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. Author manuscript; available in PMC: 2026 Oct 23.
Published in final edited form as: Ann Work Expo Health. 2026 Aug 26;70(7):wxag081. doi: 10.1093/annweh/wxag081

Aerosol mitigation efficiency of high-volume suction systems during aerosol generating dental procedures with patients

Brie Hawley Blackley 1, Jennifer Franko 2, Jean Cox-Ganser 1, Caroline P Groth 3, Tammy Chipps 4, Scott Young 4, Fotinos Panagakos 5, Aidan Davis 1, M Abbas Virji 1
PMCID: PMC13690175  NIHMSID: NIHMS2214902  PMID: 42830401

Abstract

Routine dental procedures can expose dental providers to aerosols associated with potential acute or chronic respiratory health effects. High-volume suction (HVS) systems can potentially mitigate aerosols generated during routine dental procedures; however, few studies to date have evaluated HVS systems’ aerosol exposure mitigation efficiency during procedures with patients. This study reports the aerosol mitigation efficiency of five commercially available HVS systems [standard high-volume evacuation (HVE), three intraoral HVS systems (Systems A–C), and one modified HVE (System D)] when used during dental procedures utilizing a high-speed handpiece (i.e., crown preparations) or ultrasonic scaler. Direct-reading instruments measured aerosol size distribution, aerosol number concentrations (thoracic [PM10]), and aerosol mass concentrations (respirable [PM4] and thoracic [PM10]) while using each of the five HVS systems during high-speed handpiece (n=26) or ultrasonic scaling procedures (n=25). Background and procedure aerosol measurements were collected in the (1) operatory near the dentist and (2) hallway outside the operatory. Factors including (1) HVS flow rate, (2) procedure duration, (3) crown preparation tooth location, and (4) ultrasonic scaler type and mouth quadrant(s) treated were recorded. Ratios of procedure to background aerosol concentrations were calculated and multiple linear regression models were fit accounting for covariates, to determine if a HVS system reduced mean aerosol number concentrations to concentrations no different from background concentrations (ratio 95% lower confidence limit ≤ 1). The percentage frequency of how often PM4 or PM10 mass measurements were reduced to concentrations below average background concentrations were also calculated for each HVS system. Standard HVE, System A, and System D reduced aerosol number to background concentrations during both procedure types. Additionally, standard HVE reduced aerosol mass concentrations to background most often during either procedure type. However, none of the five HVS systems fully reduced aerosol mass to background levels during high-speed handpiece procedures, despite all HVS flow rates being greater than a flow rate previously reported as sufficient for aerosol capture during high-speed handpiece procedures. Further, the effect of HVS flow rate on PM10 number ratios during either procedure type varied across HVS systems. Future studies are needed to identify factors that can improve HVS systems’ aerosol mitigation efficiency, including HVS flow rate ranges needed to sufficiently mitigate aerosol exposures during common patient procedures.

Keywords: Aerosol exposure, exposure mitigation, respirable, thoracic

INTRODUCTION

Dental providers routinely perform procedures that can generate aerosols associated with potential acute infectious or chronic respiratory effects (Piazza et al., 1987; Atlas et al., 1995; Bennett et al., 2000; Veronesi et al., 2007; Ergün et al., 2014; Hamilton et al., 2021). Several factors unique to dentistry increase dental providers’ risk for exposure to aerosols including, (1) inherent close proximity to patients’ mouths during procedures, and (2) many routinely performed aerosol generating procedures, such as those utilizing a high-speed handpiece or ultrasonic scaler. Dental procedure aerosol composition varies with patient and procedure type, and can contain a mixture of saliva, blood, bacteria, and nasopharyngeal secretions that can potentially transmit infectious disease by inhalation or contamination of nearby surfaces (Belting et al., 1964; Miller, 1995; Prospero et al., 2003; Harrel and Molinari, 2004). Additionally, procedure material-derived aerosols can contain mineral and acrylic dusts associated with occupational lung diseases such as work-related asthma or pulmonary fibrosis (Choudat, 1994; Lindström et al., 2002; Singh et al., 2013). Potential for exposure to mineral and acrylic dusts is notable given the higher than expected cases of idiopathic pulmonary fibrosis as well as elevated proportionate mortality from pulmonary fibrosis reported among dentist decedents (Nett et al., 2018; Fechter-Leggett et al., 2025). Dental aerosol exposure mitigation strategies are necessary to minimize dental providers’ potential exposures to both infectious aerosols and aerosols associated with chronic respiratory disease.

Strategies employed to mitigate exposure during dental procedures will vary with aerosol size and procedure type. Previous studies observed aerosols ranging from submicron [<1 micrometer (μm)] upward to 300 μm sized droplets during procedures utilizing an ultrasonic scaler (Ou et al., 2021; Pierre-Bez et al., 2021). Other studies evaluating aerosol sizes generated during procedures utilizing a high-speed handpiece (e.g., grinding or drilling) observed aerosols to be much smaller, in the ultrafine size range [< 100 nanometers (nm)] (Van Landuyt et al., 2014; Iliadi et al., 2020). Exposure to larger aerosols such as droplets and spatter can be minimized with standard precautions (Kohn et al., 2003; Harrel and Molinari, 2004). However, exposure to smaller aerosols such as those in the thoracic (< 10 μm) and respirable size-range (< 4 μm) are more difficult to control and require additional exposure mitigation strategies due to their long settling times, ability to travel to distant sites in the clinic, and ability to escape past standard precautions such as surgical masks and face shields (Kohn et al., 2003). Further, respirable sized aerosols are known factors in the development of occupational lung disease due to their ability to reach the gas-exchange region of the lungs (Brain and Valberg, 1979; ISO, 1992).

