Acquiring Hepatitis C at the Oral Surgery Office

One of the complications that can occur from wisdom teeth removal is to have an acquired infection. A particularly devastating infection that can be acquired is hepatitis C. There is one known case of a person acquiring hepatitis C virus (HCV) and HIV while at an oral surgery office which occurred in the fall of 2012 in Oklahoma. The patient received implants and also had a tooth removed in preparation. This case was covered at the time on this blog in the post Dental Patients Warned of Possible HIV and Hepatitis Exposure Due to Oral Surgeon’s Practices and in the media at the time such as in the article 7,000 patients warned of possible hepatitis, HIV exposure by Donna Domino appearing on DrBicuspid.com on March 29, 2013. After time was given for facts to come out, an article titled “Confirmed Transmission of Hepatitis C in an Oral Surgery Office” written by Joel M. Weaver appeared in Anesthesia Progress in Fall 2014 (vol. 61, no. 3, pp. 93–94). The article describes how genetic testing linked the transmission of HCV between two patients that were treated at the oral surgery office in Tulsa, Oklahoma.

According to the Centers for Disease Control and Prevention (CDC) only about 15%–25% of those infected with HCV are able to clear the virus before they become chronically infected. Chronic HCV can lead to liver damage, liver cancer, and cirrhosis (scarring of the liver). What is troubling is that it can be years after being infected before symptoms develop. Thus someone could potentially have HCV and risk spreading the disease to others without even knowing they have it. Unlike hepatitis A and hepatitis B, there is no vaccine for hepatitis C. The CDC says that in 2017, a total of 3,186 cases of acute hepatitis C were reported although they estimated the actual number of cases to be 44,300. The CDC estimated that in 2016, 2.4 million people in the U.S. or nearly 1% of the U.S. population had HCV. New drugs now have the ability to cure HCV but these are pricey with costs for a 12 week treatment regime approaching $100,000 for some medications. The standard treatment has involved a combination therapy with interferons and ribavirin. Many people are faced with their insurance company rejecting the claim for coverage of HCV medications.

In the article by Weaver it is argued that prevention is the best way to control the spread of HCV. In a dental office this can be accomplished by proper sterilization of instruments, washing hands with soap and water, using alcohol-based hand products before and after touching each and every patient, and wearing gloves (particularly doubling gloving). It is important to use disposable needles or cannulas and not to reuse fluid bags. If a needle or syringe comes into contact with any part of the intravenous tubing connected to the patient it must be thrown away after use. Needle stick injury is also a risk factor for dentists. The author speculates that the likely cause of the HCV transmission at the oral surgery office in Tulsa, Oklahoma, was due to substandard management of needles and syringes associated with intravenous medications. The author states

“Not only did significant harm occur to an innocent, unsuspecting patient, but the oral surgeon’s reputation and license to practice oral surgery were also placed at great risk….In the 21st century, dentistry’s slogan should be, ‘Your safety is our most important goal.'”

Weaver discusses two “game-changing” events that have forever changed how dental practices are run. One of the two “game-changing” events is the case described here where the patient acquired hepatitis C at the oral surgeon office in Tulsa, Oklahoma. The other “game-changing” event involved a dentist in the late 1980s who infected six patients with HIV. One of these patients acquired HIV at the age of 19 while having two wisdom teeth removed, see https://en.wikipedia.org/wiki/Kimberly_Bergalis. She later died at the age of 23. (This case has long been discussed on the wisdom teeth complications page).

blood test hepatitis - Acquiring Hepatitis C at the Oral Surgery Office
This image is from Pixabay and has a Pixabay license

For those interested in additional details on the case of the patient acquiring hepatitis C at the oral surgeon office, the Oklahoma State Department of Health has completed their lengthy near 100 page report titled Dental Healthcare-Associated Transmission of Hepatitis C: Final Report of Public Health Investigation and Response, 2013. The report says the patient who identified positive for HCV was a regular blood donor. A prior donation in April 2012 tested negative for HIV and HCV. The next time a donation was made in August 2012 the patient tested positive for HIV and HCV. The patient denied all major risk factors for HCV infection, but did report having multiple dental visits and oral surgical procedures in a three month period prior to the positive diagnosis in August 2012. From laboratory testing and other surveillance sources, a total of 4,208 people were tested as a result of the incident at the Oklahoma oral surgery office. Ninety six (2.3%) individuals tested positive for hepatitis C, six (0.1%) tested positive for hepatitis B, and four (0.096%) tested positive for HIV, with 36 (38%) of the 96 who tested positive for HCV having had a previous diagnosis. Thus, 60 patients tested positive for HCV that did not have a previous diagnosis, although six of the 96 HCV patients were not patients of the oral surgeon. Sixty three of the HCV positive patients were diagnosed after their initial dental visit although 32 (51%) reported high risk behaviors. The report states

“Therefore, it is possible that more patients acquired hepatitis C from exposure during an oral surgical procedure, but we had insufficient information to identify these cases.”

The report also goes into what could have led to the HCV transmission. This includes improperly sterilized dental equipment or environmental contamination. Further the report says that contaminated propofol may have been the transmission mode. The report seems to indicate the likely transmission mechanism was using propofol to sedate the patients and not adhering to the product labeling of propfol which states to only use the vial contents for a single patient. The authors state:

“We think it is most likely that HCV transmission occurred through a combination of unsafe injection practices…During the clinic site visit, staff members readily shared that it was a customary practice to use multi-dose vials of injectable medications on multiple patients…it is conceivable that needles and/or syringes may have been reused on some occasions to re-enter medication vials leading to contamination of that vial or fluid bag.”

It is also noted that the patient that acquired HCV had a dental procedure with IV sedation performed directly after the patient with hepatitis who was the source of the infection. Thus as has been mentioned before on this site, patients who have a blood-borne disease should have any wisdom tooth extraction or any oral surgery procedure performed at the end of the appointment day right before the office closes to avoid spreading their infection to others.

Based on additional reflection on this case and the toll acquired infection can take, the following are suggested to be done in a patient prior to having wisdom teeth extracted:

  1. Fully vaccinated (three doses) for Hepatitis B and Hepatitis B antibody and antigen tests. (Hepatitis B vaccination results in more than 90% developing immunity, leaving some still at risk. Thus, hepatitis B surface antibody should be tested to see if greater than or equal to 10 mIU/mL to prove immunity. Additional details at the Centers for Disease Control and Prevention, Hepatitis B, http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf)
  2. Hepatitis C antibody test
  3. HIV antibody test 
  4. MRI of the brain

Some may think that a Hepatitis B and C antibody test, HIV antibody test, and MRI of the brain are unnecessary in an otherwise healthy asymptomatic patient; however, the goal is to be able to prove you did or did not have X, Y, or Z prior to the surgery in case a complication occurs. If one were to acquire Hepatitis B, Hepatitis C, or HIV from the surgery there would be no way to prove it without a negative test shortly before the surgery. Similarly if one were to acquire a sinus infection from the surgery there would be no way to prove it without a negative imaging scan shortly before the surgery, see http://www.teethremoval.com/sinusitus_after_wisdom_teeth_removal.html for additional details.

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