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Continuing Education

Hand Hygiene: Infection Control/Exposure Control

Issues for Oral Healthcare Workers
Course Author(s): Géza T. Terézhalmy, DDS, MA; Michaell A. Huber, DDS
CE Credits: 2 hours
Intended Audience: Dentists, Dental Hygienists, Dental Assistants, Dental Students, Dental
Hygiene Students, Dental Assistant Students
Date Course Online: 03/04/2010 Last Revision Date: 09/01/2016 Course Expiration Date: 08/31/2019
Cost: Free Method: Self-instructional AGD Subject Code(s): 148
Online Course: www.dentalcare.com/en-us/professional-education/ce-courses/ce353

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their
practice. Only sound evidence-based dentistry should be used in patient therapy.

Introduction
This course presents the background essential to understand the importance of hand hygiene in healthcare
settings and provides evidence based information related to handwashing; hand antisepsis, i.e., antiseptic
handwash and antiseptic handrub; and surgical hand antisepsis. An evaluation tool to monitor institutional
policies and practices and compliance by oral HCP with hand hygiene practices that fulfill the expectations for
safe care in oral healthcare facilities is provided.

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The Procter & Gamble Company is designated as an Approved PACE Program Provider
by the Academy of General Dentistry. The formal continuing education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and Membership
Maintenance Credit. Approval does not imply acceptance by a state or provincial board
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to 7/31/2017.

