Undergraduate Dentistry Clinical Skills Lab

Standard Precautions in
Oral & Maxillofacial Surgery

WHO Surgical Hand Scrub, Gowning, and Sterile Gloving

Dr. Kezia Rachellea Mustakim, DDS, MSD, PhD

Department of Oral and Maxillofacial Surgery

Learning Objectives

Core competencies for the surgical module

Understand the Rationale

Comprehend the importance of surgical asepsis in preventing Surgical Site Infections (SSIs) in complex dental practice.

Master Hand Scrubbing

Correctly perform the WHO Surgical Hand Scrub using standard protocols, appropriate antimicrobial agents, and exact duration.

Perform Surgical Gowning

Demonstrate the precise aseptic technique for donning a sterile surgical gown independently or with an assistant.

Apply Sterile Gloves

Execute the closed-gloving technique seamlessly to maintain an unbroken chain of sterility.

The Golden Rule of Sterility

Fundamental axioms of oral surgery

"If in doubt regarding the sterility of an item or area, consider it unsterile."

While the oral cavity inherently contains diverse microflora, the introduction of exogenous pathogens during maxillofacial procedures (e.g., impactions, implants, trauma) can precipitate devastating complications such as deep-space fascial infections or osteomyelitis.

Primary Objectives of Asepsis:

Protect the patient from the surgical team's endogenous flora.
Protect the surgical team from bloodborne pathogens.
Establish and strictly delineate a defined sterile operative field.

Part 1: WHO Scrub Preparation

Pre-requisites prior to approaching the sink

Critical Principle

Once the scrub sequence begins, hands must universally remain above the level of the elbows to prevent contaminated water from running down toward the clean hands.

1. Fomite Removal

Remove all rings, watches, and bracelets. These act as reservoirs for microorganisms and inhibit adequate mechanical scrubbing.

2. Nail Inspection

Fingernails must be short (not visible over fingertips). Artificial nails and chipped polish are strictly prohibited.

3. Protective Attire

Don surgical cap/bouffant, surgical mask, and protective eyewear securely before initiating the hand wash.

4. Sink Operation

Adjust water temperature and flow using knee, foot, or infrared sensors. Dispense antimicrobial agent.

The WHO Surgical Hand Scrub Technique

Perform sequence for 3-5 minutes, extending 5cm above elbows

WHO Guidelines

I

Step I

Palmar

Rub hands palm to palm to distribute the antimicrobial agent evenly.

II

Step II

Dorsal

Right palm over left dorsum with interlaced fingers, and vice versa.

III

Step III

Interdigital

Palm to palm with fingers interlaced to meticulously clean interdigital spaces.

IV

Step IV

Knuckles

Backs of fingers to opposing palms with fingers interlocked securely.

V

Step V

Thumbs

Rotational rubbing of left thumb clasped in right palm, and vice versa.

VI

Step VI & Arms

Extremities

Rotational rubbing of fingertips in palm, then systematically progress down to forearms.

Part 2: Surgical Gowning Protocol

Aseptic technique for entering the sterile operative environment

Concept of Sterility Zones

Gowns are sterile only from the anterior chest to the level of the sterile field, and from 2 inches above the elbow to the cuff.

The back of the gown is NEVER considered sterile.

1

Aseptic Drying

Enter the OR backing through doors, hands elevated. Lift the sterile towel vertically. Dry one hand/arm using one half of the towel. Invert the towel carefully and dry the contralateral arm. Discard towel safely.

2

Lifting and Unfolding

Grasp the sterile gown firmly at the inner neckline. Step back into a clear area to allow the gown to unfold freely via gravity. Do not shake the gown.

3

Arm Insertion (Donning)

Slip both arms into the armholes simultaneously. Advance arms to the proximal edge of the cuffs. Keep hands completely inside the cuffs to prepare for the closed-gloving technique. The circulating nurse secures the back ties.

Sterile Gloving Modalities

Differentiating techniques based on procedural requirements

Closed Technique

The standard of care for major surgical procedures. Performed immediately post-gowning while the hands remain physically isolated inside the sleeves of the surgical gown.

Skin never contacts the exterior of the gown or glove.
Statistically provides the lowest risk of intraoperative contamination.
Mandatory for maxillofacial OR procedures.

Primary OR Technique

Open Technique

Utilized during minor clinical procedures (e.g., simple extractions without full gowning) or when replacing a singular contaminated glove during an ongoing surgery.

Bare skin is exposed during donning.
Strict adherence to the "Skin-to-Skin, Glove-to-Glove" paradigm is required.
Higher risk of touch contamination.

Minor Procedures / Glove Replacement

Part 3: Closed Gloving Execution

Kinematic sequence for the closed technique

I

Glove Retrieval

With hands retained completely inside the gown cuffs, utilize the non-dominant hand (acting through the fabric) to pick up the opposite sterile glove.

II

Anatomical Alignment

Place the glove on the volar aspect (palm) of the dominant hand. Ensure "Thumb to Thumb, Fingers facing the Elbow" orientation.

III

Cuff Inversion

Grasp the glove's cuff edge through the gown fabric and stretch it completely over the knitted cuff of the gown, encapsulating the hand.

IV

Extension and Refinement

Push fingers distally into the glove stalls. Repeat the entire process for the contralateral hand. Adjust finger fit only when both gloves are secured.

Maintaining the Sterile Field

Intraoperative conduct and spatial awareness

Operational Directives

Keep hands continually in view, situated above the waistline and below the shoulder level.
Do not cross arms or fold hands into axillary regions (high moisture and friction compromise sterility).
When navigating past another scrubbed individual, pass strictly back-to-back or face-to-face.
Never turn your back toward the sterile instrument table or the operative field.

Fig 1: Proper hand positioning awaiting patient prep.

Clinical Skills Laboratory Practicum

Theoretical instruction concludes here. Students will now transition to the clinical simulation area for practical evaluation.

Evaluation Checklist:

Preparation & Attire

3-5 Minute WHO Scrub

Aseptic Towel Drying

Gowning without Contamination

Closed Gloving Technique