Handwashing practice among dental students: lessons unlearned from the COVID-19 pandemic

Abstract

Background

Handwashing is essential for reducing the risk of cross-infection in the dental setting, as evidenced by the heightened significance of this practice during the COVID-19 pandemic.

Objectives

The extent of adherence to handwashing in the dental setting in the post-COVID-19 phase remains unclear, particularly regarding the pandemic’s impact on this practice among dental students. This inquiry constitutes the primary objective of the present study.

Materials and methods

A cross-sectional study was designed involving 100 randomly selected undergraduated dental students at the Santiago de Compostela University (Spain). In 2023, the handwashing procedures performed by students at the end of practical classes were recorded through direct observation. The variables analyzed were: duration of the procedure, cleaning agent used, and the location of handwashing. Results were compared with those obtained from a similar study conducted in 2015, prior to the COVID-19 outbreak.

Results

In 2023, 29% of students washed their hands after practical classes, compared to 42% in 2015 (p = 0.046). No students adhered the WHO handwashing recommendations. Among senior students, the percentage practicing handwashing increased (p = 0.019), as did the duration of the procedure (p = 0.013), compared to mid-senior students. A higher percentage of students engaged in handwashing (p = 0.01) and for a longer duration (p = 0.038) at the conclusion of clinical training session compared to preclinical simulation session.

Conclusions

Despite the impact of the COVID-19 pandemic, handwashing is not a standard practice among dental students. Therefore, it is imperative to implement educational measures that promote genuine adherence to this hygiene practice.

Introduction

In 2005, the World Health Organization (WHO) launched the “Global Challenge for Patient Safety,” asserting that “clean care is safer care.” This initiative highlighted hand hygiene as a fundamental component of patient safety in healthcare settings [1]. In 2009, the WHO introduced a new initiative under the “Patient Safety Program,” bearing the slogan “Save Lives: Clean Your Hands,” emphasizing the importance of the “Five Moments for Hand Hygiene” model (1. Before touching a patient; 2. Before clean/aseptic procedure; 3. After body fluid exposure risk; 4. After touching a patient; 5. After touching patient surroundings), which became a strategy of significant global impact [2].

COVID-19, caused by the SARS-CoV-2 coronavirus, was first reported in December 2019 in Wuhan, Hubei (China), with severe respiratory infection as its most common clinical manifestation. The rapid spread of the virus led the WHO to declare a public health emergency of international concern in January 2020 [3]. Dentists and dental auxiliary personnel were among the healthcare professionals most at risk due to aerosol generation during dental procedures [4, 5]. Furthermore, the oral cavity was identified as a preferred environment for SARS-CoV-2 due to the high concentration of angiotensin-converting enzyme 2 (ACE2) in the oral mucosa, which serves as a viral receptor [4].

During the COVID-19 pandemic, hand hygiene emerged as a critical preventive measure within the dental profession [6]. Specific protocols were proposed concerning the choice of cleaning agents and the duration of handwashing [7]. Furthermore, the requirement for patients and their companions to sanitize their hands with an alcohol-based solution provided by dental staff upon entering the clinic was emphasized [5, 8, 9]. In Spain, dentists were required to follow the WHO’s “Five Moments for Hand Hygiene” [10] and to implement a hand hygiene protocol prior to treatment. This protocol issued by the General Council of Official Colleges of Dentists of Spain included: washing hands with soap and water for one minute, drying with paper towels, and applying a 60% alcohol-based solution before donning gloves (https://coem.org.es/media/news/pdf/Proto-Covid-COEM.pdf).

Monitoring hand hygiene compliance in healthcare settings has revealed significant challenges in ensuring adherence to recommended protocols at all necessary times, despite ongoing concerns about infection [11]. Although some studies indicated an increase in hand hygiene compliance among healthcare personnel during the COVID-19 pandemic, adherence was influenced by various factors, including the evaluation period, type of healthcare professional, attendance at training sessions, awareness of hand hygiene guidelines, and availability of individually packaged alcohol-based hand sanitizers [12] The extent of adherence to these practices in the dental setting in the post-COVID-19 phase remains unclear, particularly regarding the pandemic’s impact on handwashing habits among dental students in an academic context. This inquiry constitutes the primary objective of the present study.

