Dental and Orofacial Health and Hepatitis C 1
Over the past decade, hepatitis C virus (HCV) has been one of Australia’s most
commonly notified infectious diseases. By the end of 2010, it was estimated
that 297,000 people living in Australia had been exposed to the virus, of whom
221,000 were living with chronic HCV infection.1 The number of diagnoses
of HCV infection is estimated at approximately 10,000 per year.1
This resource is written for dentists to provide an overview of the oral manifestations
and complications associated with HCV infection and treatments.
Dental and Orofacial Health
and Hepatitis C
Chronic HCV infection can cause long-term liver problems, including cirrhosis and hepatocellular
carcinoma (HCC). Despite a greater understanding of HCV infection, there is still no vaccine for HCV
and treatment is a lengthy process with a variable rate of cure. Prevention of transmission depends
on decreasing exposure to infected blood and blood products.
In providing effective dental care to people infected with HCV, the first step is to understand the virus
and the potential health and dental health problems associated with hepatitis C infection. It is also
important that issues of infection control, prevention of disease transmission and the broader health
implications of providing dental treatment for people with serious liver problems are properly understood.
2 Dental and Orofacial Health and Hepatitis C
Incidence and disease burden
In 2011, the World Health Organization estimated
130–170 million people globally to be chronically
infected with HCV.2 Each year, it is estimated that
3–4 million people are newly infected with HCV
and over 350,000 people die from HCV-related
liver diseases.2 Hepatitis rates vary widely by region
By the end of 2010, it was estimated that 297,000
people living in Australia had been exposed to the
virus, of whom 221,000 were living with chronic
HCV infection.1 The rate of HCV infection diagnosis
has declined from 58.6 to 50.1 per 100,000
between 2006 and 2010.1 It is estimated that
around 54,100 infected individuals are living
with moderate to severe liver disease or cirrhosis,
with more than 200 reported cases of liver failure
and more than 100 cases of HCC due to HCV.1
The HCV is an enveloped, single-stranded
positive-sense ribonucleic acid (RNA) virus,3 that
belongs to the Hepacivirus genus in the virus
family Flaviviridae.4 The HCV displays high genetic
diversity with six different genetically distinct
viral groups or clades and different subtypes.5, 6
The most common genotypes (G) in Australia
are G1, G1a, G1b and G3.7 Currently, genotype is
the best predictor of treatment responsiveness
but new treatment agents will change this.
Hepatitis C is a blood-borne virus. Food, water or
casual contact are not methods of transmission
of HCV,1 and it is well established that the primary
risk factor for HCV transmission is exposure to
The routes of transmission of HCV in Australia
can be seen in Figure 1. In 2010, the majority of
people with HCV were exposed to the virus by
injecting drug use in Australia.1 Contact with
injecting equipment such as tourniquets, spoons
and water contaminated with blood or when
reusing snorting devices are other ways HCV
can be transmitted.9 Exposure to HCV can occur
through unsterile tattooing or body piercing, via
a penetrating injury such as a needle-stick injury.9
The risk of HCV transmission by sexual contact
is considered low.10 Sexual transmission of
HCV is increased by unsafe sex, high-risk sexual
behaviours, and in the presence of other sexually
transmitted infections, in particular Human
Immunodeficiency Virus (HIV).11 Transfusion
of blood or a blood product is a risk factor for HCV infection.10 In
Australia, all blood or blood products are tested for HCV and have been
since 1990 and so the risk of HCV infection from blood transfusion is almost
nil.10 However, individuals from developing nations, where unscreened
blood and blood products are still being used, should be offered testing.
Transmission of the HCV by saliva alone is a remote possibility but risk
increases if the saliva is contaminated with blood.12 Household transmission
through items such as razors or toothbrushes is considered rare. However,
considering the possibility of blood contamination, these items should
not be shared.13 Vertical transmission from mother to child occurs in 5%
of cases,14 but it does not account for a large percentage of new HCV
diagnoses in Australia.1 Breastfeeding should not be discouraged and is
regarded as safe, unless cracked nipples allow blood contact.10 Hepatitis C
infection may be asymptomatic for many initially and chances are that they
may unknowingly infect others through the known routes of transmission.
Testing for Hepatitis C Infection
Testing for HCV includes detecting ‘antibodies’ to the virus (HCV Ab) or
viral RNA in the blood. There is a window period of 2 – 4 weeks after
initial infection for the HCV RNA (and it may take 2 – 6 months) for the
HCV Ab to be detectable.
