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CDHO Advisory: Viral Hepatitis

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with viral hepatitis.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Viral Hepatitis, 2023-10-31

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Viral hepatitis

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have viral hepatitis, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents or guardians of children and young persons with viral hepatitis

MAJOR OUTCOMES CONSIDERED

For persons who have viral hepatitis: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Nomenclature of viral hepatitis

Adapted from

  1. Hepatitis, inflammation of the liver
    1. termed
      1. viral hepatitis
      2. non-infectious hepatitis
    2. occurs as
      1. acute hepatitis
      2. chronic hepatitis 

Other terminology

  1. Acute hepatitis, inflammation of the liver that persists for less than six months, which may
    1. be manifested by typical symptoms
    2. or be asymptomatic. 
  2. Acute liver failure, also called fulminant hepatic failure or fulminant hepatitis in the most serious forms, is a rapidly developing medical emergency that arises when the cells of the liver die so quickly that the liver cannot keep up with its need for repairs.
  3. Ascites, swelling of the abdomen due to build-up of fluid, usually caused by severe liver disease such as cirrhosis.
  4. Blood-borne viruses, viruses that 
    1. are carried in their blood
    2. may cause severe disease in some persons and few or no symptoms in others
    3. can spread to another person, whether the carrier of the virus is ill or not.
  5. Cardiomyopathy, disease of the heart muscle which reduces the ability of the heart to pump blood.
  6. Chronic hepatitis, inflammation of the liver that lasts at least six months.
  7. Chronic infection of the liver, as evidenced for example by the presence of antigens in the blood for at least six months, which 
    1. causes the person to be infectious to others
    2. may or may not exhibit symptoms of hepatitis
    3. occurs in some persons with hepatitis B; many, with hepatitis C infection.
  8. Cirrhosis, non-reversible scarring of the liver that may result from chronic hepatitis, among other conditions.
  9. Coinfection, the term used by virologists to describe the simultaneous infection of a single liver cell by more than one type of virus
    1. as may occur with hepatitis B virus and hepatitis D virus
    2. which can also occur as a superinfection.
  10. Enteric, of or related to the intestines.
  11. Fulminant hepatitis, a severe form of acute hepatitis that may be life threatening if not treated promptly, characterized by symptoms that develop abruptly, including 
    1. mental disturbances such as confusion, lethargy, extreme sleepiness or hallucinations 
    2. collapse with fatigue 
    3. jaundice 
    4. abdominal swelling.
  12. Hepatic encephalopathy, manifested by
    1. excessive sleepiness
    2. mental confusion
    3. coma in the advanced stages.
  13. Hepatitis B immune globulin, an injection that contains large amounts of hepatitis B antibodies taken from donated human blood. 
  14. Liver failure, occurs when large parts of the liver have become damaged beyond repair so that
    1. the liver is no longer able to function
    2. a life-threatening condition is created which demands urgent medical care.
  15. Parenteral transmission, transmission that occurs through the piercing of the mucous membranes or the skin barrier through events such as 
    1. needlesticks
    2. human bites
    3. cuts
    4. abrasions.
  16. Perinatal, occurring during the period around birth.
  17. Superinfection, an infection following upon a previous infection.
  18. Viral hepatitis, also called infectious hepatitis, inflammation of the liver caused by infection with a virus.
  19. Zoonosis, the process by which an infectious disease can be transmitted from animals, both wild and domestic, to humans or from humans to animals. 

Overview of viral hepatitis

Adapted from

Viral hepatitis in general

  1. is caused by viruses, chiefly
    1. hepatitis A virus (HAV)
    2. hepatitis B virus (HBV) blood-borne virus
    3. hepatitis C virus (HCV) blood-borne virus
    4. hepatitis D virus (HDV) blood-borne virus
    5. hepatitis E virus (HEV)
  2. may be characterized 
    1. by typical symptoms and signs, chiefly
      1. abdominal pain and tenderness 
      2. inflammation and swelling of the liver
      3. jaundice
        1. yellow discoloration of the skin and the whites of the eyes 
        2. tea-coloured urine
        3. pale, clay-coloured or grayish feces
        4. enlarged, tender liver
      4. fever
      5. loss of appetite 
      6. nausea and vomiting 
      7. dehydration when associated with prolonged vomiting and diarrhea
      8. severity that ranges from an asymptomatic or self-limiting condition to a rapidly developing medical emergency, acute liver failure 
    2. by signs and symptoms, which are
      1. absent
      2. or unnoticed
  3. may have a chronic phase, which can be associated with serious complications including
    1. cirrhosis
    2. liver failure
    3. liver cancer
  4. comprises
    1. hepatitis A 
    2. hepatitis B
    3. hepatitis C
    4. hepatitis D
    5. hepatitis E