Materials and methods

Study group

A convenience sample comprising 100 undergraduate dental students at the Medical and Dental School, University of Santiago de Compostela (Spain), was established. The inclusion criteria were as follows: enrollment in the Bachelor of Dental Science program, regardless of age, sex, or prior education; active participation in clinical training classes or preclinical simulations classes using natural teeth; and enrollment as a mid-senior (3rd or 4th year of study) or a senior student (5th year of study). Participant selection for the study group was carried out by consecutively including students attending clinical training classes (n = 50) or preclinical simulation classes (n = 50), until a total of 100 individuals was reached—representing 76.3% of all students enrolled in the 3rd, 4th, or 5th year of the undergraduate dental program. All of them had received training in hand hygiene in accordance with WHO guidelines, as part of the curriculum of the subject ‘Preventive and Community Dentistry,’ which is delivered at the beginning of the third year of the undergraduate dental program.

Study design and variables

A cross-sectional observational study was conducted between April and June 2023 (post-COVID), approved by the Bioethics Committee of the University of Santiago de Compostela (Spain). A single observer, acting incognito, directly recorded each student’s behavior at the conclusion of practice sessions and collected data on handwashing procedures to minimize potential inter-observer bias. Specifically, the following items were recorded during each observation:

*

Did the student wash their hands upon completing the activity, whether clinical or preclinical? (yes/no)

*

Did the student perform optimal handwashing? “Optimal” handwashing was defined as adhering to WHO recommendations,2 which require vigorous rubbing of hands for at least 20 s with an agent such as hand sanitizer or soap and water.

*

Was the activity clinical or preclinical? For clinical activities, handwashing compliance was evaluated after the students had contact with a patient or adjacent areas of the dental operatory (2 out of the 5 moments for hand hygiene as described by the WHO were assessed); observations commenced when the students began to tidy the dental operatory and continued until they exited the area. For preclinical activities, handwashing was assessed after direct contact with organic material (e.g., extracted teeth for practicing fillings); observations commenced 30 min prior to the end of the activity.

*

The time (in seconds) taken to perform handwashing.

*

The agent used for handwashing (water, soap, hand sanitizer, or others).

*

The location where handwashing occurred: Washing (1) in the operatory or preclinical simulation room; Washing (2) in the restroom while still wearing work attire; Washing (3) in the restroom in street clothing; Washing (4) in the changing room.

*

The role of the student (operator, assistant, or circulating staff).

Control group

Data were sourced from a similar study (unpublished data) conducted in 2015 (pre-COVID-19), which also involved 100 students from the Bachelor of Dental Science program at the Medical and Dental School, University of Santiago de Compostela (Spain). The comparison with the historical group was made on the basis that both studies—the current and the historical control— share key characteristics, including the same study population (3rd, 4th, and 5th year dental students), the same institutional setting, and the use of identical data collection methods and measurement protocols.

Statistical analysis

Independent variables included the students’ sex (female/male), year of study (3rd, 4th, or 5th), type of activity performed, and the role assumed. Dependent variables comprised handwashing, the agent used, and the time taken to complete the procedure. A bivariate analysis was conducted for each variable in relation to the post-COVID and pre-COVID groups, followed by a multivariate logistic regression analysis adjusting the model (applying collinearity criteria to eliminate highly correlated variables). The model selection employed a stepwise backward elimination approach, wherein an initial model with all independent variables was fitted, and the least influential variable was iteratively removed based on individual contrasts using the likelihood ratio test. The goodness-of-fit for each model was assessed using the Hosmer-Lemeshow statistic and deviance.

Results

Exploratory analysis of post-COVID results

Among the 100 students in the study group, the majority were female (71%); half were in their 4th year (n = 50) and half participated in clinical training sessions (n = 50). Regarding the roles assumed by the students, most were operators (n = 72) (Table 1).

