This document discusses several viruses including hepatitis, HIV, COVID-19, and H1N1. It provides information on the structure, transmission, clinical features, diagnosis, and treatment of each virus. Precautions for dental professionals are discussed, including protective equipment, sharp disposal, sterilization of instruments, and handling potential exposures. The document aims to educate on viral infections that are important for dental care providers to understand for infection control.

1. HEPATITIS, HIV, COVID-19
AND H1N1
Presented By- Dr Eeshita Behl
Department Of Orthodontics And Dentofacial Orthopaedics

2. CONTENTS
 MORPHOLOGY AND STRUCTURE OF VIRUS
 LAB DIAGNOSIS
 PROPHYLAXIS
 CLINICAL FEATURES
 TREATMENT
 MODES OF TRANSMISSION
 COMPLICATIONS
 PREVENTION
 DENTAL IMPLICATIONS
HEPATITIS, HIV, COVID 19, H1N1

3. HEPATITIS
 Hepatitis is inflammation of the liver which results in
damage to hepatocytes with subsequent cell death.
 Acute hepatitis is generally followed by complete
recovery.
 Prolonged inflammation may be accompanied by
fibrosis and progression to cirrhosis

4. HEPATITIS VIRUSES

5.  LABORATORY DIAGNOSIS &
PROPHYLAXIS

6. HEPATITIS E
Route : Oral
Spread : Contaminated water, person to person not
common
Age group: 15-40 years
Incubation period : 2 to 8 weeks

7. STRUCTURE OF VIRUS

8. CLINICAL FEATURES (HEPATITIS A & E)

9. TREATMENT (HEPATITIS A & E)
Not required as the illness is mild and self-limiting.
Patients with severe disease need close observation.
Fulminant hepatic failure – lactulose, oral non- absorbable
antibiotics (neomycin)

10. HEPATITIS B
Leading cause of liver cirrhosis, liver cancer and
chronic hepatitis
DNA virus
Disease caused by this virus is popularly known
as serum hepatitis
Longer incubation period: 30-180 days

11. MORPHOLOGY AND STRUCTURE

12. Parenteral
Sexual
Mother to child transmission
MODES OF TRANSMISSION

13. CLINICAL FEATURES
• Malaise, Anorexia,
• Weakness, Nausea,
• Vomiting, Myalgia,
• Pain in the rt. upper abdominal
quadrant,, Mild fever
PREICTERIC
PHASE

14. • Jaundice
• Clay coloured stool
• Dark urine
ICTERIC PHASE
• Malaise
• fatigue
• Uncomplicated hepatitis usually
resolves in 8-10 weeks
CONVALESENT
PHASE

15. COMPLICATIONS
Chronic active hepatitis
Cirrhosis
Hepatocellular carcinoma
Carrier state
90-95 % patients recover fully within 2-3
months
Less than 1% of cases die of fulminant hepatitis

16. TREATMENT
GOALS OF TREATMENT
INCLUDE
• Prevention of long term complications
• Reduction in mortality
• Symptomatic improvement
• Loss of HBV DNA

17. PREVENTION

18. PREVENTIVE MEASURES IN DENTAL
PRACTICE

19. IMMUNISATION
Hepatitis B immuno globulin is prepared from donors
with high titres of HBsAg
Given after accidental exposure and as early as possible
300-500 IU given I/M
2nd dose - 4 weeks after the first
PASSIVE IMMUNISATION

20. ACTIVE
IMMUNISATION
Required for high risk
individuals
VACCINES
AVAILABLE
Plasma derived hepatitis B vaccine
Recombinant yeast hepatitis B
vaccine
Recombinant Chinese Hamster
ovary cell hep B vaccine
Synthetic peptide vaccines
Vaccinia Virus Hybrid vaccine
using HBsAg gene

21. IMMUNIZATION
FOR HEALTH
CARE
PERSONNEL

22. DENTAL IMPLICATIONS
Bleeding tendency
Saliva collected may contain HBV
Main danger of infection is from needle-stick injuries.