Testing is usually undertaken by a medical practitioner. Testing should
only be performed after an open discussion and the provision of informed
consent, and any results should be given to the patient in person. (See
the 2012 National Hepatitis C Testing Policy for more information at www.
Presentation, Progression and Prognosis
Acute hepatitis causes symptoms in a minority of cases at the time of
infection, but most people will remain asymptomatic. Symptoms include
fatigue, nausea, headaches, psychiatric disorders, upper abdominal pain
and changes in appetite.15-17 Figure 2 illustrates the natural history of
HCV infection. Once infected with HCV, between 25% and 45% of people
will clear the virus within 12 months (usually 3–6 months) after initial
Figure 1: Number of diagnoses of newly acquired HCV infection
in 2010 by exposure. (Modified from HIV, viral hepatitis and
sexually transmissible infections in Australia Annual Surveillance
Report 2011 table 2.1.13)1
Injecting drug use (256)
Blood/tissue recipient (1)
Healthcare exposure (5)
Sexual contact (11)
Household contact (3)
Dental and Orofacial Health and Hepatitis C 3
infection. Those who do not clear HCV are described as having chronic
hepatitis C infection. After 20–40 years some patients will experience
progressive liver fibrosis and may develop signs and symptoms of
cirrhosis, liver failure or liver cancer.
Figure 2 shows the different potential outcomes for untreated chronic
hepatitis C. It does not show the outcome for individual people. Factors
such as alcohol intake, age when HCV was acquired and current level of
inflammation may influence the outcome.
Chronic HCV infection tends to have nil or minimal symptoms.17, 19, 20
Affected individuals may complain of nausea, anorexia, itching and weight
loss; however, these symptoms are nonspecific, mild and intermittent.17
Those with chronic hepatitis C most commonly complain of fatigue and
malaise, and these symptoms mainly account for a compromised quality of
life.15 HCV is monitored by liver enzymes such as alanine aminotransferase
(ALT) and these may fluctuate throughout the course of the disease,
being normal at times.17
Progressive fibrosis from ongoing inflammation results in cirrhosis. Not
only do these changes affect the function of the liver but also blood
flow through the liver is impaired and can cause portal hypertension
and its sequelae. Compensated cirrhosis is generally asymptomatic but
once the complications of cirrhosis occur the patient is said to have
decompensated cirrhosis or end-stage liver disease (ESLD).17, 21 The main
manifestations of decompensated cirrhosis are ascites, bleeding varices,
encephalopathy and coagulopathy. 21, 22 As with all chronic and advanced
liver disease, patients will have low platelet
counts, impaired coagulation factor production
and altered drug metabolism which need to be
taken into account when treatment planning.
Chronic HCV infection is linked with many extrahepatic
diseases, and in some cases the association
is strong while in others the exact relationship
remains controversial.23 A recent large case-control
study found a significant association between
chronic hepatitis C infection and porphyria cutanea
tarda, lichen planus (LP), vitiligo, cryoglobulinaemia,
membranoproliferative glomeruonephritis, and
Non-Hodgkin’s lymphoma (NHL).24 Many more
diseases have been associated with chronic HCV
infection but only the orofacial manifestations
will be covered in this review.
Twenty-five percent of the liver transplants
performed in 2010 were for liver disease caused
by HCV, this is eightfold more than for hepatitis B.1
Currently, HCV-associated cirrhosis represents the
leading primary indication for liver transplantation
Summary of HCV Profile
Virus Profile Transmission Vaccination Treatment Notifiable
Hepatitis C infection is likely to
become a chronic condition in
70%–80% of people exposed
to HCV. Approximately 10% of
cases will develop severe liver
disease after 20 years.
Transmitted when infected
blood enters the bloodstream
of another person (blood-toblood
It is uncommon for HCV to be
transmitted by sexual activity
or through mother-to-child
Hepatitis C is not transmitted by
food or water contamination.
None for HCV.
To prevent the complications
of co-infection, people
with HCV infection should
be vaccinated against
hepatitis A and B.
Figure 2: The natural history of chronic hepatitis C infection. (Adapted from G Dore/Hepatitis NSW – 2012)18
For individuals with chronic hepatitis C who remain untreated, it is estimated that…
45% will not
After 40 years
After 20 years
30% will not
4 Dental and Orofacial Health and Hepatitis C
Hepatocellular Carcinoma (HCC)
Hepatic carcinogenesis during chronic HCV
infection is a complex multi-factorial process.
