dentistry journal
Article
Comparative Dissemination of Aerosol and Splatter Using
Suction Device during Ultrasonic Scaling: A Pilot Study
Nutthawadee Engsomboon 1 , Praewpat Pachimsawat 2 and Bhornsawan Thanathornwong 1, *
Citation: Engsomboon, N.;
Pachimsawat, P.; Thanathornwong, B.
Comparative Dissemination of
Aerosol and Splatter Using Suction
Device during Ultrasonic Scaling: A
Pilot Study. Dent. J. 2022, 10, 142.
https://doi.org/10.3390/dj10080142
Academic Editor: Enrico Spinas
Received: 4 July 2022
Accepted: 26 July 2022
Published: 1 August 2022
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Copyright: © 2022 by the authors.
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This article is an open access article
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Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Dent. J. 2022, 10, 142. https://doi.org/10.3390/dj10080142
1 Faculty of Dentistry, Srinakharinwirot University, Bangkok 10110, Thailand; nutthawadee@g.swu.ac.th
2 Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand; praewpat.pac@mahidol.ac.th
* Correspondence: pornsawa@g.swu.ac.th
Abstract: Objective: This study compared the aerosol and splatter diameter and count numbers
produced by a dental mouth prop with a suction holder device and a saliva ejector during ultrasonic
scaling in a clinical setting. Methodology: Fluorescein dye was placed in the dental equipment
irrigation reservoirs with a mannequin, and an ultrasonic scaler was employed. The procedures
were performed three times per device. The upper and bottom board papers were placed on the
laboratory platform. All processes used an ultrasonic scaler to generate aerosol and splatter. A dental
mouth prop with a suction holder and a saliva ejector were also tested. Photographic analysis was
used to examine the fluorescein samples, followed by image processing in Python and assessment of
the diameter and count number. For device comparison, statistics were used with an independent
t-test. Result: When using the dental mouth prop with a suction holder, the scaler produced aerosol
particles that were maintained on the upper board paper (mean ± SD: 1080 ± 662 µm) compared to
on the bottom board paper (1230 ± 1020 µm). When the saliva ejector was used, it was found that the
diameter of the aerosol on the upper board paper was 900 ± 580 µm, and the diameter on the bottom
board paper was 1000 ± 756 µm. Conclusion: There was a significant difference in the aerosol and
splatter particle diameter and count number between the dental mouth prop with a suction holder
and saliva ejector (p < 0.05). Furthermore, the results revealed that there was a statistically significant
difference between the two groups on the upper and bottom board papers.
Keywords: aerosols; dental equipment; dental scaling; suction; algorithms
1. Introduction
In the dental clinic, undergraduate dental students still lack adequate operating
experience and skill. Furthermore, the faculty of dentistry does not provide each dental
student with a dental assistant. Moreover, dental work is a difficult process that necessitates
a good view of the operation field, and the procedures are frequently associated with
patient saliva, dispersed aerosol, and splatter [1–3]. Moreover, aerosol and splatter are
carriers of infection from the blood and saliva [4]. The difference between aerosol and
splatter is the size of the particle. Aerosols and splatters are defined by the World Health
Organization [5] as having a diameter ≤50 and ≥50 µm, respectively. Due to the airborne