23. HEPATITIS C
Commonest type of post-transfusion
hepatitis
Route: Blood-borne
Transmissibility lower than HBV infection

24. HEPATITIS C VIRUS

25. CLINICAL FEATURES
Incubation period: 15-160 days
More than 75% of acute HCV infections
are silent
Only 25% manifest Hepatitis

26. • ELISA
• Qualitative HCV RNA
testing
• Immunoblot assay
• PCR
• Branched DNA assay
LABORATORY
DIAGNOSIS

27. TREATMENT
Combination of Interferon alpha &
Ribavirin for 1 year
Interferon: 3 mIU subcutaneously on
alternate days
Ribavirin: 10 to 15 mg/kg body
weight orally

28. HEPATITIS D

29. Can only infect in presence of Hepatitis B infection
High risk group: IV drug users & heamophiliacs
HDV and HBV infect together – delta coinfection
HDV infects a chronic HBV infected patient – delta
superinfection
Transmission : parenterally & sexually
80-90% recover completely

30. CLINICAL FEATURES
Yellow skin and eyes (jaundice)
Stomach upset
Pain in your belly
Throwing up
Fatigue
Not feeling hungry
Joint pain
Dark urine

31. HEPATITIS G
Two Flavivirus-like isolates were obtained in 1995 from Tamarin
monkeys inoculated with blood from a young surgeon (GB) with acute
hepatitis.
These isolates were called GB viruses.
In 1996, an isolate closely resembling GBV-C was obtained from a
patient with chronic hepatitis. This has been called hepatitis G virus
(HGV).

32. MOST COMMON ORAL MANIFESTATIONS
RELATED TO HEPATITIS
Lichen Planus
Sjogren's Syndrome
Sialadenitis
Oral Cancers
Thrombocytopenia
Petechiaes Or Excessive Gingival Bleeding With Minor Trauma

33. HEALTH CONSIDERATIONS
Most Frequent Problems
Risk of cross
infection on the part
of the dental
professionals and
patients
Excessive bleeding
Alterations in the
metabolism of
certain drugs which
increase the risk of
toxicity.

34. • Clinical care
• Testing
• Counseling
• Post-exposure
prophylaxis (PEP)
• Testing and counseling
of source patients
Resource should be
available that permits
rapid access of
exposed DHCP to

35. Exposures that might place a dentist at risk
of hepatitis infection
Percutaneous
injuries
(needlestick or cut
with a sharp
object)
Contact with
potentially
infectious blood,
tissues, or other
body fluids
Mucus membranes
of the eye, nose,
or mouth or non-
intact skin
(exposed skin that
is chapped,
abraded, or
afflicted with
dermatitis).

36. HIV
(AIDS) is a condition in which progressive
failure of the immune system allows life-
threatening opportunistic infections
and cancers to thrive
HIV, the virus that causes AIDS, infects more
than 34 million people worldwide. Once in the
body, HIV attacks and destroys immune cells.

37. STRUCTURE OF HIV

38. TRANSMISSION
1. During sexual contact
2. Through infected needles and syringes
3. Through infected blood and blood products
4. From mother to child

39. HIV LIFE CYCLE
HIV INFECTS ALL CD4+ CELLS
They include- CD4+ T Lymphocytes,
macrophages, dendrites, langerhans cells
HIV binds to these cells by gp120
Entry into the cell requires gp41 and CCR5
(chemokine cell receptor)
Virus kills these cells and the count of CD4+
cells goes down

40. CLINICAL FEATURES
DIVIDED INTO 4 GROUPS:
Group 1- acute HIV infection
Group 2- asymptomatic infection
Group 3-Persistent generalized lymphadenopathy
(PGL)
Group 4-Symptomatic HIV infection -which
includes constitutional and neurological diseases,
secondary infections and cancers

41. LABORATORY TESTS FOR HIV
Home tests
Screening tests (e/r/s) : (a) ELISA
(b) Rapid tests- dot blot assays
(c) Simple tests-based on ELISA
Supplemental tests: Western Blot assay Immunofluorescence
Confirmatory tests:- done for early HIV detection: (A) Virus isolation
(b)Detection of p24 antigen
(c) PCR

42. LESIONS STRONGLYASSOCIATED WITH
HIV INFECTION
Candidiasis
Kaposi’s
sarcoma
ANUG,
Linear
Gingival
Erythema
Hairy
leukoplakia
Non-
Hodgkin’s
lymphoma

43. LESIONS LESS COMMONLY ASSOCIATED
WITH HIV INFECTION
Bacterial
infections:
Mycobacterium
tuberculosis
Melanotic hyper-
pigmentation
Necrotizing
ulcerative
stomatitis
Salivary gland
disease: Dry mouth,
Unilateral/bilateral
swelling of salivary
glands
Thrombocytopenia
purpura
Non-specific
ulcerations
Viral infections:
Herpes simplex
virus, Human
papillomavirus,
Varicella-zoster
virus, Condyloma
acuminatum

44. VIRAL INFECTIONS ASSOCIATED WITH
HIV
HSV-1 is more frequently associated with oral
lesions
Manifests as single or coalescent crops of vesicles
with subsequent ulceration that heals in 7 to 10 days
but may be extended in immuno-compromised
patients
HSV-1

45. PERIODONTAL DISEASE
LINEAR GINGIVAL ERYTHEMA
It is an atypical gingivitis that is depicted as a 2 to 3
mm distinct band of fiery redness at the marginal
gingiva around the teeth
Such erythema is not proportional to the plaque
accumulation.

