1 0 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
General health of dentists. Literature review
Alina Puriene, Vilija Janulyte, Margarita Musteikyte, Ruta Bendinskaite
REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 9:10-20, 2007
*Institute of Odontology, Faculty of Medicine, Vilnius university,
Lithuania
Alina Puriene* – D.D.S., PhD, assoc. prof.
Vilija Janulyte* – student
Margarita Musteikyte* – student
Ruta Bendinskaite* – D.D.S., PhD
Address correspondence to Dr. Alina Puriene, Institute of Odontology,
Zalgirio 115, Vilnius, Lithuania
E-mail: alina.puriene@mf.vu.lt
SUMMARY
The studies show a dental practitioner as a subject of a wide variety of physical and psychological
ailments. It is induced or aggravated by the work specificity and greatly affects the health of
dental professionals. Therefore, general health of dentists, especially effect of dental activity on it, is
present-day, important and as a matter of fact not well documented subject.
The aim of our review is to summarize and ascertain dental practice-related disorders influencing
the physical and psychological health of practitioner. Also we would like to highlight the most
vulnerable systems of the dental professional and to survey the best methods to overcome these
ailments.
Results. There is growing body of evidence that suggests surprisingly high vulnerability within
the dental profession to certain disorders and afflictions that can be categorized as practice-related.
Conclusions. In different countries dentists reported having poor general health and suffer from
various health-related problems. To enjoy and be satisfied with their professional and personal lives,
dentists must be aware of the importance to maintain good physical and mental health.
Key words: dentist's general health, physical disorders, psychological disorders.
INTRODUCTION
Dentists always knew the dentistry is not an
easy job. However until recently not many would
classify their profession as hazardous. This job is a
social interaction between helper and recipient in
their limited job setting and with personal characteristics.
A healthy dentist is one of the most important
components in a successful dental practice.
Despite the fact, that even 88 percent of dentists
report good or excellent health [47], some studies
show one out of ten dentists reports having poor
general health, and three out of ten dentists report
having poor physical state [29]. Many were feeling
unhealthy, worse than other high-risk-groups in a
human service working situation [39]. Dentists can
and do experience illnesses and problems that can
disrupt or impair a practice. Yet there is a growing
body of evidence that suggests increased vulnerability
within the profession to certain disorders and
afflictions that can only be categorized as practice
related. It is especially seen after we have gained
our independence. The work character and amount
of health care workers and dentists has changed a
lot.
The dentist is a subject to a wide variety of
physical and psychological ailments that are induced
or aggravated by the work environment and
they greatly affect the health of dental professionals.
PHYSICAL DISORDERS
When talking about physical disorders we have
to take into account musculoskeletal problems, dermatoses,
allergies and possible cross-infection.
The prevalence of musculoskeletal complaints
among dentists like among other health care workers
is high and well documented [2,20,39,73,
76,89,94]. Most of dentists (87.2 percent) reported
at least one symptom of musculoskeletal diseases
in the past 12 months [51]. A big study in Greece
showed: 62 percent of dentists reported at least
one musculoskeletal complaint, 30 percent chronic
complaints, 16 percent spells of absence and 32
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 1
percent ought medical care. Self-reported factors
of physical load were associated with the occurrence
of back pain, shoulder pain and, hand/wrist
pain. Physical load showed a trend with the number
of musculoskeletal complaints. The physical
load among dentists seems to put them at risk for
the occurrence of musculoskeletal disorders [2].
The dentistry seems to generate relatively high
muscular load on both trapezius and dominant extensor-
carpi-radialis muscle [59]. We have to account
not only instantaneous physical loads. They
cumulate (cumulative loads) and affect physical
health. Smaller loads cannot be ignored due to their
magnitude if their duration is long because the time
dependent properties of the tissues become modulating
factor. Thus the measurement of instantaneous
loads on tasks in dentists is not indicative of
the amount of cumulative stress experienced by
them [65].
Low-back pain is the most prevalent musculoskeletal
complaint [2,62,71,90]: in a Greek study –
46 percent prevalence [85], in an Australian study –
as much as 53.7 percent [51]. More than 25 percent
of all subjects with back pain reported the severe
chronic back pain [2]. Dentists who work in
the sitting position have more severe low back pain
than do those who alternate between sitting and
standing [71].
Prevalence of hand/wrist complaints among dentists
and especially dental hygienists is really high
[2,33,48,49,53,90]. Hand/wrist complaints follow low
back disorders [2,53] and result in a significant
higher chronicity than any other complaint [2]. The
prevalence of particularly carpal tunnel syndrome
among dentists is not very high, about 5 percent [33].
Though 56 percent of dental hygienists exhibit probable
or classic symptoms of carpal tunnel syndrome
[49].
Neck and shoulder complaints were less prevalent
than back pain. Musculoskeletal co morbidity
was high – 62 percent of all subjects reported at
least one musculoskeletal complaint, 35 percent reported
at least two musculoskeletal complaints, 15
percent reported at least three musculoskeletal complaints
and 6 percent reported spells of all four complaints
in the past 12 months [2].
Subjects with back pain more often reported neck
pain and hand/wrist pain than those without back
pain. Neck and hand/wrist pain was strongly associated
since 50 percent of subjects with neck pain
also experienced hand/wrist pain in the past 12
months. Age and gender were significant only for
neck pain. Senior people and women suffered from
neck pain more [2,76].
Educational level and working without breaks
were significant factors for shoulder pain. Living
alone was significant for neck and shoulder pain.
All complaints chronicity increased with age. Female
gender was significantly related to chronic back
and shoulder pain. Co morbidity was elevated among
those reported with higher physical load, lower job
control and working long hours [2].
Chronic musculoskeletal pain appears early in
dental careers, and more than 70 percent of dental
students of both sexes reporting pain by their third
year [76]. A study in Turkey gives us amazingly high
pain prevalence among dental students: headaches
(34 percent, 22 percent), neck pain (67 percent, 43
percent), back pain (56 percent, 47 percent), upper
limp pain (46 percent, 43 percent) and shoulder pain
(78 percent, 58 percent), respectively [91].
One cause of musculoskeletal disorders may be
mechanical vibrations affecting the organism through
the upper limbs and causing changes in the vascular,
neural and osteoarticular systems. These
changes may produce an occupational disease called
vibration syndrome. But on the basis of the available
literature it can not be decided unequivocally if
it exists a direct link between vibrations emitted by
the working dental instruments and the incidence of
symptoms characteristic of the vibration syndrome
[89].
Apart from vibrations, other harmful factors
connected with the profession seem to play a role,
and they modify the hand-arm symptoms [89].
The causes of musculoskeletal pain and disorders
common to dental operators are multifactorial.
