Original Article

Assess the knowledge of dentists regarding Hepatitis B serological profile:

a cross-sectional study

Qurat-ul-ain Tariq1, Shazia Tariq2, Mariam Ajmal Tareen1, Iftikhar Uddin2, Fahad Qiam1
1 Khyber College of Dentistry, Peshawar, Pakistan
2 Gajju Khan Medical College, Swabi, Pakistan
3 University of Agriculture, Peshawar, Pakistan

Abstract
Introduction: The primary aim of the study was to determine the knowledge of dental practitioners regarding HBV serological markers. Second
objective was to determine prevalence of occupational exposures to HBV amongst dentists.
Methodology: A questionnaire was constructed pertaining to various aspects of HBV serology; validated by an expert panel; and piloted at 49
dentists. A Cronbach-alpha value of 0.7 was attained and thus extensive survey was conducted among dentists in routine practise treating
hepatitis B patients at dental teaching hospitals in Peshawar, KP. The data was analysed using SPSS v.22.
Results: A response rate of 58% (a total of 290 respondents) was attained. All respondents were vaccinated against HBV. Over 50% reported
not to follow Standard precautions for every patient. Overall, 20.3% experienced HBV exposure, eight were administered PEP. Fifty-four
percent of FYs; 74.5% PGTs and 71.6% of faculty dentists correctly answered: HBsAg to be the ‘serological hallmark of HBV infection’; this
was the most correctly answered question. Sixty-four percent dentists failed to identify the infectious carrier phase. Over 50% of dentists in
each category failed to correctly answer 5/8 of the HBV serology.
Conclusions: Over 20% reported HBV occupational exposure but zero transmissions. Majority of dentists did not have correct information on
HBV serological profile which may jeopardise cross-infection control. Further education on HBV serological markers and its clinical relevance
to dentistry along with stringent adherence to Standard precautions is recommended.

Key words: Hepatitis B; serological markers; education; occupational blood exposures; dentists.

J Infect Dev Ctries 2020; 14(10):1210-1216. doi:10.3855/jidc.12295

(Received 07 December 2019 – Accepted 30 June 2020)

Copyright © 2020 Tariq et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction of active viral replication and infectivity. The risk of

According to the 2018 Hepatitis B (HepB) HBV infection following percutaneous inoculation is
guidelines set by American Association of the Study of 6% (HBeAg-negative source) to 30% (HBeAg- positive
Liver Disease (AASLD) all citizens born in a country source) as opposed to 1.8% for hepatitis C virus (HCV)
with ≥ 2% prevalence of hepatitis B surface antigen and 0.3% for human immunodeficiency virus (HIV)
(HBsAg) are at high risk of chronic hepatitis B (CHB) [1,8,9].
and need to be screened [1]. Several studies conducted Most individuals who test positive for HBsAg have
in the past decade across various regions of Pakistan CHB [10]. Combinations of these serological markers
among various groups observed HBsAg seroprevalence along with alanine transferase levels (ALTs) and liver
of ≥ 3% [2-6]. Khyber Pukhtunkhwa (KP) province has fibrosis markers define various phases of CHB –
a huge burden of hepatitis B with over 10 million detailed in ANNEXURE 1 [1,11]. Liver disease often
chronic carriers [7]. Hepatitis B virus (HBV) has hinders haemostasis and alters metabolism of certain
several proteins detectable in serum and of clinical drugs. For such patients additional workup may be
significance: presence of HBsAg establishes diagnosis required prior to dental treatment [12]. The study solely
of infection. Persistence of HBsAg over 6 months focuses on HepB because HBV has a greater risk of
defines chronicity. Sero-conversion to anti-HBs is an infection after inoculation; various serological markers;
index for clearance and immunity – it is usually potential infectivity in the inactive carrier state and
spontaneous in acute infection but rare in CHB. Sero- transmission is easily preventable by adequate
reversion to HBsAg can occur in resolved cases. vaccination as opposed to HCV and HIV infections.
Hepatitis B e Antigen (HBeAg)-positivity is indicative Primarily, the aim of this research was to determine the
Tariq et al. – Knowledge of dentists regarding HBV serological markers J Infect Dev Ctries 2020; 14(10):12010-1216.

