Occupational Health Problems among Dentists in Croatia

Abstract

Aim

To assess the health status among dentists in Croatia regarding the symptoms of musculoskeletal, dermatological, sight, hearing and neurological disorders.

Methods

The anonymous online survey was conducted among 506 Croatian dentists.

Results

It was found that over 78.18% of the surveyed dentists experienced work related pain in upper back, 76.97% of them in lower back. Work-related skin problems were reported by 29.29% of dentists. Vision problems were reported by 46.87% and hearing problems by 19.03% of participants. Neurological disorders were reported by 15.76% of dentists.

Conclusion

This study is the first to report on the overall health status of Croatian dentists and, unfortunately, it showed undesirable results. Numerous health hazards, increased professional requirements and limited ergonomics in the work environment of Croatian dental practitioners cause various health disorders, and the prevalence of occupational diseases is very high.

Introduction

An occupational (professional) disease can be defined as a disease or health disorder that is caused by the work or working conditions (1). Legislation of some countries distinguishes occupational diseases and diseases related to work. In this case, the occupational etiology of the occupational disease must be undoubtedly evidenced and confirmed by medical experts and such diseases or disorders are listed on the official list of occupational diseases of the country. Work related diseases have multifactorial origin and working conditions appear to be among dominant factors contributing to occurrence and development of health disorders. Usually, the number of officially accepted occupational diseases in a country is inversely proportional with the number and rights which individuals affected by occupational diseases have. In 2013, a review of the European Commission of the current situation related to the occupational diseases system in EU Member States was released. In this document, occupational diseases were defined as diseases having a specific or a strong relation to occupation, generally with only one causal agent, and recognized as such. Work-related diseases were defined as diseases with multiple causal agents, where the factors in the work environment may play a role, together with other risk factors in the development of such diseases, which have a complex etiology. The diseases affecting working populations were defined as diseases without a causal relationship with work but which may be aggravated by occupational hazards to health (2).

Compared to other health related professions, dental profession is considered to be among the most hazardous professions (3-5). Health risks and hazards in dentistry can be classified as biological, biomechanical, physical, chemical and psychological (6, 7). Biological hazards (biohazards) are biological substances that pose a threat to the health of dental personnel and include viruses, bacteria, fungi and prions (7, 8). Biohazards can cause body infections of different kind. Biomechanical hazards in dentistry include awkward body working posture, single or repetitive movements and forces imposing stress on the body with a potential to cause or contribute to injury or disease affecting the musculoskeletal or neurological systems (9, 10). Physical hazards in dental medicine include radiation (ionizing and non-ionizing), noise, artificial light including polymerization light etc. (11). Physical hazards can cause hearing and sight disorders and health problems related to radiation. Chemical hazards in dentistry are recognized as drugs and remedies, dental materials, dental personal equipment, gloves, disinfectant etc. (12). Chemical hazards can cause allergies, toxic reactions, hypersensitivity, chemical injuries etc. Psychological hazards include stress, chronic tiredness and burn-out syndrome (4, 13). Exposure to psychosocial hazards in the workplace not only produces psychological damage to individual employees such as depression and anxiety, but also causes somatic disorders such as cardiovascular diseases, hypertension, neurological disorders etc.

A long-lasting economic crisis which commenced in the middle of the first decade of 21^st century and frequent rationalization initiatives in public and private dental care in Croatia during the last two decades have made dental profession on average less lucrative and more demanding regarding professional, business and administrative requirements. The effects of this economic downturn were additionally highlighted on 1 July 2013, when Croatia became the 28th EU member introducing new changes and challenges in the everyday work of Croatian dentists. The results of investigations that address health related problems among Croatian dentists and increased requirements are not available in the relevant literature. This study is the first to report on the overall health status of Croatian dentists. The aim of this study was to assess the health status among dentists in Croatia regarding the symptoms of musculoskeletal, dermatological, sight, hearing and neurological disorders.

Participants and methods

A total of 800 randomly selected dental practitioners from all parts of Croatia were invited by e-mail to participate in an anonymous and voluntary online survey related to the occupational health disorders. All subjects had at least one year experience in clinical practice.