spread of splattered fluid, droplets, and aerosols, the risk of transmitting potentially
pathogenic bacteria (such as Legionella pneumophila or Pseudomomas aeruginosa) and both
oral and respiratory viruses, including human influenza viruses and SARS-CoV-2, is a
major concern in dental practice. Aerosols with smaller particle sizes have a higher risk of
transmitting respiratory infections [6–8]. Especially during the scaling procedure, the use
of an ultrasonic scaler is the greatest producer of contaminated aerosol and splatter [9].
However, the saliva ejector is the only low-velocity air evacuation equipment available
for scaling and polishing, restorative, and prosthodontics procedures in the undergraduate
dental student clinic. Traditionally, undergraduate dental students in years 4, 5, and 6
provide treatment without the help of a dental assistant. They require a saliva suction hose
https://www.mdpi.com/journal/dentistry
 undergraduate dental student clinic. Traditionally, undergraduate dental students in
years 4, 5, and 6 provide treatment without the help of a dental assistant. They require a
saliva suction hose to make patients feel more at ease and can also work [10]. In the
dental clinic, the assistant helps by holding the saliva hose; however, in the undergrad-
Dent. J. 2022, 10, 142 uate dental student clinic, dental students hang the suction hose in the patient’s mouth 2 of 9 or
use their non-dominant hand to hold the suction hose. The dominant hand, which is
skilled at manipulating tools, should be used for dental procedures. As mentioned above,
ittoismake
evident that feel
patients thismore
situation
at easeis and
a cause of stress
can also work for
[10].both patients
In the dental and dental
clinic, students.
the assistant
The dental mouth prop with a suction holding device is designed
helps by holding the saliva hose; however, in the undergraduate dental student clinic, to attach to a
low-volume
dental students suction
hanghose. It can hose
the suction provide suction
in the in both
patient’s mouth theormaxillary and mandibular
use their non-dominant
quadrants
hand to hold andthebe suction
used onhose.the right and left side
The dominant to alleviate
hand, which is dental
skilled students’ concerns
at manipulating
during the procedure.
tools, should Otherprocedures.
be used for dental advantagesAs of the device
mentioned above,include prevention
it is evident that this of
situation is a fatigue
oro-muscular cause ofduring
stress extended
for both patients
visits andand dental students.
accidental The dental
patient closure of themouth
mouth,
prop with
which could a suction
result inholding
trauma, device
and is designedof
reduction to moisture
attach to acontamination
low-volume suction of the hose.
treated
It canItprovide
area. suction
is routinely used ininboth the maxillary
dentistry and the
to improve mandibular
quality ofquadrants and be used
dental treatment on it
because
the right and left side to alleviate dental students’ concerns during
can provide good access in the operation area, decrease the moisture in the patient’s the procedure. Other
advantages
mouth, and ofincrease
the device
theinclude
patient’sprevention
comfortofand oro-muscular fatigue during
safety. However, extended
the amount of visits
aerosol
and accidental patient closure of the mouth, which could result in
and splatter spread by dental equipment is undetermined. Finally, researchers expect trauma, and reduction
of moisture contamination of the treated area. It is routinely used in dentistry to improve
that the use of this device in the dental clinic will improve dental students’ performance
