HBV, HCV, and HIV in the

Dental Office:
Prevention and Recommendations
for
Postexposure Prophylaxis (PEP)

Roseann Mulligan DDS, MS

University of Southern California
Pacific AIDS Education and Training Center
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 Hepatitis B Virus (HBV),
Hepatitis C
Virus (HCV),
and Human
Immunodeficiency Virus (HIV)

• Bloodborne viruses
• Can produce chronic infection
• Transmissible in healthcare settings
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Preventing Transmission of
Bloodborne Viruses in
Healthcare Settings
 Promote HB Vaccinations
 Treat all patients as potentially
infectious
 Use barriers to prevent blood or body
fluid contact
 Prevent percutaneous injuries
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 Annual Number of
Percutaneous Injuries*
1987–1993
12 11.4
10 8.8
Number

8
6.2
6 5.4
4 3.5
2.9
2.2
2
0
1987 1988 1989 1990 1991 1992 1993
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*ADA Health Screening, per dentist
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 Factors Influencing Risk of
Occupational Exposure
 Consistent usage of engineering
controls
 Proper handling and disposal of sharps
 Prevalence of infection among patients
 Nature and frequency of exposure
 Type of virus
 Body fluid and level of infectivity
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Prevalence of Bloodborne Virus
Infection Varies in Patient
Populations
 Geography
 Patient risk behaviors
 Type of care or living arrangement
 Incarceration
 Sex worker
 IV Drug user
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 Question: The greatest risk of
transmission of disease occurs:

A. From the dental healthcare worker to

the patient.
B. From the patient to the dental
healthcare worker.
C. From one patient to another patient.
D. All transmission routes have the same
risk.
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 Potential Routes of
Transmission of Bloodborne
Pathogens
Patient DHCP

DHCP Patient

Patient Patient

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 Transmission of HBV from
Infected Dentists to Patients
 Nine clusters of HBV transmission
from infected dentists and oral
surgeons to patients were
documented between 1970 – 1987
 Lack of documented transmissions

since 1987
• may reflect increased use of gloves
and hepatitis B vaccination 10
Estimated Incidence of HBV Infections
Among HCW and General Population,
United States, 1985-1999
350
Incidence per 100,000

300
Health Care Workers
250
200
150 General U.S. Population

100
50
0
1985 1987 1989 1991 1993 1995 1997 1999
Year 11
 Average Risk of Bloodborne Virus
Transmission after Needlestick
Source Risk
HBV
HBsAg+ and HBeAg+ 22 %-31 % clinical hepatitis;
37%-62% serological evidence of
HBV infection
HBsAg+ and HBeAg- 1%-6 % clinical hepatitis;
23% - 37% serological evidence of
HBV infection

HCV 1.8% (0%-7% range)

HIV 0.3% (0.2%-0.5% range)

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CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm
CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm 13
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 Characteristics of
Percutaneous Injuries Among
DHCP
 Reported frequency among general
dentists has declined
 Caused by burs, syringe needles, other
sharps
 Occur outside the patient’s mouth
 Involve small amounts of blood
 Among oral surgeons, occur more
frequently during fracture reductions and
procedures involving wire
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 Wound Care
 Clean wounds with
soap and water
 Do not squeeze
 Flush mucous
membranes with water
 Avoid use of bleach
and other agents
caustic to skin

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Occupational Exposure to HBV

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 Hepatitis B Vaccine
 The vaccine consist of a series of 3 doses via IM
injection into the deltoid muscle of the arm.
 Dose # 1 is time zero
 Dose # 2 given one month after dose #1
 Dose # 3 is given 6 months after dose #1
 A QUANTITATIVE TITER IS DUE 30-60 DAYS
AFTER THE LAST DOSE

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 Hepatitis B

 Antibody (titer) level determines effectiveness.

 Titer level 10 or less - entire series needs
repeating (all 3 doses)
 After the second series, titer less than 10, the
person is considered to be a “primary
nonresponder”
 Nonresponder will need the HBIG if a
contaminated puncture/body fluid exposure.

