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Hand CareSection 1005 of Division 10 Title 16 of
the California Code of Regulations
(6) Health care workers shall wash
contaminated or visibly soiled hands with
soap and water and put on new gloves
before treating each patient. If hands are not
visibly soiled or contaminated an alcohol
based hand rub may be used as an
alternative to soap and water.
7) Healthcare workers who have exudative
lesions or weeping dermatitis of the hand
shall refrain from all direct patient care and
from handling patient care equipment until
the condition resolves.
Good hand care practices are an important
part of reducing the transmission of disease
in the dental environment. Hand care
practices should include:
• Hand cleansing procedures
• Hand care products to maintain
healthy skin
• Use of gloves
Hand cleansing is one of the most important
procedures we can utilize to substantially
reduce potential pathogens on the hands and
is paramount in the dental environment to
reduce the transmission of disease.
“Handwashing, hand antisepsis, or surgical
hand antisepsis is considered the single most
critical measure for reducing the risk of
transmitting organisms to patients” and
from patients to dental personnel. “
Hospital-based studies have demonstrated
that noncompliance with hand hygiene
practices is associated with health-care-
associated infections and the spread of
multiresistant organisms.” (1) “The
prevalence of health-care--associated
infections decreases as adherence of Health
Care Personnel to recommended hand
hygiene measures improves.” (2-4).
It is clear from clinical observations that
many dental professionals do not follow
handwashing protocol. It is important to
note that the use of gloves does not reduce
or negate the requirement for complete hand
hygiene practices. In contrast, the use of
gloves in the dental practice actually makes
hand hygiene even more important. Resident
and some transient microbes actually
quickly multiple underneath gloves, in the
warm, damp environment. When you do not
wash your hands before and after glove
removal or for a variety of other situations,
( see CDC Guidelines in this chapter) you
are helping increase the microbial colonies
on your skin.
Resident Microbes
The skin harbors two basic categories of
microbes that can potentially be transmitted
to patients. The first, are those microbes that
are a natural part of our bodies. They are
referred to as resident microbes because they
are always present on and within the skin.
They live on both the outer surface of the
skin and just under the surface, between the
layers of the stratum corneum. The stratum
corneum is the outermost layer of the
epidermis, and is made up of many thin
layers of continually shedding, dead cells.
As these dead cells slough off, new cells
replace them. Among other things, the
purpose of the stratum corneum is to protect
the underlying layers of skin and help keep
the skin hydrated. The thickness of the
stratum corneum varies according to the
amount of protection it is are required to
provide. Because hands are used for
grasping, holding, and manipulating objects,
the palm surfaces have a thicker layer of
stratum corneum than most other parts of the
body. This thickened multiple-layer surface
provides a source for bacterial growth.
Many members of the resident microbial
family are capable of transmitting diseases,
however they play far less a role in disease
transmission than their counterpart. Since
these microorganisms are always on and
underneath the skin, they are never totally
removed, even with surgical scrubbing
techniques. The idea of hand washing and
surgical scrubbing is to reduce the amount
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of resident microbes present in these
locations. In order to remove or reduce
resident microbes, anti-microbial soaps need
to be used since plain soap and water have
little or no effect on this type of microbial
life.
Transient Microbes
The second type of microbial life on the skin
is referred to as transient. Transient
microbes are those that we acquire on our
skin from direct patient treatment and
surfaces, instruments, and other items that
may be contaminated with debris from
patients. This form of microbial life poses
the greatest risk of disease transmission
because it potentially contains every form of
disease causing agent the patient(s) carries.
Luckily, the majority of these microbes
remains on the surface of the skin and can
therefore be removed or reduced through
proper hand cleansing procedures.
Although the Dental Board of California
regulations only state “Health care workers
shall wash contaminated or visibly soiled
hands with soap and water”, there are
specific guidelines from the Centers for
Disease Control and Prevention (CDC)
about hand hygiene methods and
indications. The important part of hand
washing is that you perform it routinely and
perform it correctly.
Below is a photograph of commonly missed
areas during hand washing. Note that the
thumb, wrist, fingertips including nails and
in- between the fingers are marked. Studies
also show that the dominant hand is less
likely to be properly cleaned than the non-
dominant hand.