the quality of dental treatment because it can provide good access in the operation area,
visually and take less time to complete each treatment, since they will not have to seek a
decrease the moisture in the patient’s mouth, and increase the patient’s comfort and safety.
saliva hose. Furthermore, the good impressions of the patients from dental students will
However, the amount of aerosol and splatter spread by dental equipment is undetermined.
be affected.
Finally, researchers expect that the use of this device in the dental clinic will improve dental
Therefore,
students’ in this visually
performance study, aand simulated
take lessclinical
time tostudy
completewaseach
conducted
treatment,to compare
since theythe
dental
will not have to seek a saliva hose. Furthermore, the good impressions of the patientsthe
mouth prop with a suction holder device and a saliva ejector and assess fromaero-
sol andstudents
dental splatter will
diameter and count number during ultrasonic scaling. As a secondary
be affected.
purpose, the researchers
Therefore, in this study,also aimed toclinical
a simulated develop a new
study wasapproach
conductedto tomeasure
compare the aerosol
dental and
splatter spread.
mouth prop with a suction holder device and a saliva ejector and assess the aerosol and
splatter diameter and count number during ultrasonic scaling. As a secondary purpose, the
2.researchers
Materialsalso andaimed
Methodsto develop a new approach to measure aerosol and splatter spread.
2.1. Laboratory Platform Setup
2. Materials and Methods
In a dentalPlatform
2.1. Laboratory clinic, Setup
the researchers constructed a laboratory platform to compare the
aerosol and splatter pattern obtained during a simulated scaling procedure. A 26 × 34 ×
In a dental clinic, the researchers constructed a laboratory platform to compare the aerosol
10-inch PVCpattern
and splatter pipe platform
obtained was built
during to enclose
a simulated the manikin
scaling procedure. head as×
A 26 it 34
was× reclined into a
10-inch PVC
usual
pipe platform was built to enclose the manikin head as it was reclined into a usual position to
position for scaling so that the maxillary dental occlusal plane was perpendicular
the
for floor
scaling[11]. A typodont
so that manikin
the maxillary dentalhead (Nissin
occlusal planeDental, Kyoto, Japan)
was perpendicular was
to the placed
floor [11]. Ain a
dental
typodont chair’s headrest
manikin position.
head (Nissin Then,
Dental, a typodont
Kyoto, Japan) was (D16FE500H (GSF)-MF
placed in a dental chair’s28headrest
teeth soft
gingivae
position. type,
Then, Nissin,
a typodontKyoto, Japan) was
(D16FE500H inserted
(GSF)-MF 28 into
teeththe
softmaxillary and mandibular
gingivae type, Nissin, Kyoto,po-
sitions
Japan) wasof the manikin
inserted head.
into the The PVC
maxillary pipe platform
and mandibular was of
positions covered with head.
the manikin a blue polypro-
The PVC
pylene (PP) corrugated
pipe platform was covered board
with athat
bluewas trimmed to(PP)
polypropylene fit. The laboratory
corrugated boardplatform was set up
that was trimmed
to fit.stands
with The laboratory platform
for support at awas set up
height ofwith standsaround
26 inches for supporttheatmanikin
a height at
of 26
theinches aroundpo-
12 o’clock
the manikin
sition. at the
In order to12 o’clock airflow
prevent position.currents
In order to prevent the
affecting airflow currents
aerosol andaffecting
splatterthe aerosolpa-
pattern,
and splatter pattern, papers were placed around
pers were placed around the laboratory platform (Figure 1). the laboratory platform (Figure 1).