HCV does not integrate into the host genome,
so it is theorised that HCV induces HCC through
the indirect mechanisms of chronic inflammation,
proliferation and necrosis.26 It is for this reason
that HCC is almost exclusively found in cirrhotic
HCV patients.26 Overall, HCC has a poor prognosis,
with 5-year survival of less than 11%.26
Current Treatment Approaches for HCV
The current standard of care for HCV infection
is an initial full clinical and liver assessment
followed by an ongoing treatment program. It is
important to define the type of HCV infection in
terms of genotype and viral load, as well as the
severity of liver disease and the stage of fibrosis
which is assessed by liver tests, ultrasound,
fibroscan and liver biopsy if indicated.
Patients with evidence of active disease and
progression to a fibrotic stage of the disease do
need to be offered treatment. In Australia at present,
the standard treatment remains pegylated
interferon and ribavirin. Pegylated interferon and
ribavirin deliver a clearance rate from 45–80%
depending on a range of factors including
genotype, viral load and presence of fibrosis.
These two antiviral agents work together to
decrease viral replication and increase host
immune response to the virus. New protease
inhibitor drugs are becoming available in Australia.
These new drugs have improved clearance
rates, and shortened treatment duration. Side
effects and drug interactions (factors leading to
a relatively low uptake of treatment at present)
are still a concern with the new agents. For many
patients, waiting for newer treatment options
while being regularly monitored is reasonable
and many patients are choosing this option.
Side Effects of HCV Treatment
HCV treatment is generally well tolerated. However, current therapy is
associated with a range of side effects, which in some are severe enough
to lead to treatment cessation.27 These include more commonly experienced
side effects such as irritability, dermatitis skin, hair loss, anorexia, nausea,
headaches, fever, myalgia, neutropaenia, thrombocytopaenia, and
anaemia. Less common side effects include those such as psychiatric
disorders, diabetes, and thyroid dysfunction.16, 28
Reported oral side effects after interferon and ribavirin treatment include
gingival bleeding, gingival swelling, toothache, gingivitis, periodontitis,
dental caries, cheilitis, taste changes, dry mouth, glossitis, glossalgia,
perioral parasthesia, oral pain, oral mucosal damage, oral lichen planus,
oral haemorrhage, dry lips and bulla of the lips.29
Dental Treatment of Hepatitis C
and Related Oral Conditions
People with hepatitis C are prone to tooth decay, suffer loss of self-esteem
due to poor oral aesthetics and have difficulty with diet due to poor oral
health, all leading to a compromised quality of life. An effective preventive
care programme for a patient diagnosed with HCV is critical and should
be an important goal for the dental practitioner.
Studies have shown that there is an increased incidence of dry mouth in
patients with HCV infection, especially those patients on antidepressants,
in addition to the known effects of HCV on salivary glands.12, 30
Saliva has many roles including: lubrication, cleaning, buffering,
remineralisation, moisturising, immunological defence against bacteria
and initiation of digestion.
Salivary depletion may result in:
■ Dental caries
■ Altered taste
■ Burning sensation in the mouth
■ Halitosis (bad breath)
■ Difficulty chewing, swallowing and talking
■ Difficulty wearing dentures
■ Dry mouth and lips
Figure 4a: Dental deterioration in a young
HCV patient with dental neglect
(Photographs courtesy Dr E Coates, South Adelaide Dental Service)
Figure 4b: Dental deterioration in an older HCV patient
Dental and Orofacial Health and Hepatitis C 5
Management of Dental Complications of HCV
Management is aimed at the prevention of damage to the dentition,
improving symptoms and increasing salivary flow and includes:
■ Education and oral hygiene
– Patient education on oral hygiene techniques including regular
tooth-brushing with fluoridated toothpaste, and flossing
– Products that are sodium laurel sulphate-free (non-foaming)
and of mild flavours may be less irritating
– Avoid using mouthwash containing alcohol, use a pH balanced
oral rinse instead
– The use of fluoridated dental products including mouth-rinses
– Remineralisation products containing casein phosphopeptide
and amorphous calcium phosphate (CPP-ACP)
– Measures required to minimise the impact of the dry mouth on
oral health such as dietary analysis and advice on reducing the
frequency and amount of carbohydrate intake
– Maintaining optimal denture hygiene is important and requires
regular brushing and soaking in chlorhexidine or dilute bleach
– Encourage smoking cessation and a reduction in intake of
coffee and tea.
