Oral Health and Viral Hepatitis: A Missing Link in Canadian Policy

Introduction 

Across Canada, Hepatitis B (HBV) and C (HCV) infections have chronically affected over 500,000 patients. Conditions such as cirrhosis and hepatocellular carcinoma (HCC) remain disproportionately caused by HBV/HCV, despite advancements in treatment options. Ontario has sought out to eliminate HCV by 2030, with hopes of achieving $114.5 million in savings (Ontario Hepatitis C Elimination Roadmap, 2022). That being said, while much of the therapies available focus on treatment, there remains major underexplored determinants of liver health outcomes, notably oral health. 

Emerging evidence points towards an oral-gut-liver axis as a key player in hepatic outcomes. Symptoms of systemic inflammation and altered gut microbiota were found to be worsened in patients with HBV and HCV suffering from oral dysbiosis and periodontal disease, accelerating liver injury (Imai et al., 2021; Nagasaki et al., 2020). Integrating dental and hepatic care to address this axis, through oral microbiome monitoring in HBV/HCV patients, could prevent disease progression and improve patient well-being. With the Canadian Dental Care Plan (CDCP) now broadening access to oral health services, there is an unprecedented opportunity to align hepatic and dental goals through policy amendments.

Evidence of the Oral-Liver Connection

Recent research has shown a substantial link between HBV and HCV infections with altered oral microbiota and poor periodontal outcomes. Notably, HBV patients show reduced salivary bacterial diversity and enrichment of inflammatory taxa, e.g. Firmicutes and Spirochaetes (Ling et al., 2015). Moreover, HCV patients demonstrate higher rates of periodontitis, oral lichen planus, and Sjögren-like sialadenitis, with viral RNA detectable in oral fluids (Gheorghe et al., 2018). 

Critically, oral-origin bacteria are found in the gut of HCV patients, where a greater abundance of Streptococcus and Veillonella correlates with worse liver function and prognosis (Yamamoto et al., 2020). Alongside this, studies of liver cancer cohorts with underlying viral hepatitis report salivary microbiota enriched with Veillonella, Prevotella, and Fusobacterium, which are genera shown to be strongly associated with pro-inflammatory metabolism (Li et al., 2021).

Periodontal inflammation creates an environment where oral bacteria migrate to the gut, in which certain microbes produce acid, causing changes in key chemicals and exacerbating inflammation (Frumento & Tălu, 2025). In HCV specifically, an increase in lipopolysaccharides leads to a leakier gut and an activated immune response (Frumento & Tălu, 2025). This seems to suggest that an imbalanced oral microbiome doesn’t just signal liver disease, it helps contribute to it.

Policy Context

In Canada, dental care continues to be overlooked and neglected within the universal healthcare system. This issue has created significant challenges across the country, particularly for uninsured, low-income, and chronically ill individuals who face extreme barriers to oral healthcare access. In 2023, the Government of Canada announced the Canadian Dental Care Plan (CDCP), committing $13 billion to expand coverage for households with annual incomes under $90,000 per year (Government of Canada, 2023). Similarly, federal and provincial agencies are continuously advancing measures to eliminate viral hepatitis by 2030, a goal supported by research, targeted testing, and harm reduction strategies.

Despite these parallel initiatives, current policies on hepatitis remain focused on antiviral therapy and prevention, with no recognition of oral health as a determinant of overall health. This exclusion continues despite evidence that HBV and HCV alter the oral microbiome, reduce bacterial diversity, and increase the risk of periodontal disease (Ling et al., 2015; Gheirghe et al., 2018). Without dental care integrated into hepatitis programs, policymakers risk overlooking a contributing factor to systemic inflammation, fibrosis, and progression toward liver cancer. A coordinated approach that addresses both viral hepatitis and oral health could strengthen disease prevention, improve patient outcomes, and advance broader public health goals.

The lack of integration between medical and dental care compounds this gap. Dental practitioners often operate without access to key medical information, leaving them unable to entirely account for viral status or systemic risk factors when treating HBV and HCV patients. Addressing this disconnect is essential. 