There is relationship between the biomechanics
of seated working postures, repeated unidirectional
twisting of the trunk, working in one position
for prolonged periods, operator's flexibility and core
strength, operators knowing how to properly adjust
ergonomic equipment and physiological damage
or pain [94,95]. Studies indicate that strategies
to prevent the multifactorial problem of dental
operators developing musculoskeletal disorders
exist. These strategies address deficiencies in operator
position, posture, flexibility, strength and ergonomics
[94,95].
A study in Poland [90] showed that dentists
work in conditions which generally produce disorders
of the musculoskeletal system. The long working
time in the course of a day is used irrationally
from the point of view of ergonomics, and over the
years consequently increases the number of disorders
of the musculoskeletal system [90].
The relationship between physical and psychological
factors in dental profession was found: den-
A. Puriene et al. REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 1
percent ought medical care. Self-reported factors
of physical load were associated with the occurrence
of back pain, shoulder pain and, hand/wrist
pain. Physical load showed a trend with the number
of musculoskeletal complaints. The physical
load among dentists seems to put them at risk for
the occurrence of musculoskeletal disorders [2].
The dentistry seems to generate relatively high
muscular load on both trapezius and dominant extensor-
carpi-radialis muscle [59]. We have to account
not only instantaneous physical loads. They
cumulate (cumulative loads) and affect physical
health. Smaller loads cannot be ignored due to their
magnitude if their duration is long because the time
dependent properties of the tissues become modulating
factor. Thus the measurement of instantaneous
loads on tasks in dentists is not indicative of
the amount of cumulative stress experienced by
them [65].
Low-back pain is the most prevalent musculoskeletal
complaint [2,62,71,90]: in a Greek study –
46 percent prevalence [85], in an Australian study –
as much as 53.7 percent [51]. More than 25 percent
of all subjects with back pain reported the severe
chronic back pain [2]. Dentists who work in
the sitting position have more severe low back pain
than do those who alternate between sitting and
standing [71].
Prevalence of hand/wrist complaints among dentists
and especially dental hygienists is really high
[2,33,48,49,53,90]. Hand/wrist complaints follow low
back disorders [2,53] and result in a significant
higher chronicity than any other complaint [2]. The
prevalence of particularly carpal tunnel syndrome
among dentists is not very high, about 5 percent [33].
Though 56 percent of dental hygienists exhibit probable
or classic symptoms of carpal tunnel syndrome
[49].
Neck and shoulder complaints were less prevalent
than back pain. Musculoskeletal co morbidity
was high – 62 percent of all subjects reported at
least one musculoskeletal complaint, 35 percent reported
at least two musculoskeletal complaints, 15
percent reported at least three musculoskeletal complaints
and 6 percent reported spells of all four complaints
in the past 12 months [2].
Subjects with back pain more often reported neck
pain and hand/wrist pain than those without back
pain. Neck and hand/wrist pain was strongly associated
since 50 percent of subjects with neck pain
also experienced hand/wrist pain in the past 12
months. Age and gender were significant only for
neck pain. Senior people and women suffered from
neck pain more [2,76].
Educational level and working without breaks
were significant factors for shoulder pain. Living
alone was significant for neck and shoulder pain.
All complaints chronicity increased with age. Female
gender was significantly related to chronic back
and shoulder pain. Co morbidity was elevated among
those reported with higher physical load, lower job
control and working long hours [2].
Chronic musculoskeletal pain appears early in
dental careers, and more than 70 percent of dental
students of both sexes reporting pain by their third
year [76]. A study in Turkey gives us amazingly high
pain prevalence among dental students: headaches
(34 percent, 22 percent), neck pain (67 percent, 43
percent), back pain (56 percent, 47 percent), upper
limp pain (46 percent, 43 percent) and shoulder pain
(78 percent, 58 percent), respectively [91].
One cause of musculoskeletal disorders may be
mechanical vibrations affecting the organism through
the upper limbs and causing changes in the vascular,
neural and osteoarticular systems. These
changes may produce an occupational disease called
vibration syndrome. But on the basis of the available
literature it can not be decided unequivocally if
it exists a direct link between vibrations emitted by
the working dental instruments and the incidence of
symptoms characteristic of the vibration syndrome
[89].
Apart from vibrations, other harmful factors
connected with the profession seem to play a role,
and they modify the hand-arm symptoms [89].
The causes of musculoskeletal pain and disorders
common to dental operators are multifactorial.
There is relationship between the biomechanics
of seated working postures, repeated unidirectional
twisting of the trunk, working in one position
for prolonged periods, operator's flexibility and core
strength, operators knowing how to properly adjust
ergonomic equipment and physiological damage
or pain [94,95]. Studies indicate that strategies
to prevent the multifactorial problem of dental
operators developing musculoskeletal disorders
exist. These strategies address deficiencies in operator
position, posture, flexibility, strength and ergonomics
[94,95].
A study in Poland [90] showed that dentists
work in conditions which generally produce disorders
of the musculoskeletal system. The long working
time in the course of a day is used irrationally
from the point of view of ergonomics, and over the
years consequently increases the number of disorders
of the musculoskeletal system [90].
The relationship between physical and psychological
factors in dental profession was found: den-
A. Puriene et al. REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 3
There are few evidences of higher hepatitis infection
risk in dental practice. The most hazardous
infection for medical staff is hepatitis B. It is most
frequently acquired through micro trauma. Even 10-
39 percent of medical staff and 12-27 percent of
dental team staff revealed seropositivity of hepatitis
B virus [47]. Greater number of years of occupation
in dentistry was independently and significantly
(P = .0004) associated with seropositivity to
hepatitis A virus. The calculated odds ratio showed
that each year of work increased the likelihood of
being seropositive by 1.06 (6 percent). Subjects
tended to have higher seropositive rates if they were
older, had a greater number of children, had a
greater number of siblings, had worked in hospitals
and worked with children (pediatric dentists and
orthodontists) [3].
A source of hepatitis and many other infectious
hazards could be a percutaneus injury. Out
of the dentists interviewed, 31.1 percent reported
accidents, with a mean incidence of 2.02 accidents
each professional year [63]. When dental personnel
were analyzed, dentists experience it most often:
36 percent of percutaneus injuries were reported
by dentists, 34 percent by oral surgeons, 22
percent by dental assistants, and 4 percent each
by hygienists and students. Almost 25 percent involved
anesthetic syringe needles. Out of 87 needle
stick injuries, 53 percent occurred after needle use
and during activities in which a safety feature could
have been activated (such as during passing and
handling) or a safer work practice used [15]. It
was found, that 90 percent of dentists recapped
needles after using them, while only 8.1 percent
re-used gloves [8].
Dentists knowledge regarding infectious diseases
that can be acquired or transmitted in the dental surgery
and the vaccinations recommended are quite
poor: only 44.1 and 32.4 percent correctly indicated
all infections that can be acquired or transmitted during
their activity. Only half of the dentists knew that
they should be vaccinated against hepatitis B and
influenza. A large proportion (85.7 percent) reported
receiving the hepatitis B vaccine, but only 56.2 percent
the three doses. [17].