Hepatitis A

  1. Nature of hepatitis A
    1. does not usually cause permanent liver damage
    2. normally recovers completely.
  2. Signs and symptoms of hepatitis A
    1. reflect the full range of severity associated with viral hepatitis
    2. include the signs and symptoms typical of viral hepatitis
    3. also include 
      1. diarrhea, especially in children 
      2. fatigue 
    4. may be absent or unnoticeable
    5. are more likely to occur in older people than children
    6. last
      1. in most persons typically less than two months
      2. in some 15 percent of persons for as long as 6 to 12 months, intermittently.
  3. Course and prognosis of hepatitis A
    1. course; the first attack 
      1. results in lifelong immunity
      2. does not normally cause permanent liver damage
    2. prognosis
      1. normally recovers 
      2. does not recur.
  4. Occurrence of hepatitis A
    1. with hepatitis B and C is one of the three most common hepatitis viruses in North America2
    2. spreads through outbreaks and epidemics.
  5. Persons at increased risk of hepatitis A include
    1. those who 
      1. may come into contact with hepatitis A virus during their work
      2. live or work in close quarters, such as dormitories, prisons, and residential facilities
      3. work in or attend daycare facilities where strict personal hygiene measures are not observed
    2. household contacts of people infected with hepatitis A virus 
    3. sexual partners
      1. of people infected with hepatitis A virus 
      2. men who have sex with other men 
    4. international travellers, especially to areas with high rates of hepatitis A
    5. military personnel stationed in areas with high rates of hepatitis A
    6. users of substances of abuse, injected or non-injected 
    7. persons with 
      1. clotting factor disorders, such as hemophilia (CDHO Advisory)
      2. chronic liver disease.
  6. Infectiveness for others of the person with hepatitis A
    1. begins about one week after the person’s exposure
    2. exists even when the person is unaware of the infection.
  7. Transmission of the hepatitis A virus occurs through or from
    1. food or drinking water contaminated with feces of a person infected with the hepatitis A virus 
    2. failure of hand-washing in food preparation by a person with hepatitis A 
    3. infected household members or sexual partners
    4. diaper-changing tables that are not cleaned properly
    5. consumption of raw or undercooked shellfish originating in sewage-contaminated water. 
  8. Treatment and short-term protection against hepatitis A.
  9. Prevention of hepatitis A
    1. hand washing
    2. attention to sanitary conditions
    3. hepatitis A vaccine, for persons at increased risk of hepatitis A.

