A SELF STUDY GUIDE

®

HAND HYGIENE: SKIN AND HAND CARE IN THE DENTAL SETTING

Dental Professionals

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

OVERVIEWHealthcare-Associated Infections (HAIs) are infections acquired in healthcare settings and are the most frequent adverse

events in healthcare. Hundreds of millions of patients are affected by HAIs worldwide each year, leading to signifi cant

mortality and fi nancial losses for health systems. Of every 100 hospitalized patients at any given time, 7 in developed and

10 in developing countries will acquire at least one HAI.1 The endemic burden of HAI is also signifi cant. The prevalence

of HAIs in developed countries varies between 3.5% and 12%. The European Centre for Disease Prevention and Control

reports an average prevalence of 7.1% in European countries. The estimated incidence rate in Canada is 11.6% and in the

U.S. is 4.5%, corresponding to 2 million affected patients annually.1 It has been estimated that overall prevalence of HAIs

in Australia is 9.7%, affecting as many as 150,000 patients each year.2

Cross-infection and cross-contamination can occur multiple ways in various healthcare settings. In the dental setting, the

oral cavity is a perfect environment for bacteria and viruses from the nose, throat and respiratory tract and transmission

of healthcare-associated pathogens most often occurs via the contaminated hands of healthcare professionals (HCPs).3, 4

Accordingly, hand hygiene (i.e. hand washing with soap and water or use of a waterless, alcohol-based hand rub) has long

been considered one of the most important infection control measures for preventing HAI. However, compliance by HCPs

with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50% of

hand hygiene opportunities.

LEARNER OBJECTIVESUpon completion of this educational activity, the learner should be able to:

1. Describe three functions of the skin.

2. List two reasons why HCPs may not be compliant with hand hygiene guidelines.

3. Describe rationale for maintaining good skin integrity.

4. List three hand hygiene products used by healthcare providers.

5. Describe methods to enhance skin health.

INTENDED AUDIENCE The information contained in this self-study guidebook is intended for use by healthcare professionals

who are responsible for or involved in the following activities related to this topic:

• Educating healthcare personnel

• Establishing institutional or departmental policies and procedures

• Decision-making responsibilities for hand-barrier products

• Maintaining regulatory compliance with agencies

• Managing employee health and infection prevention services

INSTRUCTIONS Ansell is approved for 2 hours of verifi able CPD by the New Zealand Dental Council and is an ADA CERP Recognized

Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality

providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does

it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about the CE provider may be directed

to the provider or to ADA CERP and ADA.org/CERP. Obtaining the full 2.25 contact hour credit for this offering depends on

completion of the self-study materials on-line as directed below.

Approval refers to recognition of educational activities only and does not imply endorsement of any product or company

displayed in any form during the educational activity.

To receive contact hours for this program, please go to the “Program Tests” area and complete the post test. You will

receive your certifi cate via email.

AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION.

Any learner who does not successfully complete the post test will be notifi ed and given an opportunity to resubmit

for certifi cation.

Ansell Healthcare Products LLC has an ongoing commitment to the development of quality products and services for

the healthcare industry. This self-study is one in a series of continuing educational services provided by Ansell.

For more information about our educational programs or perioperative safety solution topics, please contact

Ansell Healthcare Educational Services at 1-732-345-2162 or e-mail us at edu@ansellhealthcare.com

Planning Committee Members:

Luce Ouellet, BSN, RN

Latisha Richardson, MSN, BSN, RN

Patty Taylor, BA, RN

Pamela Werner, MBA, BSN, RN, CNOR

As employees of Ansell Ms. Ouellet, Mrs. Richardson, Mrs. Taylor and Ms. Werner have declared an affi liation that could be perceived as posing a potential confl ict of interest with development of this self-study module.

This module will include discussion of commercial products referenced in generic terms only.

2

Original release date – March 2007 Last review date – August 2016 Expiration date – June 2020

TABLE OF CONTENTS

OVERVIEW ........................................................................................................................2

INTRODUCTION ...............................................................................................................4

FUNCTIONS OF SKIN .......................................................................................................5

SKIN COMPONENTS .......................................................................................................5

LAYERS OF THE SKIN ..................................................................................................... 6

SKIN PERMEABILITY ......................................................................................................8

HISTORY OF HAND HYGIENE ..........................................................................................9

CLINICAL SKIN ISSUES ..................................................................................................10

HAND CARE OPTIONS ...................................................................................................12

HAND HYGIENE COMPLIANCE ......................................................................................14

MEDICAL GLOVES ...........................................................................................................18

NEW INNOVATIONS & NEXT GENERATION ................................................................ 19

SUMMARY .......................................................................................................................20

GLOSSARY .......................................................................................................................21

BIBLIOGRAPHY ................................................................................................................22

REFERENCES ....................................................................................................................23

3

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

INTRODUCTIONIntact skin is the best barrier protection against

microorganisms. The skin is the body’s largest organ, covering

a surface of approximately 2 square meters. It varies in

thickness from 2-3 mm. It is remarkably resilient and is an

effective barrier to microorganisms. The human skin has

an amazing ability to regenerate and renew itself in an

orderly fashion.