One study assessed attitudes toward occupational
health and knowledge of the area: clinicians
rated occupational health to be less important than
did interns and students. Prior work experience did
not affect performance; however, students from
"blue collar" families scored higher in both knowledge
and attitudes than those from "white collar"
families. Women scored higher in both areas than
did men. There was no correlation between number
A. Puriene et al. REVIEW
of hours of occupational medicine in school and performance,
either overall or within each level. This
study suggests that enthusiasm for occupational
health declines with training, and that knowledge
gains are erratic [86].
Regardless of gender, dentists do experience
other problems that may disrupt or impair dental
practice, including substance abuse involving alcohol
and/or other drugs. Therefore, dentists need
to understand gender differences associated with
risk for abuse of alcohol and other substances; related
physical, emotional, and professional effects;
and other aspects of professional health and
wellness [74].
PSYCHOLOGICAL DISORDERS
Not only physical impairments affects dentist's
health. Job-related psychological disorders also contribute
greatly. Factors that affect dentist's psychological
status can be job-related stress, tension, depression,
emotional exhaustion, depersonalization.
Dental practice is stressful. Dentists have to
deal with many significant stressors in their personal
and professional lives [30]. There is some evidence
to suggest that dentists suffer a high level of jobrelated
stress [7,22,23,62,73].
83 percent of dentists' perceived dentistry as
being "very stressful" [7], nearly 60 percent perceived
dentistry as more stressful than other professions
[60]. Dentists indicated running behind
schedule, causing pain, and heavy work load, late
and anxious patients as well being the most intense
stressors in their work [60, 99]. Dentists, who reported
that dental anxiety was primarily the result
of general psychological problems in patients, usually
had solo practices older than 18 years and reported
high perceived stress [60]. Clinicians experience
numerous workplaces, financial, practice
management and societal issues for which they often
are unprepared after finishing a university.
The difference in reported levels of stress between
dental specialties was not found. Practitioners
working in the field of pediatric dentistry reported
the highest median levels of stress though
this trend was not significant [67].
A large number of factors are implicated in
stress situations, including low autonomy, work overload,
and lack of congruence between power and
responsibility. Doctors and dentists who take on a
teaching role in addition to their clinical role may
increase their levels of stress, but there is also evidence
that this dual role may reduce job-related
stress [82].
1 4 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
Stress may produce "burnout". It is a syndrome
of emotional exhaustion, depersonalization and reduced
personal accomplishment, a particular type
of job-related stress reaction. It is a response to the
chronic emotional strain of dealing extensively with
other human beings, particularly when they are
troubled or having problems. The values of burnout
and it's constituents among dental workers are amazingly
high [7,11,22,23,28,68,93]. Recent findings suggest
that burnout has features of maladaptive coping
in the short term but is, paradoxically, protective
in the longer term. Dentists are prone to burnout
due to the nature of their work but may be able to
prevent it if they can recognize the burnout process
and take regular holiday breaks.
Burnout is assumed to have an adverse influence
on patient care, although no dental studies, as
yet, have tackled the issue [22].
The study in England exhibited high overall burnout
in 10.6 percent of examined dentists. Emotional
exhaustion was found in 25.53 percent, depersonalization
– 8.88 percent and reduced personal accomplishment
in 34.42 percent of dentists [68]. When the
Spanish dentists were questioned, high values were
detected in emotional exhaustion – 54.3 percent,
depersonalization – 55.6 percent; personal achievements
– 6.9 percent [93]. Gender differences in burnout
among dentists do exist. Male dentists reported a
higher score of depersonalization than did female
dentists [11,23]. However, results indicate that underlying
factors, such as working hours, have a profound
effect on these differences [11]. Men work
more hours and work part time less frequently [96].
Dentists are not unique experiencing high overall
burnout. Very similar data is presented among all
primary care practitioners: 19% of respondents had
a high score for emotional exhaustion, 22% had a
high score for depersonalization or cynicism and 16%
had a low score for professional accomplishment,
32% had a moderate degree and 4% had high degree
of burnout [23]. A high degree of burnout is
associated with the male sex, practicing in a rural
area, and excessive perceived stress due to global
workload, patient's expectations, and difficulties to
balance professional and private life, economic constraints
in relation to the practice, medical care uncertainty
and difficult relations with non-medical staff
at the practice [23].
Burnout comes about in situations where there
is a focus on problems, lack of positive feedback,
the level of emotional stress is high and where problems
are chronic [68].
Depression may be a consequence of prolonged
experience of burnout [41].
Recent findings suggest that burnout has features
of maladaptive coping in the short term but is,
paradoxically, protective in the longer term [41].
There is a relationship between emotional load
and volume of patients treated. Depersonalization
levels decrease with age and it could be due to a
number of factors – socialization skills increasing
with age, a slowing of pace of work which allows
more personal contact, or the establishment of personal
relationships with patients over time [68]. Older
dentists work fewer hours, with a larger impact of
age seen among men [96]. Emotional support may
be gained from co-workers that are why the numbers
of burnout syndrome may decrease in the larger
practice groups. Conversely, a particular characteristic
of private practice is the high level of control.
It allows dentists to have control over their working
conditions: a factor which is reported to help reduce
stress levels. It is also related to income, autonomy
and the match between technical aspirations
and practical outcomes [68].
Higher levels of depersonalization in unmarried
dentists compared with those who were married suggests
that involvement with a spouse and children
makes married people more experienced in dealing
with personal problems [68].
The higher levels of personal accomplishment
were in dentists with post-graduate qualifications
[68].
Also specialists, were more satisfied with their
psychosocial work environment than general practitioners,
especially regarding their personal control
over their work and the stimulation of their work.
The specialists also had more self-confidence and
experienced less anxiety than general practitioners
and head dentists [68,81].
Lack of career perspective appears to be the
stress factor strongly related to burnout [24]. This
relation should stimulate serious attention for career
planning among dentists.
The conceptual basis of burnout would seem to
imply that physical environment is probably of minor
importance in the process and no actual work
place condition could be demonstrated to be correlated
with high burnout levels, it would be prudent
to make the practice environment as pleasant as
possible. For, apart from directly reducing stress on
the dentist, it might reduce the anxiety level of patients,
and thus the emotional load on the dentist
[24,68].
There tend to be some differences in burnout
scores relating to the levels of professional isolation.
The lack of hierarchal structure to general
dental practice means that dentists have constantly
REVIEW A. Puriene et al.
