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32
5 AUTHORS, INCLUDING:
Farzaneh agha-hosseini
Saeid Safari
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Daniel Lavanchy
independant
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doi:10.1111/j.1365-2893.2010.01284.x
REVIEW
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
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
308
N. Mahboobi et al.
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
2010 Blackwell Publishing Ltd
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
2010 Blackwell Publishing Ltd
309
310
N. Mahboobi et al.
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].
312
N. Mahboobi et al.
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.
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.
REFERENCES
1 Hatzakis A, Magiorkinis E, Haida C. HBV virological
assessment. J Hepatol 2006; 44: S71S76.
313
314
N. Mahboobi et al.
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
315
316
N. Mahboobi et al.
91 Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ,
Malvitz DM. Guidelines for infection control in dental
health-care settings 2003. MMWR Recomm Rep 2003;
52(RR17): 161.
92 McCarthy GM, Koval JJ, John MA, MacDonald JK. Infection
control practices across Canada: do dentists follow the
recommendations? J Can Dent Assoc 1999; 65(9): 506
511.
93 Leggat PA, Kedjarune U, Smith DR. Occupational health
problems in modern dentistry: a review. Ind Health 2007;
45(5): 611621.
94 Gower K. Protecting staff and patients. Br Dent J 2006;
200(2): 65.
95 Chen W, Gluud C. Vaccines for preventing hepatitis B in
health-care workers. Cochrane Database Syst Rev 2005;
19(4): CD000100.
96 Cleveland JL, Siew C, Lockwood SA et al. Factors associated
with hepatitis B vaccine response among dentists. J Dent
Res 1994; 73(5): 10291035.
97 Banatvala JE, Van Damme P. Hepatitis B vaccine do we
need boosters? J Viral Hepat 2003; 10(1): 16.
98 Treasure P, Treasure ET. Survey of infection control procedures in New Zealand dental practices. Int Dent J 1994;
44(4): 342348.
99 Di Giuseppe G, Nobile CG, Marinelli P, Angelillo IF. A survey
of knowledge, attitudes, and behavior of Italian dentists toward immunization. Vaccine 2007; 25(9): 16691675.
100 Cade JE, Boozer CH, Lancaster DM, Lundgren G. HIV-1
antibody positive hepatitis B surface antigen serum in a
dental school patient population. Oral Surg Oral Med Oral
Pathol 1994; 78(5): 670672.
101 Rahbar M, Hajia M. Detection and quantitation of the
etiologic agents of ventilator-associated pneumonia in
endotracheal tube aspirates from patients in Iran. Infect
Control Hosp Epidemiol 2006; 28(8): 884885.
102 Araujo MW, Andreana S. Risk and prevention of transmission of infectious diseases in dentistry. Quintessence Int
2002; 33(5): 376382.
103 Semyari H, Sadeghi R, Ebrahimi Z. Final year dental
students awareness and opinions about infection control.
Shahed Univ Sci J 2006; 14(66): 2336.
104 Naidoo S. Dental practitioner risk, knowledge and practice
with regard to the hepatitis B vaccination in South Africa.
Oral Dis 1997; 3(3): 172175.
105 Brambilla E, Cagetti MG, Fadini L, Tarsitani G, Strohmenger
L. [Epidemiologic survey of medical and non-medical
personnel in a public dental clinic]. Ann Ig 2005; 17(2):
155162.