HSV Transmission

Highlights for Dental
Care
as a Hepatitis C Risk
Factor: A Review
of Literature
AULI A SHAFI RA RAHM A
ABSTRAC
T
Hepati ti s C (HCV) is a viral infection that aff ects an esti mated 71 million people worldwide, with over 1 million new
infections yearly.
Primary prevention and transmission risk factor identification remain key in helping decrease disease prevalence.
While intravenous drug use, healthcare exposure (i.e. blood transfusions and surgical care), and body modification (i.e.
tatt ooing and piercings) are well accepted risk factors for H C V transmission
Because dental practi ce is often associated with procedures and bleeding, the possibility of H C V transmission
seemed reasonable to investigate.
We identified a total of 1,180 manuscripts related to HCV and dental care, of which 26
manuscripts were included in the study after exclusionary criteria were applied.
INTRODUCTIO
N
The virus is subdivided into at least six major genotypes

• genotypes 1, 2, and 3 being the most common in Europe, South America, and North America
• genotype 4 found in the Middle East, Egypt, and central Africa, genotype 5 found exclusively in
South Africa, and genotype 6 found in Southeast Asia.
In the USA, 70% of all HCV infections are caused by genotype 1.

II
NTRODUCTION
Many studies have explored the risk factors involved in viral transmission, and at
present data has correlated significant transmission risk with
intravenous drug use (IVDU)

healthcare exposure (i.e. blood transfusions and surgical care), body modification
(i.e. tattooing and piercings)
as well as from infected mothers to their fetuses.
Because dental practice is often associated with bleeding, the possibility of

HCV transmission seemed reasonable to investigate.
Methods
We conducted a complete literature search using Medline/ PubMed, Scopus, and
Google Scholar for case-control studies, investigative before and after studies,
surveys, and observational studies examining dental care as a risk factor for HCV
transmission.Search hits were limited to studies published during or after the
year 2000
risk factors Oral
Hepatitis C surgery
HCV
Oral Care Transmission

Dental
Care Infection
• On initial literature search, 1,180 manuscripts
were identified and subsequently narrowed to a
final count of 34 manuscripts after search
term integration.
• An additional eight manuscripts were removed
after exclusionary criteria were applied. All
studies were further subdivided into geographic
regions of origin.
RESULT
12 of the 26 studies = an association between dental care and
HCV infection.
5 of the studies queried nationwide data (generally those of
European or American origin), 12 examined urban populations,
40% of the seven examined rural populations, and 2 investigated a mixed
USA/European studies
urban/rural population.
37.5% of the Middle
Eastern studies 16 of the studies used adult populations in the sample pool (two of
33.3% of the African which examined strictly adult pregnant women, one queried only
studies 100% of the South adults over the age of 60, and one study looked exclusively at
American studies adult healthcare workers), six used a mixed pool of adults and
60% of the Asian studies
children, and four investigated only children.
18 of the 26 studies did not define “dental care”, and one
clarified that all dental care was provided by uncertified
have found clinically significant providers.
HCV transmission risk with dental
care.
Discussion
Close to half of the studies showed dental care as a significant risk factor
for HCV transmission
no world region proved to be uniform in study findings
Findings and conclusions varied even within the same countries. For instance, in
Pakistan, three of seven studies ; in Egypt, one of five and in China, one of two-
>found a significant correlation between dental care and HCV transmission
Limitations of study design and the presence of confounding variables

highlights how these studies may have resulted in inconsistent data.
STUDY
LIMITATION
Dental care did not receive a high level of detail or subcategorization and
was rarely well-defined.
participants were not asked to specify the type of dental work they had done, it
opened the possibility of data skew given that the risk of HCV transmission is
different in cases involving blood exposure, such as during root canal placement
versus tooth filings.
most articles did not define anesthesia use in their definition of dental care, a
potential confounding variable as the use of syringes and anesthetic
solutions may increase HCV transmission risk.
Other shortcomings of the evaluated studies were the methods for
data collection.
Medhat et al.went door to door, checking blood samples from local citizenry
in Pakistan for HCV antibodies, while simultaneously asking the volunteers
questions regarding potential HCV exposure risk factors.
This method of data collection has a high risk for social desirability bias, a
subcategory of response bias where survey respondents answer questions in
a manner that they believe will be viewed favorably by others.
Given the cultural taboos of topics such as intravenous drug use (IVDU) and
sexual history in many parts of the world, Medhat et al.’s data has a high risk for
respondent bias skew.
The risks involved
In developing countries, the risks associated with HCV transmission during
dental care are likely related to improper sterile technique as well as the use
of poorly trained or legally practicing but uncertified practitioners
Studies in the West have generally concluded that dental care is not a risk
factor for HCV transmission.
However, the use of anesthesia during dental care, a practice more

prevalent in developed nations, remains an important, though not well
identified, potential source for HCV transmission.
Exposure-prone procedures, such as surgery, have shown an association between HCV
transmission from seropositive surgical providers to their patients.
Studies have found the risk of patient acquisition of HCV during an operation performed by
an infected surgeon to be between 0 and 3.7%, a risk similar to that of acquiring HCV after a
blood transfusion.
One retrospective study investigating cardiac surgeons demonstrated a surgeon-to-patient

HCV transmission rate of as high as 6% during open heart surgery.
The risks of HCV transmission from dental care providers to their patients has not been well
studied, and at present no data exists on dentist to patient HCV transmission rates.
While HCV exposure during cardiac surgery is significantly greater than during
dental care, the identification of viral particles in human blood and saliva
reported in cases of HCV transmission following splashes of infected blood on
broken skin, toothbrush sharing, and viral infectivity makes dental care an
important issue.
Identification and reduction of potential HCV transmission risk factors during

regular and interventional care remains crucial for both patients and providers
Conclusions
At present, dental care does pose a risk for H C V transmission, although the extents vary
worldwide.
In the developing world, the improper use of sterile technique and lack of provider education
likely increase the risk of H C V transmission secondary to dental care.
In developed nations, general dental care does not appear to be a signifi cant risk factor for H C V
transmission when IVDU is an excluded variable.
Anesthesia, more commonly used in developed nations, appears tobe a potential risk for viral
transmission and should be closely monitored
Standard precautions for dental care remain key in reducing the risk of
HCV transmission to patients and providers alike.
These precautions include hand hygiene, proper use of protective

equipment, such as masks and gloves, proper sharps handling and
injection practices, environmental cleaning, proper use of reusable and
single-use medical equipment and drugs, and respiratory hygiene

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Highlights for Dental

The virus is subdivided into at least six major genotypes

In the USA, 70% of all HCV infections are caused by genotype 1.

intravenous drug use (IVDU)

Because dental practice is often associated with bleeding, the possibility of

Oral Care Transmission

no world region proved to be uniform in study findings

Limitations of study design and the presence of confounding variables

However, the use of anesthesia during dental care, a practice more

One retrospective study investigating cardiac surgeons demonstrated a surgeon-to-patient

Identification and reduction of potential HCV transmission risk factors during

These precautions include hand hygiene, proper use of protective

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