Based on the available and relevant literature in a close cooperation with physicians of different specialties (orthopedist, dermatologist, otolaryngologist, ophthalmologist and neurologist) a questionnaire for the assessment of a dentist’s overall health status was developed (14-17). The questionnaire was divided into 3 sections. The first section included demographic questions regarding gender, age and work duration. The section two dealt with the awareness of dental practitioners regarding the occupational health disorders. The third section dealt with symptoms of musculoskeletal, dermatological, sight, hearing and neurological disorders. Ethics approval for the study was obtained from the Ethics Committee at University of Zagreb School of Dental Medicine.

The obtained data were subjected to descriptive statistics using “SPSS Statistics 17.0 for Windows“(SPSS Inc., Chicago, IL). Chi square test was employed to check statistical significance. P < 0.05 was considered significant at 95% confidence interval.

Results

A total of 529 dental practitioners participated in the survey (response rate was 66.1%), and finally, after elimination of incomplete questionnaires, 506 dentists completed an anonymous online questionnaire (310 females – 61.3% and 196 males - 38.7%). The age distribution of the participants and distribution of the participants regarding duration of work with patients is shown in Tables 1 and 2.

Table 1. Age distribution of participants.

	Žene • Females		Muškarci • Males		Žene + Muškarci • Females + Males
Dobne skupine (godine) • Age groups (years)	N	%	N	%	N	%
21-30	34	11.0	24	12.2	58	11.5
31-40	114	36.8	63	32.1	177	35.0
41-50	72	23.2	57	29.1	129	25.5
51-60	76	24.5	44	22.4	120	23.7
61+	14	4.5	8	4.1	22	4.3
Ukupno • Total	310	61.3	196	38.7	506	100.0

N – broj sudionika • Number of participants

Table 2. Distribution of participants regarding the duration of work with patients.

	Žene • Females		Muškarci • Males		Žene + Muškarci • Females + Males
Radni vijek (godine) • Work duration (years)	N	%	N	%	N	%
1 - 10	100	32.3	61	31.1	161	31.8
11 - 20	101	32.6	71	36.2	172	34.0
21 - 30	71	22.9	42	21.4	113	22.3
31+	38	12.3	22	11.2	60	11.9
Ukupno • Total	310	61.3	196	38.7	506	100.0

N - broj ispitanika • Number of participants

92.9% of participants considered dentistry a profession that is harmful for their health and 97.6% agreed that practicing dentistry can cause musculoskeletal disorders. Only 46.8% of participants thought that practicing dentistry can cause mental disorders. 63.8% of participants stated that professional diseases in dentistry could be prevented. There was no statistically significant difference in answers between males and females. The summarized data about awareness of dental practitioners regarding the occupational health disorders are shown in Table 3.

Table 3. Summarized data on dental practitioners’ awareness of occupational health disorders.

	Žene • Females						Muškarci • Males						Žene + Muškarci • Females + Males
	Da • Yes	%	Ne • No	%	Ne zna • Do not know	%	Da • Yes	%	Ne • No	%	Ne zna • Do not know	%	Da • Yes	%	Ne • No	%	Ne zna • Do not know	%
Bavljenje stomatologijom može štetno utjecati na moje zdravlje • Practicing dentistry can harm my health	288	92.9	16	5.2	6	1.9	182	92.9	10	5.1	4	2.0	470	92.9	26	5.1	10	2.0
Trebao bih više brinuti o svome zdravlju • I should take more care of my health	279	90.0	23	7.4	8	2.6	176	89.8	16	8.2	4	2.0	455	89.9	39	7.7	12	2.4
Mislim da bavljenje stomatologijom može izazvati mišićno-koštane poremećaje • In my opinion, practicing dentistry can cause musculoskeletal disorders	304	98.1	3	1.0	3	1.0	190	96.9	5	2.6	1	0.5	494	97.6	8	1.6	4	0.8
Mislim da bavljenje stomatologijom može izazvati dermatološke poremećaje • In my opinion, practicing dentistry can cause dermatological disorders	225	72.6	58	18.7	27	8.7	152	77.6	30	15.3	14	7.1	377	74.5	88	17.4	41	8.1
Mislim da bavljenje stomatologijom može izazvati poremećaje vida • In my opinion, practicing dentistry can cause sight disorders	250	80.6	41	13.2	19	6.1	166	84.7	21	10.7	9	4.6	416	82.2	62	12.3	28	5.5
Mislim da bavljenje stomatologijom može izazvati poremećaje sluha • In my opinion, practicing dentistry can cause hearing disorders	195	62.9	82	26.5	33	10.6	117	59.7	62	31.6	17	8.7	312	61.7	144	28.5	50	9.9
Mislim da bavljanje stomatologijom može izazvati neurološke poremećaje • In my opinion, practicing dentistry can cause neurological disorders	163	52.6	78	25.2	69	22.3	110	56.1	50	25.5	36	18.4	273	54.0	128	25.3	105	20.8
Mislim da bavljenje stomatologijom može izazvati mentalne poremećaje • In my opinion practicing dentistry can cause mental disorders	133	42.9	123	39.7	54	17.4	104	53.1	60	30.6	32	16.3	237	46.8	183	36.2	86	17.0
Profesionalne bolesti u stomatologiji mogu se spriječiti • Professional diseases in dentistry can be prevented	187	60.3	58	18.7	65	21.0	136	69.4	34	17.3	26	13.3	323	63.8	92	18.2	91	18.0