The predominance of submicron aerosol observed in previous studies during routine dental procedures such as procedures utilizing the high-speed handpiece or ultrasonic scaler (Ehtezazi et al., 2021; Blackley et al., 2022; Lahdentausta et al., 2022), alongside of (1) exposure factors unique to dentistry, including close proximity to unmasked patients during aerosol generating procedures and (2) potential for exposure to aerosols with acute infectious (Piazza et al., 1987; Atlas et al., 1995; Bennett et al., 2000; Veronesi et al., 2007; Hamilton et al., 2021) or chronic respiratory effects (Nett et al., 2018; Fechter-Leggett et al., 2025), underscore the importance of understanding the effectiveness of available aerosol exposure controls. Because dentistry requires that patients be unmasked while dental providers work near their patients’ mouths, strategies that utilize source controls to capture aerosol at the source such as high-volume suction (HVS) or local exhaust ventilation (LEV) are considered most effective. HVS can potentially serve as an effective LEV control; however, the efficiency of various designs and configurations of HVS systems as LEV controls during patient procedures in real-world clinical settings is not well characterized.

Previously, we reported the efficacy of four varied in design, commercially available HVS systems at reducing aerosol mass concentrations during simulated dental procedures with a mannequin (Blackley et al., 2022). Here, the research goal was to expand on our previous study (Blackley et al., 2022) and other previously reported simulated studies (Ehtezazi et al., 2021; Remington et al., 2022; Zhu et al., 2022; Malmgren et al., 2023) by evaluating the real-world efficiency of five commercially available HVS systems at mitigating respirable and thoracic aerosol during common aerosol generating patient procedures (i.e., patient procedures utilizing a high-speed handpiece or ultrasonic scaler). To our knowledge, few studies have measured the efficiency of varied in design, commercially available HVS systems at mitigating aerosol size fractions that are (1) difficult to control due to long settling times and ability to escape past standard precautions and (2) relevant to occupational lung disease (respirable) and airborne diseases (thoracic), during common patient procedures in routine dental clinic settings. Additionally, although aerosol exposures are most often measured by mass for ease of comparisons with mass-based exposure limits, multiple researchers suggest aerosol number as a relevant exposure metric for ultrafine aerosol exposures (Peters et al., 1997; Maynard and Aitken, 2007; Wittmaack, 2007; Park et al., 2010). Given the ultrafine aerosol observed in dental clinic settings (Tang et al., 2022; Blackley et al., 2024; Islam et al., 2025), here, we report the HVS systems’ aerosol mitigation efficiency in terms of traditional exposure metrics (aerosol mass), as well as aerosol number.

METHODS

Dental Clinic and Dental Procedures

Dental procedures were performed in a general dentistry teaching clinic designed to resemble a private clinic setting, with five semi-separated operatories (Figure 1). The clinic and ventilation system layout is described previously (Blackley et al., 2022). Briefly, supply air was provided by three supply air vents located in three of the five operatories, including the corner operatory where all dental procedures evaluated for this study were performed (Figure 1). Return air was exhausted through six return air ducts located in adjacent hallways (Figure 1). A ventilation assessment was performed to evaluate air currents and the air changes per hour (ACH) in the operatory (Supplementary Figure 1). Methods utilized for the ventilation assessment are described in the supplementary.

Figure 1.

Figure 1.

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Clinic layout and aerosol measurement locations during dental procedures.

Dental procedures assessed included procedures utilizing a high-speed handpiece (i.e., crown preparations) or ultrasonic scaler. Tooth location (tooth number) was recorded for crown preparations. Mouth quadrant(s) and ultrasonic scaler type was recorded for ultrasonic scaling procedures. Start and end times for each dental procedure were recorded when dental clinic staff signaled to study investigators that they were initiating use, or concluding use, of either the high-speed handpiece or ultrasonic scaler, respectively. Details on the handpieces, settings, as well as ultrasonic scalers used, are in the supplementary.

HVS Systems

Five commercially available HVS systems, including the same standard high-volume evacuator (HVE) and Systems A–C evaluated in our previous simulated study, as well as one additional wide tip HVE system (System D), were evaluated (Blackley et al., 2022). Two forms of high-volume evacuators (HVE) and three intraoral (“hands-free”) HVS systems were evaluated. The two forms of HVE were designed as follows:

  • Standard HVE: fitted with a disposable polyvinylchloride (PVC) tube with an 11 millimeter (mm) inner diameter and is held by the dentist or other dental personnel (Figure 2);

  • A wide tip HVE system (System D): designed with a wider (16 mm) diameter tip opening and is held by the dentist or other dental personnel.

The three forms of intraoral HVS systems were designed as follows:

  • System A: designed to span across the patient’s mouth and incorporated a bite block; suction openings were all along the mouthpiece, including suction openings extending out to the cheek retractor (Figure 2a);

  • System B: designed to span across the patient’s mouth and incorporated a bite block; suction openings were more central to the mouthpiece and did not extend the length of the mouthpiece (Figure 2b);

  • System C: designed to sit in the patient’s vestibule (sat in the cheeks of patients and suctioned from the entire perimeter of the mouthpiece (Figure 2c).

Additional details for the intraoral Systems A–C, including sizes used, are provided in the supplementary.

Figure 2.

Figure 2.