current level of knowledge of dentists regarding HepB of which were analysed by reliability scale: Cronbach-
serological markers. This is pertinent to a dental alpha. Permission was sought form Ethical and
practitioner for prevention of cross-infection and Research committee at Khyber College of Dentistry for
subsequent reduction in the burden of HBV in the collection of blood samples and subsequent analysis for
communities and for appropriate management of CHB serum HBsAg by Enzyme Linked Immunosorbent
patients. We also hoped to determine prevalence and Assay (ELISA) of any HBV exposed dentist. Approval
characteristics of HBV occupational exposures among was given for the survey but refused for blood sampling
dentists. To date, such work is non-existent in literature. and HBsAg analysis due to lack of resources. The
confidentiality of each respondent answers was assured.
Methodology Results of the pilot survey were not included in final
This descriptive cross-sectional questionnaire- analysis. All statistical analysis (counts, percentages
based study was conducted on foundation-year dentists and Pearson chi-square associations) was performed
(FYs), post-graduate trainees (PGTs) and faculty using Statistical Package of Social Sciences v.22
members of 4 main dental teaching hospitals in software program.
Peshawar, KP in April 2019. Hepatitis B-positive
patients routinely receive dental treatment at these Results
hospitals. Only dentists in routine clinical practice were Pilot questionnaire was replied with reasonable
included in this study. A questionnaire was constructed reliability with a Cronbach-alpha value of 0.7.
formatted into 12 questions: the first 4 questions asked Therefore, an extensive survey was carried out. It was
respondents ‘if they follow standard precautions for responded by 290 dentists, forming a response rate of
each patient’; ‘how often they treated hepatitis B 58%. A hundred and ten (37.9%) were FYs; 106
patients’ and ‘if they had completed HBV vaccination (36.6%) were PGTs and 74 (25.5%) were faculty
regimen’ ‘if they experienced HBV occupational members in routine clinical practise. There was a
exposure’. This question was tagged with further significant association (p-value = 0.000) between
inquiries regarding number, type and cause of exposure, designation and years of clinical experience with many
their current serum HBsAg status and being managed faculty members having over 5 years of experience,
with PEP. The next 8 items pertained to various aspects PGTs having 1- 5 years and FYs having less than a year.
of HBV serology with multiple-choice answers and ‘I Overall, 49.7% of dentists claimed to follow Standard
don’t know’ option. The last question inquired precautions of infection-control for every patient. Fifty-
regarding need for further educational programs on six percent reported to treat Hepatitis B positive patients
HepB serology. The questionnaire was presented to a 6- occasionally, 19.3% stated monthly and 19.7% on a
membered expert panel compromising of a weekly basis – of these 63.2% were FY-dentists. There
Haematologist, a Microbiologist, dental graduate in was significant association (p-value = 0.001) between
Masters of Research and three Oral Maxillofacial designation of dentist and how often they treated HepB
Surgeons, all of whom found the tool to be acceptable. patients (Table 1). All respondents stated they had
The survey was further piloted at 49 dentists, the data completed vaccination against HBV. Overall, 20.3%

Table 1. Responses to introductory items (along with chi-square association between the 2 variables).
RESPONSES TO INTRODUCTORY QUESTIONS: P VALUE
1. FOLLOW ‘STANDARD PRECAUTIONS’ FOR EACH PATIENT
DESIGNATION ONLY FOR
YES SOMETIMES POSITIVE DO NOT FOLLOW
PATIENTS 0.327
FY 57 (51.8%) 11 (10%) 40 (36.4%) 2 (1.8%)
PGT 48 (45.3%) 22 (20.8%) 35 (33%) 1 (0.9%)
FACULTY 39 (52.7%) 9 (12.2%) 26 (35.1%) 0
2. PERFORM TREATMENT OF HEPATITIS B POSITIVE PATIENTS
WEEKLY MONTHLY OCCASIONALLY DO NOT TREAT
FY 36 (32.7%) 21 (19.1%) 45 (40.9%) 8 (7.3%) 0.001
PGT 12 (11.3%) 21 (19.8%) 69 (65.1%) 4 (3.8%)
FACULTY 9 (12.2%) 14 (18.9%) 48 (64.9%) 3 (4.1%)