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 5
to rely on their own emotional resources in the
clinical situation. This contrasts with the worker
within an organization where there are colleagues
with whom to share the emotional strain of contacts
with distressed clients. Furthermore, superiors
in a hierarchy are available for support and
help when necessary, which can substantially alleviate
anxiety. This argument is counterbalanced
by the issues of autonomy and control. Large organizations
are able to deal with issues such as
staff discipline, communication with other organizations
and financial control. In small organizations
such as general dental practice, the stress
associated with these activities is concentrated to
a small number of people, frequently the dentist
[28,62,68]. A very interesting study identified the
specific situations that most frequently produce
stress. The majority of these situations could be
classified as being related either to dental procedures
and office organization or to interpersonal
relationships involving patients and/or office personnel
[10]. So, dentists consider clinical matters
their greatest stress [10,40].
Differences of individual responses to stress
may be attributable to personality factors and differences
in coping styles, and tend to support the
hypothesis that stress is a unique, perceptual and
experimental phenomenon [13]. The older dentists
are less stressed than their younger counterparts.
Some issues like those concerned with finance and
patient-management, appear to affect both groups
more or less equally, which suggests that these issues
are of global, rather than specific concern. From
a theoretical point of view, the findings tend to contradict
the generally – held belief that getting older
is automatically accompanied by degeneration and
problems of adaptation to life changes. On the contrary,
seemingly favorable adaptation and low levels
of stress are evident in most of the older dentists
[14,60].
Nervous psychological state, tension, depression
and others signs of psychological impairment also
has to be taken into account when talking about jobrelated
stress in dental practice. A huge study in
England shows amazing results: sixty percent of general
dental practitioners feel nervous, tense or depressed,
58.3 percent reported headache, 60 percent
reported difficulty in sleeping at night and 48.2
percent reported feeling tired for no apparent reason.
Levels of minor psychiatric symptoms were
high, with 32.0 percent of cases identified [62]. The
other study found that gender was associated with
depression in two specialties: periodontics and pediatric
dentistry [55].
The important thing is that only 15 percent of
depressed dentists receive treatment [55].
Job-related stress and all psychological impairments
it has led to affects dentists personal as well
as dental family life. The effect of the dentist's office-
related stress is directly felt in the family, especially
by the spouse. Strong coping patterns result
when dentists and spouses maintain a balance
of time and responsibility, satisfaction in work and
family activity, regular communication, sharing of
decision making, good physical health, and the inclusion
of an active exercise program within multiple
demands on their time [64].
A study of Sweden general practice dentists revealed
that females constitute one-quarter of all dentists.
These female dentists suffer from many problems
relating to their psychosocial working conditions.
There are wide discrepancies between their
perception of the ideal job situation and reality [38].
Physicians, who report high levels of work
stress, also report lower levels of marital satisfaction
and a higher prevalence of psychiatric symptoms
[52].
Dentists are much like physicians in their reports
of overall work stress, and the similarities and
differences regarding specific stressors suggest
these professions are very alike in reporting the
stresses of professional practice. [52].
Taking into account dental students, it must be
assumed that the level of emotional exhaustion was
higher in dental students than medical students; and,
second, that general psychological distress and
course related stress levels were associated with
the nature of the course and the immediate living
conditions of the students [42].
In our day remuneration system has led dentists
to long working hours, leaving little time to relax
from work, participate in family life [56,61]. A
huge study in Canada showed that more than 10
percent of dentists see equally or more than 30 patients
per day [56]. These factors may all be considered
to be part of current general dental practice
and they really affect dentist's health.
It is very interesting that particular traits are common
among those who decide to pursue careers in
dentistry. And these traits make dentists prone to professional
burnout, anxiety disorders and clinical depression
[21]. And that differences in approach to
work and perceived workplace climate mainly reflects
stable, long-term individual differences in doctors
themselves, reflects in measures of personality and
learning style [58]. In many cases the psychological
variables (distress, emotional exhaustion or intensity
of stressors) were influenced by gender [25,42].
A. Puriene et al. REVIEW
1 6 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
Although dentists suffer from psychical impairments,
they do not seem to be using alcohol,
tobacco and other potentially addicting drugs in
numbers greater than the nonprofessional population
[6,46,84]. But alcohol use is related to stress
among dental professionals [62]. The media repeatedly
portrays dentists and other health professionals
as being at risk of committing suicide
[1,83,87]. While this message often is accepted
without question, there are little reliable data available
that verifies this alleged risk. There is little
valid evidence that dentists are more prone to
suicide than the general population, although some
related data suggest that female dentists may be
more vulnerable [4,34,35,78,83]. It is very interesting
that male doctors seem to be at less risk than
men in the general population. The excess risk of
suicide in female doctors highlights the need to
tackle stress and mental health problems in doctors
more effectively [1,34].
On the contrary, the other study [36] revealed
that the physicians as a whole still had a higher suicide
rate than other university graduates and the general
population, both among men and women compared
to 23.5 per 100.000 person-years and 8.0 per
100.000 person-years among male and female no
graduates, respectively. The suicide rate among female
physicians was twice as high as that of the
general population as well as other female graduates,
even in the 1990s. Of interest, suicide rates
increased steeply by age among physicians and other
graduates, whereas for no graduates, the rate was
highest among those ages 40-60 years [36].
Also analysis of death distribution according to
underlying causes indicated the absence of significant
differences that might suggest increased risk
of death for dentists. Dentists' deaths did not present
worse indications for global and specific categories
of infectious diseases, central nervous system or circulatory
diseases [4]. There is only a slight tendency
of a favorable risk pattern for lung cancer
and overall cancer occurrence [85]. All these observations
suggest that dentistry can be considered
a safe profession, at least regarding exposure to
systematic risk of death. It may be because of dentists
report immediate results and aesthetics, and
long-term results of working with patients to be the
most rewarding aspects. All job resources showed
a positive correlation with job satisfaction [27].
Slightly less than half of the dentists were satisfied
with their profession and the personality types over
represented in dentistry tended to have a higher level
of satisfaction and a lower level of burnout compared
to their cohort group [7,9].
The philosophy inherent in the remuneration system
raises issues of quantity and quality. The combination
of a fee per item system of payment combined
with a fixed pool of available money witch is
not forecast to increase has strong implications related
to burnout, poorer mental health, stress
[6,9,68,80,98]. Short term increases in profit for individuals
can be achieved by higher work output,
but in the longer term as the system adjusts the increases
are eroded, though the increase work load
and therefore stress levels have been sustained. This
also has implications for quality, where quality is
poorly defined, if at all and only rewarded negatively
with retrospective punitive action. Practitioners who
feel unfairly penalized may have a greater tendency
to burnout. Furthermore, in systems of low profitability,
the ability of dentists to reinvest in their practices
and thereby improve the working environment,
increase their patients confidence and decrease their
anxiety levels is limited [68].
A study in Sweden describes how the female
general practice dentists think of the dimensions that
the dentistry profession should contain. It concluded
that the gulf between ideal and reality is wide, especially
concerning the dentist's influence on important
decisions. There must be good communication
and democracy at work, and based on freedom and
the employees influence, could bring ideal and reality
closer [37].