Hepatitis B

  1. Nature of hepatitis B
    1. caused  by the blood-borne hepatitis B virus
    2. is the most common serious liver infection in the world
    3. develops into a chronic carrier state in a substantial proportion of infected persons3, who
      1. become susceptible to chronic active hepatitis B4
      2. are likely to develop serious complications. 
  2. Signs and symptoms of hepatitis B
    1. reflect the full range of severity associated with viral hepatitis
    2. include the signs and symptoms typical of viral hepatitis
    3. acutely occur only in about 30 percent of persons infected with the hepatitis B virus; the others are initially symptom-free
    4. usually develop within 45 to 180 days (averaging 60 to 90 days) following infection by the hepatitis B virus
    5. may be mistakenly ascribed to the “flu”. 
  3. Course and prognosis of hepatitis B
    1. course of acute phase
      1. begins shortly after exposure to the virus
      2. symptoms, if any, usually become evident within 45 to 180 days following infection by the hepatitis B virus
    2. prognosis of acute phase
      1. clears up spontaneously in some 90 to 95 percent of persons infected
      2. in a small number of persons develops into acute liver failure
    3. course of chronic phase, which 
      1. is most likely to develop when the infection occurs at an early age 
      2. develops from the acute phase in 5 to 10 percent of persons
      3. lasts longer than 6 months
    4. prognosis of chronic phase
      1. may not recover completely
      2. may be a life-long infection (i.e., chronic carrier state)
      3. is fatal in 15–20 percent of persons with chronic hepatitis B.
  4. Occurrence of hepatitis B 
    1. Worldwide, results in 
      1. more than 250 million chronic carriers
      2. more than 800,000 deaths each year
    2. in Canada, recent estimates (years 2008 to 2017) indicated that
      1. about 1 percent of the population is chronically infected with hepatitis B
      2. about 5 percent of the population have had prior acute infection with hepatitis B at some point in their lives
      3. the overall reported rate of acute hepatitis B infection in 2017 was 0.54 individuals infected per 100,000 of the population.
    3. in the United States
      1. creates some 1 to 2 million chronic carriers
      2. results in about 2,000 deaths per year (2020)
      3. is one of the most important causes of viral hepatitis.
  5. Persons at increased risk of hepatitis B globally
    1. those 
      1. who reside or lived in areas of high endemicity, including much of Asia, Africa, South America, and Eastern Europe
      2. whose work exposes them to human blood
      3. who have been exposed to hepatitis B infection
      4. whose sex partners have chronic hepatitis B
      5. who live with a person with chronic hepatitis B
      6. recently diagnosed with a sexually transmitted disease
      7. with multiple sex partners
      8. who inject substances of abuse
      9. men who have sex with men
      10. who undergo tattooing and body piercing, which may result in infection if 
        1. the tools are contaminated with infected blood 
        2. the artist or piercer does not follow good health practices
    2. all unimmunized persons from birth to 18 years. 
  6. Infectiveness for others of the person with hepatitis B: high for persons who are chronic carriers regardless of whether they are or are not ill.
  7. Transmission of the hepatitis B virus occurs 
    1. from one person to another 
    2. via blood
    3. via semen and saliva because these may contain small amounts of blood 
    4. through sharing needles with an infected person
    5. contact by bodily fluids with pierced skin or mucous membrane of an uninfected person 
    6. through sex with an infected person
    7. from an infected mother to her baby during childbirth
    8. possibly by other routes, which may be unrecognized.
  8. Treatment of hepatitis B
    1. is not normally required for acute hepatitis B because it
      1. usually recovers spontaneously and
      2. creates lasting immunity 
      3. loses its infectiveness 
    2. is required for chronic hepatitis B because it
      1. requires medications
      2. retains its infectiveness
      3. may ultimately require liver transplant because of non-recoverable liver damage.
  9. Prevention of hepatitis B
    1. with hepatitis B vaccine for persons at increased risk of infection
    2. of blood-borne transmission involving
      1. oral healthcare personnel
      2. patients/clients
        1. mothers during pregnancy 
          1. blood test for hepatitis B
          2. infants born to infected mothers receive 
            1. within 12 hours after birth
              1. hepatitis B immune globulin 
              2. hepatitis B vaccine 
            2. within the first six months of life
            3. all of their hepatitis B shots by 6 months of age
        2. avoidance of sharing things that could carry an infected person’s blood, such as
          1. toothbrushes
          2. nail clippers
          3. razors
          4. washcloths
        3. avoidance of donation of blood, organs, or tissue 
        4. safe sex practices
        5. when involved in substance abuse should
          1. avoid sharing drugs, needles, syringes, water, and drug paraphernalia
          2. be vaccinated against hepatitis B.