■ Professional care
– Regular dental examinations
– Fluoride supplementation is important and may involve: the use
of a prescription-strength neutral fluoride gel in custom-made
fluoride trays depending on the reduction of saliva and degree
of caries risk
– Management of candidiasis with topical agents, avoiding those
containing sugar if dentate31
– Medications may increase dryness; changing medications or
altering the dose (if possible) may improve dryness
– Pilocarpine may be used to increase salivary flow but it has
significant side effects and its use is contraindicated in many
medical conditions and with a number of medications.32 Use
of pilocarpine is best in the hands of medical practitioners or
■ Moisture replacement
– Saliva stimulation by chewing sugar-free gum
– Moisture replacement by the sipping of water to improve
lubrication and hydration
– Saliva substitutes can provide some moisture replacement
and protection of tissues but benefits are usually short-lived
– Lanolin and papaya products are useful for dry lips
– Humidified air at night may alleviate some symptoms in dry
Liver Disease in HCV
Hepatitis C may cause liver damage with a
corresponding reduction in liver function.
The most important liver functions that have
implications in the provision of dental treatment
by dental healthcare providers are drug metabolism
and production of clotting factors (V, VII, and IX,
X, prothrombin and fibrinogen). All patients
should have a detailed medical history taken
and the dentist should consult with the patient’s
medical practitioners to ensure that a safe and
appropriate dental treatment plan is established
in light of the liver dysfunction. A detailed clinical
evaluation involving extra-oral and intra-oral
examinations may pick up signs of liver disease.33
Liver disease is often associated with a reduction
in clotting factors, which results in an impaired
haemostasis. In a patient with liver disease, the
risk for the dentist is related to the extent of the
liver disease, medications, the type of dental
treatment planned and the presence of
co-morbidities.33 Invasive treatment should be
avoided for patients with acute liver failure and
acute hepatitis. Emergency treatment should
be provided in a hospital setting.
Management of Liver Disease in Dentistry
If invasive treatment is planned, the following
blood tests may be required:
■ Complete blood exam
■ INR (> 1.7 indicated a serious risk of
bleeding for a non-warfarinised patient)34
■ Coagulation tests (prothrombin time,
activated partial thromboplastin time)
■ Liver function tests (Aspartate
aminotransferase (AST) and Alanine
If test results are significantly abnormal then any
dental treatment must be provided only after
consultation with either the relevant medical
specialist, or by referral to a dental specialist in
oral medicine or oral and maxillofacial surgery.
Hospital-based care may be required depending
on patient factors and the nature of the
Local haemostatic measures may be necessary,
including compression, sutures, dressings such
as oxidised cellulose, and antifibrinolytic agents
such as tranexamic acid. Pre-operative optimisation
with vitamin K therapy or transfusions may be
necessary. Where immune impairment is present,
antibiotic prophylaxis may be necessary.33 Attention
should be paid to minimisation of surgical trauma.35
6 Dental and Orofacial Health and Hepatitis C
Lichen planus (LP) is a chronic mucocutaneous
disease more commonly seen in middle-aged
women and affecting up to 1-2% of the
population.37 There is some evidence of an
association between HCV and oral lichen planus
(OLP); however, this varies by region.23 A 2004
systematic review of the association between
LP and HCV showed that individuals with LP are
more likely to have anti-HCV antibodies, odds
ratio 4.80 (95% Confidence Interval CI: 3.25-7.09).38
OLP is often bilateral and typically presents as a
mixture of clinical subtypes that characteristically
bear fine white striations known as Wickham’s
striae. The reticular form has a lacy pattern of
white lines while the papular type consists of
small raised areas. The plaque-like variant appears
similar to a leukoplakia. The atrophic form presents
with erythematous patches. The erosive variant
appears deep red in colour while the ulcerative
type appears as irregular and often large ulcerations.
Bullous type is extremely rare and often presents
as either erosive or ulcerative due to ruptured
bullae. If affected on the gingivae, it often appears
as erythematous and is called desquamative
gingivitis (see figure 5). Common symptoms are
of burning or oral pain, especially with acidic or
spicy foods. Symptoms are often irrespective of
(Photographs courtesy Dr B Scopacasa, South Australia Dental Service)
the clinical presentation. LP is a cutaneous disease with oral, genital and
skin lesions, most commonly on the flexor surfaces. The typical clinical
course of OLP is chronic with periods of exacerbation associated with
stress and quiescence.39 The exact pathogenesis of LP is not fully
understood; however, there is increasing evidence it represents immune
dysregulation mediated by the cellular immune system in a process
resembling a hypersensitivity reaction.40
OLP can be exacerbated by stress and candida,39 oral hygiene,41 dental
materials,39 and medications.42 OLP is thought to be associated with oral
cancer; however, the evidence must be viewed with caution. A recent
review of the literature found the malignant transformation rate of OLP
to be around 1% over 5 years.39
Diagnosis of OLP should involve a referral to a trained clinician in oral
medicine or maxillofacial surgery. A referral should include a complete
history, physical examination and biopsy results if taken. Biopsy specimens
should be sent for histopathology, including immunofluoroscopy. The
principles behind treatment of OLP are immune modulation, symptom
management, education and monitoring. Treatment of OLP is usually
reserved for symptomatic disease. There are a number of treatments
that can provide control of OLP but the mainstay is topical corticosteroids.43
At this stage there is no cure.44 Treatment is usually managed by trained
dental specialists or medical practitioners.