In addition to the vulnerabilities of the human
condition – addictive disorders, psychiatric illnesses,
family and relationship problems, or the many varieties
of human misery – dentists have undergone a
powerful process of socialization into their professional
role that makes it difficult to seek help for
themselves. Stigma about addictive and psychiatric
illnesses continues to be a problem despite significant
advances in scientific understanding of these
disorders. Many people, especially those in positions
of community visibility as dentists are, still struggle
with shame when they associate problems with personal
failure [50]. One may find out, that the reasons
for leaving practice included financial problems,
stress, and external regulation concerns. Current
careers varied widely, with business, teaching, medicine,
and investing being the most common. Respondents
ranked their current careers as considerably
more favorable on measures of perceived creativity,
freedom, belonging, and whether they would
choose the same career again. These findings indicate
that there was a difference between the perception
of a dental career and the reality of clinical
practice for the study sample. Reasons to leave
dental practice are not health problems [75].
REVIEW A. Puriene et al.
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 7
There is a need to acknowledge the existence
of the problems within the dental profession and to
establish ways to prevent and alleviate stress and
other psychological disorders among dental practitioners
[16,30]. Higher patient expectations, higher
targets for provision of dental care will put increased
demands upon dentists [45]. The highest
ranked individual stressor: 61.9 percent, was 'running
behind schedule'. [98]. Discussion of the problem
could take place at appropriate points in the
professional training program and throughout the
career of a dentist. This may, in itself, be helpful
by allowing individuals to realize that their feelings
are not unique nor representing a personality defect.
Davidove maintains that healthy self-criticism
can help bolster the dentist's sense of self-esteem
and can work as a prophylaxis against depression
[16,45]. Researches offers supervision and support
groups as a simple and powerful mean to
ease the burdens of medical practice and prevent
disillusionment and subsequent impairment among
health care workers [18,66,68]. Occupational medicine
clinics also serve as occupational training and
consultative site [79]. Dental societies, family and
friends are also in an ideal position to provide resources
and support. Active membership in local,
state and national organizations can lessen the feelings
of professional isolation and can provide contacts,
which can help starting practitioners improve
their practice environments [97]. Even the Stress
Thermometer (an easily accessible Internet-based
instrument for feedback on work stress and burnout)
was made-up to effectively call attention to
sensitive personal issues concerning work-related
stress and burnout [12]. Furthermore, the risk of
female suicides requires particular monitoring in
the light of the very large increase in the numbers
of women entering medicine [34]. All these measures
should be strongly promoted and developed
to help to overcome all these dental society problems.
Emphasis on faculty training and clinical rotations
should be strongly placed also. With reservations,
it can be concluded that the prevention
program does have a positive effect on burnout
scores among dentists, while different forms of
self-initiated prevention activities also appeared to
be effective [26].
In order to improve dental staff work in the
USA, The White Coat Ceremony was established.
Many dental schools use to mark the transition to
patient care. It is an opportunity to reflect on the
values of dental practice. Eight principles are offered
for consideration: 1) patient care is the point
of practice; 2) the doctor-patient relationship is
essential; 3) discuss options and possibilities; 4)
mistakes will be made; 5) tell the truth; be assertive;
7) consult; and 8) manage your stress and
your life. It may also be a good point in preventing
dental staff from stress and problems in their lives
[69].
As mentioned above studies indicated the occupational
health knowledge gained from school is
erratic. The curriculum reform should be developed.
The practitioner is recommended to be actively concerned
about problems. Numbers of percutaneus injury
show that dental practices should have a comprehensive
written program for preventing needle
stick injuries that describes procedures for identifying,
screening and, when appropriate, adopting
safety devices; mechanisms for reporting and providing
medical follow-up for percutaneous injuries;
and a system for training staff members safe work
practices and the proper use of safety devices [15].
In order to avoid part of musculoskeletal disorders
among dentists altering position between sitting and
standing is recommended [71]. A thorough understanding
and controlling of the underlying physiological
mechanisms leading to them is necessary to develop
and implement a comprehensive approach to
minimize the risks of a work-related injury. Dentists
must be highly aware of the importance of maintaining
good physical and mental health to enjoy and
be satisfied with their professional and personal
lives.
CONCLUSIONS
In different countries dentists reported having
poor general health and suffer from various healthrelated
problems. The dentistry has always been
known as uneasy occupation therefore one must take
into account serious difficulties before attending
medical school. First of all, students must be aware
of the health risks in dentist's job. Talking about musculoskeletal
disorders it might be assumed that
knowledge in ergonomics may be of some use. Secondly,
all sorts of protection must be used during
treatment in order to prevent infectious diseases and
other injuries. Furthermore, dentists must be taught
about coping with stress patterns. There are some
points in preventing psychological discrepancies. To
enjoy and be satisfied with their professional and
personal lives, dentists must be aware of the importance
to maintain good physical and mental health.
It is important to enjoy their lives, exercise physically,
have a hobby, create a harmonious family,
communicate with colleagues and keep learning all
their lives.
A. Puriene et al. REVIEW
1 8 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
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Received: 15 02 2007
Accepted for publishing: 27 03 2007
REVIEW A. Puriene et al.
General health of dentists. Literature review
Alina Puriene, Vilija Janulyte, Margarita Musteikyte, Ruta Bendinskaite
REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 9:10-20, 2007
*Institute of Odontology, Faculty of Medicine, Vilnius university,
Lithuania
Alina Puriene* – D.D.S., PhD, assoc. prof.
Vilija Janulyte* – student
Margarita Musteikyte* – student
Ruta Bendinskaite* – D.D.S., PhD
Address correspondence to Dr. Alina Puriene, Institute of Odontology,
Zalgirio 115, Vilnius, Lithuania
E-mail: alina.puriene@mf.vu.lt
SUMMARY
The studies show a dental practitioner as a subject of a wide variety of physical and psychological
ailments. It is induced or aggravated by the work specificity and greatly affects the health of
dental professionals. Therefore, general health of dentists, especially effect of dental activity on it, is
present-day, important and as a matter of fact not well documented subject.
The aim of our review is to summarize and ascertain dental practice-related disorders influencing
the physical and psychological health of practitioner. Also we would like to highlight the most
vulnerable systems of the dental professional and to survey the best methods to overcome these
ailments.
Results. There is growing body of evidence that suggests surprisingly high vulnerability within
the dental profession to certain disorders and afflictions that can be categorized as practice-related.
Conclusions. In different countries dentists reported having poor general health and suffer from
various health-related problems. To enjoy and be satisfied with their professional and personal lives,
dentists must be aware of the importance to maintain good physical and mental health.
Key words: dentist's general health, physical disorders, psychological disorders.