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Handwashing practices were recorded in 29 students, although none demonstrated “optimal” execution of the procedure. The remaining 71 students comprising the study cohort did not perform hand hygiene at any time. In all cases, handwashing occurred either in the dental operatory or the preclinical simulation room (Washing 1). Handwashing was not influenced by sex or the role assumed by the student. However, the likelihood of handwashing increased among students in higher academic years (p = 0.019) and was performed more consistently after clinical training sessions compared to preclinical simulation sessions (p = 0.001). These results are detailed in Table 2.

All students washed their hands using water, either alone (10.3%) or in combination with soap (89.6%). The choice of either option was independent of sex, year of study, activity, or the role assumed by the students (Table 2).

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The mean duration of handwashing was 5.1 ± 2.2 s, with no statistically significant differences detected based on sex or student role (Table 2). Handwashing duration was greater among students in higher academic years (p = 0.013) and was more frequent after clinical training sessions than after preclinical simulation sessions (p = 0.038).

Exploratory analysis of pre-COVID results

Among the 100 students in the control group, the majority were female (64%); nearly half were in their 4th year (n = 49) and half participated in clinical training sessions (n = 50). In terms of roles assumed by the students, most were operators (n = 67) (Table 1).

Handwashing practices were recorded in 42 students, but only 1 demonstrated “optimal” execution of the procedure. 82% of handwashing occurred in the clinical simulation room or dental operatory (Washing 1), while the remaining 8% took place in the restroom (Washing 2 or Washing 3). Handwashing was not influenced by sex, year of study, activity, or student role (Table 3).

A total of 34 students (80.9%) used water and soap, while 8 (19.0%) performed the procedure using water only. The mean duration of handwashing was 7.1 ± 4.3 s with no significant correlations to any of the analyzed variables (Table 3).

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Comparative analysis of post- and pre-COVID results

The multivariate logistic regression analysis (Table 4) indicated that students in the study group (post-COVID) were 46% less likely to wash their hands compared to those in the control group (pre-COVID) (p = 0.046).

The likelihood of handwashing among 5th-year students was three times greater than that of 4th-year students (p = 0.007) and nearly four times higher than that of 3rd-year students (p = 0.008).

Students assuming the role of circulating staff were 87% less likely to wash their hands compared to operators (p = 0.006), while no significant differences were found between operators and assistants.

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Discussion

Degree of compliance

This study demonstrates through direct observation that, in the post-COVID period, the percentage of assessed dental students who wash their hands after a clinical training session is below 30%, with none adhering to the protocol recommended by the WHO. We have not identified any comparable studies in the literature conducted during the post-COVID period to validate this result.

During the COVID-19 pandemic in 2020, a direct observation among dental students in Saudi Arabia confirmed a compliance rate of 80.7% [13]. In other studies conducted in the same year across dental students from various countries using surveys -an approach that may overestimate results- 97.7% of surveyed Brazilian dental students reported that they performed handwashing before and after patient appointments [14], while 90.2% of Turkish students acknowledged frequently washing their hands, with 86.7% utilizing antiseptics [15] These percentages were substantially higher than those observed in an observational study conducted among healthcare workers in a Danish hospital, which reported compliance rates of 22–29% [16], and in a survey conducted in Germany that evaluated dental students, nurses, and medical auxiliaries in training, yielding a compliance rate of 52% [17].

Prior to the pandemic, in 2015, dental students at our University exhibited a compliance rate of 42% (unpublished data). In 2019, Meisha et al. also reported a compliance rate of 30.8% through direct observation among dental students in Saudi Arabia [13]. In China, during the period 2012–2013, direct observations of postgraduate dentists reflected a hand hygiene compliance rate of 34.7% [18]. In the five years leading up to the pandemic, several studies employing direct observation were conducted regarding handwashing practices in various healthcare settings [16, 19, 20]. In Bratislava, Slovakia, 37.1% of a heterogeneous group of medical, nursing, obstetrics, and public health students demonstrated adequate adherence to the hand hygiene protocol; [20] in Ghana, the compliance rate among healthcare workers was 49.6% [19], while in Denmark, compliance rates fluctuated between 29% and 34% [16].