In participants’ opinion, an incorrect posture during work ranked first on the list of the risk factors for development of occupational diseases (33.9%), stress ranked second (24.6%), and followed by infections (18.1%), noise (7.7%) and allergy to dental materials (4.8%). For the efficient protection of occupational diseases, the participants highlighted the importance of practicing sports regularly (30.1%), vaccination (20.5%), usage of masks and gloves (18.5%), balanced and healthy diet (17.7%), frequent changes of working position (16.7%) and ergonomically shaped dental instruments and equipment (15.5%).

The most common health problem in dentists were musculoskeletal disorders with pain in upper back, lower back, shoulders, hands, fingers, legs and feet followed by dermatological disorders. The most common reasons for asking a doctor for help were pain in upper back (36.8%) in females and pain in lower back (36.1%) in males. Sight disorders ranked second (34.7% in females and 32.0% in males).

The number of females who experienced professionally related pain in upper back is higher than the number of males. There was a statistically significant difference between male and female scores. Females scored significantly higher values regarding professionally related pain in upper back and asking a doctor for help than males (36.8% females and 21.6% males, χ2=14.92 df=2 P=0.001).

The number of females who experienced professionally related pain in shoulders, hand or fingers was higher than the number of males. There was a statistically significant difference between the females who experienced professionally related pain in shoulders, hand or fingers and asking a doctor for help and the males. Females obtained significantly higher scores (36.3% females and 21.1% males, χ2=23.57 df=2 P<0.001).

The number of females who experienced professionally related pain in legs and feet was higher than the number of males. There was a statistically significant difference between the number of females who experienced professionally related pain in legs and feet and asking a doctor for help and the number of males (23.3% females and 12.4% males, χ2=15.95 df=2 P<0.001).

There was also a high correlation between the age and frequency of some health disorders. The males from age group 51-60 obtained statistically more significant scores regarding lower back pain and asking a doctor for help (χ2=18.58 df=8 P<0.017) compared to younger age groups (21-30, 31-40). In females, the age groups 41-50 and 51-60 obtained statistically more significant scores regarding lower back pain and asking for help than age groups 21-30 and 31-40 (χ2=36.07 df=8 P<0.001). Similar findings were found regarding the duration of work with a patient, which was correlated with the frequency of lower back pain.

30.0% of examined females and 27.9% of males experienced professionally related skin disorders. The females asked a doctor for help (10.3%) more often than the males (5.2%). There was a statistically significant difference between males with 1-10 year work experience and their colleagues with more than one year of work experience. Males with 1-10 year work experience asked a doctor for help more often than their colleagues with more than one year of work experience (χ2=14.89 df=6 P=0.021).

Sight disorders were recorded in 45.7% of female dentists and in 48.5% of male dentists. The number of female dentists who asked a doctor for help (34.7%) was slightly higher than the number of male dentists (32.0%). Eye injuries were the most common reported reason for asking a doctor for help. The number of females in age groups 51-60 and 60+ who asked a doctor for help in case of sight disorders was significantly higher than the number of females belonging to other age groups (χ2=76.45 df=8 P<0.001).

