Your First Line of Defense

Proper hand washing protects you and your patients.

By Sandra Nagel Beebe, RDH, PhD On Mar 13, 2008 0

Basic hand washing techniques should be second nature to all practicing dental hygienists. However, as dental hygienists are faced with many responsibilities while being pressed for time, compliance with hand washing techniques may wane.

The benefits of performing proper hand washing techniques have been taught for generations.^1-3 Throughout all 10 editions of Wilkins’ Clinical Practice of the Dental Hygienist, hand care and washing are discussed as essential for reducing the bacterial flora present on skin while reducing the transference of organisms to patients’ skin.²

Effective hand care (hands, wrists, and forearms) is essential for all health care workers (HCWs).^4-7 Hand washing reduces two types of bacterial flora—resident flora and transient flora on the skin.⁸ Resident flora colonizes several skin layers and is least likely to transmit disease, while transient flora colonizes outer skin surface layers that easily transmit disease and contaminate surfaces touched.^3,8-9 Transient flora is removed by hand washing.^3,8-9

KEY POINTS

Hand washing is the primary disease prevention procedure.
Hand washing reduces resident flora and transient flora bacteria on skin surfaces.
Wash before and after when gloves are changed.
Antimicrobial soaps are more effective than nonantimicrobial soap and water.
Use alcohol-based rubs intermittently to avoid emollient build-up on skin surfaces or for hands not visibly soiled.

A HISTORY OF HAND WASHING

History has documented disinfection and antiseptics in science since 1822 when a French pharmacist, Labarraque, provided the first solution for moistening hands. He created a solution containing chlorides of lime or soda to eradicate foul odors while working with human corpses.¹⁰ In 1846, Semmelweis discovered that students and physicians who cleansed their hands between patient care (autopsy to obstetrics) with an antiseptic agent (chlorine solution), versus plain soap and water, reduced the transmission of contagious diseases more effectively.¹¹

According to the Centers for Disease Control and Prevention’s (CDC) Guidelines for Infection Control In Dentistry, 1993 and 2003, the single most critical measure available to prevent cross-contamination for HCWs, patients, and from patient-to-patient is hand hygiene (hand washing, hand antisepsis, or hand surgical antisepsis).^3,11 The 1985 guidelines suggested washing with plain soap and water for general hand care.³ In 1993, the CDC updated its guidelines and recommended the use of antimicrobial surgical hand scrub during surgical procedures while plain soap and water were sufficient during routine dental procedures to remove transient microorganisms acquired on hands from direct or indirect patient care.¹¹ The CDC 2003 hand hygiene guidelines recommend a plain or antimicrobial (antisepsis) soap and water or an alcohol-based hand rub to remove the transient flora.¹¹

When surgical hand washing is required, the CDC recommends the use of antimicrobial soap or alcohol hand rub to prevent or inhibit the rapid production of microorganisms on moist hands when gloves are worn.³ “The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident flora for the duration of a procedure to prevent introduction of organisms in the operative wound if gloves become punctured or torn.”³ Antiseptic soaps should contain broad spectrum activity, be fast-acting, and have a persistent effect to significantly reduce microorganisms on intact skin.^3,12

Alcohol-based hand rubs need to contain antiseptics such as chlorhexidine, quarternary ammonium compounds, octenidine, or triclosan to inhibit the microorganisms on skin contact when applied.^3,13 The efficacy of antiseptics depends on various factors including the length of scrubbing procedures, hand conditions, drying techniques, and gloving.³

CHECKS AND BALANCES PRIOR TO WASHING

Before hand washing, standard practice should include checking fingernails, intact skin surfaces, and jewelry removal. Fingernails should be trimmed short to the end of the fingertips (< than 1/4 inch in length) and nails should be filed smooth to decrease the rate of bacteria embedded under or near rough edges/surfaces. Bacteria most commonly reside in the areas under the nails. Artificial nails and nail tip extenders are not recommended due to the increased ability for fungi and bacteria (gram negative organisms) to thrive.^3,14 When nails are short, polish may be worn provided no chipping is present, which can harbor bacteria.³ Carefully observe hands, wrists, and forearms for any potential skin breaks that may allow for the transportation of organisms.¹⁵ If the skin is compromised, ie, weeping, dermatitis, etc, determine what steps may be necessary to safely continue or reschedule patients. Typical skin concerns include inflamed or broken skin due to an injury or scrape, skin erosions, psoriasis, eczema, dermatitis, and cracked, dry, or chapped skin.^3,15 Personal jewelry should be removed due to the larger quantity of bacteria that reside on its surfaces. Jewelry can also make bacterial removal more difficult and skin surfaces under rings have increased bacteria present.¹⁶ Considering these factors, refrain from wearing rings, which can also potentially puncture gloves. Other jewelry such as earrings, necklaces, pins, and watches, needs to be removed to avoid aerosol contamination and direct contact.^2-4,15,17

HAND WASHING AGENTS

Hand washing has four general categories: plain hand wash, antiseptic hand wash, antiseptic hand rub, and surgical antisepsis or surgical scrub.^2-3

Plain soap and water. Nonantimicrobial liquid soap and water rinse transient flora microorganisms away. Bar soap is not recommended because of the build-up of transient flora microorganisms.
Antiseptic wash. Antimicrobial liquid soap (eg, chlorhexidine, iodine and iodophors, chloroxylenol [PCMX], triclosan) and water eliminate transient flora and reduce resident flora.
Antiseptic hand rub. Alcohol-based hand rub (no water necessary) containing 60%-95% ethanol or isopropanol can be used on unsoiled hands.
Surgical antisepsis/surgical scrub. Antimicrobial liquid soap and water eliminate transient flora and reduce resident flora with prolonged exposure, inhibiting proliferation or survival of microorganisms.