Provider ID# 211886

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Conflict of Interest Disclosure Statement
• Dr. Terézhalmy has done consulting work for
Procter & Gamble and is a member of the
dentalcare.com Advisory Board.
• Dr. Huber reports no conflicts of interest
associated with this course.
Course Contents
• Overview
• Learning Objectives
• Introduction
• Physiology of Normal Skin
• Normal Microbial Flora of the Skin
• Acquisition and Transmission of Healthcare-
associated Pathogens
• Hand Hygiene
Handwashing
Antiseptic Handwash
Antiseptic Handrub
Surgical Hand Antisepsis
• Other Factors to Consider in the Selection of
Hand Hygiene Products
Irritant Contact Dermatitis
Allergic Contact Dermatitis
• Strategies to Improve Hand Hygiene
Practices
• Summary
• Course Test
• References
• About the Authors
Overview
The transmission of healthcare-associated pathogens
most often occurs via the contaminated hands of
healthcare personnel (HCP). Accordingly, hand
hygiene is one of the most important infection
control measures for preventing healthcare-
associated infections (HAIs). However, compliance
with recommended hand hygiene practices remains
low. Oral healthcare facilities are accountable for
establishing a system in which oral HCP have the
knowledge, competence, time, and tools to practice
hand hygiene; and oral HCP have the duty to perform
hand hygiene – perfectly and every time.
Learning Objectives
Upon completion of this course, the dental
professional should be able to:
• Discuss the physiology of normal skin.
• Discuss the normal bacterial flora of the skin.
• Discuss the relationship between hand hygiene
and healthcare associated pathogens.
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• Demonstrate the knowledge and skills necessary
to be in compliance with hand hygiene practices
that fulfill expectations for oral healthcare settings.
Introduction
In 2002, the Centers for Disease Control and
Prevention (CDC) published Guideline for Hand
Hygiene in Health-Care Settings.1 Yet, reports
of outbreaks of HBV and HCV infections,
primarily in medical settings outside of acute
care hospitals, indicate a failure of healthcare
personnel (HCP) to perform hand hygiene and
wear gloves.2 While the guideline applies to
oral healthcare settings, evidence also suggests
low compliance with recommended hand
hygiene practices by oral HCP as well.3,4
Excerpts published by the CDC in 2016 from
the Guidelines for Infection Control in Dental
Health-Care Settings – 2003 emphasize that
oral HCP must perform hand hygiene with
either a non-antimicrobial or an antimicrobial
soap and water when hands are visibly soiled;
otherwise, the preferred method of hand
hygiene in clinical situations is with an alcohol-
based handrub; and when performing surgical
procedures oral HCP must perform surgical
hand antisepsis.5
Also in 2016 the CDC published a Summary
of Infection Prevention Practices in Dental
Settings: Basic Expectations for Safe Care,
which states that (1) hand hygiene is the most
important measure to prevent the spread of
HAIs; (2) ongoing education and competency-
based training are critical for ensuring that
infection prevention policies and procedures
are understood and followed; and (3) following
each training cycle, hand hygiene-related
competency should be documented.6
Physiology of Normal Skin
The skin serves as a physiologic barrier to
chemical penetration and microbial invasion
from the environment, as well as a barrier to
fluid and solute loss from within.7 Its basic
structure includes the stratum corneum (≈10
to 20 µm thick), the viable epidermis (≈50 to
100 µm thick), the dermis (≈1 to 2 mm), and the
hypodermis (≈1 to 2 mm thick).8 The stratum
corneum is a semipermeable laminated surface
aggregate of corneocytes.
Corneocytes are flat polyhedral-shaped
non-nucleated remnants of terminally
differentiated keratinocytes derived from the
viable epidermis. Corneocytes are composed
primarily of insoluble bundled keratin
surrounded by a cell envelop stabilized by
cross-linked proteins and covalently bound
lipids. These intercellular lipids, which are
generated during the terminal differentiation
of keratinocytes, form the only continuous
domain of the skin and are essential for
competent barrier function.7 It is of note that
hand hygiene products and procedures can
decrease skin-barrier function by extracting
skin lipids, chemically inducing irritation, and
physically stripping the stratum corneum.1
Under the stratum corneum is the viable
epidermis, which is composed primarily of
keratinizing epithelial cells, i.e., keratinocytes.9
This layer also contains melanocytes involved
in skin pigmentation; Langerhans cells, which
are important for antigen presentation and
immune responses; and Merkel cells, which
contain neuroendocrine peptides and appear to
have a sensory function. The viable epidermis
does not contain a vascular network and the
keratinocytes obtain nutrients from the dermis
by passive diffusion through the interstitial fluid.
The rate of keratinocyte proliferation directly
influences the integrity of the skin barrier.
Under normal conditions, differentiated
keratinocytes require about 2 weeks to exit the
nucleated compartment and 2 weeks to move
through the stratum corneum.10 However,
keratinocytes have the capacity for increased
rates of proliferation and maturation to levels
far greater than this when stimulated by injury
or infection. In such cases, the return to
normal barrier function is biphasic: 50 to 60%
of barrier recovery typically occurs within 6
hours with complete normalization of barrier
function in 5 to 6 days.
Normal Microbial Flora of the Skin
One of the largest human-associated microbial
ecosystems is the skin. To understand the
objectives of different approaches to hand
hygiene and associated adverse effects,
knowledge of the normal bacterial flora of the
skin is essential. Different areas of normal
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human skin are colonized variably primarily by
aerobic bacteria and bacterial density may be as
high as 107 cells per square centimeter.11 Total
bacterial counts on the hands of HCP have been
