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Hepatitis B virus infection in dentistry: A


forgotten topic: REVIEW
ARTICLE in JOURNAL OF VIRAL HEPATITIS FEBRUARY 2010
Impact Factor: 3.31 DOI: 10.1111/j.1365-2893.2010.01284.x Source: PubMed

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Retrieved on: 02 September 2015

Journal of Viral Hepatitis, 2010, 17, 307316

doi:10.1111/j.1365-2893.2010.01284.x

REVIEW

Hepatitis B virus infection in dentistry: a forgotten topic


N. Mahboobi,1 F. Agha-Hosseini,1 N. Mahboobi,2 S. Safari,2 D. Lavanchy3 and S-M. Alavian4
1

Department of Oral Medicine, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran; 2Tehran University of Medical Sciences, School

of Medicine, Tehran, Iran; 3World Health Organization (WHO), HSE/EPR/BDP, Geneva, Switzerland; and 4Baqiyatallah University of Medical Sciences,
Research Center for Gastroenterology and Liver Disease, Tehran, Iran
Received January 2010; accepted for publication January 2010

SUMMARY. More than two billion people have been infected

with hepatitis B virus (HBV). Globally, 350400 million suffer


from chronic HBV infection. It is postulated that dentists and
dental staff are infected and transmit the virus to their patients more than any other occupation. The aim of this article
is to review the HBV incidence in dental society, the points of
view of dentists and their patients regarding transmission of

INTRODUCTION
Hepatitis B virus (HBV) is a member of the family of the
hepadnaviridae [1], which is infectious for humans and a
few animal species [2,3]. At the beginning of the third millennium, HBV remains a major public health problem
globally with more than one third of worlds population
infected [3]. Of these, 350400 million suffer from chronic
HBV infection [35]. This infection has been identified as one
of the most important causes of liver failure and hepatocellular carcinoma (HCC) [6]. According to the world health
organization (WHO), there are more than 50 million cases of
acute hepatitis B infection annually [7,8] with 510% of
adults and up to 90% of infants becoming chronically
infected [9]. With 500 000 to 1.2 million deaths per year
caused by chronic hepatitis, cirrhosis and HCC, the virus is
the tenth cause of death globally [7,8].
The prevalence is high in the Far East, the Middle East,
Africa and parts of South America, with HBsAg rates ranging
from 8% to 15%. Furthermore, in these regions, serological
evidence of prior HBV infection (anti-HBc: Hepatitis B core
antigen and/or anti-HBs: Hepatitis B surface antigen) is almost
universal in subjects without active infection. There is
Abbreviations: DHCP, dental health care personnel; HBV, hepatitis B
virus; HCC, hepatocellular carcinoma; HCW, health care worker;
ICC, infection control coordinators.
Correspondence: Seyed-Moayed Alavian, Professor of Hepatology,
Baqiyatallah Research Center for Gastroenterology and Liver
Diseases, Ground floor of Baqiyatallah Hospital, Mollasadra Ave.,
Vanak Sq., PO Box 14155-3651, Tehran, Iran. E-mail: Alavian@thc.ir

2010 Blackwell Publishing Ltd

the virus during dental procedures, the occurrence of HBV


outbreaks in dental clinics and the importance of methods of
preventing HBV infection in dentistry.
Keywords: dental staff, dentist, epidemiology, hepatitis B
virus, outbreak, precaution method, prevention, transmission, vaccination.

intermediate prevalence (27%) in Japan, parts of South


America, Eastern and Southern Europe and parts of central
Asia. The prevalence is lowest (<2%) in Northern Europe,
Australia, the southern part of South America, Canada and
USA [2,10,11]. There is intermediate prevalence in Iran,
which has a population with 2.14% HBV infection rate [12].
Hepatitis B virus can be transmitted parenterally by percutaneous and mucous membrane exposures to infected
blood, by sexual contact or by perinatal exposure [2,13,14].
Needles and syringes may be contaminated by viruses.
Accidental injuries with infected needles and syringes can
transmit the virus to health care workers (HCWs) [15].
Although there is no strong evidence that saliva and gingival cervical fluid can transmit the virus, some studies show
HBsAg in saliva and gingival cervical fluid of HBV-positive
patients [1618].
Serological studies in different parts of the world have
found a higher prevalence of HBV infection with a high
potential for transmission, among dentists, especially among
surgical specialties (oral and maxillofacial surgeons and
periodontists) compared to the general population
[14,15,19]. Studies conducted in the prevaccination era
showed that HBV infection of dentists was approximately
three to six times greater than in the general population, and
dentists had the highest rate of HBV infection among all
HCWs [20]. Percutaneous injuries in dental students were
more frequent than in all other health care system students
[2123]. This review is aimed at clarifying the current
situation regarding the considerable risk of HBV infection in
the dental community. This article discusses HBV prevalence, the knowledge of dentists and patients about the