Today’s healthcare environment is demanding on the skin.

The hands of healthcare professionals (HCPs) are a frequent

vehicle for the transmission of pathogens to the patient and to

the environment. The importance of hand hygiene in our ever

changing world of bloodborne pathogens (BBP), healthcare-

associated infections (HAI), multiple drug-resistant organisms

(MDRO), infl uenza and pandemic potentials (H1N1, Ebola, etc.)

makes it crucial for us to be mindful of the recommended hand

hygiene practices.

Vancomycin-resistant Staphylococcus aureus

With dental professionals working outside the acute care

setting without the guidance and monitoring of an infection

preventionist or epidemiologist, tracking possible HAIs and

associated infection prevention practices is a diffi cult task.5

Due to these heightened concerns, there has been a focus by

a number of professional organizations, government agencies

and regulating bodies on improving handwashing compliance

among all HCPs across all settings.

Being unacquainted with effective hand hygiene practices may

be a contributing factor in noncompliance to recommended

hand hygiene protocols. Education is a vehicle to provide

knowledge, awareness, and information so that HCPs; nurses,

technicians, physicians dental practitioners, dental assistants,

dental hygienists, and all allied healthcare providers such

as Life Science, Emergency Medical Services (EMS), and

Correctional Services, can make the informed, committed

decision to do the right thing, improve compliance and have an

impact on bringing and keeping infections under control.

4

FUNCTIONS OF SKIN

Because it interfaces with the environment, skin plays a key

role in protecting the body against pathogens and excessive

water loss. Its other functions are insulation, temperature

regulation, sensation, synthesis of vitamin D, and the

protection of vitamin B folates.

Skin performs the following functions:

1. Protection: an anatomical barrier from pathogens and

damage between the internal and external environment

in bodily defense; Langerhans cells in the skin are part

of the adaptive immune system.

Langerhans cells

2. Sensation: contains a variety of nerve endings that

react to heat and cold, touch, pressure, vibration, and

tissue injury.

3. Heat regulation: the skin contains a blood supply far

greater than its requirements which allows precise

control of energy loss by radiation, convection and

conduction. Dilated blood vessels increase perfusion

and heat loss, while constricted vessels greatly reduce

cutaneous blood fl ow and conserve heat.

4. Control of evaporation: the skin provides a relatively

dry and semi-impermeable barrier to fl uid loss. Loss

of this function contributes to the massive fl uid loss

in burns.

5. Aesthetics and communication: others see our

skin and can assess our mood, physical state and

attractiveness.

6. Storage and synthesis: acts as a storage center for

lipids and water, as well as a means of synthesis of

vitamin D by action of UV on certain parts of the skin.

7. Excretion: sweat contains urea, however its

concentration is 1/130th that of urine, hence excretion by

sweating is at most a secondary function to temperature

regulation.

8. Absorption: the cells comprising the outermost 0.25-

0.40 mm of the skin are “almost exclusively supplied by

external oxygen” (Stücker, 2002). In addition, medicine

can be administered through the skin, by ointments or by

means of adhesive patch. The skin is an important site of

transport in many other organisms.

9. Water resistance: The skin acts as a water resistant

barrier so essential nutrients aren’t washed out of

the body.

SKIN COMPONENTSSkin has mesodermal cells, pigmentation, or melanin

provided by melanocytes, which absorb some of the potentially

dangerous ultraviolet radiation (UV) in sunlight. Skin also

contains DNA-repair enzymes that help reverse UV damage,

such that people lacking the genes for these enzymes suffer

high rates of skin cancer. One form predominantly produced by

UV light, malignant melanoma, is particularly invasive, causing

it to spread quickly, and can often be deadly. Human skin

pigmentation varies among populations in a striking manner.

This has led to the classifi cation of people(s) on the basis

of skin color.

The skin is the largest organ in the human body. For the average

adult human, the skin has a surface area of between 1.5-2.0

square meters (16.1-21.5 sq. ft.), most of it between 2–3 mm

(0.10 inch) thick. The average square inch (6.5 cm²) of skin holds

650 sweat glands, 20 blood vessels, 60,000 melanocytes, and

more than 1,000 nerve endings.

5

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

SKIN LAYERSSkin is composed of three primary layers:

• the epidermis, which provides waterproofi ng and serves

as a barrier to infection;

• the dermis, which serves as a location for the

appendages of skin; and

• the hypodermis (subcutaneous adipose layer).

EpidermisEpidermis, coming from the Greek “epi” meaning “over”

or “upon," is the outermost layer of the skin. It forms the

waterproof, protective wrap over the body’s surface and is

made up of stratifi ed squamous epithelium with an underlying

basal lamina. The epidermis is the thinnest at eyelids being

approximately 0.05 mm and thickest at the palm or soles,

approximately 1.5 mm.

