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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

  1. Kane MA, Lettau LA. Transmission of HBV from dental personnel to patients. J Am Dent Assoc 1985;110:634-6.

  2. Shaw FE, Barrett CL, Hamm R, et al. Lethal outbreak of hepatitis B in a dental practice. JAMA 1986;255:3260-4.

  3. 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.

  4. 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.

  5. CDC. Recommended infection-control practices for dentistry. MMWR 1986;35:237-42.



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