Duration of handwashing

The mean time spent by participants in this study for handwashing was nearly 4 times less than the duration recommended by the WHO [2] We have not identified similar studies in the literature conducted during either the post- or pre-COVID periods for comparative analysis. During the pandemic in 2020, a questionnaire completed by dental and medical students in Pakistan revealed that only 12% indicated that the duration of handwashing should be at least 20 s [21].

Cleaning agent

In the current study, nearly all students who performed handwashing utilized water and soap as cleaning agents, with none suggesting the use of hand sanitizers. We have not found comparable studies in the literature during the post- or pre-COVID periods. During the COVID-19 emergency in 2020, a survey conducted among Iranian dental students indicated that 55.3% considered washing hands with water and soap to be a routine hygiene practice, while 44.1% advocated for the use of water, soap, and hand sanitizer [22]. In Saudi Arabia, Divakar et al. reported that 83.8% of dental professionals preferred hand hygiene with water and soap for 30 s, compared to 60% who prioritized the use of alcohol-based gel [23]. A similar percentage (65%) was observed among Nigerian dentists, who also supported the use of alcohol solutions for hand higiene [24].

Location of handwashing

The dental students in this study predominantly performed handwashing in the dental operatory or in the preclinical simulation room. We have not identified similar studies in the literature conducted during the post- or pre-COVID periods for comparative analysis.

Impact of sex

In the present study, a higher compliance rate for hand hygiene was observed among females compared to males, although the difference did not reach statistical significance. We have not identified similar studies in the literature conducted during the post-COVID period for comparative analysis. Studies conducted during the pandemic reflected heterogeneous results, likely influenced by cultural, professional, religious, or other factors. For instance, consistent with our findings, Flores-Quispe et al. noted in a survey of dental students and dentists in Latin America and the Caribbean that sex was not a significant factor regarding handwashing habits [25]. Conversely, a group of German dental, nursing, and medical students demonstrated that females were more compliant with infection control policies [17]. In Iran, however, male dental students showed better responses regarding protective practices against COVID-19, including handwashing [22]. A notable paradox was reported in Saudi Arabia, where an observational study indicated that female dental students were 2.9 times more likely to disregard infection control practices compared to their male counterparts [13], while another survey in the same country found that women were usually more compliant [26].

In the pre-COVID period, female students at our University exhibited a compliance rate of 53%, compared to 42% for males (unpublished data). In this context, Lingawi et al. indicated that female dental students in Saudi Arabia demonstrated a higher level of knowledge about hand hygiene than their male counterparts (95.2% vs. 77.3%, respectively) [27].

In both the pre-COVID and post-COVID periods, hand hygiene compliance was slightly higher among female participants compared to their male counterparts; however, these differences did not reach statistical significance, likely due to sample size limitations. The literature on gender-based differences in hand hygiene practices among dentists remains inconclusive. Among physicians, it has been suggested that male practitioners exhibit lower compliance with hand hygiene protocols, which has been attributed to barriers such as time consumption, lack of habitual practice, forgetfulness, and perceived lack of tangible benefits [28]. Conversely, female practitioners are generally more inclined toward routine hand hygiene, although they tend to identify different barriers—such as an increased incidence of dermatological issues—as more relevant.28

Impact of year of study

A progressive increase in compliance with handwashing was observed depending on the year of study. We have not found similar studies in the literature conducted during the post- or pre-COVID periods for comparative analysis. Studies conducted in Saudi Arabia and Iran during the pandemic also described greater knowledge and commitment to handwashing practices among senior dental students compared to juniors [22, 26]. Additionally, comparisons between practicing dentists and dental students confirmed that handwashing practices were more frequent among professionals than among students [25, 29].

Impact of activity

The compliance rate for hand hygiene was substantially higher following clinical training sessions compared to preclinical simulation sessions. We have not found similar studies in the literature conducted during the post- or pre-COVID periods for comparative analysis.