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 Hepatitis D

 Hepatitis D depends on Hepatitis B for

propagation/transmission.
 Hepatitis D infections – usually injection
drug users and hemophiliacs
 Immunization with HBV vaccine confers
immunity to HDV

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 Recommendations
Hepatitis B Vaccine

Offer vaccination to all personnel who are at

risk of exposure to blood
Provide access to qualified health-care
professional for administration and follow-up
testing
No need for pre-vaccination testing for HBV
antibodies
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 Immunizations for Dental
Healthcare Workers
 Hepatitis B vaccine  If the employee
must be offered at no refuses the vaccine,
charge to employees they must sign the
who may be exposed “OSHA Bloodborne
to body fluids within Pathogens Standard
10 days of the (29 CFR 1910.1030)
potential initial Hepatitis B Vaccine
exposure. They do Declination” form.
have the right to
refuse. 37
Hepatitis B Vaccine Declination
(Mandatory) - 1910.1030 App A
I understand that due to my occupational exposure to blood or
other potentially infectious materials I may be at risk of
acquiring hepatitis B virus (HBV) infection. I have been given
the opportunity to be vaccinated with hepatitis B vaccine, at no
charge to myself. However, I decline hepatitis B vaccination at
this time. I understand that by declining this vaccine, I continue
to be at risk of acquiring hepatitis B, a serious disease. If in the
future I continue to have occupational exposure to blood or
other potentially infectious materials and I want to be
vaccinated with hepatitis B vaccine, I can receive the
vaccination series at no charge to me.
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717,
April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb.
13, 1996]
http://www.osha.gov/pls/oshaweb/owadisp.show_docume
nt?p_table=STANDARDS&p_id=10052 38
Occupational Exposure to HCV

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 Hepatitis C
 Hepatitis C - transmitted like HBV.
 Chances of infection following an exposure 10
times higher for HBV
 HCV - RNA virus with at least 6 different
genotypes and 90+ subtypes.
 U.S. - Most common genotype is type 1 -
accounts for ~70% of Hepatitis C infections
 No vaccine available for Hepatitis C
 Genotype 1 responds least favorably to alpha
interferon and ribavirin treatments.
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Reported Cases of Acute Hepatitis C by
Selected Risk Factors, United States,
1982-2001*
80
70
60
Percentage of Cases

50
Injecting drug use
40
30
Sexual
20
10
Health related work
0 Transfusion
198 2 19 84 19 86 19 88 1 990 1 992 1 994 19 96 1998 20 00 2 001
Y ear
* 1982-1990 based on non-A, non-B hepatitis
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 HCV Infection in Dentistry
 Frequency of HCV infection among dentists
similar to that of general population (~ 1-2%)
 No reports of an HCV transmission from
infected dental personnel to patients
 No reports of patient-to-patient transmission
of HCV
 Risk of HCV transmission is very low

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Occupational Exposure to HIV

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 *

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(*) 3 dentists, 1 oral surgeon, 2 assistants

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Source: Cardo, et al., N England J Medicine 1997;337:1485-90.
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 Assessment of Infection Risk
 Source evaluation
Presence of HBsAg
•
Presence of HBeAg
•
Presence of HCV antibody
•
Presence of HIV antibody
•
If source unknown, assess epidemiologic evidence
•
 Susceptibility of the exposed person
Immunity to HBV infection?
•

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Exposure Prevention Methods

 Standard/Universal Precaution
 Engineering controls

 Work place practices

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 Post-Exposure Management
 OSHA requires post exposure protocols to be in
place
• Physician providing counseling , medication, and
follow up care.
 At USC we test for : HBV, HCV, HIV, and
VDRL (syphilis)
 USC protocol states to report the injury within 2-
4 hours of sustaining the injury.
 Can only ask source patient to be tested once

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 Post Exposure Management
Protocol
An example
 All exposed faculty, staff and students are tested
at
• 1 month, 3 months and 6 months from the date of
exposure
 Employer pays for
• all medical exams and blood tests for all employees
and students.
• exam and test for source patient if he/she agrees to
be tested
• HBIG and any antiviral medication(s) recommended
and agreed to.

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HIV Post Exposure Treatment

 Considers:
• the type of injury
• the severity of the
injury
• the infection status of
the source

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 Standard Precautions
 Apply to all patients
 Expand Universal Precautions to include
organisms spread by other body fluids
 Apply to
• Blood and body fluids, except sweat
• Non-intact skin
• Mucous membranes

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 Postexposure Management
Program
 Clear policies/procedures
 Education of healthcare personnel (HCP)
 Rapid access to
• Clinical care
• Postexposure prophylaxis (PEP)
• Testing of source patients/HCP

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 National HIV/AIDS
Clinician Consultation Center

PEPline 1-888-HIV-4911
National Clinicians' Post-Exposure
Prophylaxis Hotline

Warmline 1-800-933-3413
National HIV Telephone Consultation
Service

Perinatal HIV Hotline 1-888-448-8765

National Perinatal HIV Consultation and
Referral Service

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www.cdc.gov/oral
health

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