- Owner
- Sterilization Coordinator
- Effective date
- September 15, 2026
- Review cycle
- Every 12 months
1.Purpose
To make sure every reusable dental instrument is cleaned, packaged and sterilized correctly before use, and that sterilizer performance is verified and documented.
2.Scope
Applies to reusable dental instruments and cassettes processed in the sterilization area. Single-use disposable items and dental unit waterlines are covered by separate SOPs.
Definitions
- Biological indicator
- A test vial containing spores used to confirm that a sterilization cycle actually achieved sterilization, not just the correct temperature and time.
- Instrument cassette
- A tray or case that holds a set of instruments together through cleaning, packaging and sterilization.
- Sterile shelf life
- The length of time a sterilized, packaged instrument set remains sterile if the packaging stays intact and dry.
3.Responsibilities
- Dental Assistant
- Cleans, packages and loads instruments, and runs and unloads sterilization cycles.
- Sterilization Coordinator
- Manages biological monitoring, sterilizer maintenance and processing records.
- Dentist
- Confirms sterilization compliance during case review and addresses any failed monitoring result.
RACI matrix
| Activity | Dental Assistant | Sterilization Coordinator | Dentist |
|---|---|---|---|
| Clean and package instruments | R/A | C | I |
| Run and unload the sterilization cycle | R/A | C | I |
| Perform biological indicator testing | R | R/A | I |
| Respond to a failed sterilization test | R | R/A | C |
R = Responsible, A = Accountable, C = Consulted, I = Informed
4.Materials and PPE
Materials, tools and systems
- โUltrasonic cleaner or instrument washer
- โSterilization pouches and cassette wraps
- โSteam autoclave with cycle printout or data log
- โBiological indicator vials and incubator
- โChemical indicator strips
- โSterilization processing log
Personal protective equipment
- โHeavy-duty utility gloves for cleaning
- โMask and eye protection
- โProtective apron or gown
5.Procedure
- 5.1
Transport contaminated instruments safely
Dental AssistantCarry used instruments from the operatory to the sterilization area in a covered, puncture-resistant container immediately after the appointment.
Warning: Never carry loose contaminated instruments by hand or leave them uncovered on a counter.
- 5.2
Pre-rinse and sort instruments
Dental AssistantRinse gross debris from instruments and sort sharps and cassettes before placing them in the ultrasonic cleaner or washer.
- 5.3
Clean instruments before packaging
Dental AssistantRun instruments through the ultrasonic cleaner or automated washer for the manufacturer's recommended cycle time, then rinse and dry them completely.
Checkpoint: Instruments are visibly free of debris and completely dry before packaging.
- 5.4
Inspect instruments for damage
Dental AssistantInspect each instrument for corrosion, damage or malfunction and set aside any that need repair or replacement before packaging.
- 5.5
Package instruments with a chemical indicator
Dental AssistantPlace cleaned instruments or cassettes into sterilization pouches or wraps, including a chemical indicator strip inside each package, and seal according to the manufacturer's instructions.
- 5.6
Load the sterilizer correctly
Dental AssistantLoad packages into the autoclave without overloading the chamber, leaving space between packages so steam can circulate freely.
- 5.7
Run the sterilization cycle
Dental AssistantSelect the correct cycle for the load type and run it to completion, following the sterilizer manufacturer's time and temperature settings.
- 5.8
Check the cycle printout or log
Dental AssistantConfirm the cycle reached and held the correct temperature and pressure for the required time, and file the printout or electronic log entry.
Checkpoint: Every cycle's printout or log confirms the required temperature and time were reached before packages are released.
- 5.9
Unload and cool sterilized packages
Dental AssistantUnload packages once the cycle is complete and let them cool and dry fully on a rack before handling or storage, avoiding condensation that can compromise sterility.
- 5.10
Run weekly biological indicator testing
Sterilization CoordinatorRun a biological indicator test at least weekly and with every load containing an implantable device, then incubate and read the result according to the manufacturer's instructions.
Checkpoint: Biological indicator testing is completed at least weekly and the results are documented before instruments from an implant load are used.
- 5.11
Respond to a failed biological indicator
Sterilization CoordinatorIf a biological indicator fails, remove the sterilizer from service, recall and reprocess all items sterilized since the last passing test, and have the sterilizer inspected before returning it to use.
Warning: Never use instruments from a load associated with a failed biological indicator until the sterilizer is confirmed working again.
- 5.12
Store sterile packages correctly
Dental AssistantStore sterilized packages in a clean, dry, enclosed area, rotate stock so older packages are used first, and check package integrity before use.
6.Quality checks
- โBiological indicator testing is performed at least weekly and passes every time.
- โEvery sterilization cycle has a printout or log showing correct temperature and time.
- โInstruments are packaged with a chemical indicator that changes correctly.
- โNo sterile package with damaged or wet wrapping is used on a patient.
7.Records
- โSterilization cycle printouts or logs
- โBiological indicator test results
- โSterilizer maintenance and calibration records
- โFailed test recall and reprocessing log
8.KPIs
- โBiological indicator pass rate
- โSterilizer downtime due to failed testing
- โInstrument turnaround time from operatory to sterile storage
- โPercentage of packages with intact, dry wrapping at point of use
9.Common mistakes
- โOverloading the autoclave so steam cannot circulate around every package.
- โSkipping the weekly biological indicator test when the schedule is busy.
- โPackaging instruments that are still wet from cleaning.
- โUsing instruments from a load before the cycle printout has been checked.
10.Revision history
| Revision | Date | Description | Reviewed by |
|---|---|---|---|
| 1.0 | September 15, 2026 | Initial release | Ilia Pirozhenko |
This is a template. Adapt it to your organization, equipment and local regulations before use.