Impact of role

Paradoxically, assistants exhibited a higher frequency of hand hygiene compliance than operators, although this difference did not reach statistical significance. We have not identified similar studies in the literature conducted during the post- or pre-COVID periods for comparative analysis.

Limitations

Among the limitations of the present study, the sample size should be noted, as it constitutes a convenience sample (n = 100 students), and the statistical power of the findings remains unknown. Another limitation is its cross-sectional design, as we do not know whether there is variability in students’ habits over time (e.g., in relation to accidental contaminations of themselves or peers). While the historical control study pertains to a period prior to the COVID-19 pandemic, we consider it relevant for contextualizing the current findings, as it allows for the identification of potential changes in hand hygiene practices attributable to new health regulations and educational interventions implemented in the post-pandemic period. However, we acknowledge the limitations of this comparison, given the cross-sectional nature of both studies and the lack of experimental control, which precludes drawing definitive causal conclusions. The nature of clinical training procedures (e.g., distinguishing between invasive and non-invasive) may also influence the results. Finally, the findings may be affected by cultural stereotypes [30]. The primary strength of this study arises from the methodology employed, particularly the reliability of direct observation as opposed to surveys.

Perspectives

In a Cochrane Library-sponsored review published in 2015, it was concluded that no definitive evidence could be drawn regarding the effectiveness of educational interventions aimed at improving hand hygiene compliance, due to the overall low certainty of the available evidence [31]. Since that time, only a limited number of studies have contributed new insights on this matter [32]. Nevertheless, the introduction of novel technologies—such as the LiftUpp digital educational platform, which employs a dedicated iPad application—has shown potential to enhance both compliance and hand hygiene efficacy [33]. However, the considerable methodological heterogeneity and the lack of rigor across existing studies continue to preclude clear conclusions regarding which interventions are most effective [34].

To enhance hand hygiene compliance in the context of dental education, we propose implementing a multimodal intervention specifically adapted to the clinical environment. This strategy should include didactic modules focused on the importance of hand hygiene in preventing cross-contamination during dental procedures, supplemented by hands-on training using standardized protocols and real-time instructor feedback. Visual reminders should be installed in preclinical laboratories and clinical areas to reinforce awareness. Furthermore, regular compliance audits with personalized feedback, integration of hand hygiene into clinical competency assessments, and the use of ultraviolet light-based simulation tools to visualize microbial contamination could further reinforce proper technique and adherence.

The optimal frequency of hand hygiene assessments remains undetermined, as do the most effective types of assessments and reminder strategies. Given the pivotal role of hand hygiene in dental practice, and the ongoing discrepancy between evidence-based guidelines and real-world compliance, there is an evident need for structured evaluation and continuous enhancement of hand hygiene protocols [35].

Conclusion

The frequency of handwashing among dental students at the University of Santiago de Compostela (Spain) in the post-COVID era following clinical training sessions was poor, and even lower than that observed in the pre-COVID period. None of the evaluated students performed handwashing in accordance with WHO recommendations. These results call for a reevaluation of the promotion of cross-infection control practices among dental students, such as routine handwashing, by implementing specific actions that are measurable and ensure compliance with WHO recommendations.

Data availability

Data and materials will be provided by the authors upon request.

Abbreviations

WHO:

World Health Organization

COVID-19:

Coronavirus Disease 2019

SARS-CoV-2:

Severe Acute Respiratory Syndrome-Coronavirus-Type2

ACE2:

Angiotensin-converting enzyme 2

References

Martos-Cabrera MB, Mota-Romero E, Martos-García R, et al. Hand hygiene teaching strategies among nursing staff: A systematic review. Int J Environ Res Public Health. 2019;16(17):3039. https://doi.org/10.3390/ijerph16173039.

World Health Organization, WHO Patient Safety. Hand hygiene technical reference manual: to be used by health-care workers, trainers and observers of hand hygiene practices. Geneva: World Health Organization. 2009. Available from: https://iris.who.int/handle/10665/44196

World Health Organization. WHO Director-General’s statement on IHR Emergency Committee on Novel Coronavirus. (2019-nCoV). Geneva: World Health Organization. 2020. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov).