The epidermis contains no blood vessels, and cells in the

deepest layers are nourished almost exclusively by diffused

oxygen from the surrounding air and to a far lesser degree by

blood capillaries extending to the upper layers of the dermis.

The main type of cells which make up the epidermis are Merkel

cells and keratinocytes, with melanocytes and Langerhans cells

also present.

The epidermis can be further subdivided into the following

strata (beginning with the outermost layer): corneum,

lucidum (only in palms of hands and bottoms of feet),

granulosum, spinosum, and basale. The corneum layer of

the epidermis consists of 25 to 30 layers of dead cells.

This layer regulates water loss and prevents harmful

pathogens from entering the body.

6

DermisThe dermis is the layer of skin beneath the epidermis that

consists of connective tissue and cushions the body from stress

and strain. The dermis is tightly connected to the epidermis

by a basement membrane. It also harbors many nerve endings

that provide the sense of touch and heat. It contains the hair

follicles, sweat glands, sebaceous glands, apocrine glands,

lymphatic vessels and blood vessels. The blood vessels in the

dermis provide nourishment and waste removal from its own

cells as well as from the Stratum basale of the epidermis.

The dermis is structurally divided into two areas: a superfi cial

area adjacent to the epidermis, called the papillary region, and

a deep, thicker area known as the reticular region.

7

HypodermisThe hypodermis is not part of the skin, and lies below the

dermis. Its purpose is to attach the skin to underlying bone and

muscle as well as supplying it with blood vessels and nerves.

It consists of loose connective tissue and elastin. The main

cell types are fi broblasts, macrophages and adipocytes (the

hypodermis contains 50% of body fat). Fat serves as padding

and insulation for the body.

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

8

SKIN PERMEABILITYHuman skin has a low permeability; that is, most foreign

substances are unable to penetrate and diffuse through

the skin. However, dry skin may occur reducing the barrier

effectiveness of the skin. Dry skin is a result of decreased

water content in the outermost layers of the stratum corneum

(Rawlings). This disruption of the skin’s natural barrier function

has a number of causes unique in the healthcare setting. The

constant need to wear gloves, due to Standard Precautions

guidelines, means hands are in a perspiration environment

that softens the skin and weakens the epidermis.

Additionally, frequent handwashing with detergents or soaps

and/or use of alcohol-based hand rubs can attack the skin’s

lipid layer. Seasonal changes in humidity, soaps, detergents,

caustic chemicals, and metals commonly used in the dental

setting, like nickel, chromium, mercury, amalgam, glutaralde-

hyde, can affect the skin.4,6 Glove powders can be irritating

to the skin, like sand in your shoe. And the friction of donning

and removing gloves numerous times during the workday can

increase skin irritation.

HISTORICAL REVIEW OF HAND HYGIENEA number of historic events and discoveries that occurred in

the U.S. and Europe in the 1800s set the stage for our current

knowledge in microorganisms and disease processes.

1825 – Earliest paper on hand hygiene published. It

suggested that utilizing a liquid chlorine solution would

benefi t healthcare workers.

1843 – Oliver Wendell Holmes (1809-1894) – His independent

work on spread of puerperal fever, The Contagiousness of

Puerperal Fever.

1847 – Ignaz Semmelweis (1818-1865) – work utilizing

chlorinated lime solutions for washing hands to decrease the

incidence of puerperal fever.

1865 – Louis Pasteur (1822–1895) – Germ Theory – explains

that germs can cause infectious diseases.

1867 – Joseph Lister (1827-1912) – Carbolic acid solution to

cleanse and dress wounds.

1878 – Robert Koch (1843-1910) – Utilizes steam sterilization

for surgical instruments and dressings.

1896 – William Halsted requests that a surgical glove be

made for his assistant.

Regulatory agencies and professional organizations develop and refi ne hand hygiene guidelines to meet patient and staff safety needs.

1961 – U.S. Public Health Service – Recommended hand

washing prior to having patient contact.

1975 – CDC writes formal guidelines for handwashing.

1985 – CDC revises written guidelines for handwashing.

1987 – Universal Precautions/Standard Precautions

1988 – APIC guidelines for hand washing and hand

antisepsis.

1991 – Bloodborne Pathogens (BBP) Standard

1995 – APIC guidelines published with detailed discussion on

alcohol-based hand rubs

1995 and 1996 – HICPAC recommends antimicrobial soap or

waterless antiseptic agent for cleaning hands for multiple

drug-resistant organisms (MDRO)

2003 – CDC Recommended Infection Control Practices for

Dentistry Update

2016 – CDC Summary of Infection Prevention Practices in

Dental Settings: Basic Expectations for Safe Care

9

Ignaz Semmelweis

William Halsted

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

CLINICAL SKIN ISSUESThe healthy, intact condition of our skin is our best barrier

protection, but there are a number of factors in the healthcare

environment that affect the skin’s condition. The need to

perform hand hygiene activities throughout the day with

soaps, detergents, alcohol-based rubs and antimicrobials sets

the stage for local skin reactions. One of the most frequent is

irritant contact dermatitis (ICD) which is simply an irritation of

the skin and should not be confused with an allergy. Symptoms

can include redness, chapping, chafi ng, dryness, scaling,

cracking and subjective symptoms such as itching and burning.