Treatment of Oral Lichen Planus
Topical Corticosteroids: Betamethasone dipropionate 0.05% ointment.
Apply sparingly to lesion twice a day after meals. (Topical corticosteroids should
not be used continuously for more than 3 weeks without specialist advice.)
Hepatitis C Infection Related Oral Diseases
Figure 5: A series of photographs showing exacerbation of lichen planus from a single patient with HCV-associated
cirrhosis undergoing PEG IFN/RBV therapy. The images show A) reticular and plaque-like; B) desquamative
gingivitis; C) erosive over the corners of the mouth and plaque-like on the dorsum and D) erosive and ulcerative
over the lateral border of the tongue
Dental and Orofacial Health and Hepatitis C 7
Sjogren’s Syndrome and Sialadenitis
It is known that HCV affects the salivary glands but the exact nature of
this effect is yet to be fully understood. Hepatitis C virus is thought to
cause a syndrome with features similar to Sjogren’s Sydnrome (SS) in a
proportion of infected individuals.45, 46 It has been proposed HCV may
lead to the development of SS; however, this link is contentious.45 The
dental implications of this disease process are related to the effects of
hyposalivation (see figure 6), which is discussed below.
Figure 6: Image of patient with HCV and Sjogren’s Syndrome.
There is hyposalivation, and teeth are worn, chipped and decayed.
(Photograph courtesy Dr E Coates, South Australia Dental Service)
Investigation of HCV-associated sialadenitis and SS is complicated and
should be left to medical specialist such as a rheumatologist or a dental
specialist, in particular an oral medicine specialist. The histopathology of
chronic HCV-associated sialadenitis and primary SS are similar, with a general
picture of inflammation and lymphocytic infiltration in the salivary
tissues, but they are not identical.47 A number of studies have detected
the HCV in salivary glands.45 However, it was not possible to correlate
xerostomia, hyposalivation and sialadenitis with detection of HCV RNA
in saliva or salivary glands.48 The exact pathogenesis of HCV-associated
sialadenitis is uncertain. Treatment of HCV can improve the clinical
salivary abnormality but it is not clear if the improvement is related to
virological clearance or to the medications themselves.49 Strategies to
treat the effects of HCV-related salivary gland dysfunction are described
in the section on Management of dental complications of HCV (page 5).
Non-Hodgkin’s Lymphoma (NHL) comprises
a heterogenous group of haematological
malignancies that can arise in lymph nodes
or extranodal sites. There is a variable natural
history, from indolent to aggressive,
depending on tumour and host factors.
The head and neck region is the second most
common place for extra-nodal NHL to occur,
with lesions commonly arising in Waldeyer’s
Ring, salivary lymph nodes or the salivary gland
parenchyma itself.50 Clinical presentation varies
on the site and type of NHL but commonly it
manifests as a mass, which may ulcerate.
Lesions can occur in bone and cause swelling,
neurological symptoms and loosening of teeth
(see figure 7). There can be systemic symptoms
that include painless swelling of lymph nodes,
fever, night sweats, fatigue, weight loss, skin rashes
and pain. A recent meta-analysis found that the
pooled relative risk of NHL in individuals affected
with HCV as 2.5 (95% CI, 2.1-3.0), which is low.51 The
exact way HCV infection leads to the development
of lymphoma is not clear but multiple mechanisms
have been reported.
Diagnosis and treatment should be by a
multi-disciplinary team, and care should be
carried out in specialist treatment centres. There
are two main modalities of treatment, radiotherapy
and chemotherapy, but sometimes the disease
may be closely monitored but not treated.50 In
the treatment of NHL, especially head and neck
disease, it is important to be mindful of the
orofacial side effects that can occur with these
treatments, such as mucositis, osteoradionecrosis
and radiotherapy-induced salivary gland dysfunction.