reported to range from 3.9 x 104 to 4.6 x 106
colony-forming units per cubic centimeter.12-14
Hand surfaces harbor >150 unique bacterial
phylotypes and a total of 4,742 phylotypes have
been identified across all hands examined.15
The most abundant genera (Propionibacterium,
Streptococcus, Staphylococcus, Corynebacterium,
and Lactobacillus) are found on nearly all palm
surfaces. Although there appears to be a
core set of bacteria commonly found on palm
surfaces, women appear to have significantly
higher diversity than men; and microbial
community composition is further affected by
handedness and time since last washing hands.15
Acquisition and Transmission of
Healthcare-associated Pathogens
Microbes recovered from hands can be divided
into two categories: transient and resident
organisms. Transient microorganisms tend
to colonize the superficial layers of skin and
while they are amenable to removal by washing
hands with plain (i.e., non-antimicrobial) soap
and water, they are responsible for most HAIs.
Resident organisms are attached to deeper
layers of the skin and while they are more
resistant to removal, they are less likely to be
associated with HAIs.
The number of transient and resident organisms
may vary greatly among HCP, yet it is often
relatively constant for any one individual.15
Transient organisms are acquired during:
1. contact with a patient’s intact skin (e.g., when
taking a pulse or blood pressure),
2. contact with nonintact skin and mucous
membranes,
3. direct contact with blood and OPIM; and
4. contact with contaminated instruments,
equipment, and environmental surfaces.
The hands of HCP may also become persistently
colonized with transient pathogenic organisms
(e.g., S. aureus, gram-negative bacilli, or yeast),
which subsequently may be transmitted
to patients. It is of note that organisms are
transferred in much larger numbers from
wet hands than from hands that have been
thoroughly dried.16 The transmission of
healthcare-associated pathogens from one
patient to another via the hands of HCP must
meet 4 criteria:1,3
• Organisms present on the patient’s skin or
mucous membranes, or on contaminated
instruments, equipment, and environmental
surfaces must be transferred to the hands
of HCP.
• The organisms transferred must then
be capable to survive for at least several
minutes on the hands of HCP.
• Hand hygiene by HCP must be inadequate
or omitted entirely, or the agent used for
hand hygiene is inappropriate.
• The contaminated hands of HCP must come
in direct contact with another patient, or
with an inanimate object that will come into
direct contact with the patient.
To prevent or reduce the risk of occupational
exposure, the standard of care mandates that
HCP wear gloves.1,3,17 However, gloves do not
provide complete protection against cross-
infection. Bacterial flora colonizing patients
have been recovered from the hands of ≥30% of
HCP who wore gloves during patient contact.18,19
The acquisition of hepatitis B, hepatitis C, and
herpes simplex viruses (HSV-1) by HCP wearing
gloves has also been documented.2,20,21
It is also of note that at least 70% of the
population shed HSV-1 asymptomatically at
least once a month, many individuals shed
the virus >6 times a month, and the virus can
survive for several hours in a variety of fluids,
on dental charts, and environmental surfaces.22
Since pathogens can be transmitted via small
defects in gloves or by contamination of the
hands during glove removal, wearing gloves
does not eliminate the need for appropriate
hand hygiene practices.18-21,23
Hand Hygiene
Hand hygiene is a general term that applies
to (1) handwashing; (2) hand antisepsis, i.e.,
antiseptic handwash and antiseptic handrub;
and (3) surgical hand antisepsis.1,3,5,6 Performing
hand hygiene is indicated (1) when hands are
visibly soiled, (2) after barehanded touching of
inanimate objects likely to be contaminated by
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blood and OPIM such as saliva or respiratory
secretions, (3) before and after treating each
patient, (4) before donning gloves, and (5)
immediately after removing gloves.
Products used for hand hygiene in healthcare
settings include detergents and antiseptic
agents. Detergents contain esterified fatty
acids and sodium or potassium hydroxide and
are often referred to as “soaps.” Plain soap
does not contain an antimicrobial agent or
contains low concentrations of an antimicrobial
agent that is effective solely as a preservative.1
The cleaning activity of plain soap results in
the removal of dirt, soil, and various organic
substances from the hands.
Antiseptic agents (Table 1) in hand hygiene
products used in healthcare settings should
have a broad spectrum, be fast acting, reduce
the number of microorganisms on intact skin
to an initial baseline level (i.e., by 2-log10 or
99% on each hand within 5 minute after the
first use of a product and by 3-log10 or 99.9%
on each hand within 5 minutes after the tenth
use) after adequate washing, rinsing and/or
rubbing and drying; and should have persistent
or residual activity.1,24
Persistence is characterized by prolonged
antimicrobial activity that prevents or inhibits
the survival or proliferation of microorganisms
after application of the product. Some
antiseptic products also demonstrate
substantivity, i.e., they adhere to the stratum
corneum of the skin and continue to provide
an inhibitory effect on microbial growth after
rinsing or drying. However, substantivity is not
an absolute requirement for an agent to lower
the number of bacteria following hand hygiene.
The FDA classifies antiseptic agents (Table
2) as Category I, i.e., generally recognized
as safe and effective and not misbranded;
as Category II, i.e., not generally recognized
as safe and effective or misbranded; or as
Category III, available data are insufficient
to classify as safe and effective. Based on
available evidence, the FDA concluded that only
ethanol (60 to 95%) and povidone iodine (5 to
10%) formulations meet the test and product
labeling requirements as antiseptic agents.24
 Table 1. Microbial spectrum of various antiseptic agents.*