Hepatitis C

  1. Nature of hepatitis C 
    1. is caused by the blood-borne hepatitis C virus
    2. is an increasing public health concern throughout the world. 
  2. Signs and symptoms of hepatitis C
    1. reflect the full range of severity associated with viral hepatitis
    2. include the signs and symptoms typical of viral hepatitis
    3. are absent acutely in about 80 percent of persons with the disease
    4. when they do occur 
      1. may in a minority of persons 
        1. develop typically 6–9 weeks after exposure (range 2 weeks to 6 months)
        2. last a few weeks or months
        3. be described as flulike
      2. may in other persons
        1. not appear for 10–30 years
        2. be intermittent
        3. be mild and vague 
        4. have concealed serious harm to the liver. 
  3. Course and prognosis of hepatitis C
    1. course: varies greatly in its long-term effects
    2. prognosis
      1. infection is self-limited in only a small minority of infected persons
      2. develops into chronic hepatitis in 50–85 percent of persons infected with the hepatitis C virus
      3. chronic infection may be associated with serious complications, such as 
        1. cirrhosis, which typically develops within 20 years of disease onset in at least 20 percent of persons with chronic infection
        2. liver cancer, which 
          1. develops each year in 1–4 percent of persons with cirrhosis, after an average of 30 years
          2. is more common in the presence of 
            1. cirrhosis
            2. alcoholism
            3. hepatitis B coinfection
      4. has cure rates as high as 95 percent with current medications
      5. is variable for those who are superinfected because it depends on
        1. the duration and severity of hepatitis B infection
        2. alcohol consumption
        3. comorbidity, complications and associated conditions
        4. age
      6. a small minority of persons infected with hepatitis C may develop complications outside the liver, which can affect 
        1. blood
        2. bone marrow
        3. joints
        4. kidneys
        5. muscles
        6. skin and connective tissues.
  4. Occurrence of hepatitis C
    1. in Canada, 
      1. about 194,500 persons are estimated to be chronically infected with HCV infection in Canada (about 0.5% of the population) but many don’t know it (2017)
      2. 11,441 new cases of hepatitis C were reported in 2019, with people who inject drugs (PWID) accounting for about 60% to 85% of these new cases
      3. of the persons who had been infected with hepatitis C in their lifetime
        1. persons who inject or had injected drugs accounted for almost half (2017)
        2. 35% were foreign-born (2011)
      4. an estimated 44% of persons living with chronic hepatitis C infection were unaware of their infection in 2011
      5. an estimated 24% of all persons infected with hepatitis C infection (acute and chronic) were unaware of their infection in 2019
    2. in the United States,
      1. hepatitis C is one of the most common causes of chronic liver disease 
      2. hepatitis C is believed to be the cause of 
        1. 50 percent of all cases of cirrhosis, liver failure, and liver cancer
      3. more than 17,000 new hepatitis C infections occur each year
      4. an estimated 3.2 million persons live with hepatitis C 
      5. hepatitis C is a leading reason for liver transplantation.
  5. Persons at increased risk of hepatitis C
    1. highest risk: injection drug users
    2. medium risk
      1. infants at the time of birth with an infected mother  
      2. a person who 
        1. has sex with an infected person
        2. has multiple sex partners
        3. shares a toothbrush, razor, nail clippers, or other such items with an infected person
    3. low risk: healthcare personnel’s developing hepatitis C infection from a needlestick with blood contaminated with the hepatitis C virus; risk estimated to be about 0.2%5 
    4. previously high but now low risk
      1. transfusion with infected blood or blood products
      2. transplantation of organs from infected donors. 
  6. Infectiveness for others of the person with hepatitis C: high.
  7. Transmission of the hepatitis C virus is chiefly by contact with blood or blood products.
  8. Treatment and short-term protection of hepatitis C
    1. medications
    2. patient adherence to and compliance with prescribed treatment
      1. is critical to the success of treatment of hepatitis C 
      2. involves management of side effects such as depression
      3. involves management of risky behaviour such as substance abuse.
  9. Prevention of hepatitis C and its comorbidities, complications and associated conditions
    1. is not supported by vaccination because no hepatitis C vaccine is currently available 
    2. relies on avoidance of
      1. contact with infected blood and organs
      2. high-risk sexual behaviour such as multiple partners and anal contact 
      3. alcohol and medications that can damage the liver.