46. ANUG
 NUG is a fuso-spirochetal infection. It shows ulceration, or
sloughing limited to marginal gingiva.
 Whereas, NUP is characterized by localized to generalized
aggressive alveolar bone and attachment destruction .

47. CARIES AND HIV
HIV may cause Xerostomia which contributes to RAMPANT
CARIES. These lesions develop at the cervical region of the tooth. The
tooth surface in this area consists of cementum that decay at a faster
rate. This can lead to formation of an abscess
Treatment includes scooping out of carious lesion usually without
anaesthesia, using hand instruments — and replaced with a temporary
filling that contains fluoride to inhibit further decay. The filling material
of choice is glass ionomer cement

48. PREVENTION
Personal protective equipment like GLOVES, MASKS, EYE-SHIELDS, APRONS
etc. Should be used as general measures for people who are likely to come in contact
with body fluids.
Consistent condom use reduces the risk of HIV transmission by approximately 80%
over the long term
Circumcision reduces the acquisition of HIV by heterosexual men by between 38%
and 66% over 24 months
Comprehensive sexual education provided at school may decrease high risk behavior
Bottle feeding instead of breastfeeding in case mother is HIV positive

49. CLINICAL CONSIDERATIONS FOR TREATING
HIV/HEPATITIS PATIENTS IN DENTAL
CLINICS
 CDC in 1993 published guidelines for specific infection control
for treating dental patients that was further modified in 2003
PROTECTIVE ATTIRE AND BARRIER TECHNIQUE:-
 Latex/vinyl gloves
 Hand washing before gloves
 Chin length plastic face shield, surgical masks, protective
eyewear
 Disposable gowns
 Impervious covers over non disposable/ cleansable areas
 Rubber dams, high velocity air evacuation, proper patient
positioning

50. SHARP INSTRUMENT AND NEEDLE
MANAGEMENT
 One handed scoop technique
 Needles should not be bent/broken
 Sharps to be placed in puncture resistant
containers

51. FOR STERILIZATION AND DISINFECTION
OF DENTAL INSTRUMENTS
 EPA-registered hospital disinfectant with tuberculocidal activity
 A designated central processing area divided into sections for
receiving, cleaning and decontamination, preparation and
packaging, sterilization, and storage.
 Heat-tolerant dental instruments must be sterilized by autoclaving,
dry heat, or unsaturated chemical vapor. For heat-sensitive critical
and semi-critical instruments and devices, liquid chemical
germicides registered by the FDA as sterilants can be used.
 Appropriate barriers should be used on dental components that are
permanently attached to dental units

52. DENTAL UNIT WATER QUALITY
• Each dental office should develop a strategy for the cleaning and
disinfection of blood spills, medical waste disposal, and utilization of
state-approved treatment technologies for containing blood and
saliva discharge into the sewer system.
• To reduce the possibility of virus and other microorganisms
contaminating treatment water within dental hand pieces, ultrasonic
scales, or air/water syringes should be discharged for 20-30 seconds
after each patient’s visit and before next use (even if a device is
equipped with an anti retraction valve).

53. INFECTION CONTROL RELATED TO
LABORATORY SUPPLIES AND
MATERIALS AND BIOPSY SPECIMENS
 Disinfection of impression materials, models, appliances, and other
materials that have been potentially contaminated by blood or
saliva before sending to the lab and then prior to placing in patient’s
mouth when returned from lab
 An EPA-registered hospital germicide labeled with antimyobacteria
(tuberculocidal) activity (defined as an intermediate-level
disinfectant) is recommended for use on laboratory supplies and
materials

54. SHARPS INJURY AND HIV EXPOSURE
 It is suggested that post needle stick the affected area should be
immediately washed with soap and water
 The eyes should be irrigated with clean water, saline, or sterile
irrigating solutions post exposure by fluids.
 Any exposure incident should be immediately reported and medical
treatment should be quickly pursued (within one to two hours).