Table 2. The FDA classification of healthcare

antiseptic agents.24

Handwashing It is indicated when (1) hands are visible soiled

Handwashing is defined as washing hands with with blood and OPIM, and (2) as part of two-
plain soap (follow technique described in Figure stage surgical hand antisepsis (see below).1,5,6,25
1 for 40 to 60 seconds). Handwashing removes However, when the hands are not visibly soiled,
loosely adherent transient microorganisms.1,5,6,25 the CDC and the WHO recommend the use

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of an alcohol-based handrub (see below) for
routine hand hygiene.1,5,6,25
The frequent use of plain soap and hot water
can cause considerable skin irritation and
dryness. When performing handwashing
wet hands with warm water and follow the
manufacturer’s recommendations regarding
the volume of soap to be used. Bar, liquid,
leaflet, or powdered forms of plain soap are
acceptable. When bar soap is used, soap racks
that facilitate drainage should be used. Plain
soaps may become contaminated with gram-
negative bacilli and cause nosocomial infection.26

Figure 1. How to Handwash when hands are visibly soiled?25

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Once handwashing is completed, the hands
should be dried thoroughly with a single use
towel. As noted earlier, microorganisms are
transferred in much larger numbers from
wet hands than from hands that have been
thoroughly dried.16 Multiple-use cloth towels of
the hanging or roll type are not recommended
for use in healthcare settings. Antimicrobial-
impregnated wipes (i.e., towelettes) are
acceptable alternatives to handwashing.
Antiseptic Handwash
Antiseptic handwash is defined as washing
hands with a soap containing an antiseptic
agent and water.1,3,5,6 As shown in Table 2, the
FDA classifies povidone iodine (5 to 10%) as a
Category I agent.24 Povidone iodine is an iodophor
composed of elemental iodine, iodide or triiodide.
The free iodine penetrates the microbial cell
wall, forms complexes with amino acids and
unsaturated fatty acids, and determines povidone
iodine’s level of antimicrobial activity.27
Antiseptic handwash for 40 to 60 seconds
(follow technique described in Figure 1) with
povidone iodine removes or destroys transient
microorganisms and reduces the resident hand
flora.1 It is an alternative to handwashing and
an acceptable method of hand hygiene when
the hands are visibly soiled. However, when the
hands are not visibly soiled, the CDC and the
WHO recommend the use of an alcohol-based
handrub (see below) for routine hand hygiene.1,24,25
The concomitant use of an alcohol-based
handrub and an iodophor-based antimicrobial
soap is contraindicated because alcohol interferes
with the antimicrobial activity of iodophors.
Occasionally, povidone iodine antiseptic agents
have become contaminated with gram-negative
bacilli and have caused outbreaks of nosocomial
infection.27 The use of antimicrobial-impregnated
wipes (i.e., towelettes) is not an acceptable
alternative to antiseptic handwash.
Antiseptic Handrub
Antiseptic handrub is defined as applying a
waterless antiseptic agent (i.e., an antiseptic
agent that does not require the use of
exogenous water) to the hands. As shown in
Table 2, the FDA classifies ethanol (60 to 95%)
as a Category I agent.24 The antiseptic activity of
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ethanol is attributed to its ability to denature
proteins.28 Ethanol, 60-95% (expressed as
percent by volume) is more effective than
higher concentrations because proteins are not
denatured easily in the absence of water.
Antiseptic handrub removes or destroys
transient microorganisms and reduces the
resident flora.1,25 The CDC and the WHO have
concluded that antiseptic handrub is more
effective than handwashing or an antiseptic
handwash and it is recommended for routine
hand hygiene in clinical situations when the
hands are not visibly soiled.1,24,25 As noted
earlier, the concurrent use of an alcohol-based
handrub and an iodophor-based antimicrobial
soap is contraindicated.
Perform antiseptic handrub for 20 to 30 seconds
according to the technique described in Figure
2 and follow manufacturers’ recommendations
regarding the volume of product to be
used. Alcohol-based liquids, gels, or foam
formulations are all acceptable. Contamination
of alcohol-based products is remote.29 It is of
import, however, to note that alcohol-based
handrub products are flammable and should
be stored away from high temperatures (flash
points range from 210C to 240C) or flames.30
Surgical Hand Antisepsis
The CDC concluded that performing surgical
hand antisepsis by scrubbing the hands/
forearms with a brush for 10 minutes can
damage skin and result in increased shedding of
microorganisms from the hands; scrubbing for
5 minutes is as effectively as a 10 minute scrub;
scrubbing for 2 to 3 minutes reduces microbial
counts to acceptable levels; and neither a brush
nor a sponge is necessary reduce microbial
counts on the hands of surgical personnel.1
Surgical hand antisepsis is defined as
performing either (1) two-stage surgical hand
antisepsis, i.e., handwashing with plain soap and
water followed by antiseptic handrub, preferably
with an alcohol-based formulation containing
0.5% to 1% chlorhexidine gluconate for persistent
residual activity (Table 3); or (2) surgical
antiseptic handwash (Table 4).1,5,6,25 The use of
antimicrobial-impregnated wipes (i.e., towelettes)
in surgical hand antisepsis is inappropriate.
Figure 2. How to Handrub when hands are not visibly soiled?25

