Your first line of defence
Basic hand washing techniques should be second nature to all practising 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 (Boyce JM, Pittet D, 2002; Wilkins EM, 2005; Centers for Disease and Control Prevention, 2003).
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 (Wilkins EM, 2005).
Effective hand care (hands, wrists and forearms) is essential for all healthcare workers (HCWs) (Daniel SJ, Harfst SA, Wilder RS, 2008; Larson EL, 1995; Organization for Safety and Asepsis Procedures, 1997; Huber MA, Holton RH, Terezhalmy GT, 2006).
Hand washing reduces two types of bacterial flora: resident flora and transient flora on the skin (Florman M, 2007). Resident flora colonises several skin layers and is least likely to transmit disease, while transient flora colonises outer skin surface layers that easily transmit disease and contaminate surfaces touched (Centers for Disease and Control Prevention, 2003; Florman M, 2007; Darby ML, 2006). Transient flora is removed by hand washing (Centers for Disease and Control Prevention, 2003; Florman M, 2007; Darby ML, 2006).
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 odours while working with human corpses (Labarraque AG, 1829).
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 (Centers for Disease Control and Prevention, 1993).
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).
The 1985 guidelines suggested washing with plain soap and water for general hand care. 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 micro-organisms acquired on hands from direct or indirect patient care. 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.
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 micro-organisms on moist hands when gloves are worn: ‘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.’
Antiseptic soaps should contain broad spectrum activity, be fast-acting and have a persistent effect to significantly reduce micro-organisms on intact skin (Centers for Disease Control and Prevention, 2003; Garner JS, Favero MS, 2003).
Alcohol-based hand rubs need to contain antiseptics such as chlorhexidine, quarternary ammonium compounds, octenidine or triclosan to inhibit the micro-organisms on skin contact when applied (Centers for Disease Control and Prevention, 2003; Darby ML, Walsh MM. 2003). The efficacy of antiseptics depends upon various factors, including the length of scrubbing procedures, hand conditions, drying techniques and gloving (Centers for Disease Control and Prevention, 2003).
Checks and balances prior to washing
Before hand washing, standard practice should include checking fingernails, intact skin surfaces and jewellery 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 (Centers for Disease Control and Prevention, 2003; 2008). When nails are short, polish may be worn provided no chipping is present, which can harbour bacteria (Centers for Disease Control and Prevention, 2003). Carefully observe hands, wrists and forearms for any potential skin breaks that may allow for the transportation of organisms (DePaola LG, Fried JI, 2007). If the skin is compromised, i.e. weeping, dermatitis, etc, determine what steps may be necessary to continue safely 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 (Centers for Disease Control and Prevention, 2003; DePaola LG, Fried JI, 2007). Personal jewellery should be removed due to the larger quantity of bacteria that reside on its surfaces. Jewellery can also make bacterial removal more difficult and skin surfaces under rings have increased bacteria present (Promed, 2008). Considering these factors, refrain from wearing rings, which can also potentially puncture gloves. Other jewellery such as earrings, necklaces, brooches and watches need to be removed to avoid aerosol contamination and direct contact (Wilkins EM, 2005; Centers for Disease Control and Prevention, 2003; Daniel SJ, Harfst SA, Wilder RS, 2008; De Paoloa LG, Fried JI, 2007; Eklund KJ, Bednarsh H, 2007). Hand washing agents
Hand washing has four general categories: plain hand wash, antiseptic hand wash, antiseptic hand rub, and surgical antisepsis or surgical scrub (Wilkins EM, 2005; Centers for Disease Control and Prevention, 2003).
1. Plain soap and water
Non-antimicrobial liquid soap and water rinse transient flora micro-organisms away. Bar soap is not recommended because of the build-up of transient flora micro-organisms.
2. Antiseptic wash
Antimicrobial liquid soap (e.g. chlorhexidine, iodine and iodophors, chloroxylenol [PCMX], triclosan) and water eliminate transient flora and reduce resident flora.
3. Antiseptic hand rub
Alcohol-based hand rub (no water necessary) containing 60%-95% ethanol or isopropanol can be used on unsoiled hands.
4. Surgical antisepsis/surgical scrub
Antimicrobial liquid soap and water eliminate transient flora and reduce resident flora with prolonged exposure, inhibiting proliferation or survival of micro-organisms.
There are three hand washing techniques: routine soap and water hand washing (non-antimicrobial or antimicrobial soaps); alcohol-based rub; and surgical scrub. See Table 1 overleaf 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.
Boyce JM, Pittet D (2002) Healthcare infection control practices advisory committee. HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations 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 51 (RR-16): 1
Centers for Disease Control and Prevention (1993) Recommended infection-control practices for dentistry. MMWR Recomm Rep 42(RR-8): 1-12
Centers for Disease Control and Prevention (2003) Guidelines for infection control in dental health-care settings. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed 12 February 2008
Centers for Disease Control and Prevention (2008) Hand Hygiene Guidelines Fact Sheet. Available at: www.cdc.gov/od/oc/media/ pressrel/fs021025.htm. Accessed 12 February 2008
Daniel SJ, Harfst SA, Wilder RS (2008) Mosby’s Dental Hygiene Concepts, Cases and Competencies. 2nd ed. St Louis: Mosby Elsevier; 108-109, 127-130
Darby ML, Walsh MM (2003) Dental Hygiene Theory and Practice. 2nd ed. St Louis: Saunders; 88-90
Darby ML (2006) Mosby’s Comprehensive Review of Dental Hygiene. 6th ed. St Louis: Mosby Elsevier; 407-409
DePaola LG, Fried JI (2007) Hand hygiene: the most effective way to prevent the spread of disease. Access 11: 22-27
Eklund KJ, Bednarsh H (2007) The critical component. Dimensions of Dental Hygiene 5(1): 20-24
Florman M (2007) Hand hygiene saves lives. RDH 27(12): 1-8
Garner JS, Favero MS (1986) CDC guideline for hand washing and hospital environmental control. Infect Control 7: 231-235
Huber MA, Holton RH, Terezhalmy GT (2006) Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract 7: 37-45
Labarraque AG (1829) Instructions and Observations Regarding the Use of the Chlorides of Soda and Lime. Porter J, ed. New Haven, Conn: Baldwin and Treadway
Larson EL (1995) APIC guideline for hand washing and antisepsis in healthcare settings. Am J Infect Control 23: 251-269
Organization for Safety and Asepsis Procedures (1997) Infection Control In Dentistry Guidelines. Annapolis, Md: OSAP
Promed (2008) 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 12 February 2008
Scaramucci MK, Pacak DK (2006) The foundation of infection control. RDH 4(1): 18-20
Wilkins EM (2005) Clinical Practice of the Dental Hygienist. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 56-58, 1135