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N. Mahboobi et al.

routes of transmission in dental offices, about the role of


dental clinics in HBV outbreaks and about the importance of
methods of preventing infection.

The third problem is that different methods have been


used to evaluate rates of HBV infection, so it is difficult to
compare the results in the various studies [28].

EPIDEMIOLOGY OF HEPATITIS B IN DENTAL


PRACTITIONERS

HEPATITIS B TRANSMISSION: KNOWLEDGE OF


DENTISTS AND PATIENTS ABOUT DENTAL
PROCEDURES

Despite extensive vaccination programmes against HBV since


1989, this infection has not yet been fully eradicated, and still
is a concern in dental fields [24]. In the past few years, because
of the availability of HBV vaccine, the incidence of HBV
infection began to decrease. However, this incidence is still
higher than in the general population [25]. A 2008-study
stated that this variation is still 2.56 times more than in the
general population, but the references in this article refer to
the prevaccination age [26]. In recent years, two studies from
Brazil discussed HBV infection in dentists. One study showed
that 10.8% of 474 dentists were seropositive for HBV infection. Three dentists (0.6%) were HBsAg positive, and 43
(9.1%) were anti-HBc/anti-HBs positive [22]. The second
study of 135 dentists showed that one dentist (0.7%) was
positive for HBsAg. Eleven dentists (8.1%) had anti-HBs and
anti-HBc in their serum samples [27].
In a study of the global challenge of hepatitis B, the dental
community had the highest risk of infection of all health care
personnel. Dentists and oral surgeons are in the first rank,
nurses, dental hygienists and assistants are in the third rank,
and dental students and dental laboratory technicians are
ranked sixth and seventh, respectively [28].
According to several studies, the incidence of HBV infection increases with the length of clinical practice of dentists
[29], dentists age, irregular use of protective glasses and
clothing [19,21,22,26] and presumed contact with infected
blood [22].
In Canada and in USA, 101 dental anaesthesiologists
completed a questionnaire regarding percutaneous and
mucocutaneous injuries. The calculated annual risk of
acquiring HBV, HCV and HIV from percutaneous and
mucocutaneous injuries was <0.2%. In Canada, the risk of
acquiring HBV in nonimmune dental anaesthesiologists was
150 times greater than the risk of acquiring HIV. In the
USA, the risk of acquiring HBV in nonimmune dental
anaesthesiologists was 50 times greater than the risk of
acquiring HIV [30].
It is worth emphasizing that there are still three problems that hinder decisions regarding HBV infection in
dentistry.
The first problem is that there is insufficient data on HBV
infection incidence among dentists and related communities,
so it is currently difficult to make conclusions on its prevalence in these subjects.
The second problem is that existing studies are normally
conducted with a blood sample from one venipuncture. It
appears that dentists, who knew they were infected with
HBV, did not participate in the survey [21].