(A) (B) (C)

Figure 1. (A) A typodont manikin head setting. (B) The laboratory platform before it was covered by
papers. (C) The operator worked in the laboratory platform set-up stand.
Dent. J. 2022, 10, x FOR PEER REVIEW 3 of 9

Dent. J. 2022, 10, 142 3 of 9

Figure 1. (A) A typodont manikin head setting. (B) The laboratory platform before it was covered
by papers. (C) The operator worked in the laboratory platform set-up stand.

2.2. Experimental
2.2. Experimental Design
Design
A repeated-measures
A repeated-measures laboratory
laboratory study
study waswas conducted
conducted in in the
the dental
dental clinic
clinic of
of the
the
faculty of dentistry at Srinakharinwirot University. Six trials were carried
faculty of dentistry at Srinakharinwirot University. Six trials were carried out by a single out by a single
operatorusing
operator usingstandard
standardscaling
scalingtechniques
techniquesand andoperator
operator positions
positions were
were incorporated
incorporated [5–
[5–7].
7]. The
The operator
operator (B.T)
(B.T) waswas a licensed
a licensed dentistwith
dentist withover
over1515years
yearsofofexpertise
expertise in in the field.
Aerosoland
Aerosol andsplatter
splatterwere
wereproduced
producedutilizing
utilizing a Thai
a Thai dental
dental product,
product, thethe Superson
Superson MarkMarkIII
III electromagnetic
electromagnetic 25,000
25,000 cycles
cycles perper second,
second, manually
manually tuned
tuned ultrasonic
ultrasonic sealer,
sealer, fitted
fitted with
with a
a P-10
P-10 series
series tiptip insert.Following
insert. Followingthe thedirections
directionsofofthe themanufacturer,
manufacturer,prior priortotothe
the onset
onset ofof
scaling, the
scaling, the water
water lines
lines were
were flushed.
flushed. For all trials,
trials, the
the power
power and and water
water flow
flow indicator
indicator
knobs on
knobs on the
the ultrasonic
ultrasonic instrument
instrument werewere setset to
tomedium.
medium. The The operator
operator performed
performed timedtimed
simulated
simulated scaling
scaling on on the
the facial
facial and
and lingual
lingual portions
portions of of maxillary
maxillary teeth
teeth assigned
assigned tooth
tooth
numbers
numbers 17 17 to
to 25
25 of Dentoform®® (Kyoto,
of aaDentoform (Kyoto, Japan) model model covered
covered with
with aa Nissin
Nissin Mask
Mask M M
(w/Single
(w/Single Drain).
Simulated
Simulated upper
upper arch
arch scaling
scaling was
was used
used in
in the
the experiment,
experiment, along
along with
with aa low-volume
low-volume
evacuation system with a saliva ejector. Another experimental
evacuation system with a saliva ejector. Another experimental condition condition included the same
included the
simulated situation
same simulated but withbut
situation thewith
addition of a dental
the addition ofmouth
a dentalprop with aprop
mouth suction
withholder and
a suction
saliva
holderejector. The dental
and saliva ejector.mouth prop with
The dental mouth a suction
prop with holder attached
a suction to the
holder saliva ejector
attached to the
provided simultaneous
saliva ejector suction to thesuction
provided simultaneous maxillary and
to the mandibular
maxillary and quadrants.
mandibularThe device
quadrants.
also
The assisted
device alsoin mouth
assisted opening,
in mouth as opening,
a porous as structure
a porous that allows that
structure fluidallows
evacuation
fluid to be
evac-
easily managed, and hands-free suction (Figure
uation to be easily managed, and hands-free suction (Figure 2).2).

(A) (B) (C)

Figure 2.
Figure 2. (A)
(A) The
The dental
dental mouth
mouth prop
prop with
with the
thesuction
suctionholder
holder device
device (Thai
(Thai Patent
Patent No:
No: 19329,
19329, Thai
Thai
FDA No: 64-1-3-2-0000523). (B) The location at which the dental mouth prop with a suction
FDA No: 64-1-3-2-0000523). (B) The location at which the dental mouth prop with a suction holder holder
attachedto
attached tothe
thesaliva
salivaejector
ejectorwas
wasplaced
placed
in in
thethe typodont
typodont manikin
manikin head.
head. (C)(C)
TheThe location
location at which
at which the
the saliva ejector was placed.
saliva ejector was placed.

Sodium fluorescein
Sodium fluorescein (Himedia,
(Himedia, India)
India) was
was added
added toto the
the coolant
coolant water
water to
to give
give aa final
final
concentration of 10 mg/mL [6,11]. The water spray aerosolized and scattered
concentration of 10 mg/mL [6,11]. The water spray aerosolized and scattered away from the away from
the ultrasonic
ultrasonic dental
dental scaler
scaler during
during the simulated
the simulated scaling
scaling procedure;
procedure; the resulting
the resulting aerosol
aerosol and
and splatter
splatter that dropped
that dropped surrounded
surrounded the typodont
the typodont mouth and mouth
landedand
onlanded on the pa-
the paper-covered
per-covered
platform. Theplatform.
proceduresThewere
procedures werefor
carried out carried
5 min.out for each
After 5 min. After
test, each papers
2 board test, 2 board
were
allowed to thoroughly dry for 10 min and removed. Then, we allocated a number of thea
papers were allowed to thoroughly dry for 10 min and removed. Then, we allocated
numberand
aerosol of the aerosol
splatter and splatter
particles particles
to each piece to eachpaper.
of covered piece of covered
Then, paper. of
the amount Then,
aerosolthe
amount
and of aerosol
spatter and
particles onspatter particles
each piece on each
of paper was piece of paper was measured.
measured.