The number of females (20.4%) who experienced professionally related hearing disorders was higher than the number of males (16.5%), and females asked more often a doctor for help than males (females 6.0%, males 4.1%). The number of dentists with professionally related hearing disorders increases with age. Similar results were obtained for females in the age group 51-60. The difference between age groups is statistically significant (χ2=34.73 df=8 P<0.001).

Neurological disorders were found in 17.0% of females and in 14.0% males. In case of neurological disorders, 9.0% of females and 5.2% of males asked a doctor for help. The frequency of neurological disorders also increases with age and years of work experience. The females in the age group 41-50 (and above) obtained higher scores compared to younger age groups. There was a statistically significant difference between the mentioned groups regarding neurological disorders

• (χ2=24.88 df=6 P<0.001).

Summarized data on health status of dental practitioners are shown in Table 4.

Table 4. Summarized data on health status of dental practitioners.

Da li ste tijekom svoje stomatološke karijere iskusili profesionalno izazvane … • Have you experienced any profession related disorders during your dental carrier	Žene • Females						Muškarci • Males						Žene + Muškarci • Females + Males
	Da-D • Yes-D	%	Da-ND • Yes-ND	%	Ne • No	%	Da-D • Yes-D	%	Da-ND • Yes-ND	%	Ne • No	%	Da-D • Yes-D	%	Da-ND • Yes-ND	%	Ne • No	%
bol u gornjem dijelu leđa • pain in upper back	110	36.8	136	45.5	53	17.7	42	21.6	98	50.5	54	27.8	152	30.8	234	47.5	107	21.7
bol u donjem dijelu leđa • pain in lower back	100	33.4	126	42.1	73	24.4	70	36.1	83	42.8	41	21.1	170	34.5	209	42.4	114	23.1
bol u ramenima, rukama, prstima • pain in shoulders, hands or fingers	109	36.3	137	45.7	54	18.0	41	21.1	85	43.8	68	35.1	150	30.4	222	44.9	122	24.7
bol u nogama i stopalima • pain in legs and feet	70	23.3	117	39.0	113	37.7	24	12.4	65	33.5	105	54.1	94	19.0	182	36.8	218	44.1
dermatološke poremećaje • dermatological disorders	31	10.3	59	19.7	210	70.0	10	5.2	44	22.7	140	72.2	41	8.3	103	20.9	350	70.9
vidne poremećaje • sight disorders	104	34.7	33	11.0	163	54.3	62	32.0	32	16.5	100	51.5	166	33.6	65	13.2	263	53.2
slušne poremećaje • hearing disorders	18	6.0	43	14.4	238	79.6	8	4.1	24	12.4	162	83.5	26	5.3	67	13.6	400	81.1
neurološke poremećaje • neurological disorders	27	9.0	24	8.0	249	83.0	10	5.2	17	8.8	167	86.1	37	7.5	41	8.3	416	84.2

Da-D znači „Da, tražio sam pomoć liječika“. Da-ND znači „Da, ali nisam tražio pomoć liječnika“ • Yes-D means “Yes and I asked a doctor for help”. Yes-ND means “Yes, but I have not asked a doctor for help”.

Discussion

The findings of this study are consistent with those from other studies since a claim that dental health professionals are at high risk of occupational and work related diseases is supported by evidence. The preparation process for joining the European Union and the long-lasting economic crisis in Croatia led to different changes and rationalization initiatives in dental care. The research of Jonker et al. has shown that rationalization often results in increased risk of developing work-related musculoskeletal disorders (18). This study is the first to report on the overall health status of Croatian dentists and, unfortunately, it showed undesirable results. A lack of previous similar studies in Croatia makes the interpretation of obtained data in a historical perspective and in the light of the Croatian accession to the European Union impossible.

Our study involved 506 dentists representing almost 20% of the entire number of active dental practitioners in Croatia. According to the data from the available literature, this study is among the most comprehensive national studies on occupational diseases in dentists with the highest number of participants compared to total number of active dental practitioners in the country. The study similar to ours according to the number of participants and response rate was performed by Šustova et al. in Czech Republic but without data about total number of active dentists (19). Their study involved 581 participants with response rate of 72.6%. A large number of participants contributed to reliability of obtained data.