In the CDC Guideline for Hand Hygiene in the Health-Care

Setting (2002) the reports of contact dermatitis are frequently

reported as an explanation for non-compliance by HCPs. An

HCP with an ICD is a potential threat to their patient and it is a

serious occupational issue. HCP skin disorders are the number

one occupational illness across all occupations and costs

$1 billion annually (Cantrell 2005).

An ICD is a surface condition affecting the skin. Avoiding

contact with the irritants, including glove powders, and

maintaining a regular regimen of proper skin care will help keep

hands healthier and free of irritation. Damaged skin more often

harbors increased numbers of pathogens. Moreover, washing

damaged skin is less effective at reducing numbers of bacteria

than washing normal skin, and the number of organisms shed

from damaged skin is often higher than from healthy skin.

Irritant contact dermatitis (ICD)

10

Moisturizing is benefi cial for skin health and reducing microbial

dispersion from the skin. These are important concepts when

discussing hand washing techniques and products for hand

washing compliance and skin care.

Any of the antiseptic agents used in healthcare can cause ICD.

It is most commonly reported with iodophors, but chlorhexidine,

PCMX, triclosan and alcohol-based products can also cause

local skin reactions. Industry addresses this issue by its

continued improvement to products.

Today, chemical allergy, or allergic contact dermatitis (ACD),

remains an even more important cause of disability and loss

of work than latex allergy. A chemical allergy is an expansive

allergic condition; combined with ICD, these conditions

represent the second largest occupational disability reported

to U.S. OSHA.7 In Norway, one study discovered that 40% of

dentists suffer from occupational skin disorders. In a Belgian

study, researchers found that 32% of dental practitioners suffer

from job related skin disorders, while another study in Australia

revealed that 9-22% of those employed in dentistry suffer from

the same.8 Occupational contact dermatitis is the most common

occupational skin disease (OSD) in westernized industrial

countries – about 90-95% of all OSD (Lushniak 2000).

Chemical allergy reaction

A survey of U.K. National Health Service (NHS) staff showed

that 43% had signs or symptoms of ICD or allergic ACD, and

10% showed latex hypersensitivity. (Johnson G.1997) In

addition, ACD brings a greater risk of bloodborne pathogen

infection, because the body’s most effective barrier – intact

skin – becomes compromised. The breakdown of the dermis

may also allow latex proteins to enter the body, which may

facilitate latex protein hypersensitivity in some individuals.7

Chemical allergies to glove products are generally associated

with the chemicals used in the glove manufacturing process.

A chemical allergy is due to an immunological reaction to a

residual chemical leached from fi nished glove products into

the skin of the wearer.

The chemicals used in the glove manufacturing process fall into

the following

broad classifi cations:

• Accelerators

• Accelerator activators

• Stabilizers

• Antidegradants

• Retarders

• Fillers

• Extenders

The chemical accelerators induce the majority of chemical

allergies. The residues from these accelerators have become

a major concern because of their ability to sensitize users and

elicit chemical allergic reactions. Over 80% of reported glove-

associated ACD is attributable to chemical accelerators.9

It is important to note that chemical allergy can occur from the

use of both latex and non-latex medical gloves as both types of

gloves are generally manufactured using accelerators.

These fi gures demonstrate that contact dermatitis—whether

irritant or allergic—is a signifi cant issue for those providing

medical and technical services.

11

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

HAND CARE OPTIONSThere is an abundant offering of hand care options in the

medical marketplace. For ease of discussion they are split into

two categories: hand hygiene products and skin care products.

Hand Hygiene Products – Products used in handwashing,

antiseptic handwash, antiseptic hand rub or surgical hand

antisepsis.

Skin Care Products – Products provided for hydration and

improved water retention of the skin.

HAND HYGIENE PRODUCTSThe primary consideration when selecting handwashing/

sanitizing products must be effi cacy. Other factors include,

dermal tolerance, aesthetic preferences (fragrance, foaming,

color), costs, accessibility, and dispensing.

Handwashing products used by HCPs are regulated by

government agencies. There are specifi c test protocols,

procedures and log reductions that must be achieved for the

products to be available in the marketplace. This is also true of

surgical hand antisepsis products.

The following are some of the preparations used for hand

hygiene. These will vary pending government approval.

1. Plain (non-antimicrobial) soapSoaps are detergent-based products that contain esterifi ed

fatty acids and sodium or potassium hydroxide. They are

available in various forms including bar soap, tissue, leafl et, and

liquid or foaming preparations. Their cleaning activity can be

attributed to their detergent properties, which result in removal

of dirt, soil and various organic substances from the hands.