INTRODUCTION
Dentists always knew the dentistry is not an
easy job. However until recently not many would
classify their profession as hazardous. This job is a
social interaction between helper and recipient in
their limited job setting and with personal characteristics.
A healthy dentist is one of the most important
components in a successful dental practice.
Despite the fact, that even 88 percent of dentists
report good or excellent health [47], some studies
show one out of ten dentists reports having poor
general health, and three out of ten dentists report
having poor physical state [29]. Many were feeling
unhealthy, worse than other high-risk-groups in a
human service working situation [39]. Dentists can
and do experience illnesses and problems that can
disrupt or impair a practice. Yet there is a growing
body of evidence that suggests increased vulnerability
within the profession to certain disorders and
afflictions that can only be categorized as practice
related. It is especially seen after we have gained
our independence. The work character and amount
of health care workers and dentists has changed a
lot.
The dentist is a subject to a wide variety of
physical and psychological ailments that are induced
or aggravated by the work environment and
they greatly affect the health of dental professionals.
PHYSICAL DISORDERS
When talking about physical disorders we have
to take into account musculoskeletal problems, dermatoses,
allergies and possible cross-infection.
The prevalence of musculoskeletal complaints
among dentists like among other health care workers
is high and well documented [2,20,39,73,
76,89,94]. Most of dentists (87.2 percent) reported
at least one symptom of musculoskeletal diseases
in the past 12 months [51]. A big study in Greece
showed: 62 percent of dentists reported at least
one musculoskeletal complaint, 30 percent chronic
complaints, 16 percent spells of absence and 32
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 1
percent ought medical care. Self-reported factors
of physical load were associated with the occurrence
of back pain, shoulder pain and, hand/wrist
pain. Physical load showed a trend with the number
of musculoskeletal complaints. The physical
load among dentists seems to put them at risk for
the occurrence of musculoskeletal disorders [2].
The dentistry seems to generate relatively high
muscular load on both trapezius and dominant extensor-
carpi-radialis muscle [59]. We have to account
not only instantaneous physical loads. They
cumulate (cumulative loads) and affect physical
health. Smaller loads cannot be ignored due to their
magnitude if their duration is long because the time
dependent properties of the tissues become modulating
factor. Thus the measurement of instantaneous
loads on tasks in dentists is not indicative of
the amount of cumulative stress experienced by
them [65].
Low-back pain is the most prevalent musculoskeletal
complaint [2,62,71,90]: in a Greek study –
46 percent prevalence [85], in an Australian study –
as much as 53.7 percent [51]. More than 25 percent
of all subjects with back pain reported the severe
chronic back pain [2]. Dentists who work in
the sitting position have more severe low back pain
than do those who alternate between sitting and
standing [71].
Prevalence of hand/wrist complaints among dentists
and especially dental hygienists is really high
[2,33,48,49,53,90]. Hand/wrist complaints follow low
back disorders [2,53] and result in a significant
higher chronicity than any other complaint [2]. The
prevalence of particularly carpal tunnel syndrome
among dentists is not very high, about 5 percent [33].
Though 56 percent of dental hygienists exhibit probable
or classic symptoms of carpal tunnel syndrome
[49].
Neck and shoulder complaints were less prevalent
than back pain. Musculoskeletal co morbidity
was high – 62 percent of all subjects reported at
least one musculoskeletal complaint, 35 percent reported
at least two musculoskeletal complaints, 15
percent reported at least three musculoskeletal complaints
and 6 percent reported spells of all four complaints
in the past 12 months [2].
Subjects with back pain more often reported neck
pain and hand/wrist pain than those without back
pain. Neck and hand/wrist pain was strongly associated
since 50 percent of subjects with neck pain
also experienced hand/wrist pain in the past 12
months. Age and gender were significant only for
neck pain. Senior people and women suffered from
neck pain more [2,76].
Educational level and working without breaks
were significant factors for shoulder pain. Living
alone was significant for neck and shoulder pain.
All complaints chronicity increased with age. Female
gender was significantly related to chronic back
and shoulder pain. Co morbidity was elevated among
those reported with higher physical load, lower job
control and working long hours [2].
Chronic musculoskeletal pain appears early in
dental careers, and more than 70 percent of dental
students of both sexes reporting pain by their third
year [76]. A study in Turkey gives us amazingly high
pain prevalence among dental students: headaches
(34 percent, 22 percent), neck pain (67 percent, 43
percent), back pain (56 percent, 47 percent), upper
limp pain (46 percent, 43 percent) and shoulder pain
(78 percent, 58 percent), respectively [91].
One cause of musculoskeletal disorders may be
mechanical vibrations affecting the organism through
the upper limbs and causing changes in the vascular,
neural and osteoarticular systems. These
changes may produce an occupational disease called
vibration syndrome. But on the basis of the available
literature it can not be decided unequivocally if
it exists a direct link between vibrations emitted by
the working dental instruments and the incidence of
symptoms characteristic of the vibration syndrome
[89].
Apart from vibrations, other harmful factors
connected with the profession seem to play a role,
and they modify the hand-arm symptoms [89].
The causes of musculoskeletal pain and disorders
common to dental operators are multifactorial.
There is relationship between the biomechanics
of seated working postures, repeated unidirectional
twisting of the trunk, working in one position
for prolonged periods, operator's flexibility and core
strength, operators knowing how to properly adjust
ergonomic equipment and physiological damage
or pain [94,95]. Studies indicate that strategies
to prevent the multifactorial problem of dental
operators developing musculoskeletal disorders
exist. These strategies address deficiencies in operator
position, posture, flexibility, strength and ergonomics
[94,95].
A study in Poland [90] showed that dentists
work in conditions which generally produce disorders
of the musculoskeletal system. The long working
time in the course of a day is used irrationally
from the point of view of ergonomics, and over the
years consequently increases the number of disorders
of the musculoskeletal system [90].
The relationship between physical and psychological
factors in dental profession was found: den-
A. Puriene et al. REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 1
percent ought medical care. Self-reported factors
of physical load were associated with the occurrence
of back pain, shoulder pain and, hand/wrist
pain. Physical load showed a trend with the number
of musculoskeletal complaints. The physical
load among dentists seems to put them at risk for
the occurrence of musculoskeletal disorders [2].
The dentistry seems to generate relatively high
muscular load on both trapezius and dominant extensor-
carpi-radialis muscle [59]. We have to account
not only instantaneous physical loads. They
cumulate (cumulative loads) and affect physical
health. Smaller loads cannot be ignored due to their
magnitude if their duration is long because the time
dependent properties of the tissues become modulating
factor. Thus the measurement of instantaneous
loads on tasks in dentists is not indicative of
the amount of cumulative stress experienced by
them [65].
