1

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

2

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.

3

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

4

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.

5

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)

6

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

7

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.

8

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

9

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.

10

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

11

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.

12

1. the Healthcare Infection Control Practices

Advisory Committee and the

HICPAC/SHEA/APIC/IDSA Hand Hygiene

Task Force

2. Casewell M, Phillips I. Hands as route of

transmission for Klebsiella species. Br Med

J 1977;2:1315--7.

3. Larson EL, Early E, Cloonan P, Sugrue S,

Parides M. An organizational climate

intervention associated with increased

handwashing and decreased nosocomial

infections. Behav Med 2000;26:14--22.

4. Pittet D, Hugonnet S, Harbarth S, et al.

Effectiveness of a hospital-wide programme

to improve compliance with hand hygiene.

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

Epidemiol 2000;21:505–9.

7.. Pottinger J, Burns S, Manske C. Bacterialcarriage by artificial versus natural nails.Am J Infect Control 1989;17:340–4.8. McNeil SA, Foster CL, Hedderwick SA,Kauffman CA. Effect of hand cleansing withantimicrobial soap or alcohol-based gel onmicrobial colonization of artificialfingernails worn by health care workers.Clin Infect Dis 2001;32:367–72.

Lowbury EJL. Aseptic methods in the

operating suite. Lancet 1968;1:705--9.

9. Hoffman PN, Cooke EM,

McCarville MR, Emmerson AM. Micro-

organisms isolated from skin under wedding

rings worn by hospital staff. Br Med J

1985;290:206--7.

10. Jacobson G, Thiele JE, McCune JH,

Farrell LD. Handwashing: ring-wearing and

number of microorganisms. Nurs Res

1985;34:186--8.

11. Hayes RA, Trick WE, Vernon MO,

et al. Ring use as a risk factor (RF) for hand

colonization in a surgical intensive care unit

(SICU) [Abstract K-1333]. In: Program and

abstracts of the 41st Interscience Conference

on Antimicrobial Agents and

Chemotherapy. Washington, DC: American

Society for Microbiology, 2001.

12. Salisbury DM, Hutfilz P, Treen LM,

Bollin GE, Gautam S. The effect of rings on

microbial load of health care workers' hands.

Am J Infect Control 1997;25:24--7.