55. TREATMENT – ANTIRETROVIRAL THERAPY
1. Inhibitors of viral attachment: Recombinant soluble CD4 or immunoglobulins
2. Nucleoside analogue Reverse Transcriptase inhibitors(NRTI): Zidovidine (ZDV),
Didanosine, Zalcitabine, Adenosine, Stavudine, Lamivudine (3 TC),
Abacavir(ABC)
3.Non-nucleoside analogue Reverse Transcriptase inhibitors(NNRTI): Neverapine,
Delaviridine, Thiobenzimidazoline derivatives.
4. Protease Inhibitors: Saquinavir, Retonovir, Indinavir, Nelfinavir
5. Integrase Inhibitors
6.Agents that block virus assembly and budding: Interferons

56. COVID 19

57. HISTORY
Coronaviruses (CoV) are a large family of viruses that cause illness
ranging from the common cold to more severe diseases such as Middle
East Respiratory Syndrome (MERS-CoV) and Severe Acute
Respiratory Syndrome (SARS-CoV).
Coronaviruses are zoonotic, meaning they are transmitted between
animals and people.
Several known coronaviruses are circulating in animals that have not
yet infected humans.
A novel coronavirus (nCoV) is a new strain that has not been previously
identified in humans.

58. PATHOGENESIS
Infection is transmitted through large droplets generated during
coughing and sneezing by symptomatic patients but can also occur from
asymptomatic people and before onset of symptoms.
These infected droplets can spread 1–2 m and deposit on surfaces. The
virus can remain viable on surfaces for days in favourable atmospheric
conditions but are destroyed in less than a minute by common
disinfectants like sodium hypochlorite, hydrogen peroxide etc.

59. SPREAD OF INFECTION
Infection is acquired either by
inhalation of these droplets or
touching surfaces
contaminated by them and
then touching the nose, mouth
and eyes.
The incubation period varies
from 2 to 14 days.
Studies have identified
angiotensin receptor 2
(ACE2) as the receptor
through which the virus
enters the respiratory mucosa

60. SEVEN STRAINS OF CORONAVIRUSES
WHICH ARE KNOWN TO INFECT HUMANS
Human
coronavirus
229E
(HCoV229E)
Human
coronavirus
OC43
(HCoVOC43)
Severe acute
respiratory
syndrome-
related
coronavirus
(SARS-CoV)
Human
coronavirus
NL63
(HCoVNL63,
New Haven
coronavirus)
Human
coronavirus
HKU1

61. MORPHOLOGY OF CoV - 2
Viruses in the family Coronaviridae are enveloped, positive -sense,
single - stranded RNA viruses.
It has the largest viral RNA genome.
The virus on its outer surface shows large club -shaped projections
which under an electron microscope resemble the solar corona.
An envelope is made up of glycoproteins which help in the entry of the
virus into the host cells.

62. • Common signs
• Respiratory symptoms
• Fever
• Cough
• Shortness of breath
• Breathing difficulties.
• In more severe cases,
• Infection can cause pneumonia
• Severe acute respiratory
syndrome
• Kidney failure and even death.
CLINICAL
FEATURES

63. CLINICAL FEATURES
In a subset of patients, by the end of the first week the disease can
progress to pneumonia, respiratory failure and death.
The median time from onset of symptoms to dyspnea was 5 days,
hospitalization 7 days and acute respiratory distress syndrome (ARDS)
8 days.
Complications witnessed included acute lung injury, ARDS, shock and
acute kidney injury.

64. COVID 19 VARIANTS
• The COVID-19 variant that was first
detected in South Africa
Beta
• The COVID-19 variant that was first
detected in Brazil
Gamma
• The COVID-19 variant that was first
detected in India
Delta
• The COVID-19 variant that was first
detected in South Africa
Omicron

65. DIAGNOSIS
Molecular detection of SARS-CoV-2 nucleic acid is the gold
standard.
SARS-CoV-2 is detected from a variety of respiratory sources, including throat
swabs, posterior oropharyngeal saliva, nasopharyngeal swabs, sputum and
bronchial fluid, the viral load is higher in lower respiratory tract samples.
Chest CT was used to quickly identify a patient when the capacity of molecular
detection was overloaded.
Patients with COVID-19 showed typical features on initial CT, including
bilateral multilobular ground-glass opacities with a peripheral or posterior
distribution

66. TREATMENT
If a person tests positive for COVID-19 and has mild to moderate
symptoms (non-hospitalized, not requiring oxygen or an increase in
home oxygen), they may be eligible for antiviral treatments including
oral antivirals or an IV (intravenous or in your arm) antiviral.