CDC Hand Hygiene 2002
RecommendationsThe following are excerpts form the CDC
guidelines of indications for handwashingand hand antisepsisA. When hands are visibly dirty orcontaminated with proteinaceous material orare visibly soiled with blood or other bodyfluids, wash hands with either a non-antimicrobial soap and water or anantimicrobial soap and water.B. If hands are not visibly soiled, use analcohol-based hand rub for routinelydecontaminating hands. Alternatively, washhands with an antimicrobial soap and water.C. Decontaminate hands before havingdirect contact with patients.D. Decontaminate hands before donningsterile gloves. F. Decontaminate hands after contact with apatient’s intact skin (e.g., when taking apulse or blood pressure, and lifting apatient).G. Decontaminate hands after contact withbody fluids or excretions, mucousmembranes, nonintact skin, and wounddressings.H. Decontaminate hands if moving from acontaminated-body site to a clean-body siteduring patient care.I. Decontaminate hands after contact withinanimate objects (including medicalequipment) in the immediate vicinity of thepatient .J. Decontaminate hands after removinggloves.K. Before eating and after using a restroom,wash hands with a non-antimicrobial soapand water or with an antimicrobial soap andwater.
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Hand Washing For StandardNon-Surgical Procedures
See video series on hand
cleansing techniques
Ideally, foot controlled or sensor controlledwater and soap dispensers should be usedfor handwashing. The use of such deviceswill help reduce the cross contamination thatcan occur when using regular faucets andhand dispensed soap containers. If suchdevices are not available, barriers ondispensers and the use of paper towels toturn water faucets on and off should beutilized.When designing a new office or remodelingan existing one, care should be used whenselecting sinks and sensor faucets. The sinkin the photo below is too small, too shallowand the faucet is not mounted close enoughto the sink to allow for hand rinsing withoutcontacting the dirty sink. Although wellintended, the sink selection and faucetplacement are poor choices.
Handwashing Procedure
1. Remove any hand jewelry. Somestudies have demonstrated that the skinunderneath rings can harborsignificantly larger colonies of microbesthan other areas of the hands. Inaddition, rings often lower the integrityof gloves and make it more difficult toplace and remove gloves.
2. With fingertips facing downward,apply a liberal amount of water to thehands, starting from the wrists. Utilizecool to lukewarm water. Hot waterremoves more protective oil layers fromthe skin and will hasten dry skinproblems including the risk of severedermatitis. Conversely, the use of coldwater prevents soap from lathering andreduces the likelihood that the microbeswill be washed from the surface of theskin.
3. Place a liberal amount of soup onto thepalms of the hands (about 5ml, which isapproximately 1 1/2 teaspoons).
4. Vigorously rub hands together to createlather. The soap lather pulls microbes fromthe skin surface and holds them insuspension until they are rinsed away with
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water. Wash at least 15 seconds. If handsare visibly soiled a longer time period maybe necessary. Make sure the hands andforearms are kept lower than the elbowsduring the entire procedure.
5. Make sure to include the wrist area.
6. Interlace fingers to remove debris frombetween the fingers.
7. Include the fingertips and fingernail area.
8. Rinse hands thoroughly starting at thewrists. The water should flow from the leastto the most contaminated areas, so thatmicroorganisms are rinsed into the sink.
9. Dry hands thoroughly with paper towelsor single-use cloth towels. Multiple-usecloth towels are not recommended for use inhealth-care because they harbor significantmicrobial colonies.
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10. If foot or sensor operated water controlsare not available, utilize paper towels to turnoff the water faucets.
Add Hand Washing For SurgicalProcedures
Hand Cleansing Agents
The exclusive use of anti-microbial soaps is
very drying to the hands and can cause skin
irritation. Although it was recommended in
the past that anti-microbial soaps be used in
all dental procedures, current
recommendation utilize different criteria for
making that decision. The decision to use
anti-microbials, non-antimicrobial, or
alcohol hand rubs should be based on
• degree of contamination on the skin
• antimicrobial persistence required
• procedure being performed
Resident and transient bacteria rapidly
multiply underneath surgical gloves. When
surgical procedures are being performed an
anti-microbial soap or handwashing in
combination with an alcohol hand rub with
persistent activity should be utilized.
When routine dental procedures are
performed and hands are not visibly soiled,
antimicrobial, non-antimicrobial soaps or
alcohol based hand rubs can be utilized
depending on need.
The following are different categories of
hand cleansers available for use in the dental
environment. Several different categories of
hand hygiene products should be available
in your office for use in different situations
When choosing products keep in mind the
following factors.