Plain soaps have minimal, if any, antimicrobial activity.

2. AlcoholThe majority of alcohol-based hand antiseptics contain either

isopropanol, ethanol, n-propanol, or a combination of two

of these products. Although n-propanol has been used in

alcohol-based hand rubs in parts of Europe for many years, it is

not listed in Tentative Final Monograph (TFM) as an approved

active agent for HCP handwashes or surgical hand-scrub

preparations in the U.S. A concentration of 60% or higher

is generally required for effi cacy. Alcohols have excellent

in vitro germicidal activity against gram-positive and gram-

negative vegetative bacteria, including multi-drug resistant

organisms (MDRO) (e.g., methicillin-resistant Staphylococcus

aureus (MRSA) and vancomycin-resistant enterococcus (VRE),

Mycobacterium tuberculosis, and various fungi). Alcohols

are not appropriate for use when hands are visibly dirty or

contaminated with proteinaceous materials. It is recommended

12

you wash your hands when visibility dirty. When hands are

not visibility dirty, alcohol hand rub is the preferred method of

decontaminating hands. Alcohols are effective for preoperative

cleaning of the hands of surgical personnel. Some products

have combined alcohol with antimicrobial products such as CHG

to increase effi cacy.

3. Antimicrobial Handwash

Handwash preparations containing antimicrobial agent/s which

demonstrate effi cacy against various microorganisms.

• Chlorhexidine gluconate, was developed in England

in the early 1950s and was introduced into the U.S. in the

1970s. Chlorhexidine gluconate has been incorporated

into a number of hand-hygiene preparations. Aqueous

or detergent formulations containing 0.5% or 0.75%

chlorhexidine are more effective than plain soap, but they

are less effective than antiseptic detergent preparations

containing 4% chlorhexidine gluconate (CDC). Preparations

with 2% chlorhexidine gluconate are slightly less effective

than those containing 4% chlorhexidine (CDC).

• Chlorhexidine has substantial residual activity and

often used as a surgical scrub. Chlorhexidine has a good

safety record with minimal, if any, absorption of the

compound through the skin. (CDC)

• Chloroxylenol, also known as parachlorometaxylenol (PCMX), was developed

in Europe in the late 1920s and has been used in the

U.S. since the 1950s. PCMX is not as rapidly active as

chlorhexidine gluconate or iodophors, and its residual

activity is less pronounced than that observed with

chlorhexidine gluconate.

• Hexachlorophene was fi rst used in the 1950s. Studies

of hexachlorophene as a hygienic handwash and surgical

scrub demonstrated only modest effi cacy after a single

handwash. Hexachlorophene has residual activity for

several hours after use and gradually reduces bacterial

counts on hands after multiple uses.

• Iodines have been recognized as an effective antiseptic

since the 1800s. However, because iodine often causes

irritation and discoloring of skin, iodophors have largely

replaced iodine as the active ingredient in antiseptics.

Iodine and iodophors have bactericidal activity against

gram-positive, gram-negative, and certain spore-forming

bacteria (e.g., clostridia and Bacillus spp.) and are active

against mycobacteria, viruses and fungi.

• Quaternary ammonium compounds. Of this large

group of compounds, alkyl benzalkonium chlorides are

the most widely used as antiseptics. Other compounds

that have been used as antiseptics include benzethonium

chloride, cetrimide, and cetylpyridium chloride. The

antimicrobial activity of these compounds was fi rst

studied in the early 1900s, and a quaternary ammonium

compound for preoperative cleaning of surgeons’ hands

was used as early as 1935.

• Triclosan is a colorless substance that was developed

in the 1960s. It has been incorporated into soaps for use

by HCPs and the public and into other consumer products.

Concentrations of 0.2%–2% have antimicrobial activity.

SKIN CARE PRODUCTSOne has only to look in any grocery store to see the number

of products available for skin care. These products do not

necessarily work well in the healthcare facility, but they do

fi nd their way through the door. The products that should be

provided by the healthcare facility should meet the needs of

HCPs to help minimize ICD that may be associated with their

hand hygiene practices. Additionally, skin care products in

the healthcare environment must not negate the effects of

antimicrobial soaps and rubs used in the facility or compromise

glove barrier materials like latex. Hydrocarbon lotions that

contain petroleum, mineral oil or lanolin fall into this category

(Davis 2008). such products may affect the barrier property of

glove fi lms and particularly latex.

Moisturizing and hydrating ingredients found in skin care

products may include the following:

• Glycerin is noted as being one of the best moisturizers.

It hydrates the dermis due to its water-retaining abilities.

• Citric acid is a pH adjuster that balances acidity

and alkalinity.

• Sorbitol is also used as a moisturizer.

• Gluconolactone helps minimize skin fl aking.

• Chitosan helps to retain moisture.

• Panthenol is a vitamin with moisturizing effects.

