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Hepatitis B Virus Transmission in a Dental Office

Infection Control

Hepatitis B virus (HBV) is a bloodborne virus of major concern in dental infection control. HBV transmission in a dental health care setting is rare, particularly since standard precautions and routine vaccinations for dental workers were adopted (1985 and 1987, respectively). There has been no reported transmission from a dental worker to a patient since 1987.

Patient-to-Patient Hepatitis B Virus Transmission in an Oral Surgery Practice, 2001

A Journal of Infectious Diseases article describes a patient-to-patient transmission of HBV in a dental setting. The event occurred in 2001, when a person with acute hepatitis B was reported to a state health department. The state health department's epidemiologic investigation found that the patient had none of the traditional hepatitis B risk factors, but reported having recent oral surgery. An investigation of the oral surgery practice where the patient received dental treatment revealed that another surgical patient seen earlier on that same day was on the state's reportable disease registry for HBV. Molecular epidemiologic techniques indicated transmission of HBV between the two patients.

When investigators later visited the office and monitored its operation, they found that the office followed standard infection control practices, and that all staff had been previously vaccinated and were negative for HBV. The investigators could only speculate that a lapse in cleanup procedures had occurred after the source patient, leaving an area contaminated with blood.

Hepatitis B Virus Transmission Associated with a 2-Day Portable Dental Clinic Serving Large Numbers of Patients

In 2009, a cluster of 5 cases of acute hepatitis B virus infections was reported among attendees of a two-day, portable dental clinic in West Virginia. The clinic was held in a gymnasium staffed by 750 volunteers, including dental care providers, who treated 1,137 adults. A retrospective investigation was conducted by using treatment records and volunteer logs, interviews of patients and volunteers with acute HBV infection as well as other clinic volunteers, and molecular sequencing of the virus from those acutely infected. Five acute HBV infections—involving three patients and two volunteers—were identified by the local and state health department. Of four viral isolates available for testing, all were genotype D. Three case patients had extractions; one received restorations and one a dental cleaning. None shared a treatment provider with any of the others. One case volunteer worked in maintenance; the other directed patients from triage to the treatment waiting area. None of the cases reported behavioral risk factors for hepatitis B (e.g., recent history of injection drug use or multiple sex partners).

The investigation revealed several infection control breaches that could have resulted in exposure of patients and staff to HBV and other blood-borne pathogens. For example, outer surfaces of dental handpieces and disposable mirrors were cleaned with disinfectant wipes and returned to service without being heat sterilized between patient uses, used instruments were sterilized unwrapped, and it was reported that some patients were allowed to carry their partially used anesthetic carpules in the metal syringes on a tray to other stations if needed for later reuse. In addition, training on bloodborne pathogens standards was not provided to volunteers. Written information on individual patient procedures and providers was limited. Thus, specific breaches in infection control could not be linked to these HBV transmissions.

All dental settings should adhere to recommended infection control practices, including operational oversight of infection control practices; training in prevention of bloodborne pathogens transmission; receipt of HBV vaccination for staff who may come into contact with blood or body fluids; use of appropriate personal protective equipment, sterilization and disinfection procedures; and measures, such as high-volume suction, to minimize the spread of blood.

Radcliffe RA, Bixler D, Moorman A, Hogan VA, Greenfield VS, Gaviria DM, Patel PR, Schaefer MK, Collins AS, Khudyakov YE, Drobeniuc J, Gooch BF, Cleveland JL. Hepatitis B virus transmissions associated with a portable dental clinic, West Virginia, 2009. J Am Dent Assoc 2013; 144(10):1110–1118.

Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. J Infect Dis 2007;195(9):1311–1314. View full text.

Allos BM, Schaffner W. Transmission of hepatitis B in the health care setting: the elephant in the room ... or the mouse? J Infect Dis 2007;195(9):1245–1247. View full text.

Additional Resources

Guidelines for Infection Control in Dental Health-Care Settings – 2003
Recommendations for infection control from CDC.

IC Checklist for Dental Settings Using Mobile Vans or Portable Dental Equipment
Guidance for dental settings that use portable dental equipment addressing site assessments and an infection control checklist may be found at the Organization for Safety, Asepsis and Prevention (OSAP) website.

Healthcare-Associated Hepatitis B and C Outbreaks Reported to the Centers for Disease Control and Prevention (CDC) in 2008–2012
The tables summarize healthcare-associated outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection reported in the United States during 2008–2012.

The Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care is a companion to the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.

Hepatitis B Information for Health Professionals – Vaccination of Adults
Offers targeted information and resources pertaining to the settings where adult hepatitis B vaccinations are recommended.

Mobile-Portable Dental Manual and Safety Net Dental Clinic Manual
Association of State and Territorial Dental Directors (ASTDD) and Health Resources and Services Administration (HRSA).

Epidemiologic Notes and Reports Outbreak of Hepatitis B Associated with an Oral Surgeon — New Hampshire.
Oral surgeon who was not vaccinated against HBV unknowingly transmitted HBV to four patients.

Hepatitis B Frequently Asked Questions
These FAQs cover hepatitis B infections, vaccinations, chronic hepatitis B, serology, traveler’s health, and more.

Viral Hepatitis Transmission in Ambulatory Health Care Settings
The delivery of health care has the potential to transmit HBV and hepatitis C virus (HCV) to both health care workers and patients. Recommendations At A Glance to prevent outbreaks in health care settings.

Hepatitis B Vaccination Recommendations for Adults
Offers information and resources targeted to each of the different settings in which adult hepatitis B vaccination is recommended.

A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States [PDF–470K]
Health care providers should inform all adult patients about the health benefits of vaccination, who is at risk for HBV infection, and who should be vaccinated.

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