67. VACCINATION FOR COVID 19
Safe and effective vaccines are an important tool, in combination with
other measures, to protect people against COVID-19, save lives and
reduce widescale social disruption.

68. H1N1

69. H1N1
H1N1 influenza is a subtype of
influenza A virus, a communicable
viral illness which causes upper and
in some cases lower respiratory tract
infections in its host.
This results in symptoms such as
nasal secretions, chills, fever,
decreased appetite, and in some
cases, lower respiratory tract disease.

70. STRUCTURE OF VIRUS
The H1N1 influenza virus is an orthomyxovirus and produces virions that
are 80 to 120 nm in diameter, with an RNA genome size of approximately
13.5 kb. The swine influenza genome has 8 different regions which are
segmented and encode 11 different proteins

71. Although it had originated in
pigs, it was able to spread from
human to human.
When the flu spreads from
human-to-human, instead of
from animals to humans,
there can be further
mutations, making it harder
to treat because people have
no natural immunity.
HISTORY

72. RISK OF INFECTION
 People who have a higher risk of becoming seriously ill if
infected include:
• Children younger than 5 years old
• Adults older than age 65, younger adults, and children under
age 19 who are on long-term aspirin therapy
• People with compromised immune systems due to diseases
such as AIDS
• Currently gestating females
• People suffering from chronic diseases such as asthma, heart
disease, diabetes mellitus, or neuromuscular disease

73. HISTOPATHOLOGY
Interstitial edema with possible inflammatory infiltrate,
alveolar proteinaceous exudation associated with
membrane formation
Thrombosis of capillaries
Necrosis of the alveolar septae
Intra-alveolar hemorrhage dislocation of desquamated
pneumocytes
Diffuse alveolar damage with infiltration by the
lymphocytes and histiocytes into the interstitium

74. LATER STAGES
During the late stage, the following changes have
been reported in patients:
 Diffuse alveolar damage
 Fibrosis
 Hyperplasia of the type II pneumocyte
 Epithelial regeneration
 Squamous metaplasia

75. PREVENTION
1. Prevention of swine flu in swine: Main methods to prevent swine flu
in pigs involve facility management, herd management and vaccination
Prevention of swine to human viral transmission : These individuals are
encouraged to wear face-masks when dealing with the animals to prevent
transmission through respiratory droplets. The most important step of
prevention is vaccination of the swine
1. Current CDC recommendations to prevent the spread of the virus from h
uman to human frequent handwashing with soap and water or alcohol-based
sanitizers, and also disinfecting with a diluted bleach solution.

76. VACCINATION
In September 2009, the FDA permitted the new swine flu
vaccine, and various studies by the National Institute of Health
(NIH) showed that a single dose was enough to create
sufficient antibodies to protect against the virus within 10 days

77. MANAGEMENT AND TREATMENT
The management for infected patients
depends on the severity of symptoms of
influenza
mild to moderate influenza can be treated
at home with rest, oral hydration and
symptomatic treatment with antipyretics
like paracetamol, antihistamines
NSAIDS or Paracetamol for headaches and
body aches.

78. MANAGEMENT OF PROGRESSIVE OR
SEVERE DISEASE
Patients with progressive or severe symptoms should be
admitted to hospitals and preferably in intensive care units
(ICU) if there are signs suggestive of impending respiratory
failure or sepsis or multiorgan dysfunction.
Aggressive supportive measures like intravenous (IV)
hydration, correction of electrolyte imbalances, antibiotics for
concomitant bacterial infections.
Patients developing acute respiratory distress syndrome
(ARDS) secondary to influenza should be treated with
noninvasive or invasive mechanical ventilation.

79. ANTI-VIRAL MEDICATIONS
The antiviral medications like:
Zanamivir
Oseltamivir
Peramivir
have been documented to help reduce, or possibly prevent, the effects of
swine flu if the medication is taken within 48 hours of the onset of
symptoms.

80. REFERENCES
1. API Textbook of Medicine – 7th Edition
2. Textbook of Pathology by Harsh Mohan
3. Davidson's Medicine: Principles And Practice Of Medicine
4. Textbook of Medicine by Harrison
5. Hepatitis A, B, C, D and E viruses: Structure of their genomes
and general properties- Pablo VALENZUELA
6. Dental Settings and Hepatitis B, 2020
7. https://www.ada.org/resources/research/science-and-research-
institute/oral-health-topics/hepatitis-viruses

81. THANK YOU