Low-back pain is the most prevalent musculoskeletal
complaint [2,62,71,90]: in a Greek study –
46 percent prevalence [85], in an Australian study –
as much as 53.7 percent [51]. More than 25 percent
of all subjects with back pain reported the severe
chronic back pain [2]. Dentists who work in
the sitting position have more severe low back pain
than do those who alternate between sitting and
standing [71].
Prevalence of hand/wrist complaints among dentists
and especially dental hygienists is really high
[2,33,48,49,53,90]. Hand/wrist complaints follow low
back disorders [2,53] and result in a significant
higher chronicity than any other complaint [2]. The
prevalence of particularly carpal tunnel syndrome
among dentists is not very high, about 5 percent [33].
Though 56 percent of dental hygienists exhibit probable
or classic symptoms of carpal tunnel syndrome
[49].
Neck and shoulder complaints were less prevalent
than back pain. Musculoskeletal co morbidity
was high – 62 percent of all subjects reported at
least one musculoskeletal complaint, 35 percent reported
at least two musculoskeletal complaints, 15
percent reported at least three musculoskeletal complaints
and 6 percent reported spells of all four complaints
in the past 12 months [2].
Subjects with back pain more often reported neck
pain and hand/wrist pain than those without back
pain. Neck and hand/wrist pain was strongly associated
since 50 percent of subjects with neck pain
also experienced hand/wrist pain in the past 12
months. Age and gender were significant only for
neck pain. Senior people and women suffered from
neck pain more [2,76].
Educational level and working without breaks
were significant factors for shoulder pain. Living
alone was significant for neck and shoulder pain.
All complaints chronicity increased with age. Female
gender was significantly related to chronic back
and shoulder pain. Co morbidity was elevated among
those reported with higher physical load, lower job
control and working long hours [2].
Chronic musculoskeletal pain appears early in
dental careers, and more than 70 percent of dental
students of both sexes reporting pain by their third
year [76]. A study in Turkey gives us amazingly high
pain prevalence among dental students: headaches
(34 percent, 22 percent), neck pain (67 percent, 43
percent), back pain (56 percent, 47 percent), upper
limp pain (46 percent, 43 percent) and shoulder pain
(78 percent, 58 percent), respectively [91].
One cause of musculoskeletal disorders may be
mechanical vibrations affecting the organism through
the upper limbs and causing changes in the vascular,
neural and osteoarticular systems. These
changes may produce an occupational disease called
vibration syndrome. But on the basis of the available
literature it can not be decided unequivocally if
it exists a direct link between vibrations emitted by
the working dental instruments and the incidence of
symptoms characteristic of the vibration syndrome
[89].
Apart from vibrations, other harmful factors
connected with the profession seem to play a role,
and they modify the hand-arm symptoms [89].
The causes of musculoskeletal pain and disorders
common to dental operators are multifactorial.
There is relationship between the biomechanics
of seated working postures, repeated unidirectional
twisting of the trunk, working in one position
for prolonged periods, operator's flexibility and core
strength, operators knowing how to properly adjust
ergonomic equipment and physiological damage
or pain [94,95]. Studies indicate that strategies
to prevent the multifactorial problem of dental
operators developing musculoskeletal disorders
exist. These strategies address deficiencies in operator
position, posture, flexibility, strength and ergonomics
[94,95].
A study in Poland [90] showed that dentists
work in conditions which generally produce disorders
of the musculoskeletal system. The long working
time in the course of a day is used irrationally
from the point of view of ergonomics, and over the
years consequently increases the number of disorders
of the musculoskeletal system [90].
The relationship between physical and psychological
factors in dental profession was found: den-
A. Puriene et al. REVIEW
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 3
There are few evidences of higher hepatitis infection
risk in dental practice. The most hazardous
infection for medical staff is hepatitis B. It is most
frequently acquired through micro trauma. Even 10-
39 percent of medical staff and 12-27 percent of
dental team staff revealed seropositivity of hepatitis
B virus [47]. Greater number of years of occupation
in dentistry was independently and significantly
(P = .0004) associated with seropositivity to
hepatitis A virus. The calculated odds ratio showed
that each year of work increased the likelihood of
being seropositive by 1.06 (6 percent). Subjects
tended to have higher seropositive rates if they were
older, had a greater number of children, had a
greater number of siblings, had worked in hospitals
and worked with children (pediatric dentists and
orthodontists) [3].
A source of hepatitis and many other infectious
hazards could be a percutaneus injury. Out
of the dentists interviewed, 31.1 percent reported
accidents, with a mean incidence of 2.02 accidents
each professional year [63]. When dental personnel
were analyzed, dentists experience it most often:
36 percent of percutaneus injuries were reported
by dentists, 34 percent by oral surgeons, 22
percent by dental assistants, and 4 percent each
by hygienists and students. Almost 25 percent involved
anesthetic syringe needles. Out of 87 needle
stick injuries, 53 percent occurred after needle use
and during activities in which a safety feature could
have been activated (such as during passing and
handling) or a safer work practice used [15]. It
was found, that 90 percent of dentists recapped
needles after using them, while only 8.1 percent
re-used gloves [8].
Dentists knowledge regarding infectious diseases
that can be acquired or transmitted in the dental surgery
and the vaccinations recommended are quite
poor: only 44.1 and 32.4 percent correctly indicated
all infections that can be acquired or transmitted during
their activity. Only half of the dentists knew that
they should be vaccinated against hepatitis B and
influenza. A large proportion (85.7 percent) reported
receiving the hepatitis B vaccine, but only 56.2 percent
the three doses. [17].
One study assessed attitudes toward occupational
health and knowledge of the area: clinicians
rated occupational health to be less important than
did interns and students. Prior work experience did
not affect performance; however, students from
"blue collar" families scored higher in both knowledge
and attitudes than those from "white collar"
families. Women scored higher in both areas than
did men. There was no correlation between number
A. Puriene et al. REVIEW
of hours of occupational medicine in school and performance,
either overall or within each level. This
study suggests that enthusiasm for occupational
health declines with training, and that knowledge
gains are erratic [86].
Regardless of gender, dentists do experience
other problems that may disrupt or impair dental
practice, including substance abuse involving alcohol
and/or other drugs. Therefore, dentists need
to understand gender differences associated with
risk for abuse of alcohol and other substances; related
physical, emotional, and professional effects;
and other aspects of professional health and
wellness [74].
PSYCHOLOGICAL DISORDERS
Not only physical impairments affects dentist's
health. Job-related psychological disorders also contribute
greatly. Factors that affect dentist's psychological
status can be job-related stress, tension, depression,
emotional exhaustion, depersonalization.
Dental practice is stressful. Dentists have to
deal with many significant stressors in their personal
and professional lives [30]. There is some evidence
to suggest that dentists suffer a high level of jobrelated
stress [7,22,23,62,73].