Knowledge of dentists
The acquisition of HBV infection by health service staffs or
HCWs from patients is an occupational hazard [31], which
can be estimated by comparing infection rates in health
service staff with the general population [32]. During normal dental practice, dentists are at risk of infection from
micro-organisms carried by patients [33]. Injuries in dental
offices happen because of a confined space, the frequent
patient movement and the variety of sharp dental instruments used in normal dental practice [34]. In dentists
opinion, infection with HBV is still the most dangerous
blood-borne disease [35,36]. Studies from different parts of
the world show that dental HCWs have totally different
levels of knowledge about viral hepatitis transmission and
about prevention and infection control programmes [37,38].
As is seen in several other illnesses, this virus infection has
no signs or symptoms. HBV transmission from patients to
HCWs may occur, because these HCWs do not know their
patients are infected [39]. Two studies from Japan reveal
that HBV infection in dental patients with impacted teeth or
jaw deformities is 0.7% and in patients with oral cancer or
oral cysts is 1.2% [40,41]. A study from Nigeria shows that
18.3% of patients undergoing extractions are positive for
HBsAg [42]. Therefore, in developing countries, it seems
reasonable to diagnose the presence of HBsAg at high risk
patients prior to dental treatment [43,44].
Despite vaccination against HBV, many physicians are still
reluctant to conduct dental procedures on HBV-infected
patients [45,46]. Because of negative reactions from dentists
(for example, not treating or admitting in the last working
hours), patients often hide their infection from dentists [45].
In spite of such studies, there are also reports that state there
are many dentists who work on HBV-positive patients. In
1976, a study showed that approximately 50% of dental
surgeons had knowingly treated HBV-infected patients, and
some dentists had treated patients with HBV infection many
times. However, these dentists also believed they had always
taken appropriate precautions [47]. A study from Taiwan
revealed that approximately 75% of dental students would
treat an HBV-positive patient [48].
Exposure to blood possesses a small but significant risk
of transmission of blood-borne pathogens including HBV.
An incident involving blood from a patient with HBV
infection may infect the dentist with HBV and is likely to
cause anxiety and stress in the dentist. At times, the
dentist may require counselling [49]. Unfortunately, there
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Hepatitis B virus infection in dentistry


is not enough data regarding dentists experiences about
exposures.
In a Canadian national survey of dentists, 4107 dentists
responded to a questionnaire (adjusted response rate 66.4%).
Occupational exposure hazards in the previous year were
reported by 2766 respondents (67%). The total number of
blood splashes to the eye, nose or mouth was 6164 splashes
with a range of between no splashes and 60 splashes and
with a mean of 1.53 splashes per year. Percutaneous injuries
included needlestick, wire injuries, cuts and other types of
percutaneous injuries. The total number of percutaneous
injuries was 12 048 with a range of between no percutaneous injuries and 74 percutaneous injuries with a mean of
3.03 percutaneous injuries per year for each participant.
The study indicated that 28 dentists stated that they had
been exposed to HBV-infected blood during the previous
year, and 652 dentists stated that they were not sure if they
had been exposed to HBV-infected blood during the previous
year [50]. Moreover, approximately 6800 nonvaccinated
HCWs in USA become infected with HBV every year.
Approximately 100 of these HCWs will die from cirrhosis,
liver cancer or fulminant hepatitis [51]. As explained
previously, dentists are at higher risk than other HCWs.
The probability of infection decreases significantly by
using infection control strategies. The Canadian dental
association (CDA) and the American dental association
(ADA) have stated it is unethical for a dentist to refuse to
treat a patient solely on the grounds that the person has a
blood-borne virus or any other transmittable disease or
infection. The associations stated that these patients may be
treated safely in dental offices if the vaccinated dental staff
follows recommended infection control practices [52,53].
It is necessary to conduct clinical research to observe and
monitor dental occupational injuries and infection control
knowledge and practices among dental health care personnel (DHCP). The research provides continuous assessment
for the efficacy of vaccination, infection control education
and training programmes, and it assists in the development
of educational interventions to improve adherence to
guidelines and reduce injuries [54].

Knowledge of patients
Patients attendance in dental clinics exposes them to two
risks: first, the probability of cross-infection from one patient
to another from an infected dental instrument; and second,
the potential hazard of an infected dentist [47]. Because of
HBV vaccination, the infection rate has decreased significantly. Because of extensive HBV vaccination, it can now be
claimed that transmission from a HCW to a patient is
unlikely [39]. Obvious positive changes in infection control
behaviours were observed in a study within two consecutive
years [53]. A study estimated that the probability of transmission of HBV infection from dentists to patients is 1 in
250 000 [32]. In some parts of the world, physicians
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309

positive for HBV are not allowed to conduct exposure-prone


procedures [55]. In England, students are being screened for
HBV and other blood-borne pathogens [56] and are not
being admitted to the study programme if they are positive
for the virus [57].
It has been proved that despite the anxiety that may be
caused to patients, the patient should be informed if their
dentist is infected with HBV [58]. According to a study, 82%
of participants confirmed that they want their infected dentist or doctor to disclose his or her condition before starting
treatment, and almost all respondents reported that they
would tell their doctor or dentist to stop if they started to use
an instrument that appeared to be contaminated with blood
or other body fluids [59].
Presenting office procedures to patients as a part of an
evolutionary process will help us offset negative reaction and
pose dentistry as a caring profession with an excellent track
record on safety [60]. Patients have shown that they want
information in the field of hepatitis B [58]. Better education
of the public and health care providers on the risks and
prevention of blood-borne virus transmission during health
care is a necessary step towards any change in public attitudes, opinions and policy [59,61,62]. Periodic assessment
of public attitudes and opinions regarding the risk of bloodborne virus transmission during health care is important for
several reasons [59].