Hepatitis D 

  1. Nature of hepatitis D, an infection which
    1. is caused  by the blood-borne hepatitis D virus
    2. is clinically indistinguishable from other forms of viral hepatitis
    3. causes a unique infection that requires the assistance, through coinfection, of the hepatitis B virus to infect the cells in the liver 
    4. produces acute and chronic inflammation of the liver.
  2. Signs and symptoms of hepatitis D virus infection 
    1. reflect the full range of severity associated with viral hepatitis
    2. include the signs and symptoms typical of viral hepatitis.
    3. may be absent in as many as 90 percent of infected persons
  3. Clinical course and prognosis of hepatitis D 
    1. course
      1. ranges from acute self-limited infection to acute liver failure
      2. may include chronic liver infection, which can lead to liver failure 
      3. incubation period is 21–45 days but may be shorter in cases of superinfection (2–8 weeks)
    2. prognosis of hepatitis D is
      1. good for persons with coinfection for whom treatment eradicates both viruses
      2. variable for those who are superinfected because it depends on 
        1. the duration and severity of hepatitis B infection
        2. alcohol consumption
        3. comorbidity, complications and associated conditions
        4. age.
  4. Occurrence of hepatitis D infection
    1. more common among adults than children
    2. children from countries in which hepatitis D is endemic are likely to contract the infection through breaks in the skin 
    3. globally affects nearly 5 percent of people who have a chronic infection with hepatitis B virus
    4. globally the overall number of persons infected with HDV has decreased since the 1980s, mainly due to successful global HBV vaccination programs
    5. more common among persons
      1. with a history of intravenous drug use
      2. where hepatitis B is endemic (current hotspots for HDV infection include Western and Middle Africa, Moldova, and Mongolia)
    6. involves about 12 million people worldwide.
  5. Persons at increased risk of hepatitis D, chiefly those who
    1. are infected with hepatitis B
    2. live with or have sex with a person infected with hepatitis D
    3. received a transfusion of blood or blood products before 1987
    4. receive multiple blood transfusions.
  6. Infectiveness for others of the person with hepatitis D
    1. occurs by sexual transmission but to a lesser degree than with hepatitis B
    2. is rare by perinatal transmission.
  7. Transmission of hepatitis D infection 
    1. parenteral transmission
    2. intravenous drug use
    3. multiple blood transfusions
    4. sex with an infected person.
  8. Treatment of hepatitis D
    1. consists primarily of support
    2. does not require dietary restrictions 
    3. medications
    4. liver transplantation for liver failure.
  9. Prevention of hepatitis D
    1. use of precautions by and for health care personnel
    2. vaccination 
      1. with hepatitis B vaccine 
        1. which is effective for persons no already infected with hepatitis B
        2. does not provide protection against HDV for persons already infected with hepatitis B 
      2. lacks a vaccine specific to the hepatitis D virus
    3. modification of high-risk behaviours, such as
      1. intravenous drug use
      2. unsafe sexual practices
    4. avoidance of exposure to
      1. infected blood
      2. contaminated needles
      3. an infected person’s personal items such as
        1. toothbrushes
        2. razors
        3. nail clippers
    5. by infected persons, avoidance of
      1. donating blood
      2. sharing of toothbrushes or razors
      3. consuming alcohol.

Hepatitis E

  1. Nature of hepatitis E, an infection which 
    1. is an enterically transmitted infection that is typically self-limited
    2. is spread by fecally contaminated water within endemic areas
    3. occurs as outbreaks 
    4. shares many characteristics with hepatitis A. 
  2. Signs and symptoms of infection by hepatitis E
    1. reflect the full range of severity associated with viral hepatitis
    2. include the signs and symptoms typical of viral hepatitis.
  3. Course and prognosis of hepatitis E
    1. course
      1. is a self-limiting viral infection followed by recovery
      2. does not lead to chronic infection 
    2. prognosis
      1. occasionally develops as acute liver failure, which
        1. is fatal for some 4.0 percent of persons affected with acute liver failure
        2. occurs more frequently in pregnancy, causing death in 20 percent of affected pregnant women in the 3rd trimester.
  4. Occurrence of hepatitis E
    1. is the most common cause of acute hepatitis and jaundice in the world
    2. in the United States and Canada has not been reported in the form of outbreaks (which are usually waterborne in nature) though
      1. persons traveling to an endemic region may return with the infection
      2. according to antibody studies, some 20 percent of the US population may have been exposed to the infection
    3. is highest in regions where low standards of sanitation promote the transmission of the virus
    4. occurs
      1. as epidemics where fecal contamination of drinking water is common
      2. sporadically elsewhere.
  5. Persons at increased risk of hepatitis E or its consequences: women in the third trimester of pregnancy are especially susceptible to fulminant disease and death; elderly adults are particularly susceptible to certain genotypes; young adults are susceptible to epidemics in endemic regions
  6. Infectiveness for others of the person with hepatitis E: hepatitis E infection has been associated with chronic hepatitis in solid organ-transplant recipients.
  7. Transmission of hepatitis E virus
    1. via the fecal-oral route involving
      1. fecally contaminated water or food supplies
      2. ingestion of raw or uncooked shellfish in endemic areas
      3. possible zoonotic spread of the virus from pigs, cows, sheep, goats and rodents, which are susceptible to infection 
    2. via person-to-person transmission, which is uncommon (but likely related to fecal-oral transmission)
    3. via blood transfusion, which is rare.
  8. Treatment and protection
    1. once infection occurs, treatment is limited to support
    2. currently offers neither vaccine nor medication in North America (although a vaccine is available in China)
    3. should emphasize prevention through
      1. clean drinking water
      2. good sanitation
      3. proper personal hygiene
      4. precautions for travelers to endemic areas
        1. avoidance of drinking water or other beverages that may be contaminated
        2. avoidance of uncooked shellfish
        3. care in preparation of uncooked fruits or vegetables.
  9. Prevention of acute hepatitis E infection
    1. high quality standards for public water supplies
    2. proper disposal of sanitary waste. 