13

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

HAND HYGIENE COMPLIANCE

Transmission of pathogens most often occurs via the

contaminated hands of HCPs. Hand hygiene (i.e., handwashing

with soap and water or use of a waterless, alcohol-based hand

rub) has been considered one of the most important infection

control measures for preventing HAIs. However, compliance

by healthcare professionals with recommended hand hygiene

procedures has remained unacceptable, with compliance rates

generally below 50% of hand hygiene opportunities. (CDC,

WHO, ECDC)

Alcohol-based hand rub use

Observed risk factors for poor adherence to recommended hand

hygiene practices*

• Physician status (rather than a nurse)

– Nursing assistant status (rather than a nurse)

– Male sex

• Working in an intensive-care unit

• Working during the week (versus the weekend)

• Wearing gowns/gloves

• Automated sink

• Activities with high risk of cross-transmission

• High number of opportunities for hand hygiene per hour of

patient care

Self-reported factors for poor adherence with hand hygiene*

• Handwashing agents cause irritation and dryness

• Sinks are inconveniently located/shortage of sinks

• Lack of soap and paper towels

• Often too busy/insuffi cient time

• Understaffi ng/overcrowding

• Patient needs take priority

• Hand hygiene interferes with healthcare worker

relationships with patients

14

• Low risk of acquiring infections from patients

• Wearing of gloves/belief that glove use obviates the

need for hand hygiene

• Lack of knowledge of guidelines/protocols

• Not thinking about it/forgetfulness

• No role model among colleagues or superiors

• Skepticism regarding the value of hand hygiene

• Disagreement with the recommendations

Additional perceived barriers to appropriate hand hygiene*

• Lack of active participation in hand hygiene promotion

at individual or institutional level

• Lack of role model for hand hygiene

• Lack of institutional priority for hand hygiene

• Lack of administrative sanction of non-compliers/

rewarding compliers

• Lack of institutional safety climate

* CDC Hand Hygiene Guidelines

Recognizing a need to improve hand hygiene in healthcare

facilities, a number of organizations launched Guidelines

on Hand Hygiene in Healthcare. These global consensus

guidelines reinforce the need for multidimensional strategies

as the most effective approach to promote hand hygiene. Key

elements include staff education and motivation, adoption of

an alcohol-based hand rub as the primary method for hand

hygiene, use of performance indicators, and strong commitment

by all stakeholders, such as front-line staff, managers and

healthcare leaders, to improve hand hygiene.

2002 CDC Guideline for Hand Hygiene in Health-Care Settings

2003 National Patient Safety Standards

2005 World Health Organization (WHO) launched its Guidelines on Hand

Hygiene in Health Care (Advanced Draft) in October 2005

2006 Institute for Healthcare Improvement

– How To Guide: Improving Hand Hygiene

2008 Hand Hygiene Australia

2000-2009

European Center for Disease Prevention and Control (ECDC)