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Intraoral high-volume suction (HVS) systems (System A, panel A; System B, panel B, System C, panel C) evaluated during routine patient procedures with high-speed handpiece or ultrasonic scaler (pictured with mannequin to protect patient privacy).

All HVS systems were connected to a HVS vacuum port. HVS flow rates were measured prior to each procedure using a 0–20 standard cubic feet per minute (SCFM) flowmeter (Easy-Read High-Pressure Flowmeter for Air, McMaster-Carr, Elmhurst, IL) connected to the vacuum port, before removing the flowmeter and connecting the HVS system to the vacuum port.

Aerosol Measurements

Sampling carts were placed in two locations (Figure 1): (1) near the dentist in the operatory (located 0.9 meters (m) from the patient head rest) and (2) in the hallway outside the operatory (located 2.4 m from the patient head rest). Sampling carts in each location were equipped with:

  1. an Optical Particle Sizer (OPS, TSI Inc., Maplewood, MN) measuring aerosols ranging from 0.3 μm to 10 μm and NanoScan Scanning Mobility Particle Sizer (NanoScan SMPS nanoparticle Sizer Model 3910, TSI Inc.) measuring aerosols ranging from 10 nm to 420 nm (NanoScan SMPS), both measuring aerosols every 60 seconds. The OPS’s limit of detection (LOD) is approximately 0.003 particles/cm3 when operating with a sampling duration of 60 seconds and the NanoScan SMPS’s LOD is 1 particle/cm3; and

  2. two personal DataRAMs (pDRs) equipped with a red cyclone. One pDR was operated at 2.65 liters per minute (Lpm) and one pDR was operated at 1.19 Lpm for PM4 or PM10 size cut points, respectively (pDR-1500, Thermo Scientific, Franklin, MA). The pDRs’ LOD was 1 microgram per cubic meter of air (μg/m3) and recorded measurements every 10 seconds.

Background measurements were collected by all instruments when no other dental procedures were performed in the clinic, for 20–30 minutes duration, prior to patient arrival time. After completing background measurements, all aerosol instruments were stopped and then restarted prior to the procedure start time and stopped when the procedure was completed (i.e., when use of the high-speed handpiece or ultrasonic scaler was completed).

Data Preparation and Statistical Analyses

The order of the five HVS systems used for procedures was randomized and each procedure was repeated a minimum of five times for each HVS system (Supplementary Table 1). Procedure aerosol measurements used in analyses were limited to measurements occurring during high-speed handpiece or ultrasonic scaler use. All statistical analyses were performed using JMP 16.0 and SAS 9.4 (SAS Institute, Inc., Cary, NC).

Analysis of Aerosol Number Concentrations

Aerosol size distributions and average PM10 number concentrations were calculated using TSI’s Multi-Instrument Manager (MIM™) software to merge the OPS and NanoScan SMPS data. An example of the merged size distributions from OPS and NanoScan SMPS data using TSI’s MIM software is provided in Supplementary Figure 2. Count median diameters (CMD), geometric mean (GM) and geometric standard deviation (GSD) for particle diameter, and GM and GSD for PM10 number concentrations were calculated for each repetition with each HVS system during each measurement condition (i.e., procedure and background measurements). Descriptive statistics including GM, GSD, and 95th percentile for PM10 number concentrations were calculated for each HVS system by procedure type.

Ratios of procedure- to background aerosol concentrations were calculated to compare the average PM10 number concentration generated during the procedure with the corresponding average background PM10 number concentration measured prior to the procedure. A ratio of ≤ 1 indicates exposures during the procedure were reduced to background levels. The ratios were plotted as boxplots.

PM10 number ratios were log transformed using the natural logarithm (ln) to enable use of linear regression-based methods because of the right skew of the ratio data. Multiple linear regression models were fit to the log-transformed PM10 number ratios to test if a HVS system reduced aerosol number concentrations to background concentrations (defined as procedure measurements not significantly different from background measurements; lower confidence limit (LCL) of 95% CI for ratio ≤ 1) during each procedure type. The models accounted for covariates such as HVS flow rate and sampler location, and the interaction between HVS system and HVS flow rate. When the interaction was significant (p<0.05), the effect of HVS flow rate was evaluated in stratified analyses by HVS system. Other covariates such as duration, tooth location, ultrasonic scaler type, and quadrant treated were explored in single-variable analyses (Supplementary Table 3); however, they were not included in the full models because (1) they were not significant in single-variable analyses or (2) some of their subcategories had too few observations (details provided in Supplementary). We note that although sampler location was not significant on single-variable analyses, it was included as a covariate in the full models because our previous simulated study in the same clinic measured differences in HVS system’s aerosol mitigation efficiency that varied by sampler location (e.g. operatory versus hallway) (Blackley et al., 2022), suggesting that airflow patterns in the dental clinic could potentially cause variation in aerosol measurements and measured HVS system efficiency. Additionally, HVS flow rate was included in the full model despite not being significant in univariate analyses because further exploration with an interaction term with HVS system indicated the effect of HVS flow rate varies by HVS system, and the association between flow rate and PM10 number ratios was masked in the univariate model. Least square means were exponentiated to estimate GMs and 95% CIs ratios for each HVS system and covariates. All significance tests were performed using two-sided tests and a p-value < 0.05 was considered significant.