HEPATITIS B OUTBREAKS IN DENTAL CLINICS


Practitioners and most of the public believe that dental
procedures are extremely hazardous [62,63]. Such a view
might be a result of the negative picture created by the
media that depicts dentistry as a profession filled with
dangers [60].
The evidence for viral transmission in dental offices is
based on the results of seroprevalence studies, epidemiological investigations and case reports. It should be mentioned
that many cases of infection transmission are not
documented, because approximately 50% of infections are
subclinical, there is difficulty in linking isolated sporadic
cases with a HCW and the variation in completeness of
surveillance among jurisdictions [51]. It is a sad fact that
HBV infection shows a higher prevalence in hospitalized
dental patients than the general population [64].
Contaminated sharp instruments, such as needles, lancets,
scalpels, broken glass, specimen tubes and other instruments, can transmit blood-borne pathogens such as HBV.
Transmission of blood-borne pathogens to patients, HCWs
and community members can occur from nonsterile injections, accidental needlesticks and improper recycling of
needles and syringes [65].
To transmit HBV from HCWs to patients, the HCW must
be infected and have an infectious virus circulating in the
bloodstream, the HCW must be injured or have a condition
such as weeping dermatitis or eczema that provides direct

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N. Mahboobi et al.

exposure to infected blood or body fluids, and finally the


injury mechanism or condition must present an opportunity
for the HCWs blood or body fluids to directly contact
a patients mucous membranes, wound or traumatized
tissue [34].
From 1972 to 1999, 46 HCWs (including six DHCPs)
transmitted HBV to their patients: a general dentist transmitted to 13 patients [66], an oral surgeon to 55 patients
during 42 months [67], a general dentist to at least six
patients [68], an oral surgeon to 52 patients causing clinical
illness developing in 12 patients [69], an oral surgeon to 62
patients during a period of 9 months [70] and a general
dentist to four patients [70]. There have been at least three
other published reports about dentists who infected their
patients, but further studies rebutted the probability [71].
Since 1987, there have been fewer documented cases of
HBV transmission from dentists to patients. This decrease
has been attributed to increased use of gloves, greater care in
handling sharp instruments and HBV vaccination [72].
Considering that all of these reports were from USA, where
HBV has a low prevalence, it can be inferred that such cases
might have happened in other parts of the world and may be
under estimated, because they have been anicteric.
Although standard precaution programmes have existed
for many years, outbreaks still happen in various nations.
For example, one report from USA showed that HBV was
transmitted from a 36-year-old woman patient to a 60-yearold woman in 2002 during teeth extraction in a private
clinic, despite standard infection control system being used
[73]. Recent experience indicates that identifying transmission from an outpatient clinical source is difficult, and the
identification may not occur unless there are special circumstances such as the infection of numerous patients [74].
It was suggested that serum viral concentration and dose
of an exposure are the critical factors for the transmission of
blood-borne pathogens. It is well documented that
transmission of HBV following an HBsAg positive needlestick
injury is a function of the concentration of serum viral
particles in the blood of the source patient. Conversely, blood
borne pathogens do not appear to be transmitted below a
certain threshold. Finally, it has been shown that the serum
concentration of specific blood-borne pathogens is directly
related to the rate of transmission [75].
Cumulative risk that a nonvaccinated dentist will
become infected by HBV is increased if the dentist treats an
infected patient and the dentist has a percutaneous injury
while delivering therapy to the infected patient. The risk to
the dentist increases as the number of visits by each
infected patient increases. The risk to the dentist also
increases as the number of different infected patients
increases [76,77].
There is another growing concern about the issue of crossinfection in dental clinics and laboratories, especially after
several studies found that transmission of infection to
dental laboratory technicians is mainly by contaminated

impressions or by improper handling of clinical items after


arrival at the dental laboratory [78,79].
Finally, it should be stated that unfortunately, because of
the procedures conducted in a dental office, there is a high
risk of needlestick and percutaneous injury in dentists and
dental staff. If dentists acquire the infection, they will be an
important source for transmission to their patients. The
probability of cross-infection should be imprinted in all
dental personnel minds. Applying precautionary methods is
still the only method to reduce the probability of outbreaks in
dental clinics.

