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Instrument decontamination guidance

Scottish Health Technical Memorandum (SHTM) 01-05 Management, equipment, and process of the decontamination of dental instruments in a Local Decontamination Unit (LDU) in NHSScotland is national, best practice guidance published by Health Facilities Scotland in April 2024.

SHTM 01-05 comprises three parts:

  • Part A - Management

Focuses on the management of the decontamination process within the LDU and applies to dental instruments that are processed by the User or a third party to be made ready for use.

  • Part B - Decontamination equipment / test methods

Covers decontamination equipment used to carry out processing of dental instruments. It details the maintenance, periodic testing, and test equipment requirements for decontamination equipment in line with the Chief Dental Officer (CDO) letter (2010) and current guidance.

  • Part C - Process

Provides practical guidance on the whole instrument decontamination process, presented in a form designed to be readily understandable by members of the dental team.

SHTM 01-05 guidance replaces relevant parts of SHTM 2010 relating to small steam sterilizers, SHTM 2030 for washer disinfectors (WD), other previous NHSScotland dental decontamination guidance and the SDCEP Decontamination into Practice guidance, which has been withdrawn.

About SHTM 01-05 Part C

SHTM 01-05 part C brings together and replaces the extensively used SDCEP Decontamination Into Practice guidance series, has been written in collaboration with SDCEP and has SDCEP endorsement.

Building on the success of the SDCEP guidance, part C presents practical, up-to-date advice on each aspect of decontamination within dental practice. Reference to parts A or B may be necessary for more detailed technical guidance.

Advice and templates to support the management of decontamination in dental practice in accordance with SHTM 01-05 are provided in SDCEP’s Practice Support Manual.

Key messages and changes in Part C include:

  • Use of a washer disinfector is a requirement for compliant reprocessing of dental instruments in an LDU. An ultrasonic cleaner, while useful as an additional cleaning aid, may only be used as a back-up in the event of washer disinfector failure (para 3.13).
  • For washer disinfectors, potable water that meets manufacturer’s requirements is adequate (para 3.12) (otherwise filtration is required). Sterile water for irrigation is preferred for use in sterilizers (para 4.15).
  • Dental handpiece decontamination and lubrication should follow manufacturer’s instructions (para 3.5, 3.21 & 4.11).
  • Equipment testing schedules should follow Manufacturer’s Instructions, or if unavailable, the schedules recommended in Part C (section 5).
  • Sterilizer Automatic Control Tests are required to be carried out weekly (no longer daily) (para 5.33).
  • Equipment records are to be retained for the lifetime of the equipment plus 25 years. (paras 5.7-5.10)
  • Policies and procedures should be reviewed and updated periodically with revisions noted (para 6.2).
  • New titles of personal involved in decontamination are used (Appendix 1).

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