Analysis of Aerosol Mass Concentrations

A large fraction of the 10-second mass concentration measurements were below the pDR’s LOD of 1.0 μg/m3 during procedure sample collection (range < LOD: 0.0–70.8% during crown preparations, 0.0–94.6% during ultrasonic scaling; Supplementary Table 4) and background sample collection (range <LOD: 0.0–95.8%; Supplementary Table 4). Additionally, distributions of the 10-second measurements varied from normal, lognormal, to neither. Therefore, average concentrations for each procedure and background sample were obtained using the non-parametric reverse Kaplan-Meier method. This method does not assume any underlying data distribution and is reported to have acceptable bias and root mean square error, up to 70% censoring in simulation analysis (Antweiler and Taylor, 2008). Samples with ≥70% censoring in the 10-second measurements collected across a procedure or background sample were considered LOD samples. Distributions of the average concentrations for procedure or background samples by location, particle size, procedure type, and HVS system (n ranging from 3 to 6; Supplementary Table 4) were approximately lognormal, and were summarized using the maximum likelihood estimation (MLE) method to account for the LOD samples (Lubin et al., 2004). Summary statistics including GM, GSD, and P95 were calculated for PM4 and PM10 mass concentrations and for each location, HVS system and procedure type.

Ratios of procedure to background aerosol samples were calculated for PM4 and PM10 mass concentrations as described above for number concentration. A ratio of ≤ 1 indicates exposures during the procedure were reduced to average background levels. The ratios were plotted as boxplots.

For direct comparison with results from our previous simulated study (Blackley et al., 2022), percentage frequency was used to measure how often each HVS system reduced PM4 or PM10 aerosol concentrations during each procedure type to background concentrations at each sampling location. Percentage frequency was calculated by dividing the sum of the number of PM4 or PM10 measurements below the average background concentration by the sum of the total number of PM4 or PM10 measurements, multiplied by 100%. This is an indication of the percent of time aerosol concentrations during a procedure were reduced to background levels. Because the percentage frequencies were not normally distributed, the median and the inter quartile range (IQR) for percent frequencies by location, particle size, procedure type, and HVS system were used to summarize percent frequency results.

RESULTS

Dental procedures

A total of 26 crown preparations and 25 ultrasonic scaling procedures were evaluated. HVS flow rates ranged from 12.0 to 14.5 SCFM. Mean flow rates measured with each HVS system ranged from 13.1 to 13.6 SCFM during crown preparations and 12.9 to 13.3 SCFM during ultrasonic scaling procedures (Supplementary Table 1). Mean procedure duration ranged from 47.9 to 67.4 mins during crown preparations and 30.4 to 37.0 mins during ultrasonic scaling procedures (Supplementary Table 1).

Aerosol size distribution and PM10 number concentration

Background CMDs were all less than 100 nm and ranged from 43.6 to 86.8 nm (Table 1). CMDs measured near the dentist during procedures were also all less than 100 nm and ranged from 43.7–63.0 nm during crown preparations and 41.3–57.3 nm during ultrasonic scaling procedures (Table 1). CMDs measured in the hallway just outside the operatory during procedures were similar and ranged from 47.2–60.3 nm during crown preparations and 40.0–56.4 nm during ultrasonic scaling procedures.

Table 1.

Count median diameter (CMD), geometric mean (GM), and geometric standard deviation (GSD) for PM10 aerosol measured in nanometers (nm) during dental procedures with HVE, System A, System B, System C, and System D.

Procedure, Location HVS System Procedure Measurements Background Measurements
CMD (nm) GM (nm) GSD CMD (nm) GM (nm) GSD
Crown Preparation, Near Dentist HVE (n=6) 63.0 67.3 2.22 85.2 88.2 1.85
System A (n=5) 55.3 59.8 2.33 77.9 80.9 2.00
System B (n=5) 47.9 51.5 2.14 74.7 77.9 1.88
System C (n=5) 43.7 47.9 2.15 67.9 70.5 1.80
System D (n=5) 56.7 59.1 2.02 70.2 71.6 1.70
Crown Preparation, Hallway HVE (n=6) 60.3 64.5 2.20 86.8 89.9 1.88
System A (n=5) 57.8 62.0 2.29 75.5 78.6 2.06
System B (n=5) 47.2 50.1 2.09 72.5 75.6 1.90
System C (n=5) 53.7 57.4 2.09 67.9 70.5 1.80
System D (n=5) 52.7 53.3 1.99 64.1 66.4 1.69
Scaling, Near Dentist HVE (n=5) 46.2 48.9 2.00 45.2 47.6 1.95
System A (n=4*) 41.3 45.1 2.15 53.0 55.8 1.93
System B (n=5) 44.1 46.3 1.82 61.6 65.0 2.14
System C (n=5) 57.3 60.0 1.91 60.0 69.8 1.81
System D (n=5) 53.3 56.7 2.16 60.5 63.6 1.97
Scaling, Hallway HVE (n=5) 46.4 48.9 2.00 43.6 46.3 1.98
System A (n=4*) 41.6 45.7 2.18 49.8 52.4 1.94
System B (n=5) 40.0 42.2 1.79 61.7 64.8 2.08
System C (n=5) 56.4 58.8 1.88 70.0 72.7 1.82
System D (n=5) 51.9 56.1 2.17 60.0 63.1 1.95
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HVE=standard high-volume evacuation.

*

One procedure repeat excluded due to instrument error.

Background PM10 number concentration GMs ranged from 809–3,372 particles per cubic centimeter (cm3) and were similar across both locations (Supplementary Table 2). PM10 number concentration GMs measured near the dentist ranged from 1,770–3,357 particles/cm3 during crown preparations and 974–2,532 particles/cm3 during ultrasonic scaling procedures (Supplementary Table 2). PM10 number concentration GMs measured in the hallway were similar and ranged from 1,823–3,577 particles/cm3 during crown preparations and 1,071–2,704 particles/cm3 during ultrasonic scaling procedures (Supplementary Table 2). The highest 95th percentile for aerosol number concentrations measured at both locations was observed with System C during a crown preparation (near dentist=13,888 particles/cm3; in hallway=15,907 particles/cm3; Supplementary Table 2).

