Since the worldwide spread of the Coronavirus, people are getting very conscious about hygiene procedures wherever they go. In a dental care facility, infection control protocols should already be standard and established in your daily routine. The most frequently used sterilization method across the globe is via steam, a process that can be assessed by mechanical monitoring and biological and chemical indicators.[1] Luckily, infections in dental care are rare, but the US Centers for Disease Control and Prevention (CDC) says it is mostly due to inadequate infection prevention procedures, a weak sterilization protocol, and insufficient monitoring.[2] Refreshing each step’s pros and cons in the monitoring process will benefit you and all your facility’s employees. Minimizing breaches will encourage patients to keep visiting dental professionals during this pandemic. The following overview gives you insight into sterilization monitoring in dental instrument reprocessing. While some monitoring procedures might be more frequently used than others, they all have their own unique importance in the process. The biological indicator (BI) When used correctly, biological indicators are a very reliable method for monitoring the sterilization process.[3] Unfortunately, not all professionals use them. In a recent Dental Economics survey, 84% of respondents used biological monitoring. Especially when reopening your practice during the pandemic, the CDC strongly recommends that medical professionals use the Biological Indicator test to assess the sterilizer’s condition.[4] The BI test assesses the effectiveness of the sterilizer in killing highly resistant bacterial spores. The probability that a single microbe remains on an instrument after sterilization is expressed as a sterility assurance level (SAL), mostly expressed as 10-n.[5] This method is valuable, but if BI testing is the only monitoring method used, non-sterile instruments can pass through. This can happen, for example, with inadequate cleaning of dental instruments before sterilizing, or when the steam does not reach the inside of packages for the required time and temperature. Cleaning before sterilization to remove bioburden is essential, and automated cleaning is preferred before manual cleaning since it can be reproduced, and is more reliable and safer. To prevent blood, saliva and other debris from drying on the surface of dental instruments, use a pretreatment spray, gel or foam during or immediately after treatment.[6] Selecting the correct BI is a crucial step. There are numerous types: some are meant for specific cycles, while others are useful for specific sterilizers. Therefore, for a BI to be successful, it must be used correctly throughout the entire monitoring process. When removed from the sterilizer, the sample should be placed in an incubator or prepared to send to a testing facility. The incubation time and method of reading test results must always be in accordance with the manufacturer’s instructions.[7] Physical monitors of time, temperature and pressure When using a sterilizer, it is essential to follow the correct protocol, according to IFU. Physical indicators of time, temperature, and pressure give you real-time measurements to check if the indicator complies with manufacturers’ standards. They are often displayed on the sterilizer or printed out. Review these parameters before unloading the autoclave, consider the sterilization process as unsuccessful if it does not display the correct parameters.[8] Do not overlook this easy but useful monitoring. The Association for the Advancement of Medical Instrumentation strongly recommends only using sterilizers with recording devices. Chemical indicator (CI) monitoring The use of chemical indicator monitoring can help determine improper packaging, loading or sterilizer malfunction. Chemical indicators function by changing color when exposed to high temperatures, and some may also react to pressure and time.[9] The chemical indicator, located on the inside of each pack, reveals if the steam has reached the inside of a package. Jamming too many instruments into a package or overloading the sterilizer can prevent steam from penetrating them all correctly. Chemical indicators on the outside of packages also react to heat, pressure, or time but only indicate that the contents have been exposed to these factors and do not prove that the items are sterile. There are six types of chemical indicators. The two internal CIs mainly indicate if packages have had exposure to the sterilization procedure. Type-3 reacts to a single variable, type-4 to two or more variables. Type-5 reacts to all critical variables. According to the Association for the Advancement of Medical Instrumentation, the criteria to pass a type-5 indicator correspond to BI but does not replace the use of Bi testing. Type-6 also uses all variables but is used for specific sterilization cycles.[10] Dental instrument reprocessing is a multi-step process and every step must be respected. Automated cleaning will be the first step to ensure that the steam can reach every surface of the instruments. Physical monitoring of time, temperature, and pressure are essential to ensure compliance with the manufacturer’s standards. Chemical indicators react to one or more variables showing the exposure of packages to the necessary stimuli. Biological indicators will indicate the lethality of spores. This whole process can only be successful if the right equipment and quality machinery are available. Training of the entire team in these procedures is essential, and SOPs must be updated as needed. This will require a substantial effort on the part of all employees, but doing so will enable safety for yourself and your clientele, which will make your dental care practice a reliable and trustworthy place to visit. [1] "Review of Surface Steam Sterilization for Validation ... - PubMed." https://pubmed.ncbi.nlm.nih.gov/18313509/. Accessed 27 Jul. 2020. [2] "Guidelines and Recommendations | Infection ... - CDC." https://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm. Accessed 27 Jul. 2020. [3] "Biological Indicators - Protak Scientific." https://www.protakscientific.com/biological-indicators/. Accessed 27 Jul. 2020. [4] "Guidance for Dental Settings | CDC." https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Accessed 27 Jul. 2020. [5] "Selection of an appropriate Sterility Assurance Level (SAL) for ...." https://www.steris-ast.com/techtip/sterility-assurance-levels-sals-irradiation/. Accessed 27 Jul. 2020. [6] "Safe and effective instrument cleaning - Hu-Friedy." https://www.hu-friedy.com/sites/default/files/M4620_IMS_Govoni_DE_Article_1011.pdf. Accessed 27 Jul. 2020. [7] "Importance of Instrument Reprocessing - Dimensions of ...." 8 Apr. 2020, https://dimensionsofdentalhygiene.com/importance-instrument-reprocessing/. Accessed 27 Jul. 2020. [8] "Importance of Instrument Reprocessing - Dimensions of ...." 8 Apr. 2020, https://dimensionsofdentalhygiene.com/importance-instrument-reprocessing/. Accessed 27 Jul. 2020. [9] "Supporting the Success of Instrument Reprocessing." 8 Aug. 2019, https://dimensionsofdentalhygiene.com/article/supporting-the-success-of-instrument-reprocessing/. Accessed 27 Jul. 2020. [10] "Sterility Assurance in Dental Instrument Reprocessing." 24 Jul. 2018, https://decisionsindentistry.com/article/sterility-assurance-in-dental-instrument-reprocessing/. Accessed 19 Aug. 2020.