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have experienced at least one HBV occupational Table 2. Responses regarding HBV exposure.
exposure, of which 49.2% were FYs and 39% PGTs Responses of those who answered 'Yes' to HBV
(Table 2). Pearson chi-square demonstrated significant occupational exposure in the past year
association between designation and exposure with a p- Designation
value of 0.012 and significant association (p- FY 30 (49.2%)
PGT 24 (39.3%)
value=0.001) between how often dentists treated HepB
Faculty 7 (11.5%)
patients and being exposed. Needlestick/sharps injury Type of exposure
was the most commonly reported exposure. All exposed Needlestick/sharps injury 29 (47.5%)
dentists stated their current serum HBsAg-status to be Mucosal membrane exposure 21 (34.4%)
negative, forming a zero HBV transmission rate. Eight Needlestick/Sharps Injury and
3 (4.9%)
reported being managed with post-exposure Mucosal Membrane Exposure
immunoprophylaxis (PEP) after their exposure. Non-intact skin exposure 8 (13.1%)
Cause of exposure
Responses to question regarding HBV serology are
Lack of time 11 (18.0%)
given in Table 3. The correct answers are in bold. A Following improper technique 23 (37.7%)
total of 192 dentists (66.2%) correctly stated serological Both 22 (36.1%)
presence of HBsAg to be the hallmark of HBV infection Accidentally 1 (1.6%)
but only 42.4% thought anti-HBs to be index of Lack of resources 3 (4.9%)
recovery/immunity. Alarmingly, 114 (39.3%) dentists Lack of concentration 1 (1.6%)
said they would consider an ‘HBsAg-positive with Frequency of exposure
low/undetectable HBV DNA levels’ as HepB negative, 1-2 times 49 (80.3%)
3-4 times 9 (14.8%)
while 25.2% ticked ‘I don’t know’. Question 6
≥5 times 3 (4.9%)
regarding ELISA was second most correctly answered Being managed with Post-exposure
by 57.9% and question 2 was third most correctly prophylaxis (PEP)
answered by 55.9%. Overall, less than half of dentists Yes 8 (13.1%)
correctly answered 5 out of 8 questions. Over 94% of No 53 (86.9%)
respondents stated they needed further educational
programs on Hepatitis B serology. of dentists reported HBV OBE at least once, almost half
of whom were FY-dentists followed by trainees.
Discussion Therefore, increased HBV OBE may be related to
There are several KAP surveys conducted on frequent interactions with HBsAg-positive patients or
dentists/students regarding HBV but not a single may be related to work proficiency. A similar study
question regarding serological aspect of HBV. There found the incidence of self-reported OBE decreased
are few studies testing the seroprevalence of HBsAg in with a decrease in number of daily beds served per
dentists. While some research has been conducted on HCW. It also reported that in ‘doctors’ category, interns
occupational blood exposures (OBE) among health care followed by residents and then clinical fellows reported
workers (HCW) –none of them demonstrate prevalence most OBEs respectively [14]. In the present work, all
of HBV OBEs among dentists. Because of the absolute exposed respondents reported ‘HBsAg-negative status
novelty of this particular research topic, a conventional presently’. Permission for laboratory confirmation of
comparative discussion cannot be written. The dental this was not given. This supposed zero HBV
teaching hospitals of this study have assigned separate transmission rate has been demonstrated in other long-
dental units and equipment for Hepatitis B, C and HIV term follow-up studies [14,15]. This is most likely due
positive patients. Standard precautions are to adequate vaccination of HCWs and PEP
recommended by the Centre of Disease Control (CDC) management. At our institutes it is mandatory for all
whenever contact with patient’s bodily fluids is dentists, clinical technicians and sanitary personnel to
expected, regardless of infection status [13]. A third of be vaccinated against HBV as per recommendations of
dentists reported following these measures only with CDC and that PEP is administered to those inadequately
known hepatitis B-positive patients. A greater number or unvaccinated.
of foundation-year dentists treated Hepatitis-positive With regards to HepB serology, the presence of
patients on a weekly basis than PGTs and faculty. This HBsAg in serum indicates current active infection or
discrepancy is perhaps because some of these dental inactive carrier state [1,16,17]. Over 70% of trainees
teaching hospitals have allotted FY-dentists on the and faculty dentists and 54% of FYs correctly stated
‘HBV HCV HIV-positive’ dental units. Twenty percent HBsAg to be the hallmark of HB infection. However, a