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Table 3. Two-stage surgical hand antisepsis.
Table 4. Surgical antiseptic handwash.
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Other Factors to Consider in the
Selection of Hand Hygiene Products
Before making purchasing decisions evaluate
the dispenser system to make sure that it
functions reliably, delivers an appropriate
volume of the product, and that the dispenser
for alcohol-based formulations is approved for
flammable materials. The cost of hand hygiene
products should not be the primary factor
influencing product selection; however, it of
note that the routine use of an alcohol-based
handrub is more cost effective than the use of
an antimicrobial soap and water.31
When selecting a plain (non-antimicrobial)
soap, an antimicrobial soap, or an alcohol-
based handrub solicit information from
manufacturers regarding any known
interactions between hand hygiene products;
skin care products; the type of gloves used
in the healthcare setting; and the risk of
contaminating the product. Hand care
products should be stored in disposable/
reusable closed containers. Never “top off”
partially empty soap dispensers as it can lead
to bacterial contamination of the content.
HCP should be provided with efficacious hand
hygiene products that have low irritability
potential and with compatible hand lotions
to minimize the occurrence of irritant contact
dermatitis. To maximize acceptance of hand
hygiene products solicit input from HCP
regarding fragrance (smell), consistency (“feel”),
skin tolerance, and color. Formulations with
strong fragrances may be poorly tolerated by
HCP and patients with respiratory allergies.
Irritant Contact Dermatitis
The most common reaction associated with the
frequent and repeated use of hand-hygiene
products is irritant contact dermatitis
(ICD). ICD is a non-immunologically mediated
dermatitis characterized by dryness, itchiness,
or burning; the skin may feel “rough;” and
appear erythematous, scaly, or fissured. These
signs and symptoms of ICD are similar to those
associated with allergic contact dermatitis
(ACD), which can be ruled out by allergy testing.
Detergents damage skin by (1) denuding the
stratum corneum, (2) depleting or reorganizing
intracellular lipid moieties, (3) decreasing
corneocyte cohesion, and (4) decreasing the
water-binding capacity of the stratum corneum.32
Other factors that contribute to ICD include
using hot water, the quality of paper towels
used, physically stripping the stratum corneum
while scrubbing, shear forces associated with
wearing and removing gloves, and low relative
humidity (winter months).
ICD may also be caused by the antimicrobial
agent or by other ingredients in a product. ICD
is most commonly reported with iodophors.
Other antiseptic agents that can cause ICD,
in order of decreasing frequency include
chlorhexidine, phenolic derivatives, and
triclosan. Following an exhaustive review of
available data, the CDC concluded that alcohol-
based handrubs are the safest antiseptics
available and ethanol is usually less irritating
than isopropanol.33
Washing hands with soap and water after each
use of an alcohol-based handrub may also
contribute to ICD. However, because HCP may
feel a “build-up” of emollients on the hands after
repeated use, some manufacturers recommend
washing hands with soap and water after 5 to
10 applications of a handrub product. ICD may
facilitate the colonization of damaged skin by
staphylococci and gram-negative bacilli and also
increases the potential for ACD.
Allergic Contact Dermatitis
Allergic contact dermatitis (ACD) is a T cell-
mediated delayed hypersensitivity reaction
(Gell and Coombs Type IV) caused primarily by
fragrances and preservatives; and less commonly
by emulsifiers found in hand-hygiene products.34,35
ACD is characterized by a rash, redness, and
itching, which usually begins 24 to 48 hours after
contact with offending allergen and may progress
to oozing skin blisters and spread to areas of skin
untouched by the product.
ACD has been reported with chlorhexidine,
phenolic derivatives, iodine and iodophors,
triclosan, and quaternary ammonium
compounds. ACD to alcohol-based handrub
or to the various additives present in certain
formulations is rare.36,37 While ACD with alcohol-
based products is uncommon, such reactions
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may represent true allergy to alcohol, allergy to
an impurity or aldehyde metabolites, or allergy
to another constituent of the product.30,36
Strategies to Improve Hand Hygiene
Practices
The Institute for Healthcare Improvement in
its How-to Guide: Improving Hand Hygiene
recommends a multidimensional approach
(e.g., introduction of alcohol-based handrub,
and educational and behavioral initiatives)
to improve compliance with hand hygiene
guidelines in healthcare settings.38 The science
supporting a multidimensional approach to
hand hygiene is sufficiently established to be
considered the standard and consist of four
components (Table 5).1,3,5,6
A novel strategy of video surveillance of hand
hygiene coupled with real-time compliance
feedback has been reported.39 The study was
conducted in a 17-bed intensive care unit.
Cameras were placed with views of every sink
and hand sanitizer dispenser to record hand
hygiene of HCP. Sensors in the doorways
identified when an individual entered/exited.
Video auditors observed HCP performing hand
hygiene upon entering and exiting a room and
assigned a pass or fail grade.
Hand hygiene was measured during a 16-week
period without feedback and a 91-week period
with feedback. During the 16-week pre-
feedback period, hand hygiene rates were less
than 10%. In the first 16-week post-feedback
period compliance improved to 81.6%; and,
subsequently, was maintained through 75
weeks at 87.9%. While quality of hand hygiene
and HAI-data were not presented, this approach
to improve compliance merits consideration.
The Summary of Infection Prevention Practices
in Dental Settings: Basic Expectations for
Safe Care published by the CDC in 2016
includes an Infection Prevention Checklist
for Dental Settings: Basic Expectations for
Safe Care.6 Section I.5 of the checklist relates
to institutional hand hygiene policies and
practices, while Section II.1 is an evaluation tool
to monitor the compliance of oral HCP with
hand hygiene practices that fulfill expectations
for dental healthcare settings (Box A).
Table 5. Multidimensional approach to improve compliance with hand
hygiene guidelines.