Fragrance
Strong fragrances may be offensive to some
individuals, and discourage product use.
Some staff may also have sensitivity to
certain smells that trigger respiratory
problems such as asthma. Check with all
staff before purchasing products.
Persistent Activity
If you are using an anti-microbial product,
choose one that has persistent activity for a
wide variety of microbes. Persistent activity
will help protect your skin better between
handwashing.
Skin Integrity
Many hand hygiene products can be very
drying to the skin. Choose products with
emollients, and other agent to help protect
from drying. Additionally products such as
those in the iodine/iodophor category may
have a higher potential for causing irritation.
If staff members experience irritation from
certain products, other products should be
provided. Our skin is a primary defense
against diseases. Any product that causes
drying, or cracking of the skin will lower
skin integrity and provide an entrance way
for microbes. The additional use of glove
compatible lotions should be available and
encouraged. (See hand care section in this
chapter)
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Dispenser
Do NOT add soap to dispensers unless they
have been washed and completely dried.
The addition of soap to a container which is
partially full can cross-contaminate the soap
and container. The use of disposable
containers or single dose packets will
elevate this problem.
Anti-MicrobialsThis category of hand cleansers may be used
for antiseptic handwashing or surgical
antisepsis. The duration of time spent
washing your hands and the techniques
utilized vary depending on hand
hygiene requirements. See
video series on hand
cleansing productss.
Chlorhexidine
Chlorhexidine based preparations have a
persistent residual activity by binding to the
skin to give prolonged antimicrobial effects.
Allergic response to these products is rare.
Chlorhexidine based products are currently
one of the most widely utilized classification
of products in healthcare settings. Some
well-known professional brands of hand
cleaners that utilize Chlorhexidine are :
• Hibiclens
• SaniClenz
• Endure
Triclosan
Triclosan may have prolonged activity on
the skin, however acceptability varies. They
are more effective against gram-positive
microbes. Triclosans lack of potent activityagainst gram-negative bacilli has resulted inoccasional reports of contamination (CDCGuidelines ). They are not a good choice for
surgical scrubs. Triclosan is widely used incommercial soaps such as liquid Dial anddishwashing detergents advertised as anti-bacterial for their odor reducingcharteristics. Some well known professional
brands of hand cleaners that utilize Triclosan
are:
• Bacti-Stat
• Steris
Alcohols
Alcohols based preparations have a broad
range of activity at optimum concentrations
of at 60-90% alcohol. Although theyexcellent immediate effects, they only somepersistent effect on microbes. Without theaddition of emollients the products in thecategory are drying to skin. A well known
professional brands of hand cleaner that
utilize Alcohol is:
• VioNexus Handwash
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Iodophors
Iodophors cause less skin irritation and
fewer allergic reactions than iodine hand
washes, however they can cause more
irritant contact dermatitis than other
commonly used hand hygiene substances.
For the most part, other products have
replaced them. A well known professional
brands of hand cleaner that utilize iodophor
is:
• Alphadine
Antiseptic Hand Rubs
Based on several studies, alcohol based hand
rubs have been shown to be more effective
than plain soap and water in reducing
bacterial counts on the skin and may have a
more significant residual effect than anti-
microbial soaps. These products may be
used for general use when hands are NOT
visibility soiled. They have also been shown
to be very effective for surgical hand
antisepsis in conjunction with handwashing
because of their persistent effective.
Products are available in liquid, gel or foam.
A minor drawback to these products is that
they cause a minor stinging sensation on
hands with any cuts or abrasions.
When choosing a product, be sure to choose
those products that:
• Don’t reduce glove integrity
• Have the addition of emollients or
other skin conditioners to help
reduce the drying effects of
alcohols.
Because of the alcohol content, hand
rubs are flammable. Caution should be
used. These products should be stored
away from any heat source.
Techniques For Antiseptic Hand Rub
Remove all jewelry and push up sleeves
on gown or lab jackets.
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Read product label for:
• Directions
• Product content
• Emergency procedures
• Hazards
Apply a liberal amount of product to the
palm of one hand. Hands should remain
moist for a minimum of 15 seconds during
the process. If the product dries prior to that
time, you have used too small an amount of
product.
Vigorously apply the alcohol rub to all
surfaces of the hands including:
• Palms
• Back of hands
• Between the fingers
• Wrists
• Finger tips
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Non Anti-Microbial Cleansers
There are a variety of professional and
consumer based products that may be used
for handwashing when hands are NOT
visibility soiled and the situation would not
require anti-microbials or alcohol hand rubs.
