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The coronavirus disease (COVID-19) caused by the SARS-CoV-2 coronavirus impacted worldwide without any precedents, including the dental world, from the education to the advanced cares. The co-existence with the virus circulation imposed the use of personal protection equipment such as respiratory protective equipment. The aim of this paper is to report the modifications made to a Power Air Power Respirator to improve the quality of work during dental hygiene procedures. The device is composed of a hood and a power-air unit. The power-air unit is equipped with a strap to secure the filters and battery at the waist. The hood and the power-air unit presented visibility, weight, and use issues during dental hygiene procedures. The modifications to the hood made the shield more resistant and allowed the place for magnifying loupes. In addition, placing the battery-unit in a backpack, the weight was better distributed. Further innovations in PPE, barrier devices to minimize aerosol contamination, air purification systems, antiviral adjuvants, chairside screening for COVID-19, changes in clinical techniques could be envisaged to minimize the spread of COVID-19, possibly adapted, and adopted in future pandemics.
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Annali di stomatologia
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COVID19-Personal Protective Equipment ergonomic improvements: necessary considerations for the dental team health
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COVID19-Personal Protective Equipment ergonomic improvements: necessary considerations for the dental team health
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                                                                                                            Article


COVID19-Personal Protective Equipment ergonomic
improvements: necessary considerations
for the dental team health


Giulia Fantozzi1                                         Key words: COVID-19; prevention & control; dentist-
Mauro D’Agostino2                                        ry; dental hygiene; occupational exposure.
Sara Bernardi3
Serena Bianchi3                                          Introduction
Ettore Lupi4
                                                         The coronavirus disease (COVID-19) caused by the
Fabiola Rinaldi5
                                                         SARS-CoV-2 coronavirus has had an unprecedented
Roberto Gatto3
                                                         impact worldwide1. However, the nature of the virus
Gianluca Botticelli3*
                                                         spreading modality, no single strategy could limit the
                                                         pandemic diffusion, requiring a continuous struggle by
1
  Private Dental Hygienist, 65100, Pescara, Italy.       even the most advanced healthcare systems to address
2
  Private Architect, 65100, Pescara, Italy.              the challenges of COVID-19.
3
  Department of Life, Health and Environmental Scienc-   COVID-19 disease began in December 2019 in the Wu-
  es, University of L’Aquila, 67100 L’Aquila, Italy      han fish market in China and then rapidly spread to Thai-
5
  Department of Innovative Technologies in Medicine      land, Japan, South Korea, Singapore, and Iran. Subse-
  & Dentistry, University of Chieti—Pescara ‘Gabriele    quently, the viral spread affected Italy, Spain, the USA,
  d’Annunzio’, 66100 Chieti, Italy                       the UAE, and the UK2. Therefore, the rapid spread of the
4
  Maxillofacial Surgery Unit, San Salvatore Hospital,    disease led the World Health Organisation (WHO) to de-
  67100, L’Aquila, Italy.                                fine COVID-19 as a pandemic on 11 March 20203. Sig-
* Corresponding Author                                   nificant challenges have followed since then, with virus
                                                         isolation, an effective vaccine development towards the
*Corresponding author:                                   multiple variants, and appropriate disease management
Gianluca Botticelli                                      as the main objectives.
                                                         In terms of structure, COVID-19 is an RNA virus, thus
                                                         more prone to changes and mutations than DNA viruses,
                                                         which are single-stranded positive with an envelope.
Abstract
                                                         The viral genome has a 5’ terminal rich in open read-
The coronavirus disease (COVID-19) caused by the         ing frames that encodes proteins essential for virus
SARS-CoV-2 coronavirus impacted worldwide with-          replication. Instead, the 3’ terminal includes five struc-
out any precedents, including the dental world,          tural proteins, Spike protein (S), membrane protein (M),
from the education to the advanced cares. The            nucleocapsid protein (N), an envelope protein (E), and
co-existence with the virus circulation imposed          haemagglutinin-esterase protein (HE). The Spike protein
the use of personal protection equipment such as         is mainly responsible for pathogenesis in the human spe-
respiratory protective equipment. The aim of this        cies because its receptor-binding domain (RBD) binds to
paper is to report the modifications made to a Pow-      the human cell surface receptor protein Angiotensin-con-
er Air Power Respirator to improve the quality of        verting enzyme - 2 (ACE - 2), encoded by the ACE2
work during dental hygiene procedures. The device        gene4. It then binds to the transmembrane protease
is composed of a hood and a power-air unit. The          serine-2 (TMPRSS2), a cell surface protein expressed
power-air unit is equipped with a strap to secure        by epithelial cells of specific tissues4. The ubiquitous dis-
the filters and battery at the waist. The hood and the   tribution of ACE - 2 in organs means that SARS-CoV-2
power-air unit presented visibility, weight, and use     infection may mainly affect the lungs, leading to respira-
issues during dental hygiene procedures. The mod-        tory failure. However, this infection involves several or-
ifications to the hood made the shield more resis-       gans, from the kidneys to the heart, blood vessels, liver,
tant and allowed the place for magnifying loupes. In     pancreas, and immune system. Moreover, virus entry
addition, placing the battery-unit in a backpack, the    into host cells enhances the immune response, produc-
weight was better distributed. Further innovations       ing a profound secretion of inflammatory cytokines and
in PPE, barrier devices to minimize aerosol con-         chemokines, inducing acute respiratory distress and
tamination, air purification systems, antiviral adju-    multi-organ failure2,4,5.
vants, chairside screening for COVID-19, changes         SARS-CoV-2 has been found in nasopharyngeal se-
in clinical techniques could be envisaged to mini-       cretions and saliva. Thus, the infection spreads mainly
mize the spread of COVID-19, possibly adapted,           through respiratory droplets and direct contact with in-
and adopted in future pandemics.                         fected individuals and inanimate objects6.