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 Box A. Hand hygiene compliance: checklist for oral
healthcare settings.

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Summary
Factors that contribute to poor hand hygiene
practices among HCP include (1) lack of
knowledge about the importance of hand
hygiene, i.e., how hands become contaminated
with microorganisms and spread infection, (2)
lack of understanding of correct hand hygiene
techniques, (3) lack of access to appropriate
hand hygiene products, (4) irritant and allergic
contact dermatitis, and (5) lack of institutional
commitment to good hand hygiene practices.
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The most effective hand hygiene technique, if
the hands are not visibly soiled, is the routine
use of an alcohol-based handrub. Alcohol-
based handrub has been shown to be more
effective in reducing the number of viable
bacteria, viruses, and fungi on hands than
a plain or an antimicrobial soap and water;
require less time to use; can be made available
at the point of care; cause less hand irritation
and dryness with repeated use; and improves
compliance with hand hygiene standards.
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please
go to: www.dentalcare.com/en-us/professional-education/ce-courses/ce353/start-test

1. All of the following statements regarding hand hygiene in healthcare settings are true
EXCEPT which one?
a. Outbreaks of HBV and HCV infections, primarily in medical settings outside of acute care
hospitals, indicate a failure of healthcare personnel (HCP) to perform hand hygiene and wear
gloves.
b. While the hand hygiene guideline applies to oral healthcare settings, evidence suggests low
compliance with recommended hand hygiene practices by oral HCP.
c. Ongoing education and competency-based training are critical for ensuring that infection
prevention policies and procedures are understood and followed.
d. Hand hygiene-related competency following each training cycle does not need to be
documented.

2. Intercellular lipids, which form the only continuous domain of the skin essential for a
complete barrier function, e.g., to minimize microbial invasion from the environment,
are a basic component of the _______________.
a. stratum corneum
b. viable epidermis
c. dermis
d. hypodermis

3. Hand hygiene products and procedures can decrease the barrier function of skin by
_______________.
a. extracting skin lipids
b. chemically inducing irritation
c. physically stripping the stratum corneum
d. All of the above.

4. Which of the following statements is correct in relation to homeostatic control and the
rate of keratinocyte proliferation?
a. Under normal conditions, differentiated keratinocytes require 2 weeks to exit the nucleated
compartment and an additional 2 weeks to move through the stratum corneum.
b. When stimulated by injury or infection, keratinocytes have the capacity for increased rates of
proliferation and maturation, and 50 to 60% of barrier recovery typically occurs within 6 hours.
c. When stimulated by injury or infection, keratinocytes have the capacity for increased rates
of proliferation and maturation, and complete normalization of barrier function occurs in 5
to 6 days.
d. All of the above.

5. All of the following statement in relation to the normal skin flora and the acquisition and
transmission of healthcare-associated pathogens are correct EXCEPT which one?
a. One of the largest human-associated microbial ecosystems is the skin.
b. Transient organisms tend to colonize the superficial layers of skin, they are amenable to
removal by handwashing with plain soap and water, and they are more likely to cause HAIs
than resident pathogens.
c. Resident organisms are attached to deeper layers of the skin and while they are more
resistant to removal, they are less likely to be associated with HAIs.
d. Organisms are transferred in much larger numbers from dry hands than from hands that
are wet.

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6. All of the following statements are correct with respect to the wearing of gloves in
healthcare settings EXCEPT which one?
a. To prevent or reduce the risk of occupational exposure, the standard of care mandates that
HCP wear gloves.
b. Bacterial flora colonizing patients have been recovered from the hands of HCP who wore
gloves during patient contact.
c. The acquisition of hepatitis B, hepatitis C, and herpes simplex viruses (HSV-1) by HCP wearing
gloves has been documented.
d. All of the above.