2009 WHO re-launched their campaign as “Save Lives: Clean Your Hands”

2013Hand Hygiene Practices in Healthcare Settings, Public Health Agency

of Canada (PHAC) 2013

2014 Hand Hygiene Australia

2016 CDC Summary of Infection Prevention Practices in Dental Settings:

Basic Expectations for Safe Care

Members of ECDC1. European Centre for Disease Prevention and Control, Stockholm

2. National Services Scotland, Edinburgh, United Kingdom

3. General Directorate of Health, Lisbon, Portugal

4. Health Protection Surveillance Centre, Dublin, Ireland

5. Ministry of Health, Youth and Sport, Paris, France

6. Mater Dei Hospital, Malta

7. Quality Agency, Ministry of Health and Consumer Affairs, Madrid, Spain

8. Norwegian Institute of Public Health, Oslo, Norway

9. Scientifi c Institute of Public Health, Brussels, Belgium

10. Ministry of Health, Nicosia, Cyprus

11. Regional Health and Social Agency, Infectious Risk Unit, Region

Emilia-Romagna, Bologna, Italy

12. Institute of Hygiene and Environmental Medicine, Berlin, Germany

13. Institute of Public Health, Bucharest, Romania

14. National Centre for Nosocomial Infection, Sofi a, Bulgaria

15. National Patient Safety Agency, London, United Kingdom

16. Health Directorate, Luxembourg

17. Hellenic Centre for Disease Control and Prevention, Athens, Greece

18. National Ministry of Health, Vienna, Austria

19. National Center for Epidemiology, Budapest, Hungary

20. University Medical Centre, Ljubljana, Slovenia

21. Stradins University Hospital, Riga, Latvia

22. Offi ce for Public Health, Vaduz, Liechtenstein

23. Landspitali University Hospital, Reykjavik, Iceland

24. Jagiellonian University Medical College, Cracow, Poland

25. Central Military Hospital, Prague, Czech Republic

26. Statens Serum Institut, Copenhagen, Denmark

27. Health Protection Inspectorate of Estonia, Tallinn, Estonia

28. National Institute for Health and Welfare, Helsinki, Finland

29. The National Board of Health and Welfare, Stockholm, Sweden

30. Regional Public Health Authority, Trenčín, Slovakia

31. Institute of Hygiene, Vilnius, Lithuania

32. Radboud University Nijmegen Medical Centre and Canisius-Wilhelmina

Hospital, Department of Clinical Microbiology and Infectious Diseases,

Nijmegen, The Netherlands

15

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

Studies indicate sustained improvements in hand hygiene

are attainable through the application of broad, multimodal

programs that include a communications campaign, education,

leadership engagement, environmental modifi cations, team

performance measurement, and feedback. According to the

WHO, there is convincing evidence that good hand hygiene

practices lead to a reduction of infections caused by multidrug

resistant bacteria in health facilities. For example, when hand

hygiene compliance in health facilities increases from <60% to

90%, there can be a 24% reduction in MRSA acquisition.

It is important to understand when hand hygiene should

be practiced. A 2011 study published in Infection Control

and Hospital Epidemiology observed that the rate of HCPs

practicing hand hygiene when exam gloves were worn was

worse than when exam gloves were not worn. The chances of

hands being cleaned before or after patient contact appear to

be substantially lower if gloves were being worn10.

These fi ndings reinforce the need to continue educating on the

importance of hand hygiene and when it should be practiced.

According to the 2016 CDC Summary of Infection Prevention

Practices in Dental Settings: Basic Expectations for Safe Care,

the following are key recommendations for hand hygiene in the

dental setting:

Wash hands:

• When hands are visibly soiled

• After barehanded touching of instruments, equipment,

materials, and other objects likely to be contaminated by

blood, saliva, or respiratory secretions

• Before and after treating each patient

• Before putting on gloves and again immediately after

removing gloves

Use soap and water when hands are visibly soiled (e.g., blood,

body fl uids); otherwise, an alcohol-based hand rub may be

used.

16

17

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

MEDICAL GLOVESMedical gloves are an important personal protective device

and should be worn during all patient care activities that may

involve exposure to blood and other bodily fl uids, including

contact with mucus membranes and non-intact skin.

Medical gloves serve many purposes, including to help reduce

the risk of:

• Contamination of HCPs hands with blood and other

body fl uids

• Pathogen dissemination to the environment

• Transmission from the HCP to the patient and vice versa,

as well as from one patient to another

Gloves should always be changed or removed:

• AFTER contact with blood or body fl uids

• BEFORE seeing a new patient

• NEVER wear the same pair of gloves for the care of

more than one patient

• BETWEEN clean and contaminated sites on the

same patient

NEVER wash and reuse gloves since this practice has been

associated with transmission of pathogens.11,12

Unfortunately, glove misuse is regularly present in healthcare

facilities, and medical staff often fail to follow gloving best

practices, thus facilitating the spread of microorganisms.

Studies have demonstrated that HCPs acquire microorganisms

on gloved hands when touching contaminated surfaces, which

could result in transmission to patients. Bacterial contamination

of unused disposable gloves from recently open boxes has

also been demonstrated. The unwashed contaminated hand of

the HCP reaching into glove boxes has been identifi ed as the

source.13

18

A research article published in Antimicrobial Resistance and

Infection Control 2013, demonstrated that an antibacterial

examination glove coated on its outside surface with

polyhexanide (PHMB), was able to reduce cross-contamination

by > 4 log10, compared to a control non-coated examination

glove. The results are encouraging and bolster further

clinical investigation on the impact of an antibacterial

examination glove.14

Petrie Dish

Bacterial Growth No Bacterial Growth

Additionally, surgical gloves coated on the internal surface with

a topical antimicrobial known as chlorhexidine gluconate (CHG)

demonstrated the ability to reduce the microbial growth on the

hands of the wearer. (Reitzel 2009)

The science of this antimicrobial technology is both

theoretically and practically sound and has the potential

to prevent microbial transmission in conjunction with good

hand hygiene.

NEW INNOVATIONS & NEXT GENERATION

MEDICAL GLOVES WITH ENHANCED SKIN CARE PROPERTIES.The newest innovations for HCPs have come in the form of

protective hand-healthy coatings applied to the inside of

surgical and examination gloves. These coatings offer specifi c

benefi ts to retain moisture and rehydrate skin, despite the

negative effects of continual glove-wearing and frequent

contact with anti-bacterial handwashing products. Glycerin

is found in numerous skin care lotions and has made the

transition into a coating for gloves in healthcare. Glycerin is

a skin-friendly humectant moisturizer that penetrates into

the stratum corneum, where it attracts and retains water.

Dimethicone used for decades to protect the skin of babies

from diaper rash, is also being incorporated as a coating inside

examination gloves. Dimethicone, forms a protective barrier

that blocks attack from foreign substances and prevents the

skin from drying out has also been utilized in glove coatings.

There is a “Dry Skin Model” (Dermatology Foundation) that

describes the path to dry skin and further describes that if there

are interventions along this path then this cycle can be broken.

