DEN-SOP-003: Aerosol and splatter control

Standards › Standard 31 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · DEN-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 31.7

At a glance

High-volume evacuation and rubber dam are used for procedures that generate aerosol.
Staff wear protective equipment for aerosol-generating work (HH-SOP-001).
The room is left unoccupied for its fallow time after aerosol-generating work.
Surfaces are cleaned after each procedure.
Stop and get help straight away if: an aerosol-generating procedure is started with no evacuation and no fallow time.

1. Purpose

To reduce the spread of infection through aerosol and splatter during dental treatment (31.7).

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 drills and scalers make a fine spray that carries bacteria and blood into the air and onto staff. Measures such as high-volume suction and protective equipment reduce that spread.

5. Responsibilities

Role	Responsibility	Competence
Clinician	Uses the controls for each procedure	Infection prevention lead
Dental nurse or assistant	Sets up the evacuator and checks the room log	Clinician

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. Prepare.

Set up the high-volume evacuator and rubber dam before the procedure.
Put on the protective equipment set for aerosol work.

Key point: Prepared.

Step 2. Treat.

Use the controls throughout the procedure.

Key point: Treated.

Step 3. Clear the room.

Clean the surfaces and respect the fallow time before the next patient.

Key point: Cleared.

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
Aerosol procedures with controls used	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
HH-SOP-001	Hand hygiene and standard precautions	Procedure

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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