Systems B and C had the highest ratios for PM10 number concentrations during either procedure type (Supplementary Figure 3). Ratios for PM10 number concentration while using System C during crown preparations were all > 1 (Supplementary Figure 3). In single-variable analyses crown preparations had significantly higher ratios for PM10 number concentrations than ultrasonic scaling procedures (p=0.03; Supplementary Table 3).

Multiple linear regression models of PM10 aerosol number concentrations ratios

HVE, System A, and System D controlled PM10 number concentrations to background concentrations during both procedure types (crown preparations and ultrasonic scaling). Systems B and C had significantly higher PM10 number concentrations when compared to background concentrations (ratio 95% LCL > 1) during crown preparations (Figure 3). System B also had significantly elevated PM10 number ratios when compared to background levels (ratio 95% LCL > 1; Figure 3) during ultrasonic scaling preparations.

Figure 3.

Figure 3.

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Error bar plots of multiple linear regression model estimates for PM10 number concentration ratios by dental procedure accounting for model covariates. Dotted line indicates reference line (ratio of ≤ 1 indicates reductions to background concentrations). HVE=standard high-volume evacuation.

In the crown preparation model for PM10 number ratios, the interaction term between HVS system and flow rate was significant suggesting the slope of the effect of flow rate on PM10 number ratios differed by HVS system (Supplementary Table 5). Stratified analysis indicated that increasing flow rate by 1 SCFM significantly decreased the PM10 number ratio by 52.6% for HVE and 90.8% for System D (Supplementary Table 6; Figure 4).

Figure 4.

Figure 4.

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Linear regression model estimates of PM10 number concentration ratios measured near the dentist at minimum and maximum flow rates during crown preparations (A) and ultrasonic scaling procedures (B), by high-volume suction (HVS) system type. *indicates significant association (p<0.05) observed between aerosol ratio and flow rate; ‡indicates System A ratio estimates for flow rates 13.0 and 14.0 standard cubic feet per minute (SCFM). HVE=standard high-volume evacuation.

In the ultrasonic scaling model for PM10 number ratios, the interaction term between HVS system and flow rate was significant suggesting the slope for the effect of flow rate on PM10 number ratios differed by HVS system (Supplementary Table 5). Stratified analysis indicated that increasing HVS flow rate by 1 SCFM significantly increased the PM10 number ratio by 360% for System B and 630% for System D during ultrasonic scaling procedures (Supplementary Table 6; Figure 4). Although increasing flow rate was associated with significant increases in PM10 number ratios while using Systems B or D, System D controlled PM10 number concentrations to background concentrations across the entire range of flow rates observed (12.0–14.0); System B did not (Figure 3; Supplementary Table 6).

PM4 and PM10 aerosol mass concentrations

PM4 and PM10 background mass concentrations were all low, with GMs ranging from 1.3–2.9 μg/m3 and 0.5–2.9 μg/m3, respectively (Supplementary Table 4). Measurements of PM4 and PM10 mass concentrations were higher during crown preparations (GM range: 3.3–6.8 μg/m3) than during ultrasonic scaling procedures (GM range: 1.1–3.8 μg/m3; Supplementary Table 4). The highest 95th percentile for aerosol mass concentrations measured at both locations was observed with System C during a crown preparation (near dentist PM4 and PM10=19.8 μg/m3 and 25.7 μg/m3, respectively; in hallway PM4 and PM10=17.0 μg/m3 and 21.5 μg/m3, respectively; Supplementary Table 4).

Median estimates of ratios for PM4 and PM10 mass concentrations while using HVE or Systems A–D during crown preparations were all > 1 (Supplementary Figures 4 and 5). However, standard HVE had some PM4 and PM10 mass ratios that were ≤ 1 during crown preparations (Supplementary Figures 4 and 5). Standard HVE reduced PM4 and PM10 aerosol mass concentrations to average background concentrations most often during crown preparations (median percent frequency for PM4 and PM10 near dentist with HVE=39.7% (interquartile range (IQR)=2.2–57.8%) and 37.6% (IQR: 0.9–53.7%), respectively (Table 2).

Table 2.

Percentage frequency* of how often high-volume suction (HVS) systems reduced PM4 or PM10 mass concentrations below average background concentrations