7. Hand hygiene refers to _______________.

a. handwashing, i.e., washing hands with plain soap and water
b. hand antisepsis, i.e., antiseptic hand wash or antiseptic handrub
c. surgical hand antisepsis
d. All of the above.

8. All of the following statements are correct with respect to detergents EXCEPT which one?
a. Detergents contain esterified fatty acids and sodium or potassium hydroxide and are often
referred to as “soaps.”
b. Detergent formulations used in healthcare settings should have a broad antibacterial
spectrum, be fast acting, and should have persistent or residual activity.
c. Plain soap does not contain an antimicrobial agent or contains low concentrations of an
antimicrobial agent that is effective solely as a preservative.
d. The cleaning activity of plain soap results in the removal of dirt, soil, and various organic
substances from the hands.

9. All of the following statements about handwashing are correct EXCEPT which one?
a. Handwashing, which removes loosely adherent transient microorganisms, is defined as
washing hands with plain soap and water.
b. It is indicated when (1) hands are visible soiled with blood and OPIM, and (2) as part of two-
stage surgical hand antisepsis.
c. The CDC and the WHO recommend handwashing for routine hand hygiene in clinical
situations when the hands are not visibly soiled.
d. The frequent use of plain soap and hot water can cause considerable skin irritation and
dryness.

10. All of the following statements about antiseptic handwash are correct EXCEPT which one?
a. Antiseptic handwash is defined as washing hands with a soap containing an antiseptic agent
and water.
b. The FDA classifies povidone iodine (5 to 10%) as a Category I antiseptic agent.
c. The use of antimicrobial-impregnated wipes (i.e., towelettes) is an acceptable alternative to
antiseptic handwash.
d. Antiseptic handwash with povidone iodine removes or destroys transient microorganisms
and reduces the resident hand flora.

11. All of the following statements about antiseptic handrub are correct EXCEPT which one?
a. Antiseptic handrub is defined as applying a waterless antiseptic agent (i.e., an antiseptic
agent that does not require the use of exogenous water) to the hands.
b. The FDA classifies ethanol (60 to 95%) as a Category II antiseptic agent.
c. Antiseptic handrub removes or destroys transient microorganisms and reduce the resident flora.
d. The CDC and the WHO have concluded that antiseptic handrub is more effective than
handwashing or an antiseptic handwash and it is the preferred method for routine hand
hygiene in clinical situations when the hands are not visibly soiled.

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12. All of the following statements regarding surgical hand antisepsis are correct EXCEPT
which one?
a. Antimicrobial counts on hands are reduced as effectively with a 5-minute scrub as with a
10-minute scrub.
b. A brush or sponge must be used when performing surgical hand antisepsis to adequately
reduce bacterial counts on hands.
c. Surgical hand antisepsis is defined as performing either (1 surgical hand antisepsis using
an antimicrobial soap and water or (2) two-stage surgical hand antisepsis.
d. Handwashing with plain soap and water followed by the application of an alcohol-based
hand rub is an acceptable method of surgical hand antisepsis.

13. Before making purchasing decisions related to hand hygiene products _______________.
a. evaluate the dispenser system to make sure that it functions reliably
b. confirm that the dispenser delivers an appropriate volume of the product
c. confirm that the dispenser for alcohol-based formulations is approved for flammable
materials
d. All of the above.

14. All of the following statements are correct with respect to selecting and/or handling
plain (non-antimicrobial) or antimicrobial soaps, or an alcohol-based handrub EXCEPT
which one?
a. Solicit information from manufacturers regarding any known interactions between hand
hygiene products; skin care products; the type of gloves used in the healthcare setting.
b. Hand care products should be stored in disposable or reusable closed containers.
c. To minimize the risk of product contamination, always “top off” partially empty soap
dispensers at the end of each day.
d. To maximize acceptance of hand hygiene products solicit input from HCP regarding
fragrance (smell), consistency (“feel”), skin tolerance, and color.

15. All of the following statements are correct with respect to irritant contact dermatitis
(ICD) EXCEPT which one?
a. The most common reaction associated with the frequent and repeated use of hand-
hygiene products is ICD.
b. ICD is an immunologically mediated dermatitis.
c. ICD is characterized by dryness, itchiness, or burning; the skin may feel “rough;” and
appear erythematous, scaly, or fissured.
d. Skin damage can lead to colonization by staphylococci and gram-negative bacilli and also
increases the potential for ACD.