Annali di Stomatologia 2022; XI (1-4): 9-14                                                                              9
     COVID19-Personal Protective Equipment ergonomic improvements

     SARS-CoV-2 can likely spread through aerosols (usu-            by the user. These devices have been considered during
     ally defined as small airborne particles <5μm) gener-          the early stages of the pandemic, also by the dental
     ated during dental procedures, reaching considerable           workers, due to the shortages of PPE supplies16,17. How-
     distances and even remaining suspended in the air for          ever, the ergonomics and the costs lower the quality of
     several hours, making the dental office environment a          life of the dental professionals during the procedures.
     high-risk area for nosocomial spread7–12.                      This paper aims to report the modifications made to a
     Until the development and delivery of an effective vac-        PAPR to improve the quality of work during dental hy-
     cine against COVID-19, the first measures affected den-        giene procedures.
     tal care treatments, which were limited to emergency
     treatment in most developed countries13,14.
     For the protection of patients and all the dental team,        PAPR defects and proposed solutions
     in-office consultation was restricted to a selected group
                                                                    The device is composed of a hood and a power-air unit.
     of patients after appropriate risk assessment. In addition,
                                                                    The power-air unit is equipped with a strap to secure the
     appropriate physical and temporal separation measures
                                                                    filters and battery at the waist. The hood and the pow-
     have been implemented in dental practices, and ade-
                                                                    er-air unit presented visibility, weight, and use issues
     quate time was set aside for clearance and decontam-
                                                                    during dental hygiene procedures. The power-air unit
     ination of the working field between patients15.
                                                                    aims to filter the air in the hood to guarantee protection
     The global protocols for clinical dentistry during
                                                                    against the external droplets generated during the aero-
     COVID-19 showed a widespread and broad consensus
                                                                    sol procedures. However, the air outlet led to two prob-
     on the observance of proper and thorough hand hygiene
                                                                    lems: 1) the device would go into alarm when catching
     and appropriate personal protective equipment (PPE)16.
                                                                    the hair (even under the cap), 2) the air was directed
     Recommended PPE included disposable gowns, gloves,
                                                                    over the neck and sometimes into the ear.
     FFP2 or FFP3 masks or N95 masks, and appropriate
     eye protection13,17.
     Additional measures suggested during operational pro-
     cedures included using high-volume suction devices,
                                                                    The hood
     rubber dam isolation, and mouthwashes with 0.2% ch-            The object of the study is the product ‘K20 hood 0326003’
     lorhexidine before the procedure to reduce the viral load      manufactured by KASCO SRL (Reggio Emilia, Italia),
     in the oral cavity18.                                          which conditions were found to improve its durability.
     The adopted measures have been proved effective in             After short periods of use, indeed, cracks appear along
     limiting the virus diffusion19.                                the perimeter path from the transparent visor (Figure1)
     According to dental procedures, different types of PPEs        and scratches on the inside due to friction on the inner
     are required. For example, the procedures generating           surface from magnifying glasses (Figure 1). Therefore,
     aerosol, such as dental hygiene procedures, require the        two essential features of the usage: the separation with
     use of a cap, protective glasses or face shield, FFP2 or       the outside and its unfiltered, positive-pressure leakage
     FFP3 mask, Uniform, Fluid-resistant gown, Gloves,              from the front (perimeter cracking) and blurring of visi-
     Clinical footwear, and shoe covers13. Dental health care       bility (scratch marks from magnifying glasses).
     professionals have also considered the Powered Air-Pu-         The two critical points are due to the considerable light-
     rifying Respirator (PAPR) as alternative PPE when in           ness and flexibility of the cover that provides comfort
     shortages of FFP2 masks14,20.                                  and considerable deformation in operation, inducing
     The PAPRs usually are composed by a hood which can             creases in the visor and impacts with the glasses.
     be loose or tight fit type, or a rigid helmet, and by a bat-   Although a material of remarkable plasticity, the trans-
     tery-powered unit which filter and purify the air, breathed    parent polycarbonate shield is weakened by the seam