2.3.
2.3. Effects
Effects of
of Dental
Dental Suction
Suction
In
In a laboratory platform
a laboratory platform setup,
setup, researchers
researchers covered
covered the
the air
air inlet
inlet vent
vent to
to the
the operatory
operatory
so
so that
thatnonoairflow
airflowcurrents were
currents present,
were as this
present, as could have affected
this could the aerosol
have affected the and splatter
aerosol and
pattern.
splatter The suction
pattern. Theflow rate was
suction flowcontrolled
rate was at a standard
controlled atlow-volume evacuation level
a standard low-volume [12].
evacua-
After, the saliva
tion level ejectorthe
[12]. After, andsaliva
the dental
ejectormouth
and theprop withmouth
dental a suction holder
prop withand saliva ejector
a suction holder
device were placed in a 2-liter graduated cylinder filled with 2000 mL of water and their
suction rates were tested. In 50 s, the saliva ejector cleared all of the water in the cylinder,
 water in the cylinder, equal to a rate of 40 mL/s. All of the water in the cylind
cleared at the same time with a dental mouth prop with a suction holder and a
ejector device.
Dent. J. 2022, 10, 142 4 of 9
2.4. Image Processing
The researchers processed the images according to the following steps. Fi
covered
equal to apaper
rate of coated
40 mL/s.withAll ofaerosol and
the water splatter
in the particles
cylinder wasatplaced
was cleared the sameon the floor
time
was
with completely
a dental mouthdry.propSecond, a digital
with a suction holdersingle-lens reflexdevice.
and a saliva ejector camera (Pentax; manua
setting, focal length = 105 mm, aperture area = F10, and shutter speed = 1/60 s) wa
2.4. Image Processing
to capture an image of the covered paper. The camera was 210 cm above the g
The researchers processed the images according to the following steps. First, the
when
covereditpaper
was coated
used with
to capture thesplatter
aerosol and paper.particles
Third,wastheplaced
images
on thewere
floortranslated
until it was to gra
and identified
completely between
dry. Second, the paper
a digital and reflex
single-lens the aerosol and splatter
camera (Pentax; manualparticles.
mode setting,The image
focal length = 105from
distinguished mm, aperture area = F10,
the grayscale and shutter
photos usingspeed
the= brightness
1/60 s) was used to capture
threshold point an
an image of the covered paper. The camera was 210 cm above the ground when it was used
converted to black and white. The aerosol and splatter particles were recognize
to capture the paper. Third, the images were translated to gray scale and identified between
again
the paperusing
and algorithm
the aerosol andblob detection
splatter [13,14]
particles. by analyzing
The images a set of black
were distinguished from the and whit
in the images
grayscale photosand generating
using circle-like
the brightness threshold patterns.
point andThe
thenalgorithm
converted to enclosing
black and circle w
white. The aerosol and splatter particles were recognized once again
plied. With the support of this method, a circle was generated by encircling using algorithm blob it wit
detection
from the[13,14]
images.by analyzing a set ofeach
As a result, black aerosol
and whiteand spotssplatter
in the images and generating
particle was surrounde
circle-like patterns. The algorithm enclosing circle was applied. With the support of this
green circle. After, the droplets were surrounded by a green circle. The drops were
method, a circle was generated by encircling it with spots from the images. As a result,
green circle.and
each aerosol Finally,
splatterthe aerosol
particle and splatter
was surrounded by aparticles in the
green circle. After,paper were detect
the droplets
identified.
were surrounded The bysize of the
a green aerosol
circle. andwere
The drops splatter
then aparticles was
green circle. proportionate
Finally, the aerosol to the
and splatter particles
circle (Figure 3). in the paper were detected and identified. The size of the aerosol and
splatter particles was proportionate to the green circle (Figure 3).

Figure 3. Image processing steps.

Figure 3. Image processing steps.
Dent. J. 2022, 10, 142 5 of 9

2.5. Statistical Analysis

Opencv-python for Python 3.6 was used to create an image processing approach that
demonstrated the aerosol and splatter size and count number. The data were analyzed
using SPSS version 22.0 (SPSS, Chicago, IL, USA). The differences between the groups were
analyzed using the independent t-test at the 95% confidence level.