There are three hand washing techniques: routine soap and water hand washing (nonantimicrobial or antimicrobial soaps), alcohol-based rub, and surgical scrub. See Table 1 for recommended hand washing techniques.

Hand washing is an integral part of providing quality care to patients. The CDC offers the most up-to-date data available in preventing infection transmission so checking its website—www.cdc.org—for updates will help dental hygienists stay at the forefront of practice.

Table 1. Recommended Handwashing Techniques^{1,2,5,13,16,17}
Prior to Handwashing
Step	Procedure	Rationale
1.	Remove jewelry, artificial nails, chipped nail polish, nails short and filed	• Harbors microorganisms transmitting infections
2.	Observe hands, wrists, and forearms for breaks or inflamed surfaces	• To eliminate potential portals of entry or exit of organisms • Inflammations weeping or draining=>Cover inflammation or reschedule to avoid cross contamination
3.	Activate water flow and temperature=> cool to lukewarm temperature	• Hot water opens pores for contamination • Cool water closes pores
Routine Soap and Water Hand Washing Technique Nonantimicrobial or Antimicrobial Soap
Step	Procedure	Rationale
1.	Wet forearms, wrists, and hands	• Water flows from least to most contaminated
2.	Apply antimicrobial liquid soap; lather 15-30 seconds on forearms, wrists, and hands	• Reduces microbial flora • Rub hands together interlacing thumbs and fingers, rub in circular motion palms and backs of hands, minimum 15 seconds to reduce organisms’ colonization
3.	Rinse, repeat steps one through three two additional times	• More effective for three short latherings • Repeated steps loosens debris and micro organisms
4.	Dry thoroughly with paper towels; raise wet hands up; dry hands/wrist/forearms; using dry paper towel, turn water off	• One time use and paper towel is disposable
Antiseptic Hand Rub Procedures Initiate hand washing with antimicrobial liquid soap/water to thoroughly cleanse. Repeat antimicrobial soap/water hand washing after every five to 10 antiseptic hand rubs to avoid emollient build-ups. Antiseptic Hand Rub
Step	Procedure	Rationale
1.	Apply alcohol-based product amount (according to label’s direction) into palm of hand depressing dispenser with paper towel	• Apply disinfectant to dry hands, rub hands together interlacing fingers until product completely absorbed • Saves significant time
2.	If hands are visibly soiled, do not use until washed with soap/water	• Remove excess microorganisms
3.	With rigorous use, hands may suffer drying and chapping	• Use emollient hand cream to prevent drying and chapping
Routine Soap and Water Hand Washing Technique Nonantimicrobial or Antimicrobial Soap
(Modified from resources)^{2, 15, 17, 19}
Step	Procedure	Rationale
1.	Perform handwashing techniques; use nail cleaner under nails if needed; extend length of time using surgical liquid antimicrobial soap to remove surface dirt; thoroughly dry fingers to elbow with paper towels	• Same techniques but allow 5-10 minutes to prepare initially; subsequent surgeries, scrub time may decrease to 5 minutes
2.	Perform antiseptic (alcohol-based) hand rub procedure as above	• Bioburdens are removed so alcohol based product has persistent activity

REFERENCES

Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recom?men?dations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. ?02;51(RR-16):1.
Wilkins EM. Clinical Practice of the Dental Hygienist. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:56-58, 1135.
Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings, 2003. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed February 12, 2008.
Daniel SJ, Harfst SA, Wilder RS. Mosby’s Dental Hygiene Concepts, Cases, and Competencies. 2nd ed. St Louis: Mosby Elsevier; 2008:108-109,127-130.
Larson EL. APIC guideline for hand washing and antisepsis in health care settings. Am J Infect Control. 1995;23:251-269.
Organization for Safety and Asepsis Procedures. Infection Control In Dentistry Guidelines. Annapolis, Md: OSAP; 1997.
Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7:37-45.
Florman M. Hand hygiene saves lives. RDH. 2007;27(12):1-8.
Darby ML. Mosby’s Comprehensive Review of Dental Hygiene. 6th ed. St Louis: Mosby Elsevier; 2006:407-409.
Labarraque AG. Instructions and Observations Regarding the Use of the Chlorides of Soda and Lime. Porter J, ed. New Haven, Conn: Baldwin and Treadway; 1829.
Recommended infection-control practices for dentistry, 1993. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1993; 42(RR-8):1-12.
Garner JS, Favero MS. CDC guideline for hand washing and hospital environmental control, 1985. Infect Control. 1986;7:231-235.
Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 2nd ed. St Louis: Saunders; 2003:88-90.
Hand Hygiene Guidelines Fact Sheet. CDC. Available at: www.cdc.gov/od/oc/media/pressrel/fs021025.htm. Accessed February 12, 2008.
DePaola LG, Fried JI. Hand hygiene: the most effective way to prevent the spread of disease. Access. 2007;11:22-27.
PROMED. Guidelines for best practice in cross infection control. A reference guide for dentists and dental nurses. Available at: www.promed.ie/acatalog/CICDental.pdf. Accessed February 12, 2008.
Eklund KJ, Bednarsh H. The critical component. Dimensions of Dental Hygiene. 2007;5(1):20-24.
Scaramucci MK, Pacak DK. The foundation of infection control. RDH. 2006;4(1):18-20.

From Dimensions of Dental Hygiene. March 2008;6(3): 28-29.