THE IMPORTANCE OF PREVENTION IN


DENTISTRY
The recommendation to use universal precautions systems
from the necessity of treating all patients, although they are
infected with HBV, HCV or HIV. Thus, additional precautions for infected patients are unnecessary [53]. Dental
surgeons, who wear glasses and work with ultrasonic and
rotary instruments, are aware of the amount of droplet
spread of saliva, blood and water because of deposits on their
glasses [47]. Considering that the annual cumulative HBV
infection risk of routine treatment of patients whose seropositivity is undisclosed is 57 times greater than HIV and
mortality risk of HBV infection is 1.7 times greater than HIV,
one must attempt to restrict HBV exposure as much as
possible [76]. Blood-borne infections, such as HBV, are
occupational risks in the dental community [80,81]. The
associated risk of a percutaneous exposure to HBV is estimated to be 2% for HBeAg-negative and about 30% for
HBeAg-positive blood [43]. Indeed, it is essential for dental
HCWs to have a good knowledge of disinfection systems to
eliminate the risk of cross-infections [82]. Furthermore, strict
sterilization procedures must be used to prevent infection
transmission [81].
Most dentists have a needlestick or puncture of finger skin
once or more each week [83]. Dentists are among the most
highly exposed groups of HCWs [62,84]. Reusing local
anaesthetic syringes following recapping, and cleaning
instruments were the two most important causes of needlestick injuries in dental students and dental hygienists [85]. It
should be emphasized that HBV transmission can occur in
dentistry if there is any lapse in sterilization procedures or if
there is transmission of infected body fluids to patients [83].
It was also demonstrated that the risk of the spread of
infections through the use of inadequately sterilized instruments is much higher than that by blood transfusion [86]. In
a study in Canada, 42% of dental anaesthesiologists reported
at least one percutaneous injury within the previous
6 months, and one of the participants reported nine injuries
[30]. Another research study stated that more than 40% of
dental anaesthesiologists have had at least one needle injury
during the last year in their occupational settings [87].
There is also another potential source. Despite the suggestion
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Hepatitis B virus infection in dentistry


that HBV can not be transmitted from oral fluids, one can
not neglect the possibility that oral fluids can cause infection
[88]. Infection control strategies including policies, procedures and practices are designed to break one or more of
these links in the infection chain, thereby preventing infection [89,90].
The CDC recommendations for infection control include
the use of protective attire and barrier techniques, hand
washing and care of hands, caution when using sharp
instruments and needles, instrument sterilization or disinfection, disposal of waste materials and treatment of water
and dental unit waterlines [91].
Although there is no evidence that pathogens have been
transmitted via dental handpieces, the potential of crossinfection has been demonstrated. Routine heat sterilization of
handpieces between patients is, therefore, recommended [92].
Clinicians should comply with the current infection control
recommendations of the CDC, the organization for safety and
asepsis procedures (OSAP) and ADA [13]. Infection control
procedures and vaccination remain the best defence not only
for the dentists themselves, but also to help prevent transmission of infectious agents to the patients [93,94]. As future
dentists, dental students must be taught about the risks of the
disease and must be trained in the procedures needed for
effective prevention of infection and in the actions to take after
an occupational exposure to patient body fluids [33].
Currently, vaccination is the most important method of
preventing HBV infection [95]. The number of vaccinated
dentists is increasing constantly [96]. Unvaccinated dentists
are five times more likely to be infected than vaccinated
dentists [21]. The object of vaccination against HBV is not
only to prevent infection, to reduce the incidence of persistent HBV infection and chronic liver disease, but also to
eliminate the pool of chronic carriers, which limits the
transmission of infection to susceptible patients [97]. The
main reason reported for not being vaccinated or not
being completely vaccinated was lack of information
[15,19,87,98]. Vaccinated dentists had fewer years of dental
practice, had knowledge about HBV and its transmission by
dentists, participated in educational courses and associations
and received information about vaccination from guidelines
[99]. Nonvaccination is one of the most important reasons
for HBV transmission [15]. Nonvaccination was significantly
higher among dentists aged 40 and over, and in dentists,
who had not attended refresher courses in the 2 years prior
to a survey [21]. Complete vaccination rate was higher
among surgeons and periodontists in comparison with other
dental fields [19].
Incomplete vaccination was positively correlated with
nonuse of gloves during work [19]. A study showed that
routine glove usage is more frequent in younger dentists and
female dentists [72]. It should be stressed that even with HBV
vaccination, the dentist must continue to use prevention
methods, because HBV-positive patients may also be infected
with other blood-borne pathogens such as HIV [83,100].
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311