Procedure Aerosol Size Fraction HVS System N Near Dentist, Median % Frequency (Interquartile Range) N In Hallway Outside Operatory, Median % Frequency (Interquartile Range)
Crown Preparations PM4 HVE 6 39.7 (2.2–57.8) 6 40.7 (0.6–57.2)
System A 5 27.2 (5.2–35.6) 5 8.0 (0.3–41.6)
System B 5 2.4 (0.0–24.4) 5 2.2 (0.0–16.0)
System C 4** 2.4 (0.0–8.9) 5 0.2 (0.0–12.2)
System D 5 0.0 (0.0–8.6) 5 0.0 (0.0–7.5)
PM10 HVE 6 37.6 (0.9–53.7) 6 37.9 (0.7–53.6)
System A 4** 2.7 (0.1–16.5) 4** 4.9 (0.5–35.9)
System B 5 1.8 (0.0–20.4) 5 2.2 (0.0–23.6)
System C 5 0.0 (0.0–23.7) 5 0.0 (0.0–21.1)
System D 5 0.0 (0.0–5.9) 5 0.0 (0.0–3.6)
Ultrasonic Scaling PM4 HVE 5 91.7 (42.9–95.2) 5 61.8 (19.2–95.0)
System A 5 65.2 (3.6–83.0) 5 68.3 (25.6–91.0)
System B 4** 66.6 (20.7–79.4) 4** 72.0 (45.8–90.0)
System C 4** 64.5 (29.3–93.8) 4** 79.2 (51.5–92.0)
System D 4** 41.8 (17.5–83.3) 4** 39.1 (10.0–83.7)
PM10 HVE 4** 85.5 (29.1–96.5) 4** 83.7 (41.7–95.4)
System A 5 12.7 (0.0–81.7) 5 41.4 (6.4–72.0)
System B 4** 79.2 (38.0–88.8) 5 74.2 (22.1–82.7)
System C 3** 87.1 (2.7–94.2) 5 79.2 (37.8–91.7)
System D 3** 1.9 (0.0–74.2) 3** 54.8 (26.1–98.0)
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HVE=standard high-volume evacuation. Avg=average. % Frequency=percent frequency. St Dev=standard deviation.

*

Percentage frequency of aerosol mass measurements reduced to concentrations below average background concentrations were calculated by dividing the sum of the number of aerosol measurements below the average background concentration during the procedure, by the sum of the total number of aerosol measurements during the procedure, multiplied by 100%.

**

Some procedure repeat(s) excluded due to sampling instrument error.

Ratios for PM4 and PM10 mass concentrations were generally lower during ultrasonic scaling procedures than during crown preparations. Median estimates of ratios for PM4 and PM10 mass concentrations while using HVE, System B, or System C during ultrasonic scaling were all < 1, and all HVS systems had some ratios for PM4 and PM10 mass concentration ratios that were ≤ 1 during ultrasonic scaling procedures (Supplementary Figure 5). Standard HVE reduced PM4 and PM10 aerosol mass concentrations to average background concentrations most often during ultrasonic scaling procedures (median percent frequency for PM4 and PM10 near dentist with HVE=91.7% (IQR: 42.9%–95.2%) and 85.5% (IQR: 29.1%–96.5%) respectively; Table 2).

DISCUSSION

High-speed handpiece and ultrasonic scaler procedure-generated PM10 observed in this study was quite small, with CMDs ranging from 40 nm to 86.8 nm. Previous studies have similarly reported PM10 generated by routine dental procedures utilizing a high-speed handpiece or ultrasonic scaler was predominantly less than 1μm in diameter (submicron), both with and without aerosol-mitigating interventions (Ehtezazi et al., 2021; Blackley et al., 2022; Lahdentausta et al., 2022). The small size of the dental procedure-related aerosol measured here and in previous studies is notable for multiple exposure and health related reasons. First, when unmitigated, aerosol in this size range can remain suspended in the air for hours to days and can travel to distant sites in a clinic, potentially exposing other personnel or patients in the clinic (Holliday et al., 2021). Unsurprisingly, distance from source had no significant effect on aerosol number or mass concentrations in our study here, suggesting that unmitigated PM4 and PM10 aerosol migrated into the hallway during procedures. Dental operatories are commonly designed to be under positive pressure relative to adjacent spaces (as was observed in the clinic utilized for this study), further emphasizing the need to capture submicron aerosol at the source, to prevent migration into adjacent spaces. Second, submicron aerosol is not effectively mitigated by standard precautions often used in dental settings such as face shields or face masks (Kohn et al., 2003). Third, aerosol in this size range can reach the gas-exchange region of the lungs, and depending on the composition of the aerosol, can potentially contribute to chronic respiratory disease (Brain and Valberg, 1979; ISO, 1992; Choudat, 1994). The ability of aerosol generated during dental procedures to reach the gas-exchange region of the lungs is particularly relevant given the recently reported higher than expected cases of idiopathic pulmonary fibrosis among dentists as well as elevated proportionate mortality from pulmonary fibrosis among dentist decedents (Nett et al., 2018; Fechter-Leggett et al., 2025) and further emphasizes the need for effective aerosol exposure controls in dental settings.

Aerosol concentrations generated during common dental aerosol generating procedures can vary by procedure type, and the subsequent effectiveness of aerosol exposure controls can also vary by procedure type. Previous studies observed procedures utilizing a high-speed handpiece generate higher levels of PM10 number and mass concentrations than ultrasonic scaling procedures. Yang et al. (2021) reported high-speed handpieces generate approximately 8-fold higher levels of PM10 number concentrations than ultrasonic scaling when not using HVS (Yang et al., 2021). Likewise, Lahdentausta et al. (2022) reported that even while using HVS, PM10 mass concentrations during high-speed handpiece procedures were 2- to 5- fold higher when compared to PM10 mass concentrations during ultrasonic scaling (Lahdentausta et al., 2022). Similarly, we observed higher ratios for PM10 number concentrations as well as PM4 and PM10 mass concentrations during high-speed handpiece procedures (crown preparations) than ultrasonic scaler procedures.

