Novel Approach to the Clinical Management of Completely Edentulous Hepatitis B Carrier Patient.

Incidence of infections is more common in the dental practice. In this article, we describe a novel approach to the clinical management of a completely edentulous patient who is in hepatitis B carrier state including infection control protocol for all clinical and laboratory steps. Furthermore, a novel method of incorporating patient's medical history in the form of a QR code in the processed denture is also described. Copyright:

INTRODUCTION

Viral infections tend to occur commonly in the general population at any given point of time. Dental professionals are at a higher risk of getting exposed to viral infections through contact with blood, saliva, and nasopharyngeal secretions of the patients.[12] Viral diseases such as hepatitis and AIDS are potentially fatal and pose a greater risk (occupational hazard) to the dentists. It is essential to know the history of exposure and rule out active disease before treating such patients. The incidence of hepatitis B among dentists is 13.6%–38.5% which is higher than the normal population. The risk of infection varies from 6% to 30% through injury from cutting/piercing of contaminated sharp instruments, and a minute amount of blood (1 × 10−7 ml) might transmit the hepatitis B virus (HBV).[34] Apart from blood, others body fluids such as saliva and crevicular fluid are also highly contagious. In the department of prosthodontics, the transmission might occur during both clinical and laboratory procedures. Hence, following the appropriate infection control protocols during all the steps are mandatory.

Dr. Robert H. Griffins was the one who emphasized upon the significance of the identification of dentures.[5] The main purpose of the use of denture identification is in the identification of victims during natural calamities for the forensic experts. Other purposes include the identification of denture wearers having amnesia or senility, cases of homicide or suicide, to identify the dentures by the technicians and denture delivery to the respective patient. The methods are classified as surface markings (e.g., engraving and embossing methods) and inclusion methods (e.g., ID band, T-bar, laser etching, and electron microchip).[6]

CASE REPORTS

A 41-year-old female patient reported to the Department of Prosthodontics, CSICDSR, Madurai, with the chief complaint of missing teeth in both the jaws for the past 2 months. It was decided to rehabilitate the patient with removable complete denture prostheses on both the maxillary and mandibular arches. Medical history revealed that the patient was a hepatitis B carrier. Intraoral examination revealed completely edentulous maxillary and mandibular arches [Figure 1a and b]. Proper personal barrier protection techniques such as wearing double gloves, protective eye wear, mouth mask, and apron were followed during all the steps of the procedure (examination and treatment).[4] Field sterilization was carried out by cleaning the areas (working surfaces, countertops, and cabinet) with 70% isopropyl alcohol and using disposable items (disposable suction tips, instrument tray sheets, head rest, and chair handle cover).[4] The diagnostic instruments were sterilized by steam autoclave at 121°C for 15–20 min at 15 lbs pressure/square inch after each step.[7] Proper healing of the mucosa was ensured, and the presence of any sharp bony spicules was ruled out before making impressions. The stock tray was selected with proper extension, and primary impressions were made with alginate [Figure 2a]. Impressions were washed in running water and dried with air-water spray. The impressions were then disinfected by immersing in 2% glutaraldehyde for 10 min.[7] The metal stock tray was disinfected using steam autoclave (121°C for 15 to 20 minutes at 15 lb pressure/square inch.[7] The custom tray was fabricated on the primary cast, and it was made sure that there were no sharp margins. Sectional border molding was carried out with low fusing compound, and the final impression was made with addition silicone impression material (monophase) [Figure 2b]. The secondary impressions were disinfected by immersing in 2% glutaraldehyde for 1 h followed by rinsing with sterile water. The master cast was disinfected by spraying sodium hypochlorite and leaving it for 10 min.[7] The temporary denture base and occlusal rims were fabricated on the master cast, and jaw relation was recorded using the Niswonger's method (physiologic technique) and verified for esthetics and phonetics which was mounted in the articulator [Figure 3a]. Try-in verification of jaw relation [Figure 3b] was done after which wax up and polishing were carried out. The QR code was generated using the mobile application (QR code generator and scanner) with the patient's personal details and medical conditions including hepatitis B carrier state and was printed and laminated. The dimensions of the laminated QR code were measured and found to be 10 mm × 10 mm × 2 mm. Following this, the laminated QR code was cut with retention tags, and its position of incorporation in the maxillary denture was determined [Figure 4a–c]. After the wax up, a small bead of wax was incorporated in the palatal region of the maxillary arch corresponding to the future position of the laminated QR code and to enable the retention of the putty index [Figure 4d]. Then, flasking and dewaxing were done. A putty index was fabricated to be positioned in the place of the QR code with the help of the space created by the wax bead [Figure 5a and b]. Conventional packing and curing procedure were carried out. After deflasking, the putty index was removed from the maxillary denture and the dentures were finished, and the QR code was incorporated in the maxillary denture using autopolymerizing resin after creating retention groves in the denture [Figure 6a and b]. Polishing of the denture was done and was made sure that there were no sharp edges/margins before the denture was inserted. The pumice used for polishing was discarded.[7] The QR code was scanned using the mobile application downloaded from the play store (QR code generator and scanner) and checked for the details incorporated in the QR code [Figure 7]. Denture insertion was done [Figure 8a–c] and checked for extensions, esthetics, phonetics, retention, stability, and occlusion. Postinsertion instructions were given. The patient was recalled after 24 h for review. The denture was disinfected by immersing in alkaline glutaraldehyde solution after rinsing in running water and removing the debris by placing in ultrasonic cleaner.[7]

Figure 1

(a and b) Intraoral view

Figure 2

(a and b) Primary and secondary impressions

Figure 3

(a and b) Jaw relation recorded and wax trial

Figure 4

(a-d) Laminated QR code fabrication and locating its position

Figure 5

(a and b) Fabrication of putty index and incorporating it during processing.

Figure 6

(a and b) Incorporation of the laminated QR code

Figure 7

QR code scanned and verified for the details

Figure 8

(a-c) Postinsertion

(a and b) Pre- and post treatment

DISCUSSION

The risk of hepatitis B infection is higher in dental profession, the main source of transmission being blood and saliva. Around 6% of the entire population in the Southeast Asia are HBV carriers, and in India, over 40 million are in the carrier state.[8] About 1.4% of the hospital workers are infected with HBV out of which the dentists are at a higher risk.[8] After injury with cutting/piercing which involves a higher risk carrier to a susceptible individual, risk of seroconversion of HBV is around 30%.[4] Nowadays, the rate of infection has reduced due to vaccination and following proper infection control protocols.[9] However, in rare cases, where the professionals have not completed the course of vaccination, or nonresponders to the vaccine are highly prone to infection. They might need prophylaxis with hepatitis B immunoglobulin following the injury.[10] In this article, a completely edentulous patient with hepatitis B carrier state was treated by following proper infection control protocol during both the clinical and laboratory procedures. Denture labeling with QR code with patient details and the present medical status was laminated and incorporated in the maxillary denture as a precautionary measure for future medical interventions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.