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substantial portion of FYs (30.9%) stated they did not conditions have been known to manifest in patients with
know despite the fact that every patient seeking liver disease. Chronic liver disease (CLD) is associated
consultation or treatment at our institutes is screened for with high perioperative morbidity and mortality. Major
HBsAg. If positive, then is assigned to ‘positive’ dental complications include excessive bleeding and toxicity
units. The test is renewed after 3 months. Even with this of drugs like some general anaesthetics [12,18].
filter, placed by the institute, lack of understanding of Physician consultation and pre-operative hemodynamic
this test and its significance would be detrimental to assessment and meticulous management of drugs
cross-infection control particularly in private practice. administered is required in CLD patients undergoing
Relative to the previous question, fewer dentists elective surgery [18,19]. An even smaller percentage of
correctly defined CHB to be persistence of serum dentists correctly stated that the serological presence of
HBsAg for over 6 months. Acute HBV infection can be Antibody to Hepatitis B surface antigen (Anti-HBs)
asymptomatic in 50-70% and chronic infection is indicates immunity (or recovery from infection in case
usually indolent during the early immune-tolerant phase of positive Anti-HBc). Acute HBV infection in
and the inactive carrier phase [17]. Immune-clearance immunocompetent adults is usually self-limiting
or active phase of the disease is characterised by high requiring mere supportive management. Less than 5%
ALTs, liver damage, hepatitis, cirrhosis etc. Cheilitis, of adults develop chronic infection after acute HBV
xerostomia, petechei, lichen planus among other oral exposure. The seroconversion of HBsAg to Anti-HBs

Table 3. Responses to HBV serology questions (% within designation).

Designation
Question Answer choices FY PGT Faculty
Total 110 (100%) 106 (100%) 74 (100%)
1. Hallmark of HBV infection is the serological HBeAg 11 (10.0%) 14 (13.2%) 9 (12.2%)
presence of HBsAg 60 (54.5%) 79 (74.5%) 53 (71.6%)
HBcAg 5 (4.5%) 4 (3.8%) 7 (9.5%)
I don’t know 34 (30.9%) 9 (8.5%) 5 (6.8%)
2. Persistence of HBsAg over 6 months indicates Acute infection 17 (15.5%) 11 (10.4%) 5 (6.8%)
Chronic infection 51 (46.4%) 67 (63.2%) 44 (59.5%)
Fulminant infection 1 (0.9%) 2 (1.9%) 3 (4.1%)
I don’t know 41 (37.3%) 26 (24.5%) 22 (29.7%)
3. Hallmark of recovery from HBV infection Anti-HBs 48 (43.6%) 44 (41.5%) 31 (41.9%)
Anti-HBe 12 (10.9%) 29 (27.4%) 14 (18.9%)
Anti-HBc 7 (6.4%) 7 (6.6%) 4 (5.4%)
I don’t know 43 (39.1%) 26 (25.5%) 25 (33.8%)
4. Time period for which serum HBsAg status is First month 32 (29.1%) 24 (22.6%) 6 (8.1%)
monitored after acute HBV exposure 1-2 months 20 (18.2%) 12 (11.3%) 5 (6.8%)
2-3 months 13 (11.8%) 24 (22.6%) 18 (24.3%)
3-4 months 19 (17.3%) 29 (27.4%) 22 (29.7%)
I don’t know 26 (23.6%) 17 (16.0%) 23 (31.1%)
5. If serum HBsAg-negative and anti-HBc HBeAg 13 (11.8%) 12 (11.3%) 13 (17.6%)
positive, which additional marker is tested for in HBV DNA 35 (31.8%) 42 (39.6%) 33 (44.6%)
further tests (if any) No further test 9 (8.2%) 11 (10.4%) 4 (5.4%)
I don’t know 53 (48.2%) 41 (38.7%) 24 (32.4%)
6. If patient is detected positive on ICT for first Advise ELISA 56 (50.9%) 62 (58.5%) 50 (67.6%)
time, then Advise PCR 21 (19.1%) 27 (25.5%) 14 (18.9%)
Treat patients as positive 7 (6.4%) 5 (4.7%) 0
Treat patient as negative 0 0 1 (1.4%)
I don’t know 26 (23.6%) 12 (11.3%) 9 (12.2%)
7. HBV DNA undetectable on PCR but ELISA Treat patient as negative 32 (29.1%) 48 (45.3%) 34 (45.9%)
report positive Treat patients as positive 42 (38.2%) 38 (35.8%) 23 (31.1%)
I don’t know 36 (32.7%) 20 (18.9%) 17 (23.0%)
8.Minimal protective anti-HBs level after 12 7 (6.4%) 9 (8.4%) 6 (8.1%)
completion of two months of HBV vaccination 50 23 (20.9%) 15 (14.2%) 11 (14.9%)
(mIU/mL) 100 22 (20.0%) 33 (31.1%) 15 (20.3%)
I don’t know 58 (52.7%) 49 (46.2%) 42 (56.8%)