3. Results
3.1. The Size of the Aerosol and Splatter Particles
The size of the aerosol and splatter particles was measured by the image processing
approach. The results are shown in Table 1.

Table 1. The mean ± standard deviation diameter (micrometer) of the aerosol and spatter particle
and count number between the two devices.

Upper Board Paper Bottom Board Paper

Device Time Diameter Count Diameter Count
(µm) Number (µm) Number
1 990 ± 668 9055 970 ± 779 16,486
Dental mouth 2 1170 ± 558 2426 1720 ± 1253 13,956
prop with
suction holder 3 1290 ± 659 3428 1120 ± 910 22,922
mean 1080 ± 662 4968 1230 ± 1020 17,787
1 1340 ± 678 3560 1090 ± 879 24,065
2 820 ± 486 8836 940 ± 676 19,257
Saliva ejector
3 730 ± 503 5253 940 ± 640 18,376
mean 900 ± 580 5882 1000 ± 756 20,565

3.2. Comparison of the Aerosol and Splatter Particle Size on the Upper and Bottom Board Paper
On the upper and bottom board paper, the average diameter of the aerosol and splatter
particles was measured. The scaler generated the aerosol particles that were retained on
the upper board paper during the use of the dental mouth prop with a suction holder
(mean ± SD: 1080 ± 662 µm ranging from 370 to 1307 µm) compared to on the bottom
board paper (1230 ± 1020 µm ranging from 370 to 1310 µm). The used saliva ejector
diameter of the aerosol size on the upper board paper was 900 ± 580 µm, ranging from
370 to 1260 µm, and on the bottom board paper, it was 1000 ± 756 µm, ranging from 370 to
1300 µm. There was a statistically significant difference (p < 0.001) between the two groups,
indicating that both dental mouth props with a suction holder and saliva ejector resulted in
a larger size on the upper and bottom board papers (Figure 4). Furthermore, the results
revealed that there was a statistically significant difference between the two groups on
the upper and bottom board papers. Every scaling procedure was completed after being
carried out for 5 min. In this study, there was no statistically significant difference between
the two device groups in terms of the amount of time spent performing ultrasonic scaling.

3.3. Comparison of the Aerosol and Splatter Particle Count Number on the Upper and Bottom
Board Paper
The results showed that the count number of the aerosol and splatter particles from the
use of the dental mouth prop with a suction holder was different from the count number of
the saliva ejector (Figure 5). There was a significant difference in the aerosol and splatter
count between the two devices (p < 0.01).
Dent. J. 2022, 10, x FOR PEER REVIEW
Dent. J. 2022, 10, 142 6 of 9
6 of 9

Figure 4. Bar chart showing the difference in the mean diameter of aerosol and splatter particle
between upper board paper and bottom board paper when using a saliva ejector and a denta
mouth prop with a suction holder. * Statistical significance at p < 0.001.

3.3. Comparison of the Aerosol and Splatter Particle Count Number on the Upper and Bottom
Board Paper
The results showed that the count number of the aerosol and splatter particles from
the use of the dental mouth prop in with a suction holder wasanddifferent from the coun
Figure4.4.Bar
Figure Barchart
chartshowing
showing thethe difference
difference inmean
the the mean diameter
diameter of aerosol
of aerosol and splatter
splatter particles particles
numberupper
between
between of the
upper saliva
board
board paper ejector
paper and (Figure
and bottom board5).
bottom There
board
paper was
paper
when aasignificant
when
using using
saliva difference
a saliva
ejector ejectorin
and a dental theaaeroso
and
mouth denta
and
mouth
prop splatter
prop
with count between
with aholder.
a suction suction the two devices
holder. *significance
* Statistical (p < 0.01).
Statistical significance
at p < 0.001. at p < 0.001.

3.3. Comparison of the Aerosol and Splatter Particle Count Number on the Upper and Bottom
Board Paper
The results showed that the count number of the aerosol and splatter particles from
the use of the dental mouth prop with a suction holder was different from the count
number of the saliva ejector (Figure 5). There was a significant difference in the aeroso
and splatter count between the two devices (p < 0.01).