Furthermore, not everybody actually responds to HBV vaccination. Therefore, dentists should be aware of their anti-HBs
titre [19,101]. The response to vaccination was most strongly
associated with sex, age [96,102], number of doses [102],
obesity and smoking [96], while type of vaccine and history of
hepatitis seemed to have no significant relation [102].
Fortunately, most dentists are now aware of the biological
hazards and are especially aware of the most important ones,
which are HBV and HIV [62,82]. This knowledge can be
attributed to the extensive publicity in the past few years
that discussed cross-contamination with blood-borne
pathogens in dentistry [62]. However, such knowledge is
sometimes ignored by dental practitioners, particularly in
developing countries [103]. Significantly, the majority of
HCWs use universal precautions for less than 50% of the
time when they conduct procedures on their patients. One of
the primary reasons is that the hospital cannot always
provide the necessary materials [15]. HBV vaccination coverage among dentists is highly variable, and it is not yet
compatible with the possible elimination of the occupational
risk of HBV infection, considering the fact that these professionals are in continuous exposure to blood or other fluids
potentially contaminated with HBV [22]. A study in South
Africa revealed that 97% of university students did not follow a postexposure protocol after needle-stick injuries. The
participants were poorly informed about the importance of
HBV vaccination and antibody checking [104]. In a New
Zealand study, although 92% of all practices had an autoclave in their offices, only 42.8% of practices autoclaved
dental handpieces, and only 10.9% of practices wiped, cold
disinfected or boiled extraction forceps [98].
Immunization status prevalence is still controversial in
dental societies. A study in France showed 67.2% of the
subjects were found to be positive for anti-HBs in a public
dental clinic (77.4% of medical personnel and 28.8% of
the nonmedical personnel) [105]. Interestingly, the results
of a study from Canada identified that orthodontists are
less compliant with recommended infection control than
general dentists [106]. Immunization status of dental
health care workers in various countries is summarized in
Table 1.
Transmission of blood-borne pathogens following an
exposure depends on the concentration of virus in the blood
or body fluid, the volume of infective material inoculated, the
loss of infectivity during transfer of inoculate and the port of
entry [75]. Since its inception, the postexposure management programme at New York University College of Dentistry (NYUCD), USA has included several key elements:
immediate evaluation and counselling of the exposed HCW,
investigation of the circumstances of the exposure, evaluation and/or testing of the source patient whenever possible,
assessment of risk and prophylactic measures, as well as
periodic follow-up of the HCW [43]. It was stated that those
dentists, who report more percutaneous injuries, are relatively less likely to have a postexposure protocol [114].

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Table 1 Summary of immunization status of dental health care workers in various countries

Country

Year

Dental population

Scotland
England*

1994
1995
2008

Australia

1997

South Korea

1999

Dentists
Dental students
Dentists
Dental hygienists
Nurses
Dental therapists
Nonclinical staff
Dental therapists
and assistants in
the dental clinics
Dentists

Germany

2000

Brazil*

Jordan

2003
2006
2004
2004
2004
2007
2006

Dominican
Nigeria

2007
2007

Taiwan
Turkey
Italy*

Hygienists
Assistants
Dentists
Dental assistants
Dentists
Dentists
Dental students
Orthodontics
Dentists
Dentists
Dental staffs
Dental nurses
Staff dentist
Dental students