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in CHB is rare [1,17]. MacMahon et al and Magalhaes infection, it is mandatory to practice the standard
et al conducted longitudinal studies on 1536 with precautions of infection -control for every patient and
chronic HBV infection and 100 inactive carriers and ideally patients should be screened for both HBsAg and
found that 6.9% and 4% cleared HBsAg over 12.6 years anti-HBc.
and 10 years respectively [20,21]. The clearance was After acute exposure, HBsAg status of HCP should
quicker in older carriers and those who tested HBeAg- be monitored for at least 10 weeks, 2.5months, as
negative initially. Nevertheless, immunosuppression HBsAg is detectable in serum between 10 days to 10
may result in reactivation (abrupt appearance or rise in weeks following exposure [1, 11]. Knowing this is
HBV DNA, sero-reversion to HBsAg) in resolved essential for dentist particularly one who is
infections [17]. unvaccinated, incompletely or inadequately vaccinated.
HBV can reactivate spontaneously in 25-30% of A third of respondents (34.1%) incorrectly thought < 2
inactive carriers [17]. MacMahon et al found one or months were sufficient while 22.8% ticked ‘I don’t
more reactivations in 17% of cases with a median of 3 know’.
reactivations and Magalhaes et al reported reactivation Anti-HBs titre of 12mUI/ml two months after
in 10% of the cohort [20, 20]. So, essentially there is no completion of the vaccine series is considered
cure for CHB. CHB infected individuals act as a protective and adequate vaccination [20]. Less than 10
reservoir for the virus. Therefore, regardless of dentists in each category answered this correctly.
‘undetectable’ HBV DNA levels on Polymerase Chain Though unaware of the correct titre, it is reassuring that
Reaction(PCR) report, an individual testing positive for dentists thought of higher thresholds to be protective.
HBsAg on ELISA should be considered as HBV Anti-HBs levels differentiate vaccine responders from
infected and infectious. Majority of FYs (38.2%) stated non-responders. Non-responders are characterised by
they would treat these patients as HBV positive. anti-HBs levels < 10UI/mL after vaccination and
Majority of faculty (45.9%) and PGTs (45.3%) stated require PEP administration which is most effective
they would consider such patients as HBV negative and within first 24 hours. [20]. PEP regimen consists of
hence these patients may have evaded the ‘positive’ revaccination (≥ 1 dose) with or without HepB
units. This will be detrimental to other patients and to immunoglobulin (HBIG) [1,24]. This is mandated at
the dentist particularly when standard precautions for our institute after acute exposure to known HBV
each patient are not practised. source. Upon the principle of considering every patient
HBeAg-positive source has a high infectivity as potentially infectious, a dentist should check their
factor. HBeAg is tolerogenic: allowing the virion to anti-HBs levels after vaccination to ensure adequate
evade immune system and establish infection in vivo immunisation. Henceforth, no post-exposure
[22]. Also, its serological presence is associated with management is necessary regardless of patients HBsAg
high HBV DNA levels. Seroconversion to anti-HBe and status [24].
marked reduction in HBV DNA is associated with Several studies have shown Enzyme-linked
remission of disease in majority of patients [1,11]. immunosorbent assay (ELISA) to be significantly more
Perhaps this may have lead few dentists to incorrectly specific than rapid immunochromotographic tests (ICT)
assume HBeAg to be hallmark of infection and anti- with a false negativity rate of 1.3% opposed to 12.3%
HBe to indicate immunity. for ICT [25]. Therefore, a patient testing HBsAg-
HBV DNA is used to evaluate anti-viral therapy and positive on ICT for the first time needs to be verified by
detect reactivation and occult infection [23]. Occult ELISA in case of false positive result. Twelve dentists
HBV infection is rare and is characterised by HBsAg- thought no further testing is required and to treat patient
negative, Anti-HBc positive and usually undetectable as HBV-positive whilst one dentist thought to treat as
serum DNA levels however, HBV covalently closed negative. Correct knowledge of this is pertinent to
circular DNA (cccDNA) is frequently found in infected prevent a non-infected patient being treated within
hepatocytes through liver biopsy. It acts as a working environment of hepB-infected patients.
transcription-template for HBV and permits persistence The aforementioned data and discussion highlight
of infection. [11,23]. Majority of PGTs (39.6%) and the clinical relevance of HBV serological markers to
faculty (44.6%) correctly answered that HBV DNA will safe dental practice; the need for adequate vaccination
be tested for in case of positive anti-HBc and negative- and the need to follow standard precautions for each
HBsAg. Majority of FYs (48.2%) stated they did not patient to reduce risk of horizontal transmission. The
know. Hence, because there is a possibility –albeit rare greater number of HBV occupational exposures
–an HBsAg-negative individual may harbour an occult occurring in foundation-year dentists and trainees may

