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BACKGROUND: Healthcare-associated transmission of hepatitis C virus (HCV) attributable to improper injection safety or infection control practices has been increasingly recognized in outpatient medical facilities, but has not been previously documented in a dental facility. In January 2013, the Oklahoma State Department of Health (OSDH) began investigation of acute hepatitis C in a routine blood donor with a history of dental surgery during the period of probable exposure. Based on findings of two site investigations, dental patients were determined to be at risk of exposure to blood-borne pathogens. On March 28, the OSDH and the Tulsa Health Department publicly announced patient notifications to approximately 7,000 persons recommending testing for HCV, hepatitis B virus, and human immunodeficiency virus (HIV).
METHODS: A field investigation was conducted to evaluate infection control practices within the oral surgical facility using CDC's Infection Prevention Checklist for Outpatient Settings. Other components of the field investigation included employee interviews, and review of patient records and the controlled drug inventory log. Dental patients were tested for HIV, hepatitis B surface antigen (HBsAg), and total HCV antibody through the OSDH Public Health Laboratory. Genotyping and quasispeciation analysis were performed on specimens from HCV-infected patients clustered by dental procedure date.
RESULTS: Findings of the field investigation consisted of multiple violations of the Oklahoma Dental Practice Act, including administration of intravenous sedative medications by uncertified dental assistants; improper dating and storage of multi-dose vials of controlled drugs; and lack of autoclave monitoring and maintenance. As of April 17, testing of 3,122 dental patients yielded 57 anti-HCV positive results, 3 HBsAg-positive results, and 1 confirmatory HIV test result. Quasispeciation analysis indicated 100% homology of HCV genotype 1a infections of two patients who had dental extractions performed on the same date.
CONCLUSIONS: Dental facilities have rarely been incriminated as a transmission source of healthcare-associated blood-borne infections, but lack of adherence to injection safety and other infection prevention practices in these outpatient settings can put patients at risk. Potential approaches to increase patient safety may include requiring continuing education in infection control as a condition of dental license renewal, adopting regulations to require regular unannounced inspections of dental surgical clinics, and requiring certification and advanced training of all dental assistants. Public health surveillance and investigation of HCV case reports should include review of previous dental encounters as a potential risk factor.