Figure5.5.Bar
Figure Bar chart
chart showing
showing the difference
the difference between
between the
the count countofnumber
number of aerosol
aerosol and splatter and splatter par
particles
ticles between
between theboard
the upper upper board
paper andpaper and
bottom bottom
board board
paper. paper.significance
* Statistical * Statisticalatsignificance
p < 0.01. at p < 0.01.
4. Discussion
4. Discussion
The generation of aerosol and splatter creates a significant risk for airborne contamina-
The generation
tion within of aerosol
the dental clinic and routine
[1–4]. Most splatterdental
creates a significant
treatments risk for airborne con
are aerosol-generating
tamination within the dental clinic [1–4]. Most routine
procedures that produce a mixture of splatter and aerosols that contain saliva, dental treatments
blood, and are aero
sol-generating
viable procedures
microorganisms (includingthat produce
bacteria and a mixture
viruses) ofCommonly
[1,5]. splatter and usedaerosols that contain
dental instru-
ments and ultrasonic scaling microorganisms
produce the greatest amount ofbacteria
aerosol and splatter, which
Figure 5. Bar chart showing the difference between the count number of aerosol and [1,5].
saliva, blood, and viable (including and viruses) splatterCom
par
can
monlybe disseminated
used the
dental from the treatment
instruments area. Recently, a study investigated a biosafety
ticles between upper board paperand and ultrasonic
bottom board scaling
paper.produce the
* Statistical greatest amount
significance at p < 0.01.o
protocol
aerosol toolandusing 3D printing
splatter, whichtechnology called “SUR-FACE”
can be disseminated from tothe reduce the aerosol
treatment cloud.
area. Recently, a
Nevertheless, the limitation of the technology is its high cost and the patient has to hold it
study
4. investigated a biosafety protocol tool using 3D printing technology called
Discussion
during the procedure [15]. In order to assess the benefit of any suction methods or devices,
“SUR-FACE”
Therequired
it is first
toto
generationreduce
evaluate
thethe
of aerosolaerosol
and
size
cloud.
andsplatterNevertheless, the limitation
creates ofa aerosols
count number significant
and risk
of the
for
splatter
technology
airborne
during con-
is its
dental high cost
procedures.
tamination and the patient has to hold it during the procedure
within the dental clinic [1–4]. Most routine dental treatments are [15]. In order to asses
aero-
the benefit
sol-generating of any
Therefore, in suction
this study, methods
procedures comparativeor devices,
that produce it is first
dissemination
a mixture of required
of splatter
aerosol and
andtosplatter
evaluate
aerosols thea size
using
that and
contain
count
suction number
device of aerosols
during and
ultrasonic splatter
scaling during
was dental
conducted. procedures.
The result showed
saliva, blood, and viable microorganisms (including bacteria and viruses) [1,5]. Com- a statistically
significant difference in the mean aerosol and splatter diameter between the two suction
monly used dental instruments and ultrasonic scaling produce the greatest amount of
devices. The particle size was larger when the dental mouth prop with a suction holder
aerosol and splatter, which can be disseminated from the treatment area. Recently, a
was used than when the saliva ejector was sued. Specifically, according to the weight that
study investigated a biosafety protocol tool using 3D printing technology called
“SUR-FACE” to reduce the aerosol cloud. Nevertheless, the limitation of the technology
is its high cost and the patient has to hold it during the procedure [15]. In order to assess
the benefit of any suction methods or devices, it is first required to evaluate the size and
Dent. J. 2022, 10, 142 7 of 9

