DEN-SOP-002: Dental unit waterline management

Standards › Standard 31 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · DEN-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 31.5

At a glance

Each dental unit waterline is treated on the manufacturer’s schedule and the product is logged.
Water quality is tested at the set interval (DEN-REG-002).
Any out-of-limit result is acted on and recorded the same day.
Each dental unit has a recorded set-up.
Stop and get help straight away if: patients are treated from a unit with an out-of-limit test result and no action.

1. Purpose

To keep dental unit water safe for patients and staff by treating and testing the waterlines (31.5).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Dental unit waterlines are a known source of bacteria, and the water sprayed in the mouth passes through them. Treating and testing the water keeps it safe.

5. Responsibilities

Role	Responsibility	Competence
Infection prevention lead	Owns the treatment regime and the test schedule	Clinical director
Dental nurse or assistant	Logs each treatment and reports any problem	Infection prevention lead

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Set up the unit.

Record the set-up of each dental unit, including its water source.
Start the treatment regime at the start of each day.

Key point: Set up.

Step 2. Treat and log.

Apply the treatment product as scheduled and record it in the log.

Key point: Logged.

Step 3. Test and act.

Take the water test at the set interval.
Act on any result above the limit and record the action (DEN-REG-002).

Key point: Acted on.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Scheduled treatments logged	100%	Monthly	Infection prevention lead	Escalate to the clinical director

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
DEN-REG-002	Waterline test register	Register

17. Evidence

Reference	Note
E-009	Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016).
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Dental Practice: Five Safety Criteria at the Chair (AMB-08)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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