Figure 7: Oral lesion of Non-Hodgkin’s
(Photograph © ASHM)
8 Dental and Orofacial Health and Hepatitis C
Prescribing Medications in
HCV-Associated Liver Disease
Most analgesics, antibiotics and local anaesthetics
are well tolerated by the patient with early stage
liver disease. However, where liver disease is
advanced it may be necessary to reduce the
dose or avoid some medications completely:
■ Erythromycin and metronidazole inhibit the
cytochrome P450 liver enzyme resulting in
delayed metabolism of other drugs and can
cause direct damage to liver tissues. Tetracycline
may also cause liver damage. Tetracyclines
should not be used.
■ Metabolism of clindamycin is prolonged.
■ Aspirin and non-steroidal anti-inflammatory
drugs (NSAIDs) may increase the risk of
gastrointestinal bleeding. They are metabolised
in the liver and should be avoided.
■ Paracetamol should be avoided where there
is advanced liver disease and should not be
prescribed if alcohol abuse is identified.
■ Benzodiazepines should have a lower dose
with a longer interval between doses for
patients with liver disease. Sedatives and
opiates may trigger encephalopathy.36
■ Amide local anaesthetics are metabolised in
the liver and should be used cautiously as
toxicity may occur with severe liver disease.
Articaine is initially metabolised in the serum
and therefore toxicity may be less of a problem.34
■ Ketaconazole and fluconazole are also
metabolised in the liver and should be avoided.
■ General anaesthetics and IV sedation should
only be carried out in a specialist hospital unit.
Hepatits C Treatment – Sequelae and Management
Prior to treating HCV it is important that any active dental disease be
managed. Non-urgent dental treatment may need to be postponed until
HCV treatment has ceased. Unfortunately, dental problems are known to
delay the onset of treatment for HCV.29 Dental treatment during anti-HCV
therapy should be undertaken following consultation with medical
specialists. Blood tests and further investigations may be appropriate and
in some cases in-patient care may be required. Immunocompromised
patients, particularly those with neutropaenia, are at risk of sepsis. If
emergency dental treatment is necessary, consultation with medical
specialists is recommended. If the patient is anaemic, coagulopathic
or thrombocytopaenic precautions may be needed. Pre-treatment
optimisation and comprehensive post-operative care may be required.
Particular attention must be given to haemostasis.
When prescribing medication to patients on anti-HCV therapy it is
important to be mindful of potential drug interactions. During treatment
patients may suffer depression, and associated motivation issues can
affect their oral hygiene and compound their (often compromised) oral
health problems. Most importantly, a rigorous preventive program at
the start of HCV treatment should be initiated where possible.
Preparation for Liver Transplantation
Patients being readied for liver transplantation must have a dental and
oral medicine consultation. Certain orofacial complications such as
oral mucositis and opportunistic infections are expected with organ
transplantation and these are usually managed in phases (pre-transplantation,
peri-transplantation (during) and post-transplantation/supportive care).
Active dental disease that could cause disseminated infection such as
abscessed teeth and advanced periodontal disease should be treated
prior to transplantation. This is because the conditioning regimes and
post-operative immunosuppressant therapy decrease the patient’s
ability to resist infection which may compromise the survival of any
organ transplant recipient.52 Supportive care is usually performed in
a hospital setting by trained dental specialists in liaison with the liver
transplant team due to the severe impairment of liver function. The
treatment aims of supportive care are to:
■ Eliminate or stabilise sites of oral infection53
■ Extract unrestorable teeth
■ Provide oral hygiene instruction so the transplant recipient can
maintain their oral health.
After the transplantation no elective treatment should be carried out for
3–6 months.36 Treatment post transplant should only occur after consultation
with patient’s specialist as to the need for antibiotic prophylaxis and
their ability to tolerate dental treatment and medications.53
Australian Commonwealth law prohibits discrimination against
someone with an infectious disease, unless the discrimination can be
shown to be necessary to protect public health. 54 In addition, most states
and territories have laws in the same terms as the Commonwealth law.
Healthcare workers should respect the rights of people with hepatitis C.
HCV is not a disease requiring additional precautions beyond standard
precautions therefore patients with HCV must not be treated differently.