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Annex – Supplementary items

Supplementary Table 1.
Chronic Hepatitis B (CHB)
1. HBsAg present for ≥ 6 months
2. Serum HBV DNA varies from undetectable to several billion IU/mL
3. Subdivided into HBeAg positive and negative. HBV-DNA levels are typically > 20,000 IU/mL in HBeAg-positive CHB, and lower values
(2,000-20,000 IU/mL) are often seen in HBeAg-negative CHB.
4. Normal or elevated ALT and/or AST levels
5. Liver biopsy results show chronic hepatitis with variable necroinflammation and/or fibrosis
Immune-Tolerant CHB
1. HBsAg present for ≥ 6 months
2. HBeAg positive
3. HBV-DNA levels are very high (typically >1 million IU/mL).
4. Normal or minimally elevated ALT and/or AST
5. Liver biopsy or non-invasive test results showing no fibrosis and minimal inflammation
Immune-Active CHB
1. HBsAg present for ≥ 6 months
2. Serum HBV DNA > 20,000 IU/mL in HBeAg-positive CHB and > 2,000 IU/mL in HBeAg-negative CHB
3. Intermittently or persistently elevated ALT and/or AST levels
4. Liver biopsy or non-invasive test results show chronic hepatitis with moderate or severe necroinflammation and with or without fibrosis
Inactive CHB
1. HBsAg present for ≥ 6 months
2. HBeAg negative, anti-HBe positive
3. Serum HBV DNA < 2,000 IU/mL
4. Persistently normal ALT and/or AST levels
5. Liver biopsy confirms absence of significant necroinflammation. Biopsy or noninvasive testing show variable levels of fibrosis