Acquiring Hepatitis B at the Oral Surgery Office

In late 2019 on this site, a post titled Acquiring Hepatitis C at the Oral Surgery Office described how it is possible to acquire Hepatitis C while having oral surgery. In that post, a case that occurred in Oklahoma in 2012 was described. Prior to that case, there was a case in 2001, where a patient acquired Hepatitis B virus (HBV) at an oral surgery office. This is described in the article published in 2007, titled “Patient-to-Patient Transmission of Hepatitis B Virus Associated with Oral Surgery,” written by J. T. Redd et al., appearing in The Journal of Infectious Diseases (no. 195, pp. 1311–1314). In the article, the authors, at the time, describe the first documented (via medical literature) description of a case of patient-to patient transmission of a blood-borne pathogen in the U.S. occurring in a dental setting.

In the article, the authors used molecular epidemiologic techniques to show patient-to-patient transmission of HBV between two oral surgery patients. A 60 year old woman had oral surgery on October 10, 2001, at 10:50 A.M. A 36 year old woman with Hepatitis B had oral surgery done at the same location on October 10, 2001, at 8:09 A.M, and was the cause of the 60 year old woman’s HBV. The 60 year old woman had seven teeth removed during her surgery and later developed symptoms of HBV including pain and swelling of joints, fatigue, and anterior shin lesions on February 11, 2002. The 36 year old woman with Hepatitis B had 3 teeth extracted. Both the 60 year old and 36 year old woman were given intravenous dexamethasone, methohexital, diazepam, fentanyl, and droperidol that was kept stored in multi dose vials.

What is interesting about this case is that three patients were seen in the same oral surgery operating room on the same day between when the 36 year old woman with HBV and the 60 year old woman who acquired HBV were seen. Another patient was also seen in the same surgical room on the same day right after the 60 year old woman. The authors contacted the 27 patients who were seen after the 36 year old woman with HBV was seen (during the same week – the surgery occurred on a Wednesday) and at the same oral surgery room. Twenty five of these 27 patients were tested, and 16 of them had received 3 doses of hepatitis B vaccinations. Three of these patients who were tested had evidence of a past HBV infection, but based on their history and test results the authors felt they did not seem to acquire HBV during the oral surgery.

The authors attempted to determine a cause of why HBV transmission occurred. They observed surgical procedures at the office nearly a year after the patient-to patient transmission occurred. The authors could not find in particular any likely cause of the HBV transmission. They noted the office followed standard infection control procedures and standard precautions for preventing blood-borne pathogen transmission. The authors state:

“We can only speculate about the mechanism of transmission; cross-contamination from an environmental surface is one possibility. Theoretically, many surfaces (including clothing and plastic barriers) in the operation suite and the recovery area could have been contaminated with blood. Despite good standard operating procedures, some areas could have been missed during clean-up after the source patient, with subsequent cross contamination.”

The authors were also careful to check if multi-dose vials could have been the culprit. However, based on their observation, they did not feel a multi-dose vial was the likely cause of transmission (A multi-dose vial was the likely cause of transmission of Hepatitis C in the post discussed above).

immunization needle injection - Acquiring Hepatitis B at the Oral Surgery Office
This image is from Pixabay and has a Pixabay license

It is noteworthy, that the 60 year old woman who developed HBV did not receive any prior Hepatitis B vaccinations. In addition, three of the four other patients who were seen on the same day right after the 36 year old woman with HBV, had received three prior doses of Hepatitis B vaccinations. Thus, the authors feel that Hepatitis B vaccinations was important to limit the amount of patients that became infected and also increased the difficulty of determining how it was transmitted. The authors state:

“… this case reinforces the value of universal hepatitis B childhood vaccination… and meticulous maintenance of bloodborne pathogen infection control for all patients in dental settings.”

As discussed on this site in late 2019, it is suggested prior to wisdom teeth extraction to have received three doses of Hepatitis B vaccination. It is also suggested to have Hepatitis B antibody and antigen testing performed to know your status and to ensure the vaccination worked. Furthermore, it is suggested to have a Hepatitis C antibody test performed to know your status. While, as this case suggests, it is possible to reduce Hepatitis B transmission between patients in an oral surgery setting with vaccinations, the same can not be said for Hepatitis C transmission. There is no vaccine available for Hepatitis C.

It is certainly a bit troubling that the method or likely cause of transmission of Hepatitis B from patient to patient in the oral surgery setting could not be determined. The authors seem to suggest the office followed strict protocols. However, it is possible for areas to be missed when cleaning up between patients. Hepatitis can remain on surfaces for over a week in the absence of any visible blood, which can make ensuring proper cleaning occurred challenging. This seems to suggest that perhaps patients have reason to worry because despite best efforts it is still possible to acquire hepatitis. Thus, as has been suggested on this site, patients who have a disease like hepatitis or HIV should have oral surgery such as wisdom teeth removal performed at the end of the appointment day shortly before the office closes to limit the potential to spread the infection.

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