Hand sanitizers versus handwashing: What dental professionals need to know

One of the most interesting parts of infection control is that as studies continue to enlighten, best practices continue to evolve. Balancing knowledge and actions means you have to stay up to date.

One evolving infection control issue is hand hygiene. Dental professionals may consider using hand sanitizers because they appear to save time compared to hand washing and can be used frequently. But can hand sanitizers replace handwashing?

The practice of using alcohol based hand sanitizers (ABHS) in the medical setting was reviewed by the Centers for Disease Control and Prevention (CDC) in 2002. While CDC supports use of ABHS in the health care setting, it cautioned that the products had to be hospital grade (60-95 percent ethanol or isopropanol alcohol, over the counter ABHS may or may not have the amount listed), users needed to apply a sufficient dose to rub all hand surfaces for 40 to 60 seconds, hands could not be “visibly” soiled and directions on the label needed to be followed.

ADDITIONAL READING: Infection control and the dental hygienist

ABHS’s have not proven to be effective against Norovirus and Clostridum difficile. Norovirus is a great example of one of the concerns that I have about hand sanitizers. Remember this virus is involved in more than 23 million gastrointestinal cases per year. A long-term study was done looking at this virus and the increased rates of infection. Interestingly, facilities where staff used ABHS as often or more often than soap and water were six times more likely to experience an outbreak.

While the act of washing your hands may not kill all entities, proper hand washing with water and soap and drying them with a disposable paper towel will mechanically remove both bacteria and viruses. Studies have shown soap and water are more effective than hand sanitizers at removing or inactivating certain kinds of germs, like Cryptosporidium, Norovirus, and Clostridium difficile. The mechanical debridement involved in handwashing and drying with a paper towel should not be underrated (paper towels also help remove debris).

Hand sanitizers have been shown to reduce the growth of specific microorganisms, which is important, but we need to look at the pros and cons:

• ABHS’s simply are not good cleaning agents and are not able to penetrate debris. They were never intended to take the place of hand washing in all circumstances. If hands are visibly soiled or debris is possibly present (the hand is contaminated with body fluids, etc.), ABHS may not be effective.

• The CDC indicated that alcohol-based hand sanitizers can inactivate many types of microbes very effectively when used correctly. Yet people may not use a large enough volume of the sanitizers or they may wipe it off before the recommended rub-time of 40-60 seconds. In most studies that have been conducted an adequate contact time has not been followed in the medical setting when ABHS’s are used. Many people are removing part of the hand sanitizer with a paper towel and not allowing alcohol to evaporate which is part of the process. Most label directions include the use of at least 3 to 5 mL of ABHS and specific amounts of time for rubbing the product, then allowing it to dry.

• The two major issues that challenge nurses in hand hygiene compliance are time and access to the processes. Since a sink and plumbing is not required for an ABHS to be effective, ABHS systems can be located anywhere and you can even carry them in your pocket.

• Compliance with hand hygiene in the medical setting using hand sanitizers is superior to hand washing.

• The time required to leave the patient to wash, wash and dry is significantly reduced with ABHS’s.

Hand hygiene, antibiotic resistance and other topics including identification of and responses to breaches in infection control will be discussed on the first day of the Organization for Safety, Asepsis and Prevention’s (OSAP) upcoming infection control boot camp in January 2015.

ADDITIONAL READING: Clean dentistry campaign launched

So how do we balance this information?

Washing hands with soap and water is the best way to reduce the number of microbes on hands in most situations. The CDC clearly states when healthcare workers should perform hand hygiene: “Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings)”. (10) Deciding how to perform hand hygiene is a critical clinical decision that each clinician must make. When used properly both methods are effective for the specific conditions that they were developed for.

Think about the task you will be performing. If you are just doing blood pressure on a patient, a hand sanitizer is a great alternative as you enter the room if your hands are debris-free. When in doubt about debris on your hands, wash your hands instead of applying ABHS. If soap and water are not available and your hands are debris-free, use an ABHS that contains at least 60% alcohol. Balancing ever changing knowledge and best practices saves lives.

OSAP, dentistry’s infection control advocate, has assembled a myriad of hand hygiene training and resources in one place to meet practice needs. The Hand Hygiene Tool Kit features articles, videos, patient materials and more.

Editor's Note: References available upon request. We are honored to have Noel write this article for us and congratulate her on being named one of our Top 25 Women in Dentistry in 2014.