16. All of the following statements related to ICD are correct EXCEPT which one?
a. Factors that contribute to ICD include using hot water, the quality of paper towels used,
and physically stripping the stratum corneum while scrubbing.
b. ICD may be caused by the antimicrobial agent or by other ingredients in the product.
c. To minimize the likelihood of ICD, washing hands with soap and water after each use of
alcohol-based handrub is highly recommended.
d. Skin damage can lead to colonization by staphylococci and gram-negative bacilli and also
increases the potential for ACD.

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17. All of the following statements related to allergic contact dermatitis (ACD) are correct
EXCEPT which one?
a. ACD is a T cell-mediated delayed hypersensitivity reaction (Gell and Coombs Type IV).
b. ACD is characterized by a rash, redness, and itching, which usually begins 24 to 48 hours
after contact with offending products.
c. ACD associated with alcohol-based handrub or various additives present in certain
formulations is quite common.
d. ACD may represent true allergy to alcohol, allergy to an impurity or aldehyde metabolites, or
allergy to another constituent of the product.

18. Compliance with hand hygiene guidelines is substantially improved when a

multidimensional strategy includes _______________.
a. introduction of alcohol-based handrub
b. educational and behavioral initiatives
c. institutional verification of compliance and feedback
d. All of the above.

19. Which of the following statements are correct with respect to the Infection Prevention
Checklist for Dental Settings: Basic Expectations for Safe Care published by the CDC in 2016?
a. Section I.5 of the checklist relates to institutional hand hygiene policies and practices.
b. Section II.1 is an evaluation tool to monitor the compliance of oral HCP with hand hygiene
practices that fulfill expectations for dental healthcare settings.
c. The checklist provides a mechanism to document the competence of oral HCP to perform
hand hygiene following each training cycle.
d. All of the above.

20. Oral healthcare facilities are accountable for establishing a system in which oral HCP
have the knowledge, competence, time, and tools to practice hand hygiene; and oral HCP
have the duty to perform hand hygiene - perfectly and every time.
a. True
b. False

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References
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23. Doebbeling BN, Pfaller MA, Houston AK, et al. Removal of nosocomial pathogens from the
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About the Authors

Géza T. Terézhalmy, DDS, MA

Professor and Dean Emeritus, School of Dental Medicine, Case Western Reserve
University, Cleveland, Ohio; and Consultant, Naval Postgraduate Dental School,
Walter Reed National Military Medical Center, Bethesda, Maryland.

Dr. Terézhalmy earned a BS degree from John Carroll University; a DDS degree
from Case Western Reserve University; an MA in Higher Education and Human
Development from The George Washington University; and a Certificate in Oral
Medicine from the National Naval Dental Center.

Dr. Terézhalmy held more than 30 positions in professional societies, served as editor or
contributing editor for several publications, co-authored or contributed chapters for several books,
published over 225 papers and abstracts, and accepted invitations to lecture before many local,
state, national, and international professional societies.

Email: gtt2@case.edu

Michaell A. Huber, DDS

Professor
Department of Comprehensive Dentistry
The University of Texas Health Science Center at San Antonio, School of Dentistry,
San Antonio, Texas

Dr. Huber received his DDS from the University of Texas Health Science Center at
San Antonio Dental School, San Antonio, Texas in 1980 and a Certificate in Oral
Medicine from the National Naval Dental Center, Bethesda, Maryland in 1988. He is certified by the
American Board of Oral Medicine. As an officer of the Dental Corps, United States Navy, Dr. Huber’s
assignments included numerous ships and shore stations and served as Chairman, Department
of Oral Medicine and Maxillofacial Radiology and Director, Graduate Program in Oral Medicine,
National Naval Dental Center, Bethesda, Maryland. In addition he served as Specialty Leader for
Oral Medicine to the Surgeon General of the United States Navy, Washington, DC; and Force Dental
Officer, Naval Air Force Atlantic, Norfolk, Virginia. He has many professional affiliations and over
the past 24 years, he has held a variety of positions in professional organizations.

Since joining the faculty in 2002, Dr. Huber has been teaching both pre-doctoral and graduate
dental students at the University of Texas Health Science Center Dental School, San Antonio, Texas,
and is the Director of the school’s Oral Medicine Tertiary Care Clinic. He is currently serving as
the Public Affairs Chairman for the American Academy of Oral Medicine. Dr. Huber has accepted
invitations to lecture before many local, state, and national professional organizations. He has
been published in numerous journals including: Medical Clinics of North America, Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and Endodontology; Dental Clinics of North America, Journal of
the American Dental Association, and Quintessence International.

Email: huberm@uthscsa.edu

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