Given the higher aerosol concentrations observed during high-speed handpiece procedures, unsurprisingly, aerosol mass mitigation efficiency across the five systems was worse during high-speed handpiece procedures than during ultrasonic scaling procedures. The decreased aerosol mass mitigation efficiency of HVS systems used during high-speed handpiece procedures was consistent with our results from a previous simulated study with a mannequin (Blackley et al., 2022). None of the five HVS systems were able to fully mitigate PM4 or PM10 mass to background concentrations during high-speed handpiece procedures with patients. Standard HVE reduced aerosol mass to background concentrations most often during crown preparations; however, median estimates of percent frequencies indicated that standard HVE reduced aerosol mass concentrations near the dentist to background concentrations approximately 40% of the time. Alternatively, aerosol mass mitigation efficiency was better during ultrasonic scaling than during crown preparations, for all HVS systems. Standard HVE reduced aerosol mass to background concentrations most often during ultrasonic scaling procedures (PM4 mass percent frequency median: 91.7%, IQR: 42.9%–95.2%; PM10 mass percent frequency median: 85.5%, IQR: 29.1%–96.5%).

PM10 number mitigation efficiency across different HVS systems was more consistent between procedure types. Standard HVE, the wide tip HVE (System D), and System A, controlled PM10 number concentrations to background during both procedure types. System C was able to control PM10 number concentrations to background concentrations during ultrasonic scaling procedures but not during high-speed handpiece procedures. One of the cross-mouth intraoral systems (System B) was unable to control aerosol number concentrations to background during either procedure type. We note that all PM10 number ratios for either procedure type included values greater than one, indicating that no HVS system fully reduced PM10 number to background concentrations during either procedure type.

We observed that none of the HVS systems were able to fully reduce PM number or mass concentrations to background concentrations during high-speed handpiece procedures. We also observed that increasing HVS flow rate was associated with significant decreases in PM10 number ratios during high-speed handpiece procedures while using either form of HVE (standard HVE or the wide-tip HVE, System D). This finding was unexpected given that all HVS flow rates during crown preparations were greater than the 10.6 SCFM minimum flow rate previously reported as necessary to ensure optimal particle capture by HVS (Koch and Graetz, 2021). However, the study reporting 10.6 SCFM as a minimum effective HVS flow rate was based on simulated high-speed handpiece procedures and was an assessment of visible particles larger than 650 nm. To our knowledge, no studies have established a minimum HVS flow rate needed during high-speed handpiece procedures to optimally capture the bulk of aerosols in the size range observed in ours and previous studies (< 300 nm) (Ehtezazi et al., 2021). Further, our stratified analysis indicated that increasing HVS flow rate by 1 SCFM during ultrasonic scaling procedures significantly increased the PM10 number ratios for Systems B and D. We note that this increase was meaningful only for System B, which, unlike System D, was unable to control PM10 number concentrations to background during ultrasonic scaling procedures. Factors contributing to the decreased efficiency of System B at increased flow rates were outside the scope of this study; however, higher flow rates could be exceeding the optimal capture velocity of System B potentially due to decreasing efficiency with turbulent flow from the small suction opening and associated high velocities with HVS systems, as well as other factors unique to System B’s design. Additional studies are needed to further characterize the effect of HVS flow rate on aerosol mitigation efficiency across varying HVS system designs to identify optimal flow rates needed to reduce aerosol number to background concentrations during high-speed handpiece or ultrasonic scaling procedures.

In general, standard HVE mitigated PM10 number as well as PM4 and PM10 mass concentrations to background concentrations most often. However, standard HVE often requires dental providers either devote one of their hands to hold the HVE in place or enlist the help of other personnel to hold the HVE during the procedure. Alternatively, intraoral HVS systems such as Systems A, B, and C are placed directly in the patient’s mouth and operated “hands-free”. Because intraoral systems do not require assistance from other dental personnel, their use can minimize overall personnel exposure by reducing the number of dental personnel present during a procedure. Among hands-free intraoral systems evaluated, System A most often reduced aerosol number and mass concentrations to background levels during high-speed handpiece procedures. Alternatively, in general, System C most often reduced aerosol number and mass concentrations to background levels during ultrasonic scaling procedures. Differences in system design between the hands-free systems could have contributed to our observed differences in aerosol mitigation efficiency. For example, unlike System A, System B’s suction openings do not extend the length of the mouthpiece out to the cheek retractor; increased surface coverage with suction openings located throughout the mouthpiece may increase HVS system efficiency. However, this study was not specifically designed to test the effect of location of suction openings in the mouthpiece on aerosol mitigation efficiency. We note potential differences here to highlight where additional study is needed to better understand differences between intraoral HVS systems and improve the design of hands-free HVS systems to increase their aerosol mitigation efficiency.

Lastly, additional considerations beyond aerosol exposure mitigation will affect HVS system selection during dental procedures and are worth noting here. For example, Systems A and B require sufficient teeth present on each side of the mouth to be securely placed in the mouth by using the bite block, which precludes their use in patients with many missing teeth. System C may be an alternative hands-free HVS system that can be used with these patients missing sufficient teeth on each side of the mouth. Additionally, although patient comfort was not assessed as part of this study, dentists shared anecdotally that cross-mouth intraoral HVS systems are sometimes not tolerated by patients due to discomfort. Further, noise generated by HVS systems is an additional consideration. Previous studies observed elevated prevalence of tinnitus among dentists (Myers et al., 2016) as well as noise levels in dental clinics that exceed the U.S. Occupational Safety and Health Administration (OSHA) permissible noise level of 90 dBA, with elevated noise levels observed while using a high-speed handpiece and HVS similar to HVS systems evaluated in this study (Mueller et al., 1986; Sampaio Fernandes et al., 2006; Myers et al., 2016). Here, the National Institute for Occupational Safety and Health (NIOSH) sound level meter app was used intermittently by study investigators to measure noise levels directly at the HVS system’s mouthpiece with no patient present. When HVS was operated at 13 SCFM, measured noise levels ranged from 71–72 dBA for System D, 78–80 dBA for System B, and 85–91 dBA for System C, suggesting that different designs of HVS systems can contribute to varying sound levels. However, noise measurements shared here were exploratory only. Additional study to systematically measure noise levels during routine procedures is needed to understand how factors such as flow rate and placement in a patient’s mouth affect noise level measurements while using any of the various commercially available HVS systems.