Musculoskeletal disorders are one of the most commonly reported health related problem among dentists worldwide. It is estimated that every year approximately 70% of dentists have different types of musculoskeletal complaints. Among these, low back pains, pains in the shoulders and at the neck level seem to be the most common sites of pain (20-22). Šustova et al. examined the prevalence of musculoskeletal problems among Czech dentists. Information was gathered through questionnaire completed by 581 physicians. The occurrence of difficulties associated with the musculoskeletal system was reported by 96.9% of dentists surveyed. A statistically significant correlation with the occurrence of musculoskeletal complaints of medium and major intensity was demonstrated for the following factors: sex, age, running a private practice, past injury or musculoskeletal diseases, and the perception of work as psychologically demanding (19). Kierklo et al. assessed the health status among dentists in Poland regarding the symptoms of musculoskeletal pain. Their survey was conducted among 220 dentists and they found that 92% of the surveyed dentists experienced musculoskeletal disorders, especially in the neck (47%) and lower back (35%) (14). Yi et al recruited 271 dental postgraduates to determine how early musculoskeletal disorders develop in dental professionals. Depending on dental specialty, the musculoskeletal disorders in the neck region were reported by 47.5% - 69.8% of dental postgraduates, in the shoulder region by 50.8% - 65.1%, in lower back region by 27.1% - 51.2% and in upper back region by 25.6% - 46.5%, in elbow region by 5.1% - 18.6%, in hip region by 3.4% - 16.3% and in ankle region by 5.1% - 11.6% (23). The prevalence of musculoskeletal disorders in our study varied from 55.8% (pain in legs and feet) to 78.3% (pain in upper back). Although the prevalence of musculoskeletal disorders seems to be lower than in other above mentioned studies from different countries, there were some differences in applied methodology. If the obtained results are compared at the level of specific part of the body, it is obvious that Croatian dentists have a very high prevalence of musculoskeletal disorders. As found in the study of Kazancioglu et al., the occurrence of musculoskeletal disorders is highly correlated with body posture at work and improper loading to the foot (15). According to Ritzline, the occurrence and magnitude of musculoskeletal disorders among dentists can be decreased significantly by adopting several basic principles including the management of overuse syndromes, modification of the workstation and home, maintenance of health and wellness, and participation in regular exercise (10). Thanathornwong et al. used Bayesian network and developed a system for predicting and preventing work-related musculoskeletal disorders (24). In a 2-year prospective study, Nemes at al. followed 390 dentists recruited from the western part of Romania, who were diagnosed with a musculoskeletal disorder, to show the efficiency of rehabilitation. They found that improvements of functional parameters and increase in work productivity were recorded in dentists who followed physical therapy (20). Ergonomics improvements, health promotion and organizational interventions are necessary to reduce the risk (25, 26). Unfortunately, the results of research show that most dental practitioners do not take measures to prevent or reduce the symptoms of occupational health related problems (10). As concluded by Yi et al., musculoskeletal disorders afflict dental professionals at an early stage of their career and prevention aimed at the specialty-related characteristics should be introduced as early as possible (23).

Skin diseases rank second on the list of most common occupational diseases, following musculoskeletal disorders. In their everyday work, dental professionals use different chemicals, drugs and other irritants. Most work-related dermatoses (over 95%) are subtypes of contact dermatitis (27). The main cause of contact dermatitis is skin contact with irritants and/or allergens. Latex allergy has emerged as an important cause of allergic reactions, particularly in health care workers, physicians, nurses, midwives, laboratory technicians and dentists. The manifestations of latex allergy include dermatological and respiratory symptoms and, in its most severe form, anaphylaxis. Dental personnel have a very high exposure to latex gloves as they may be gloved eight to 10 hours each working day (28, 29). The results of research of Kurpiewska et al. showed that midwives (67%) and dentists (64%) have the highest prevalence of occupational skin diseases among healthcare workers and that occupational skin diseases among dentists are (35%) caused by gloves (27). Prajapati et al. described a case of contact dermatitis due to methyl methacrylate in a dentist presented as itching and rashes of the contact areas (30). Methyl methacrylate is used for fabrication of acrylic removable partial or complete dentures for edentulous patients and has strong sensitizing properties. In this study, skin disorders are reported by 29.2% dentists and latex allergy and contact dermatitis were identified as the main cause of skin disorders.