Vaccination
rate
88
66
97
94
89
75
65
100

Rate of
evaluation
for antibodies
67
61
n/m
n/m
n/m
n/m
n/m
n/m

63.3

71.7

62.7
65.2
74
63
74.9
73.1
73.7
77.3
89.2
85.7
95
87
89
21.6

35.6
43.5
n/m
n/m
n/m
100
n/m
n/m
71.8
n/m
57
4
n/m
n/m

Immune
system
response

Method of
evaluation

Reference
number

n/m
28
n/m
n/m
n/m
n/m
n/m
n/m

Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire

[107]
[108]
[109]

76

Questionnaire/
MEIA** test
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
ELISA test***
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire
Questionnaire

[111]

n/m
n/m
n/m
n/m
n/m
74.5
n/m
n/m
n/m
n/m
n/m
n/m
n/m
n/m

[110]

[112]
[19]
[22]
[48]
[113]
[35]
[99]
[54]
[65]
[77]

*Time sequence was not considered when comparing the results of two studies from one country. This percentage included
immune system response. ** Microparticle enzyme immunoassay. The immune system response of all the participants in this
study has been evaluated. *** Enzyme-linked immunosorbent assay.

In summary, epidemiology of HBV in the world has changed, and elimination of remaining risk factors such as those
related to dentistry is important. Dental society and especially
dentists should become active parts of the health care system
to prevent transmission of the virus from residual paths.

WHAT SHOULD WE DO? CURE OR IGNORE?!


Identification of patients with blood-borne infections is not
always possible or desirable [72]. Within society, there is, a
lifetime risk of infection by such blood-borne pathogens
[115]. Dentists and dental personnel should be educated
constantly about the risk of infection from their patients and
about the potential risk of the dentists infecting their patients
and transferring infection between patients [111]. The routine use of infection control coordinators (ICC) would reduce
the risk of infection transmission to both dentists and
patients [116]. When employees are given the opportunity,

the time and the training, most employees can function


effectively and efficiently [116,117]. Compliance with universal precautions can minimize sharp injuries. Best practice
that can help prevent infection among injection recipients,
HCWs and the community includes use of a sterile syringe
and needle for each injection, avoidance of two-handed
recapping after using sharp instruments, collecting instruments in safety containers at the point of use and the proper
disposal of the sharps safety containers [65]. All HCWs,
including the dental community, should be required to use
these universal precautions. Results of studies have shown
that the dentists tendency toward treating infected patients
are significantly related to the following factors:
1. the number of years since graduation: younger dentists
are more willing to treat infected patients according to
their training and to their beliefs about their responsibly
concerning all their patients,
2010 Blackwell Publishing Ltd

Hepatitis B virus infection in dentistry


2. gender: male dentists are more willing to treat HBVinfected patients,
3. practice type: practices with two or more dentists are
more willing to treat infected patients when compared to
single dentist practices,
4. number of postgraduate courses attended: this characteristic has direct relationship with a willingness to treat
infected patients,
5. use of barrier techniques: practitioners who use barrier
techniques routinely show more willingness to treat
HBV-positive patients [118,119].
The authors again emphasize that there is not enough
data regarding dentists and much less data regarding dental
staff and their HBV vaccination and immune response rate.
The existing data are extremely limited, so we were forced to
use studies on HCWs in some parts of this review and
attribute the results to the dental community.
A global vaccination programme is the only available
effective method for eliminating HBV outbreaks in dental
offices. Policy makers in developing countries and in countries with financial problems should realize that HCWs and
the dental community are groups with the highest risk of
infection and transmission. Therefore, the programme of
vaccination should be applied to this populace first.
Dentists and dental staffs in clinics should prepare an
environment, where infected patients can be treated easily
and safely. Applying sterilization methods effectively and
using disposable instruments will reduce the probability of
cross-infection. Dental staff will be able to treat patients safely
if they are vaccinated and routinely evaluate their anti-HBs
status, if they use barrier techniques and if they are familiar
with postexposure protocol. In such an environment, infected
patients would not need to discuss their infected state.
As a part of a health care system with responsibilities for
curing patients, dental staff should not show any negative
feeling while treating an infected patient. Finally, it seems
safe to conclude that with an enhanced knowledge, a new
horizon in attitudes and operations in the dental community
and their target population will be experienced.

ACKNOWLEDGEMENT
The authors thank Dr Maryam Khalili for her invaluable
comments on preparing the manuscript.

CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest
relevant to this manuscript.

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