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
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)