Our study is subject to several limitations. First, our study was a convenience sample of pre-scheduled crown preparations and ultrasonic scaling procedures. We did not design the study to specifically test the effect of crown preparation tooth location or ultrasonic scaler type and quadrant treated during ultrasonic scaling procedures. Observation of (1) anterior or posterior crown preparations, (2) magnetostrictive or piezoelectric ultrasonic scaler used during ultrasonic scaling procedures, or (3) quadrant treated during ultrasonic scaling procedures was based on a convenient sample, and insufficient numbers within some subcategories were observed (n<3) to be able to include these covariates in the full model. Additional studies are warranted to further characterize the effect of (1) tooth location on HVS systems’ aerosol mitigation efficiency during procedures with a high-speed handpiece and (2) ultrasonic scaler and quadrant treated on HVS systems’ aerosol mitigation efficiency during ultrasonic scaling procedures. Second, we were unable to assess the effect of HVS systems in comparison with a typical control group (e.g., no HVS) on aerosol generation during patient procedures because HVS is required to mitigate aspiration risks for the patient during procedures with a high-speed handpiece or ultrasonic scaler; this is a limitation to any real-world study with patients. Additionally, because we aimed to measure during real-world conditions, other operatories were in use on the days of our sampling and could potentially have affected hallway measurements. However, this limitation was minimized by (1) selecting the corner operatory and placing hallway samplers upstream of the hallway exhaust vent, opposite of where air from the neighboring operatory was pulled toward the exhaust vent (confirmed with air flow visualization and air measurements in ventilation assessment; see Supplementary) and (2) including location in the full model. Lastly, our assessment of the effect of HVS flow rate was limited to observed HVS flow rates which ranged from 12.0 SCFM to 14.5 SCFM. Additional studies are needed to characterize (1) HVS system aerosol mitigation efficiency for flow rates outside the range of HVS flow rates observed here and (2) the optimal flow rate ranges for HVS systems with varying designs.

CONCLUSIONS

Respirable and thoracic aerosol mitigation efficiency of five commercially available HVS systems varied with dental procedure and HVS system design. PM10 number, PM4 mass, and PM10 mass concentrations were more often controlled by HVS systems during ultrasonic scaling procedures than during procedures with a high-speed handpiece. Among HVS systems evaluated, standard HVE most often reduced PM10 number, PM4 mass, and PM10 mass concentrations during either procedure type to background concentrations. Additionally, although all HVS flow rates measured in this study were greater than the HVS flow rate previously reported as sufficient for aerosol capture during simulated procedures with a high-speed handpiece, here in our real-world study with patients, no system was able to fully reduce PM10 number concentrations, or PM4 or PM10 mass concentrations during procedures utilizing a high-speed handpiece to background levels. Further, the effect of HVS flow rate upon aerosol mitigation efficiency during high-speed handpiece or ultrasonic scaling procedures varied by system. Additional studies are needed to identify optimal flow rates needed for HVS systems to sufficiently mitigate PM4 and PM10 during common aerosol generating patient procedures, especially procedures utilizing a high-speed handpiece.

Supplementary Material

Supplementary Material

What’s Important About This Paper?

This study observed variability in aerosol exposure mitigation efficiency among 5 commercially available high- volume suction (HVS) systems when used during common dental procedures involving a high-speed handpiece or ultrasonic scaler in a real-world setting with patients. Standard HVE reduced respirable and thoracic aerosol number and mass concentrations to background levels most often; however, no HVS system fully reduced aerosol mass to background levels during high-speed handpiece procedures, despite all HVS flow rates being greater than a flow rate previously reported as sufficient for aerosol capture during high-speed handpiece procedures. Additionally, the effect of HVS flow rate on aerosol mitigation efficiency varied across HVS systems. Given the potential for dental providers to be exposed to aerosols with acute infectious or chronic respiratory effects, the variability in aerosol mitigation efficiency across different HVS system designs warrants additional study to identify factors that can improve HVS systems’ aerosol mitigation efficiency, including HVS flow rate ranges needed to sufficiently mitigate aerosol exposures during common patient procedures.

Acknowledgments:

The authors would like to acknowledge Michael Beaty and Carmella Meadows for their assistance with data collection; Isna Keumala for assisting with dataset creation; and William Lindsley, Ray Derk, and Stephen Martin for assisting with the clinic ventilation assessment.

Funding:

This work was supported by NIOSH research funds.

Footnotes

Institution and Ethics approval: This activity was reviewed by CDC, deemed research not involving human subjects, and was conducted consistent with applicable federal law and CDC policy.

Conflicts of Interest Statement: The authors declare no conflict of interest relating to the material presented in this Article. Its contents, including any opinions and/or conclusions expressed, are solely those of the authors.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention. Mention of any company or product does not constitute endorsement by the U.S. Government, National Institute for Occupational Safety and Health, or Centers for Disease Control and Prevention.

Data Availability:

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material
NIHMS2214902-supplement-Supplementary_Material.docx (1,011.4KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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