Ge ZY, Yang LM, Xia JJ, et al. Possible aerosol transmission of COVID-19 and special precautions in dentistry. J Zhejiang Univ Sci B. 2020;21(5):361–8. https://doi.org/10.1631/jzus.B2000421.

Siles-Garcia AA, Alzamora-Cepeda AG, Atoche-Socola KJ, et al. Biosafety for dental patients during dentistry care after COVID-19: A review of the literature. Disaster Med Public Health Prep. 2021;15(1):e43–8. https://doi.org/10.1017/dmp.2021.109.

Peng X, Xu X, Li Y, et al. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci. 2020;12(1):9. https://doi.org/10.1038/s41368-020-0080-1.

Izzetti R, Nisi M, Gabriele M, et al. COVID-19 transmission in dental practice: brief review of preventive measures in Italy. J Dent Res. 2020;99(9):1030–8. https://doi.org/10.1177/0022034520931668.

Amato A, Caggiano M, Amato M, et al. Infection control in dental practice during the COVID-19 pandemic. Int J Environ Res Public Health. 2020;17(13):4769. https://doi.org/10.3390/ijerph17134769.

Kapote GR, Tharwani P, Vhatkar B, et al. Coronavirus outbreaks and infection prevention in dentistry: a narrative review. Can J Dent Hyg. 2022;56:140–6.

World Health Organization, WHO Patient Safety. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: World Health Organization. 2009. Available from: https://iris.who.int/handle/10665/70030

Ragusa R, Marranzano M, Lombardo A, et al. Has the COVID-19 virus changed adherence to hand washing among healthcare workers? BehavSci (Basel). 2021;11(4):53. https://doi.org/10.3390/bs11040053.

Guerrero-Soler M, Gras-Valentí P, Gómez-Sotero IL, et al. Impact of COVID-19 on the degree of compliance with hand hygiene: A repeated cross-sectional study. Epidemiol Infect. 2024;152:e69. https://doi.org/10.1017/S0950268824000368.

Meisha DE. Comparison of compliance with infection control practices among dental students in Saudi Arabia before and during the COVID-19 pandemic. Risk Manag Healthc Policy. 2021;14:3625–33. https://doi.org/10.2147/RMHP.S311236.

Aragão MGB, Gomes FIF, Pinho Maia Paixão-de-Melo L, et al. Brazilian dental students and COVID-19: A survey on knowledge and perceptions. Eur J Dent Educ. 2022;26(1):93–105. https://doi.org/10.1111/eje.12650.

Ataş O, Talo Yildirim T. Evaluation of knowledge, attitudes, and clinical education of dental students about COVID-19 pandemic. PeerJ. 2020;8:e9575. https://doi.org/10.7717/peerj.9575.

Sandbøl SG, Glassou EN, Ellermann-Eriksen S, et al. Hand hygiene compliance among healthcare workers before and during the COVID-19 pandemic. Am J Infect Control. 2022;50(7):719–23. https://doi.org/10.1016/j.ajic.2021.11.003.

Baier C, Albrecht UV, Ebadi E, et al. Knowledge about hand hygiene in generation Z: A questionnaire-based survey among dental students, trainee nurses, and medical technical assistants in training. Am J Infect Control. 2020;48(7):708–12. https://doi.org/10.1016/j.ajic.2019.11.004.

Cheng HC, Peng BY, Lin ML, et al. Hand hygiene compliance and accuracy in a university dental teaching hospital. J Int Med Res. 2019;47(4):1195–201. https://doi.org/10.1177/0300060518801444.

Labi A, Obeng-Nkrumah N, Nuertey BD, et al. Hand hygiene practices and perceptions among healthcare workers in ghana: A WASH intervention study. J Infect Dev Ctries. 2019;13(12):1076–85. https://doi.org/10.3855/jidc.12062.

Novák M, Breznický J, Kompaníková J, et al. Impact of hand hygiene knowledge on hand hygiene compliance. Med Glas (Zenica). 2020;17(2):194–9. https://doi.org/10.17392/1022-20.