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with viral hepatitis but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

With viral hepatitis, the comorbidities, complications and associated conditions include

  1. Comorbidity with HIV/AIDS (CDHO Advisory) with its comorbidities, complications and associated conditions, which include medically compromising conditions that increase in incidence with age, such as
    1. cardiomyopathy
    2. co-infection with other viruses that share similar routes of transmission, such as human herpes virus 
    3. high cholesterol, with the possibility of coronary artery disease
    4. kidney disease
    5. medication non-adherence associated with substance abuse that is comorbid with psychiatric illness
    6. osteoporosis
    7. psychiatric illness
    8. respiratory problems
    9. substance abuse
    10. tuberculosis.
  2. Complications of viral hepatitis, such as
    1. dehydration, which 
      1. is caused by persistent nausea, vomiting and diarrhea
      2. is characterized by
        1. increased thirst 
        2. xerostomia
        3. swelling of the tongue 
        4. weakness 
        5. dizziness 
        6. palpitations 
        7. confusion 
        8. fainting 
        9. inability to sweat 
        10. decreased urinary output
    2. liver failure, the signs and symptoms of which may include 
      1. ascites
      2. persistent jaundice 
      3. loss of appetite, weight loss, wasting 
      4. vomiting with blood in the vomit 
      5. bleeding from the
        1. mouth
        2. nose
        3. rectum
      6. blood in the feces 
      7. hepatic encephalopathy. 

Oral health considerations

Adapted from

Dental hygiene

  1. Is important in viral hepatitis
    1. because of the comorbidities, complications and associated conditions generally
    2. because of the potential for comorbidity with HIV/AIDS (CDHO Advisory)
    3. especially because of the particular characteristics of hepatitis B, C and D, which 
      1. can cause chronic hepatitis that
        1. is associated with prolonged, sometimes lifelong infection 
        2. can lead to cirrhosis, liver failure, and liver cancer
      2.  are spread through contact with infected blood
    4. because the number of people living with hepatitis B, C and D continues to cause concern, dental hygiene shares in the responsibility to help reduce their unmet needs for oral healthcare especially as
      1. a large segment of the at-risk population is not connected to the health system, and is therefore unlikely to be receiving adequate or any oral healthcare
      2. the disparity between need for and availability of dental care arises because of
        1. lack of dental insurance
        2. gaps in healthcare and social programs
        3. competing medical and social needs
    5. because dental hygiene is a component of the support that may be required for persons with viral hepatitis.
  2. Will increasingly be extended to the population at risk of viral hepatitis: dental hygienists will encounter persons with the condition.
  3. Must take particular account of the
    1. patients/clients who may be at increased risk of infection
    2. possibility that hepatitis B, C or D may exist in patients/clients who are unaware that they are infected
    3. infectiveness and transmission pathways of viral hepatitis
    4. procedures for 
      1. prevention of infection of
        1. patient to provider
        2. provider to patient
        3. patient to patient
      2. dealing promptly and appropriately with accidental exposure and  other incidents with the potential for transmission of infection.
  4. May require medical advice in the choice of pain medication for individual patients/clients
    1. if there is a history of substance abuse
    2. to find alternatives for medications that cause liver damage. 