Hepatitis C is a highly stigmatised condition and many people living
with the disease experience discrimination. Behaviours which reflect
stigmatisation of a patient can also reduce the standard of healthcare
received and lower the quality of life for people with hepatitis C and
should be avoided. Such behaviours include:
Dental and Orofacial Health and Hepatitis C 9
■ Breaches of confidentiality and disclosure related to hepatitis C,
even among healthcare workers
■ Assumptions about how people acquired hepatitis C
■ Assumptions about people’s past or present drug use.55
Healthcare workers should respect the rights of people with hepatitis C,
regardless of how they were infected. Everyone living with hepatitis C should
have access to care and services regardless of transmission route, gender,
race, culture, sexual orientation or lifestyle issues (such as injecting drug use).
Discrimination and stigmatising behaviours can be avoided by:
■ Ongoing health care worker education and continuing medical education
■ Ensuring standard infection-control procedures are followed, thus
reducing the need for disclosure or differential treatment
■ Ensuring people’s privacy and confidentiality are protected
Standard precautions are recommended for the care and treatment of
all patients, regardless of their perceived or confirmed infectious status,
and in the handling of all body fluids, non-intact skin and mucous membranes.
Needle-Stick Injury and Blood Spills
The risk of HCV transmission through a needle-stick injury from a known
source depends on the viral load of the source patient, the first aid
administered and the instruments involved. See Appendix (page 11).
Immediate Management of a Needle-Stick Injury56
■ Wash your skin with soap and water at the site of exposure, then cover
■ Rinse your mouth, nose and eyes well with water or saline, if exposed
■ Report the incident and follow your local workplace
Occupational Exposure Protocol
■ If further assistance with the management of a needle-stick injury
is needed then contact your local health department and
Hepatitis C Council for information and support.
Healthcare Workers with Hepatitis C
According to the Dental Board of Australia,
under s.39 of the Health Practitioner Regulation
National Law Act every dental practitioner and
student must know their infection status for
blood-borne viruses, and, if infected, seek
appropriate expert advice, for example expert
medical advice or advisory panel if diagnosed
with a blood-borne virus and cease to perform
exposure-prone procedures if viraemic.
Advice to Patients
Individuals infected with HCV should be advised
not to share sanitary and household items which
may carry traces of blood, such as toothbrushes,
razors, shavers, dental floss or barber’s hair-cutting
equipment, and not to reuse injecting or snorting
A dental practitioner must follow the guidelines
as above and if he/she is unable to manage the
oral healthcare of a patient with HCV infection, a
referral should be offered. There are many referral
options depending on the geographic location
and needs of the individual patient. Referral can
be made to an oral medicine specialist, oral and
maxillofacial surgeon or general dentist with
experience in HCV; otherwise referral to general
medical practitioners, gastroenterologists or
infectious diseases specialists may be appropriate.
The Australian Dental Association is able to
provide referral details for dentists, oral medicine
specialists and oral and maxillofacial surgeons.
10 Dental and Orofacial Health and Hepatitis C
1. HIV, viral hepatitis and sexually transmissible infections in Australia
Annual Surveillance Report 2011. 2011, The Kirby Institute, the
University of New South Wales: Sydney.
2. Hepatitis C fact sheet No 164. 2011 June 2011 cited 2012 21/2/2012;
Available from: http://www.who.int/mediacentre/factsheets/fs164/en/.
3. Houghton, M., Fields virology. 3rd ed, eds. Fields B.N., Knipe D.M.,
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Dental and Orofacial Health and Hepatitis C 11
49. Doffoel-Hantz, V., et al., Evolution of Sjogren syndrome associated with
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Appendix 1: Information about
needle-stick injury management.
In the event of a needle stick or other blood or
body fluid exposure, immediate management of a
needle-stick injury should be performed.56 The HIV,
HBV and HCV status of the source patient involved
may be established after gaining informed consent.
It should be noted, however, that the source patient
could be in the window period and therefore their
immediate blood results may be inconclusive. The
recipient of the injury can choose to have Liver
Function Tests (LFTs) and HCV RNA PCR testing four
weeks after exposure, and antibody HCV testing at
three and six months post-exposure. In order to establish
a baseline measurement, it is recommended to have
LFTs and a HCV antibody test on the day of the exposure
or shortly thereafter. Currently there is no PEP for
An Occupational Exposure Protocol ensures that
people know the specific steps to take if required (i.e.
first aid, reporting, risk assessment and counselling).