Excellent eyesight is a precondition for a safe and high quality practice of dentistry. During dental procedures, the eyes of dentists may be exposed to mechanical and/or chemical irritation and nonionizing radiation (31, 32). Zarra and Lambrianidis examined the incidence of ocular accidents during dental practice among Greek endodontists and found that ocular accidents were reported by 73% of the participants. Amalgam and NaOCl were the foreign bodies most frequently associated with ocular accidents (31, 33). Azodo et Ezeja conducted a cross-sectional study on dental surgeons to determine the ocular health practices (17). Of the 148 respondents, 27 (18.2%) rated their ocular health as poor/fair. In this study, sight disorders (including eye injuries) are reported by 46.8% of examined dentists and are the second most common occupational disease, following musculoskeletal disorders. Amalgam and dental cement particles were most frequently associated with eye injuries. High prevalence of sight disorders and eye injuries is related to a low number of dentists who use protective googles and shields. Some vision changes are normal with aging, and this must be taken into account in the interpretation of obtained data regarding ocular health in older age groups, as shown in this study among females in the age groups 51-60 and 60+. The number of females in these age groups who asked a doctor for help in case of ocular health disorders was significantly higher than in other age groups (χ2=76.45 df=8 P<0.001).

Environmental noise is considered responsible for hearing impairment and daily exposure for 8 hours to noise levels above 85 decibels is associated with permanent hearing loss. Noise is almost always present during the work of dental staff. The sources of sounds in dental office that can be treated as potentially damaging to the hearing are high-speed turbine handpieces, low-speed handpieces, high-velocity suction, ultrasonic instruments, vibrators and other mixing devices, and model trimmers (11, 34). In the research of Messano and Petti, 100 Italian dental practitioners who commenced dental practice more than 10 years ago, were interviewed on a series of occupation related hearing impairment risk factors and on hearing impairment-associated symptoms (tinnitus, sensation of fullness, hypoacusis) (11). The prevalence of hearing impairment among dental practitioners was 30% and ultrasonic scalers and dental turbines aged more than 1 year were identified as most dangerous devices. Willershausen et al. examined 53 dentists to determine the hearing ability of dentists in comparison to other academic professionals. The results of audiometric tests showed that the hearing of dentists tended to be slightly more impaired than the hearing in the control group. For the frequencies 3 kHz and 4 kHz, those differences were statistically significant for both ears (16). In our study, hearing disorders were reported by 18.9% of dentists, but only 5.3% of them asked a doctor for help without any information about diagnostic procedures performed for hearing impairment diagnosis.

In this study, 61.3% of surveyed dentists were females. Although there was no significant difference between females and males in considering dentistry as harmful profession, according to summarized data on health status of dental practitioners presented in Table 4, it is obvious that females reported a higher prevalence of pain in upper back region, pain in shoulders, hands or fingers, pain in legs and feet, hearing disorders and neurological disorders than males. In the light of motherhood and parenthood, dentistry could be very exhausting profession for females with a high risk of developing occupational diseases and their negative influence on pregnancy and motherhood.

A relatively high prevalence of occupational health problems among dentists in Croatia confirmed our suspicions that economic crisis and rationalization initiatives followed by increased professional requirements had an unwanted impact on health. Unfortunately this could be worsened in the future because of a large number of young dentists graduating each year, exceeding the Croatian needs and decreasing the chance to find an appropriate job in dental profession. Proper professional planning, territorially evenly distributed dental network, and harmonization of the number of students with the labor market needs and the inevitable taking into account the quality of education of dentists can be of significant help.

Increasing the awareness of this problem among dental students and dental professionals is the first and maybe most important step in the long process of prevention of occupational diseases. A possible solution of this problem was presented at the School of Dental Medicine University of Zagreb by introducing a new course in the study program named “Occupational diseases in dental medicine”.

Conclusion

Occupational and work-related diseases or disorders have become increasingly common among dental professionals and can initiate a series of events that could result in a too early career ending. Croatian dentists have a high prevalence of occupational health problems. Musculoskeletal, sight and skin disorders were among most commonly reported health problems. The first and most important step in protecting against occupational diseases is to improve dental health professionals’ awareness and understanding of occupational and work related diseases. Dental professionals need to recognize the significant impact of occupational diseases on health.