions such as hand hygiene practices, the use of personal protective equipment (PPE), appropriate handling of sharps, and equipment sterilisation (24, 25). Transmission of HBV and HCV are more likely to occur in a dental setting as dental procedures are invasive and generate contaminated aerosols, which are suspended in the dental environment for up to five days (26). Prior to high risk procedures, antiseptic mouthwash for the patient reduces contamination along with antibiotic prophylaxis (27, 28). Although such measures may reduce the risk of contamination, the success in preventing the spread of disease lies within consistent and appropriate use of infection control practices for all patients without the need for adopting excessive measures for patients who identify with hepatitis. For example, changing the infection protocol for patients with hepatitis, such as through double gloving, can easily be viewed as discriminatory according to the Australian Dental Journal. Sharp injuries such as needle stick injuries leads to blood virus transmission, and the correct disposal of sharps provides protection rather than double-gloving (25). Patients who feel discriminated against would be less likely to disclose their hepatitis status and be discouraged from seeking appropriate healthcare due to the stigma associated with infections, and as there are no legal obligations to disclose their status (28). Dental health practitioners need to be aware of any discriminatory actions towards hepatitis patients (29).

Dental practitioners must be aware of potential complications and the medical management of patients with hepatitis. All patients should have their medical history reviewed before a clinical examination (30). Patients identified to have a history of hepatitis should undergo additional review of liver function and medications. Disclosure of this information is vital for the clinician to deliver safe treatment (30). Unless in an emergency situation, patients with active hepatitis should not undergo any dental treatment and need to be referred to their general physician for care (31). When emergency dental treatment cannot be delayed liaisons with the patient’s physician is required and clinicians must strongly abide with standard precautions and ensure all precautions are followed such as decreasing aerosol production. Hepatitis can interfere with haemostasis, therefore prothrombin and bleeding time must be measured and extra precautions should be followed to decrease surgical trauma as excessive bleeding may occur during surgery (32). Management of a patient with a history of hepatitis will depend on several factors. It is important to obtain complete blood count, coagulation tests, hepatic serology, viral load and liver function status before treatment of a patient with a history of hepatitis (33). Patients with a history of hepatitis with normal liver function can receive dental treatment (32). As patients may be hepatotoxic, certain sedatives and NSAIDS should not be used (28, 31). Clinicians can also consider limiting treatment to one quadrant per visit when managing patients with a history of hepatitis and associated impaired liver function, which minimizes the use of local anaesthetic and the possibility of complications arising (33). Post treatment follow-up is essential to ensure that there are no physical complications or patient concerns (31).

Hepatitis has the potential to manifest as oral diseases. There is evidence that suggests hepatitis affects the salivary glands (34). Consequently, patients with hepatitis have a higher risk of reduced saliva flow, which may lead to a condition known as Xerostomia(34). Hepatitis may increase the risk of Sjogren’s syndrome, but the literature supporting this is limited (35). The treatment for HCV also leads to Xerostomia (36). Saliva has a plethora of properties including reducing caries, an antibacterial role, lubrication, and speech articulation (37, 38). Dry mouth can be alleviated by consuming more water, chewing sugarless gum, celery, avoid alcohol mouthwashes and bicarbonate mouthwash (28). Hepatitis patients have a higher chance of periodontal disease. As a result, a strong preventative program must be implemented (28).

Around 27% of HCV-affected patients also suffer from Oral Lichen Planus (OLP). While there is a high correlation between OLP and HCV, the underlying pathophysiology is poorly understood (38). Due to this correlation, a new presentation of OLP in the dental setting could be used as a trigger to test for HCV infection, especially in higher risk patients. OLP is an immunological and inflammatory disease which affects the buccal mucosa, tongue and gingiva in the oral cavity and causes painful bleeding (39). The pain that is associated with OLP can compromise the ability to carry out oral hygiene routines as a result leading to poor oral health outcomes (40).

Oral healthcare workers are in a prime position to assist in the identification, education, management and recovery of patients with hepatitis infections. Effective communication between the dentist and the patients’ general practitioner or specialist could significantly improve patient outcomes, by ensuring the dentist has a thorough understanding of the patients treatments, latest bloods and symptoms. The dentist should invest time to build a strong professional relationship with the patient such that they feel supported and comfortable discussing all aspects of their disease. The dentist should approach topics such as fecal-oral and sexual transfer of hepatitis in a sensitive yet confident manner, leading the conversation in such a way that the patient does not feel disparaged or belittled. Undertaking targeted continuing professional development activities to maintain a high level of knowledge on hepatitis, as well as other infectious or sexually-transmitted diseases, can assist in arming the dentist with all the information they require to effectively diagnose, treat and most importantly communicate with all patients, regardless of disease status.

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