Ali S, Alam BF, Farooqi F, et al. Dental and medical students’ knowledge and attitude toward COVID-19: A cross-sectional study from Pakistan. Eur J Dent. 2020;14(1):S97–104. https://doi.org/10.1055/s-0040-1701872.

Saffar Shahroudi A, Hashemikamangar SS, Ahmed Aljawad ZA, et al. Dental students’ knowledge about protective guidelines for clinical practice during the COVID-19 pandemic. J Oral Biol Craniofac Res. 2023;13(2):327–31. https://doi.org/10.1016/j.jobcr.2022.07.002.

Divakar DD, Nimbeni SB, Al-Kheraif AA, et al. Knowledge and attitude of dental professionals toward COVID-19 in riyadh, Saudi arabia: A cross-sectional survey. Asian Biomed (Res Rev News). 2021;15(4):277–84. https://doi.org/10.1515/abm-2021-0032.

Aladelusi TO, Atiba FA, Gbadebo SO, et al. COVID-19 outbreak and dental health care provision in nigeria: A National survey. BMC Oral Health. 2021;21(1):493. https://doi.org/10.1186/s12903-021-01455-5.

Flores-Quispe B, Ruiz-Reyes R, León-Manco R, et al. Preventive measures for COVID-19 among dental students and dentists during the mandatory social isolation in Latin America and the Caribbean in 2020. Dent Med Probl. 2022;59(1):5–11. https://doi.org/10.17219/dmp/139167.

Bin Mubayrik A, Al Dosary S, Alwasil W, et al. Knowledge and practice of COVID-19 infection control among dental students and interns: A cross-sectional survey. Adv Med Educ Pract. 2021;12:1419–27. https://doi.org/10.2147/AMEP.S296927.

Lingawi H, Maher Y, Afifi I. Impact of educational intervention for hand hygiene on dental students’ knowledge, attitude, and bacterial contamination level on hands. J Contemp Dent Pract. 2017;18(12):1164–72. https://doi.org/10.5005/jcdp-18-12-1164.

Park SY, Kim J, Lee E, Park S, Park JW, Yu SN, Kim T, Jeon MH, Choo EJ, Kim TH. Gender differences in psychosocial determinants of hand hygiene among physicians. Infect Control Hosp Epidemiol. 2024;45(2):215–20. https://doi.org/10.1017/ice.2023.

Bains V, Bains R, Gupta V, et al. Knowledge of COVID-19 and its implications in dental treatment, and practices of personal protective equipment among dentists: A survey-based assessment. J Educ Health Promot. 2021;10:79. https://doi.org/10.4103/jehp.jehp_528_20.

Bajunaid RM, Saeed A, Bostaji M, et al. Hand hygiene compliance and improvement interventions in the Eastern mediterranean region: A systematic review and meta-analysis. Infect Prev Pract. 2024;6(1):100363. https://doi.org/10.1016/j.infpip.2024.100363.

Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. https://doi.org/10.1002/14651858.CD005186.pub4.

Singh A, Barnard TG. Health science students’ perceptions of hand hygiene education and practice in a South African university: introducing the university hand hygiene improvement model. Healthc (Basel). 2023;11(18):2553. https://doi.org/10.3390/healthcare11182553.

Oliehoek FA, Savani R, Adderton E et al. LiftUpp: support to develop learner performance. In: André E, Baker R, Hu X, Rodrigo M, du Boulay B, editors. Artificial intelligence in education. AIED 2017. Lecture Notes in Computer Science 2017;vol 10331. Springer, Cham. https://doi.org/10.1007/978-3-319-61425-0_62

Purssell E, Gould D. Teaching health care students hand hygiene theory and skills: a systematic review. Int J Environ Health Res. 2021;32(9):2065–73. https://doi.org/10.1080/09603123.2021.1937580.

Kuroda H, Sawai NY, Yamazaki Y, et al. Impact of direct observation on hand hygiene compliance in a dental university hospital: A retrospective cohort study. Cureus. 2024;16(9):e68827. https://doi.org/10.7759/cureus.68827.