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements

Types of medications

Warnings

Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

Medications

  1. Hepatitis A
    1. vaccine for primary immunization to prevent hepatitis A
    2. antibodies for immediate, short-term protection against hepatitis A infection
    3. medications:  no specific medications are currently available for hepatitis A
  2. Hepatitis B
    1. vaccine for primary immunization to prevent hepatitis B
      • hepatitis B vaccine (Engerix-B®, Recombivax HB®, Twinrix® combination vaccine, Comvax® combination vaccine, Pediatrix® combination vaccine) 
    2. antibodies for immediate, short-term protection against hepatitis B infection
      • hepatitis B immune globulin 
    3. medications
      1. antiviral agents 
      2. interferons
  3. Hepatitis C
    1. vaccine for primary immunization to prevent hepatitis C: none is currently available 
    2. medications for hepatitis C are interferon
  4. Hepatitis D
    1. vaccine for primary immunization to prevent hepatitis D
      1. none is currently available 
      2. a person not already infected with hepatitis B receives hepatitis B vaccine (and hepatitis D can only cause infection via acute co-infection with hepatitis B or as superinfection among persons with chronic HBV infection)
    2. medications for chronic hepatitis D 
  5. Hepatitis E
    1. no available treatment capable of altering the course of acute infection
    2. no widely available active immunization with vaccines although a recombinant hepatitis E vaccine was approved in China in 2012 (currently there is no Health Canada or U.S. Food and Drug Administration approved vaccine)
    3. no passive immunization through blood serum containing antibodies against specific antigens.

Side effects of medications

Pain medications that may harm the liver include

  • acetaminophen (Tylenol®, among others) 
  • acetaminophen found in more than 600 over-the-counter preparations.

THE MEDICAL AND MEDICATIONS HISTORY

The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions.
  2. Explore the need for advice from the appropriate primary care provider(s).
  3. Inquire about
    1. the patient/client’s understanding and acceptance of the need for oral healthcare
    2. treatment currently received by the patient/client
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and specifically associated with dental/dental hygiene care
    6. how the patient/client’s state of health is at this moment
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition. 

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.
  2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.
  3. Use a consent/medical consultation form, and be prepared to securely send the form to the provider.
  4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2023)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

Occupational and other exposure to viral hepatitis infection

  1. Transmission: cases have been reported of hepatitis B or C virus transmission
    1. from a blood splash to the conjunctiva
    2. from needlestick injuries
    3. simultaneously with HIV/AIDs (CDHO Advisory) after pierced-skin exposure.
  2. Risks associated with viral hepatitis infectivity, such as those 
    1. of transmission of viral hepatitis infection in the dental office, a risk which
      1. is reportedly low
        1. despite the frequency of accidental skin punctures from instruments or needlestick injuries, possible because only small quantities of blood are involved in oral healthcare and because of hepatitis B immunization among dental workers
        2. despite hepatitis B virus potentially being in saliva, possibly due to the application of standard precautions
        3. although the risk of contracting hepatitis B from a needlestick injury during care of an infected patient ranges from 23% to 62%
      2. must be anticipated and mitigated
        1. specifically in the transmission pathways of
          1. patient to provider
          2. provider to patient
          3. patient to patient
        2. by risk-reduction strategies integral to routine clinical practice regardless of the chances of viral hepatitis infection; these chiefly involve
          1. standard precautions such as those in the Recommendations published by the Centers for Disease Control and Prevention and the Infection Prevention and Control (IPAC) Guidelines published by the CDHO
          2. clinical practice procedures, such as
            1. safety in the handling, use, assembly and cleaning of contaminated 
              1. instruments
              2. equipment
            2. use of sharps containers
          3. an ongoing office infection prevention and control program 
          4. selection of instruments and equipment designed to reduce the risk of skin-penetrating injuries
          5. a written plan for post-exposure prophylaxis of percutaneous injury with known viral hepatitis contamination; covering at a minimum
            1. first aid 
            2. urgent medical referral 
          6. require continuing, routine application of standard precautions for all patients/clients and not only those with known positive viral hepatitis status.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

When the patient/client has a history of drug or alcohol dependency, chronic hepatitis, or significant comorbidity, complications or associated conditions or viral hepatitis the dental hygienist may need to consult with the patient/client’s hepatologist (liver specialist) or primary care physician. 