falls to the ground, the dental mouth prop with a suction holder caused less spreading than
the saliva ejector. In addition, when a dental mouth prop with a suction holder was used
on both the upper and bottom boards, the average count number of aerosol and splatter
particles was less than when a saliva ejector was used. So, it is expected that the spread was
reduced because the mean diameter was larger, and the average count number was lesser.
Aerosol and spatter production during dental scaling in the oral cavity using an
ultrasonic scaler has been well documented in the literature [16–20]. This aerosol and
spatter might contain infectious agents originating from the patient or the dental unit
waterlines that pose a health threat to the dentist, patient, and staff members who are within
the spray’s pattern. Due to their heightened susceptibility to the potentially pathogenic
microorganisms found in these particles, the impact of these aerosols and splatter on
immunocompromised patients is concerning [21,22]. Smaller-sized aerosols are more likely
to spread respiratory illnesses. Especially, aerosol particles smaller than 5 µm are more
likely to remain airborne for indefinite periods and be deposited in the lower respiratory
tract [23]. However, Han et al. [6] found that in splatter and aerosol contamination in
dental aerosol-generating procedures, the splatter particle size in the ultrasonic scaler was
281 ± 188 µm, ranging from 200 to 1020 µm. In this study, the splatter particles produced
by both devices had an average diameter of 1080 ± 662 and 900 ± 580 µm, which is larger
than that found in previous research. The measurement method used in this study may
have contributed to the increased diameter of the splatters and aerosols. To construct
image processing, the researchers used Opencv-python for Python 3.6. The algorithm
was used to build the circle around the particle on the paper after converting the photo
from the cover paper to gray scale. The benefits of this technique are that it is simple to
use, count the number of particles, measure the diameter, and process. The disadvantages
include numerous processing steps and the possibility that the circle will be larger than the
realistic size.
According to previous studies, mouth supports make it easier for patients to keep their
mouths open during intraoral operations without experiencing extra pain or discomfort.
Importantly, research has shown that patients overwhelmingly prefer the use of mouth
supports [24,25]. Therefore, researchers developed a dental mouth prop with a suction hole
as a soft and gentle mouth prop that attaches to the saliva ejector with a suction hole. The
aim of this study was primarily to test the ability of the dental mouth prop with a suction
holder device to reduce aerosol and splatter in a simulated clinical study. It had better
effects than only the use of the saliva ejector. When working without dental assistance,
it can help dentists and dental students to control moisture and produce better work. It
is preferable to have less infectious propagation, especially during the COVID-19 period.
The dental mouth prop with the suction holder is composed of sterile material that can
be sterilized and reused. Furthermore, it may enable patients to maintain an open mouth
position for extended periods of time.
However, the low-volume saliva ejector is used to remove water that collects in the
floor of the mouth rather than to remove air. Therefore, it may not be a very efficient tool in
reducing the aerosol cloud. The combination of a high-volume evacuator with a large bore
evacuator tip should be advised for use during ultrasonic scaling. Additionally, there is a
chance that airborne contaminants will enter the ventilation system and spread infection.
The risk of air contamination can be reduced by the ventilation system’s high-efficiency
particulate air (HEPA) filters and UV chambers [2]. Air disinfection with a lamp that
produces UV light between 250 and 265 nm has demonstrated extremely high fungicidal,
virucidal, and bactericidal action [26]. This is because DNA chains were broken down and
proteins are denaturated. However, these techniques are expensive.
The limitation of this study is that the mouth prop with the suction holder was
positioned on the left first molar in this trial. The right side was not tested, so this study
did not know how different it was. Furthermore, in the COVID-19 situation [27–29], high-
volume suction in conjunction with the saliva ejector is recommended; however, this trial
Dent. J. 2022, 10, 142 8 of 9

did not use this setup, so it is not representative of the real situation. This study only
basically tested the device in a simulated clinical study to see how it functioned.

5. Conclusions
This study’s results showed that the aerosol and splatter diameters obtained from
the use of a dental mouth prop with a suction holder device and a saliva ejector were
significantly different (p < 0.05).

Author Contributions: N.E.: methodology, writing—original draft preparation. P.P.: methodology,

resources B.T.: conceptualization, methodology, writing—review and editing, supervision. All
authors have read and agreed to the published version of the manuscript.
Funding: This work was supported by Faculty of Dentistry (grant number 299/2564), Srinakharin-
wirot University, Bangkok, Thailand.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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