Again, as with all the previous products,
choose products that contain emollients or
other skin conditioners to help with the
drying effects of continual handwashing.
Handwashing techniques used with non-
antimicrobials are the same as those
described for anti-microbial handwashing.
Hand Care Products
Hand care products such as lotions are very
important in maintaining healthy skin.
Remember, our skin is our first line of
defense from disease transmission. When
the skin is no longer intact, we have lost an
important part of our defense system. The
Dental Board of California has adopted the
following regulation . “Healthcare workers
who have exudative lesions or weeping
dermatitis of the hand shall refrain from all
direct patient care and from handling patient
care equipment until the condition
resolves. “
Exudative lesions or weeping dermatitis are
serious concerns for the dental professional,
however, lesser skin conditions are of
concern as well. Below are several examples
of minor skin conditions that are placing
individuals at risk for disease transmission.
All of these conditions are reversible and
preventable. Unfortunately, the individuals
in these photographs were unaware that they
were jeopardizing their own health and
potentially the health of their patients by
working in the dental profession with these
chronic conditions. Conditions such as nail
–biting, severe dry skin, and poor cuticle
health should be corrected.
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The individual pictured above obviously
chews their nails and skin around their nails.
This habit may be difficult to break, but it
needs to be curtailed in order to achieve
appropriate skin protection.
Lotions should be available and used often
during the workday. Lotions used during the
workday should be free of petroleum-based
components. Petroleum-based products can
reduce the integrity of many types of gloves.
Several brands of lotions are available
specifically for healthcare workers. These
products:
• Have emollients or other skin
conditioners
• Do not contain petroleum products
• Are compatible with patient
treatment gloves.
As with other hand care products fragrance,
ease of use, and other factor will determine
weather staff will use the products.
Consulting with all staff members to help
choose products will help encourage their
use. Although cost may be a factor in
choosing hand care products, it should be of
low priority. If a less expensive product is
chosen, but on one uses the product because
they are offended by it’s fragrance for
example, you have wasted your money.
Choosing the correct products and
encouraging their use will go a long way to
help keep skin healthy.
FingernailsFingernails should be kept short, clean and
in good condition. “Studies havedocumented that subungual areas (under thefingernails) of the hand harbor highconcentrations of bacteria, most frequently
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coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.),Corynebacteria, and yeasts. (5, 6)
“Even after careful handwashing or the useof surgical scrubs, personnel oftenharbor substantial numbers of potentialpathogens in the subungual spaces.” (7-8).
The photograph below is an individual with
inappropriate nails for a dental professional.
They are:
• Long
• Dirty
• Have remnants of nail polish which
harbor even more microbes
The length of these nails make it more likely
that gloves integrity will be jeopardized
during glove placement and removal.
This individual should trim her nails, keep
them clean, and either not use polish, or
maintain it in a better manner.
Although nail polish has not been shown to
increase microbial counts on the hands,
chipped polish, and polish remnants do
increase microbial levels
Artificial Nails
Artificial nails have been linked to higher
concentrations of gram-negative organisms
than are found on individuals without
artificial nails. Several studies have shown a
link between artificial nails and the outbreak
of serious diseases in hospital settings.
Artificial nails tend to be longer, which also
makes the placement and removal of gloves
more difficult.
Jewelry
“Several studies have demonstrated that skin
underneath rings is more heavily colonized
than comparable areas of skin on fingers
without rings (9-11) One study found that
40% of nurses harbored gram-negative
bacilli (e.g., E. cloacae, Klebsiella, and
Acinetobacter) on skin under rings and that
certain nurses carried the same organism
under their rings for several months (12).
In addition to increased microbes, wearing
hand jewelry increases the possibility that
gloves will be torn or thinned during
placement and removal.
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Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force
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Effectiveness of a hospital-wide programme
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Lancet 2000;356:1307--125.. McGinley KJ, Larson EL, Leyden JJ.Composition and density ofmicroflora in the subungual space of thehand. J Clin Microbiol1988;26:950–3.6. Hedderwick SA, McNeil SA, Lyons MJ,Kauffman CA. Pathogenic organismsassociated with artificial fingernails worn byhealthcare work- ers. Infect Control Hosp
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Lowbury EJL. Aseptic methods in the
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