Prudent use of proper skin care products and gloves enhanced

with skin care ingredients may be of signifi cant help, especially

to those HCPs who have skin prone to drying.

ANTIMICROBIAL MEDICAL GLOVESNew innovations are being explored to make medical gloves

safer, reducing the risk of surface contamination and ease

of use for HCPs. A new breed of examination gloves is being

equipped with antibacterial coating on its external surface that

reduces the risk of bacterial cross-contamination following

glove contact with patients and surfaces by HCPs.

19

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

SUMMARY

As the body’s largest organ, the skin serves as a waterproof

covering that prevents excessive loss or gain of bodily moisture,

provides a barrier against invasion by outside organisms that

helps keep out disease causing pathogens (bacteria, viruses,

fungi). The skin protects underlying tissues and organs from

abrasion and other injury, and its pigments shield the body from

the dangerous ultraviolet rays in sunlight.

HCPs have a high prevalence of skin irritation because of the

need for frequent hand washing during patient care. Hand

problems associated with the hand hygiene of HCPs is due to

a combination of damaging factors: (1) the removal of barrier

lipids by detergent cleaning and alcohol antisepsis followed

by a loss of moisturizers and stratum corneum water and (2)

the over hydration of the stratum corneum by sweat trapped

within gloves. Together they facilitate the invasion of irritants

and allergens which elicit infl ammatory responses in the

dermis.

Ways to minimize adverse effects of hand hygiene include

selecting less irritating products, using skin moisturizers,

and modifying certain hand hygiene practices such as

unnecessary washing. Institutions need to consider several

factors when selecting hand hygiene products: dermal

tolerance and aesthetic preferences of users as well as

practical considerations such as convenience, storage,

and costs. (E. Larson)

20

GLOSSARY

ACCELERATORS A substance that increases the rate of a chemical reaction

ADIPOCYTESAlso known as lipocytes and fat cells, are the cells that

primarily compose adipose tissue, specialized in storing

energy as fat

ANTI-DEGRADANT, OR DETERIORATION INHIBITOR Is an ingredient in rubber compounds

EPITHELIUM Is one of the four basic types of animal tissue, along with

connective tissue, muscle tissue and nervous tissue. Epithelial

tissues line the cavities and surfaces of structures throughout

the body. Many glands are made up of epithelial cells. Functions

of epithelial cells include secretion, selective absorption,

protection, trans-cellular transport and detection of sensation.

ENZYMES Enzymes are macromolecular biological catalysts which are

responsible for thousands of metabolic processes that sustain

life. They are highly selective catalysts, greatly accelerating

both the rate and specifi city of metabolic reactions, from the

digestion of food to the synthesis of DNA. Most enzymes

are proteins, although some catalytic RNA molecules have

been identifi ed. Enzymes adopt a specifi c three-dimensional

structure, and may employ organic (e.g. biotin) and inorganic

(e.g. magnesium ion) cofactors to assist in catalysis.

FIBROBLAST A type of cell that synthesizes the extracellular matrix and

collagen and plays a critical role in wound healing.

LANGERHANS CELL Langerhans cells are dendritic cells (antigen-presenting immune

cells) of the skin and mucosa. They are present in all layers of

the epidermis, but are most prominent in the stratum spinosum.

They are named after Paul Langerhans, a German physician and

anatomist, who discovered the cells at the age of 21 while he

was a medical student.

KERATINOCYTE The predominant cell type in the epidermis, the outermost layer

of the skin, constituting 90% of the cells found there.

PIGMENT In biology, a pigment is any colored material found in plant or

animal cells. Many biological structures, such as skin, eyes, fur

and hair contain pigments (such as melanin).

MACROPHAGES Are a type of white blood cell that engulf and digest cellular

debris, foreign substances, microbes, and cancer cells in a

process called phagocytosis.

MELANOCYTES Melanin-producing cells located in the bottom layer (the

stratum basale) of the skin’s epidermis, the middle layer of the

eye (the uvea), the inner ear, meninges, bones, and heart.

MERKEL OR MERKEL-RANVIER CELLS

Oval receptor cells found in the skin of vertebrates that have

synaptic contacts with somato-sensory afferents. They are

associated with the sense of light touch discrimination of

shapes and textures. They can turn malignant and form the skin

tumor known as Merkel cell carcinoma.

POLYHEXANIDE (polyhexamethylene biguanide, PHMB) A polymer used as a disinfectant and antiseptic. Some products

containing PHMB are used for inter-operative irrigation, pre-

and post-surgery skin and mucous membrane disinfection, post-

operative dressings, surgical and non-surgical wound dressings,

surgical bath/hydrotherapy, chronic wounds like diabetic foot

ulcer and burn wound management, routine antisepsis during

minor incisions, catheterization, fi rst aid, surface disinfection,

and linen disinfection.

21

HAND HYGIENE –

SKIN AND HAND

CARE IN THE

DENTAL SETTING

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23

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