If the patient/client has active viral hepatitis (acute or chronic), initiation of dental hygiene procedures (invasive or non-invasive) by the dental hygienist is contraindicated; medical clearance/consultation should be sought (e.g., patient’s hepatologist or primary care physician). Medical clearance is also indicated if prolonged bleeding time or severe liver disease is suspected on the basis of history and/or examination. Also, medical clearance may be required if the patient/client is being treated with antiviral medications (for hepatitis B, C, or D) associated with immunosuppression +/- increased risk of infection +/- prolonged haemostasis; the patient/client on antiviral therapy should be assessed by his/her physician prior to invasive dental procedures to ensure safety, and non-urgent oral treatment may need to be postponed until antiviral therapy has ceased. [Note: Hepatitis B, C, and D have chronic, life-long carrier states, which do not necessarily preclude dental hygiene procedures, but for which standard precautions should be exercised.]

For a patient/client whose chronic viral hepatitis is under control there is no contraindication to the Procedures (beyond situations specified immediately above). But the Procedures may be postponed pending medical advice if the patient/client has

  1. Symptoms or signs of severe debilitation.
  2. Recently changed medications, under medical advice or otherwise.
  3. Recently experienced changes in his/her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2).

For a patient/client with a history of viral hepatitis, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

  1. The patient/client is urged to alert any healthcare professional who proposes any intervention or test 
    1. to his or her history of viral hepatitis 
    2. to the type of hepatitis.
  2. As appropriate, discuss 
    1. the importance of a good diet in the maintenance of oral health
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. home oral hygiene including information about 
      1. choice of toothpaste, tooth-brushing devices, dental flossing, mouth rinses and saliva control 
      2. the risk of sharing of toothbrushes in particular circumstances
    4. the role of the family caregiver for persons at an advanced stage of the disease, with emphasis on maintaining an infection-free environment, and advice on wearing gloves 
    5. medication side effects such as dry mouth, and recommend treatment
    6. scheduling and duration of appointments for patients/clients with chronic or debilitating condition
    7. comfort level while reclining, and stress and anxiety related to the Procedures
    8. mouth ulcers and other conditions of the mouth relating to viral hepatitis, comorbidities, medications or diet
    9. pain management with particular reference to medications that damage the liver.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promotion of health through oral hygiene for persons who have viral hepatitis
    1. by positioning the dental hygienist as a member of the healthcare team involved in providing care and support for persons with viral hepatitis
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  2. Reduction of risk of oral health needs being unmet.

POTENTIAL HARMS

  1. Causing harm by failing to recognize
    1. a risk of transmitting a hepatitis virus infection
    2. when special procedures are indicated.
  2. Performing the Procedures at an inappropriate time, such as 
    1. during active viral hepatitis (acute or chronic) without antecedent medical clearance/consultation
    2. in the presence of a comorbidity, complication or associated condition for which prior medical clearance/advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with viral hepatitis.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2010-05-07

DATE OF LAST REVIEW

2020-05-19; 2023-10-31

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2010, 2020, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 Since the introduction of hepatitis A vaccine in Canada (in 1996), the incidence of hepatitis A has declined substantially in Ontario and elsewhere in Canada. The average annual number of cases of hepatitis A reported in 2011 and 2015 was 236, with the actual number of cases estimated to be about seven times higher given under-diagnosis, under-reporting, and subclinical infections. Regions of the world with higher levels of endemicity and risk of HA transmission include much of Asia, Africa, Latin America, and Oceania.
3 90% of newborns infected with HBV become carriers with chronic HBV infection versus 30% of infants and fewer than 10% of adults.
4 Chronic active hepatitis B develops in 2% to 7% of adults infected with HBV.
5 After occupational needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is about 0.2% (based on recent longitudinal data). This estimate updates the previous estimate of 1.8% from the Centers for Disease Control and Prevention. The risk following non-percutaneous (e.g., mucous membrane) exposure is even lower.