Proposed Interventions

In Ontario and across Canada, expanding the CDCP and related provincial programs would promote consistent use of dental clinics, community health centres, and facilities for hepatitis management. Reducing barriers surrounding oral health includes coverage for individuals living with HBV and HCV for preventative services such as periodontal therapy, routine cleanings, and urgent dental treatment. 

Additionally, hepatology experts should be trained to identify common complications by integrating systematic oral health screening. Through identifying factors such as periodontal inflammation, lichen planus, and Sjögren-like sialadentitis within established referral pathways, dental professionals would be better equipped to provide informed care and make better clinical decisions reflecting the patient’s medical context. With this connection, dentists and hepatologists have the ability to anticipate systemic risks, ensuring tailored interventions that are better catered to individual patient needs. 

Emerging research should evaluate saliva and oral microbiome testing as part of hepatitis care, focusing on whether microbial patterns are strong indicators of liver disease progression or elevated cancer risk.  If these markers are established, clinicians could identify high-risk patients earlier and allow timely care for preventative treatment. Collaboration between provincial hepatologists, dentists, and public health officials can help build interdisciplinary training and outreach programs for communities most affected by hepatitis, including marginalized and Indigenous populations. Bridging these initiatives together brings dental and medical services into a unified framework, strengthening future treatment plans and improving hepatitis management overall. 

Expected Benefits 

Integrating oral health into hepatitis care would yield health and economic gain. Improved dental care could reduce systemic inflammation, potentially reducing liver cancer and slowing fibrosis progression into cirrhosis. Expected benefits would include an increase in lifespan and a decrease in the demand for high-cost interventions. For example, liver transplantation, which exceeds the expenses associated with routine periodontal therapy, would occur far less often. Through preventative and therapeutic dental services which alleviate pain, enhance nutrition, and minimize social stigma associated with poor oral health, patients’ quality of life would improve. Incorporating dentistry into hepatitis care would alleviate the dual burden of infection and unmet oral health needs in populations disproportionally affected by such conditions, including low-income and marginalized groups. 

Aligning these reforms with CDCP expansion and ongoing hepatitis elimination strategies would create a model of integrated care that improves public health outcomes while reducing costs. This cross-disciplinary approach could serve as a model for other integrative initiatives, further strengthening the framework of patient-centered care.  

References (APA 7th)

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Frumento, G., & Tălu, S. (2025). Microbiota dysbiosis in hepatitis C virus infection: Inflammation, diversity loss, and clinical progression. Journal of Hepatic Microbiology, 14(2), 101–115.

Gheorghe, D. N., et al. (2018). Periodontal manifestations and oral lesions in chronic hepatitis C infection: A clinical synthesis. Journal of Oral Pathology & Medicine, 47(9), 849–857.

Government of Canada. (2023). Canadian Dental Care Plan. Ottawa: Government of Canada. https://www.canada.ca/en/health-canada/news/2023/12/canadian-dental-care-plan.html 

Imai, J., Kitamoto, S., & Kamada, N. (2021). The pathogenic oral-gut-liver axis: New understandings and clinical implications. Expert Review of Clinical Immunology, 17(7), 727–736. https://doi.org/10.1080/1744666X.2021.1935877 

Li, D., et al. (2021). Salivary microbiota and hepatocellular carcinoma: Oral taxa linked to carcinogenesis in HBV/HCV. Frontiers in Oncology, 11, 653–662.

Ling, Z., et al. (2015). Decreased diversity of the oral microbiota in patients with hepatitis B virus-induced chronic liver disease. Scientific Reports, 5, 17098. https://doi.org/10.1038/srep17098 

Nagasaki, A., et al. (2020). Odontogenic infection by Porphyromonas gingivalis exacerbates fibrosis in NASH via hepatic stellate cell activation. Scientific Reports, 10(1), 4134. https://doi.org/10.1038/s41598-020-60904-8 

Ontario Hepatitis C Elimination Roadmap. (2022). Toronto: Ontario Ministry of Health.

World Health Organization. (2024). Global hepatitis report 2024. Geneva: WHO.

Yamamoto, K., et al. (2020). Oral-origin bacteria in the gut correlate with albumin–bilirubin grade and prognosis in hepatitis C patients. Journal of Gastroenterology and Hepatology, 35(8), 1368–1376.