  Figure 1. A. Cracks on the edge of the v sor and B. scratches due to magn fy ng g asses.



10                                                                                     Annali di Stomatologia 2022; XIII (1-4): 9-14
G. Fantozzi et al.

2 mm from the edge, binding it to the rest of the device.         entrusted with the anchorage of the support for wearing
It also takes on the burden of anchoring the support for          (Figure 2).
wearing. Moreover, the construction system does not               This modification provides excellent stability in the dis-
provide for the visor replacement by the operator. A re-          tance from the face during the movements, avoiding
placement or any other intervention leads to the loss of          abrasions due to impact from the glasses magnifying
certification (EN 529:2006). Therefore, the user has to           glasses (Figure 3). Furthermore, leakage to the outside
resort to a new and costly purchase.                              is ensured with a thin rubber gasket compressed by the
The goal is to make the visor less perishable and re-             pressure of the visor transparent polycarbonate visor
placeable simply and efficiently to make the general              on the frame, an action exerted by a series perimeter
maintenance exclusively based on sanitization.                    of M3 nylon screws (Figure 2). However, this stiffen-
To obtain our prototype, we thought of providing the vi-          ing creates problems with air intake at the rear. More-
sor with a PETG frame as slender as possible to pro-              over, with the helmet’s oscillation reduction, the tube
vide stiffening and anchorage in strict mode towards the          becomes stiffened at the outlet and can find an obstacle
fabric of the cover and in removable by screws towards            in the hair or the cap. To overcome this latter handicap,
the transparent visor. Furthermore, the same frame is             the inner ring nut of the inlet pipe with a radial diffuser




Figure 2. Exp oded v ew of the construct on deta s re at ng to the mod ficat on (exc ud ng the band for the wear ng that comes
reused)



Annali di Stomatologia 2022; XIII (1-4): 9-14                                                                                    11
     COVID19-Personal Protective Equipment ergonomic improvements

     Although the use of this device on conscious patients in              plant Guided Surgery Procedures Coatings 2022;12(2)
     dental practices is unlikely in its current form, it opens            doi:10 3390/coatings12020240
     the door to innovation in the development of barrier sys-        11   Mummolo S Botticelli G Quinzi V Giuca G Mancini L
                                                                           Marzo G mplant safe test in patients with peri implantitis J
     tems23. For example, in the study by Alì and Raja24 fluo-             Biol Regul Homeost Agents 2020;34(3):147 153
     rescein dye and ultraviolet (UV) light were used to limit        12   Botticelli G Severino M Ferrazzano GF et al Excision of
     aerosol diffusion during operative dentistry.                         lower lip mucocele using injection of hydrocolloid dental im
     Further innovations in PPE, barrier devices to minimize               pression material in a pediatric patient: A case report Appl
     aerosol contamination, air purification systems, antivi-              Sci 2021;11(13) doi:10 3390/app11135819
     ral adjuvants, chairside screening for COVID-19, and             13   Melo P Afonso A Monteiro L Lopes O Alves RC COV D 19
                                                                           Management in Clinical Dental Care Part : Personal Pro
     changes in clinical techniques could be envisaged to                  tective Equipment for the Dental Care Professional Int Dent
     minimize the spread of COVID-19, possibly adapted,                    J 2021;71(3):263 270 doi:10 1016/j identj 2021 01 007
     and adopted in future pandemics.                                 14   Estrich CG Gurenlian JAR Battrell A et al nfection Pre
                                                                           vention and Control Practices of Dental Hygienists in the
                                                                           United States During the COV D 19 Pandemic: A longitudi
     Conflict of Interest                                                  nal study J Dent Hyg JDH 2022;96(1):17 26
                                                                      15   Chasib NH Alshami ML Gul SS Abdulbaqi HR Abdulka
     None
                                                                           reem AA Al Khdairy SA Dentists Practices and Attitudes
                                                                           Toward Using Personal Protection Equipment and Associa
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14                                                                                         Annali di Stomatologia 2022; XIII (1-4): 9-14