This also includes having access to the names and
contact details of relevant professionals, such as GPs,
Accident and Emergency departments and hepatitis C
12 Dental and Orofacial Health and Hepatitis C
Other ASHM resources, including the following hepatitis C
related publications, are available from the ASHM website:
Profession Based Booklets
■ An Overview of Hepatitis C: Clinical management
in opiate pharmacotherapy settings
■ Correctional Officers and Hepatitis C
■ General Practitioners and Hepatitis C
■ Nurses and Hepatitis C
■ Pharmacy and Hepatitis C
■ GP Companion Resource to 12 Questions on Hepatitis C
■ Hepatitis C in Brief – patient factsheet (Available online
only in English and 8 community languages: Arabic,
Chinese, Greek, Indonesian, Italian, Khmer, Spanish and
■ Hepatitis C Management and Treatment for Clients
of Pharmacotherapy Sevices (Available online only)
■ 2011–2012 Directory of HIV, Viral Hepatitis & Sexual
■ Co-infection HIV and Viral Hepatitis: a guide for
■ Hepatitis C: clinical management in opiate
■ HIV and Viral Hepatitis C: policy, discrimination,
legal and ethical issues
■ HIV, Viral Hepatitis and STIs: a guide for primary care
■ Australasian Contact Tracing Manual
Available in hardcopy and online at www.ashm.org.au/ctm
■ C Me, Hear Me. Hepatitis C in our own words
Online Learning Modules
To access online education modules visit the
Australasian Society for HIV Medicine (ASHM)
website at www.ashm.org.au/e-learning
LMB 5057 Darlinghurst NSW 1300
Tel: +61 2 8204 0700
Fax: +61 2 9212 2382
Print more copies of this supplement from: www.ashm.org.au/publications
Published September 2012
ABN: 48 264 545 457
© Copyright ASHM 2012
Printed with vegetable based inks on stock comprising 55% recycled content and FSC Certified virgin fibre and ISO14001 Environmental Certification.
ASHM offers training in HIV, viral hepatitis and sexually transmissible infections for general
practitioners, nurses and allied health care workers around Australia.
For further information on upcoming ASHM courses visit www.ashm.org.au/courses.
Further information and contacts
Provides links to state and territory hepatitis organisations.
National Infoline 1300 437 222
Australian Injecting and Illicit Drug Users League (AIVL)
Provides information and advocacy around injecting drug use.
Tel: 02 6279 1600
Gastroenterological Society of Australia / Australian Liver Association
Tel: 1300 766 176
Australian Commission on Safety and Quality in Healthcare (ACSQHC)
ACSQHC have a number of programs, publications and resources to support healthcare professionals,
healthcare organisations and healthcare policy makers, working with patients and carers, to deliver
safe and quality healthcare across Australia.
Tel: 02 9126 3600
Fax: 02 9126 3613
National Health and Medical and Research Council
Australian guidelines for the Prevention and Control of Infection in Healthcare
(available on line or PDF only)
Tel: 13 000 NHMRC (13 000 64672)
Therapeutic Guidelines Ltd
Oral and Dental Expert Group. Therapeutic guidelines: oral and dental. Version 2.
Melbourne: Therapeutic Guidelines Limited; 2012.
The Australasian Society for Infectious Diseases (ASID) Inc
Tel: 02 9222 6204
Hepatitis C Support
Tel: +64 9 377 8500
The Hepatitis Foundation
Tel: +64 7 307 1259
Freecall: 0800 332 010 (in NZ only)
Written and Reviewed by:
■ Dr Andrew Timothy McLean BDS, MBBS
■ Dr Bronwyn Scopacasa BDS, RACDS
■ Dr Raj Nair MSc (Oral Med Lond.), PhD (HK), MRACDS (Oral Medicine), Oral Medicine
Fellow Harvard University
■ Dr Elizabeth Coates BDS, MDS (Oral Pathology), FADI, FICD, FPFA, registered specialist in
special needs dentistry
■ Dr Wayne Sherson, BDS with distinction Otago, MSc Dent Sydney
■ Prof. Robert Batey AM, MD, BSc (Med), FRACP, FRCP (UK), FAChAM,
■ Nikki Woolley – Program Manager – Viral Hepatitis and Testing - NPED
■ Karen Seager – Senior Project Officer, Operations NPED
Australian Dental Association (ADA), Australian LIver
Association (ALA), The Australasian Hepatology Association
(AHA) and The Australasian Society for Infectious Diseases (ASID).
The Australian Government,
Department of Health and Ageing
Disclaimer: Whilst the Australian Department of Health and Ageing
provides financial assistance to ASHM, the material contained in
this resource produced by ASHM should not be taken to represent
the views of the Australian Department of Health and Ageing.
The content of this resource is the sole responsibility of ASHM.