Epidemiologic Notes and Reports Outbreak of Hepatitis B
Associated with an Oral Surgeon -- New Hampshire
During the first 6 months of 1986, four clinical cases of
hepatitis B were reported in a city in New Hampshire. Each case
was
serologically confirmed, and the patients had all been seen by the
same oral surgeon. All patients had undergone tooth extractions 3
to
5 months before becoming ill; three had had multiple extractions
during single office visits. All four patients denied other risk
factors for hepatitis B virus infection. One patient developed
periarteritis nodosa with severe complications, including
mesenteric
arteritis with colonic perforation, mononeuritis multiplex with
paraplegia, and ulceration into the joint space of one ankle.
Of the four patients, one remained seropositive for hepatitis B
surface antigen (HBsAg) for more than 6 months and became a chronic
hepatitis B carrier. He was tested and found to have HBsAg subtype
ad, the same subtype as the oral surgeon. Ten other cases of
hepatitis B were reported in the city during the first 6 months of
1986. Two of the patients were intravenous drug users; two were
contacts of patients with unreported cases of hepatitis; and six
had
no identified risk factors. None of these ten patients had been
treated by a dental professional or had undergone surgery.
The oral surgeon had been practicing in the city (population
75,000) for 25 years. His practice was limited to dental
extractions,
usually performed with a combination of intravenous sedation and
local
anesthesia. He had never had any symptoms suggestive of hepatitis
B
and had never received hepatitis B vaccine. He had never been
tested
for hepatitis B serologic markers prior to the outbreak. In July
1986, he was seropositive for HBsAg and hepatitis e antigen (HBeAg)
and negative for IgM antibody to hepatitis B core antigen,
indicating
that he was probably a hepatitis B carrier. He was not aware of
having had any skin lesions on his hands in the past year.
Although
he was careful to scrub his hands between surgical procedures, he
did
not wear gloves.
The oral surgeon discontinued his practice when the outbreak
was
discovered on June 30, 1986, and has not reopened his office.
Letters
were sent to all patients whom he had treated after January 1,
1985,
informing them of their possible exposure to hepatitis B virus and
offering free testing for hepatitis B serologic markers.
Reported by JJ Cournoyer, K Brandenburg, E Schwartz, MD, State
Epidemiologist, Bur of Disease Control, C Zumbrunnen, DDS, Bur of
Dental Health, Div of Public Health Svcs, Public Health Laboratory,
New Hampshire Dept of Health and Welfare; Div of Field Svcs,
Epidemiology Program Office, Hepatitis Br, Div of Viral Diseases,
Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Eight other outbreaks of hepatitis B traceable to
dentists or oral surgeons have been reported since 1974 (1,2). The
number of clinically infected patients in each outbreak has ranged
from three to 55. Two of the nine clinically ill patients in one
outbreak died of fulminant hepatitis B (2); no other deaths have
been
reported. In each outbreak, the implicated dentist or oral surgeon
was seropositive for HBsAg and (if tested) HBeAg and did not use
gloves during dental or surgical procedures. None of the dentists
who
were hepatitis B carriers were aware of their chronic infections.
Traumatic procedures (surgery, extractions) have been associated
with
a higher infection risk than non-traumatic procedures (fillings,
denture fittings, etc.). Transmission has been thought to occur
through apparent or inapparent lesions on the dentist's hands.
The repeated occurrence of outbreaks associated with dentists
or
oral surgeons is especially disturbing because there are easily
available and widely recommended measures to prevent them. A safe,
effective vaccine against hepatitis B became available in 1982,
and,
since the late 1970s, national dental authorities have urged dental
practitioners to wear gloves during all procedures involving hand
contact with patients' mouths (3-5). In March 1986, a national
random
telephone survey revealed that 44% of non-federal, practicing
dentists
and oral surgeons in the United States had been vaccinated against
hepatitis B (CDC, unpublished data). Only 15% of respondents used
gloves routinely for all procedures.
Recurrent, avoidable outbreaks such as this one should prompt
dentists and oral surgeons to seek hepatitis B vaccination and to
use
gloves routinely when treating patients.
References
Kane MA, Lettau LA. Transmission of HBV from dental personnel
to
patients. J Am Dent Assoc 1985;110:634-6.
Shaw FE, Barrett CL, Hamm R, et al. Lethal outbreak of
hepatitis
B in a dental practice. JAMA 1986;255:3260-4.
Council on Dental Material and Devices, Council on Dental
Therapeutics, American Dental Association. Infection control
in
the dental office. J Am Dent Assoc 1978;97(4):673-7.
Council on Dental Therapeutics, American Dental Association.
Guidelines for infection control in the dental office and the
commercial dental laboratory. J Am Dent Assoc 1985;110:969-72.
CDC. Recommended infection-control practices for dentistry.
MMWR
1986;35:237-42.
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