83 percent of dentists' perceived dentistry as
being "very stressful" [7], nearly 60 percent perceived
dentistry as more stressful than other professions
[60]. Dentists indicated running behind
schedule, causing pain, and heavy work load, late
and anxious patients as well being the most intense
stressors in their work [60, 99]. Dentists, who reported
that dental anxiety was primarily the result
of general psychological problems in patients, usually
had solo practices older than 18 years and reported
high perceived stress [60]. Clinicians experience
numerous workplaces, financial, practice
management and societal issues for which they often
are unprepared after finishing a university.
The difference in reported levels of stress between
dental specialties was not found. Practitioners
working in the field of pediatric dentistry reported
the highest median levels of stress though
this trend was not significant [67].
A large number of factors are implicated in
stress situations, including low autonomy, work overload,
and lack of congruence between power and
responsibility. Doctors and dentists who take on a
teaching role in addition to their clinical role may
increase their levels of stress, but there is also evidence
that this dual role may reduce job-related
stress [82].
1 4 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
Stress may produce "burnout". It is a syndrome
of emotional exhaustion, depersonalization and reduced
personal accomplishment, a particular type
of job-related stress reaction. It is a response to the
chronic emotional strain of dealing extensively with
other human beings, particularly when they are
troubled or having problems. The values of burnout
and it's constituents among dental workers are amazingly
high [7,11,22,23,28,68,93]. Recent findings suggest
that burnout has features of maladaptive coping
in the short term but is, paradoxically, protective
in the longer term. Dentists are prone to burnout
due to the nature of their work but may be able to
prevent it if they can recognize the burnout process
and take regular holiday breaks.
Burnout is assumed to have an adverse influence
on patient care, although no dental studies, as
yet, have tackled the issue [22].
The study in England exhibited high overall burnout
in 10.6 percent of examined dentists. Emotional
exhaustion was found in 25.53 percent, depersonalization
– 8.88 percent and reduced personal accomplishment
in 34.42 percent of dentists [68]. When the
Spanish dentists were questioned, high values were
detected in emotional exhaustion – 54.3 percent,
depersonalization – 55.6 percent; personal achievements
– 6.9 percent [93]. Gender differences in burnout
among dentists do exist. Male dentists reported a
higher score of depersonalization than did female
dentists [11,23]. However, results indicate that underlying
factors, such as working hours, have a profound
effect on these differences [11]. Men work
more hours and work part time less frequently [96].
Dentists are not unique experiencing high overall
burnout. Very similar data is presented among all
primary care practitioners: 19% of respondents had
a high score for emotional exhaustion, 22% had a
high score for depersonalization or cynicism and 16%
had a low score for professional accomplishment,
32% had a moderate degree and 4% had high degree
of burnout [23]. A high degree of burnout is
associated with the male sex, practicing in a rural
area, and excessive perceived stress due to global
workload, patient's expectations, and difficulties to
balance professional and private life, economic constraints
in relation to the practice, medical care uncertainty
and difficult relations with non-medical staff
at the practice [23].
Burnout comes about in situations where there
is a focus on problems, lack of positive feedback,
the level of emotional stress is high and where problems
are chronic [68].
Depression may be a consequence of prolonged
experience of burnout [41].
Recent findings suggest that burnout has features
of maladaptive coping in the short term but is,
paradoxically, protective in the longer term [41].
There is a relationship between emotional load
and volume of patients treated. Depersonalization
levels decrease with age and it could be due to a
number of factors – socialization skills increasing
with age, a slowing of pace of work which allows
more personal contact, or the establishment of personal
relationships with patients over time [68]. Older
dentists work fewer hours, with a larger impact of
age seen among men [96]. Emotional support may
be gained from co-workers that are why the numbers
of burnout syndrome may decrease in the larger
practice groups. Conversely, a particular characteristic
of private practice is the high level of control.
It allows dentists to have control over their working
conditions: a factor which is reported to help reduce
stress levels. It is also related to income, autonomy
and the match between technical aspirations
and practical outcomes [68].
Higher levels of depersonalization in unmarried
dentists compared with those who were married suggests
that involvement with a spouse and children
makes married people more experienced in dealing
with personal problems [68].
The higher levels of personal accomplishment
were in dentists with post-graduate qualifications
[68].
Also specialists, were more satisfied with their
psychosocial work environment than general practitioners,
especially regarding their personal control
over their work and the stimulation of their work.
The specialists also had more self-confidence and
experienced less anxiety than general practitioners
and head dentists [68,81].
Lack of career perspective appears to be the
stress factor strongly related to burnout [24]. This
relation should stimulate serious attention for career
planning among dentists.
The conceptual basis of burnout would seem to
imply that physical environment is probably of minor
importance in the process and no actual work
place condition could be demonstrated to be correlated
with high burnout levels, it would be prudent
to make the practice environment as pleasant as
possible. For, apart from directly reducing stress on
the dentist, it might reduce the anxiety level of patients,
and thus the emotional load on the dentist
[24,68].
There tend to be some differences in burnout
scores relating to the levels of professional isolation.
The lack of hierarchal structure to general
dental practice means that dentists have constantly
REVIEW A. Puriene et al.
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 5
to rely on their own emotional resources in the
clinical situation. This contrasts with the worker
within an organization where there are colleagues
with whom to share the emotional strain of contacts
with distressed clients. Furthermore, superiors
in a hierarchy are available for support and
help when necessary, which can substantially alleviate
anxiety. This argument is counterbalanced
by the issues of autonomy and control. Large organizations
are able to deal with issues such as
staff discipline, communication with other organizations
and financial control. In small organizations
such as general dental practice, the stress
associated with these activities is concentrated to
a small number of people, frequently the dentist
[28,62,68]. A very interesting study identified the
specific situations that most frequently produce
stress. The majority of these situations could be
classified as being related either to dental procedures
and office organization or to interpersonal
relationships involving patients and/or office personnel
[10]. So, dentists consider clinical matters
their greatest stress [10,40].
Differences of individual responses to stress
may be attributable to personality factors and differences
in coping styles, and tend to support the
hypothesis that stress is a unique, perceptual and
experimental phenomenon [13]. The older dentists
are less stressed than their younger counterparts.
Some issues like those concerned with finance and
patient-management, appear to affect both groups
more or less equally, which suggests that these issues
are of global, rather than specific concern. From
a theoretical point of view, the findings tend to contradict
the generally – held belief that getting older
is automatically accompanied by degeneration and
problems of adaptation to life changes. On the contrary,
seemingly favorable adaptation and low levels
of stress are evident in most of the older dentists
[14,60].
Nervous psychological state, tension, depression
and others signs of psychological impairment also
has to be taken into account when talking about jobrelated
stress in dental practice. A huge study in
England shows amazing results: sixty percent of general
dental practitioners feel nervous, tense or depressed,
58.3 percent reported headache, 60 percent
reported difficulty in sleeping at night and 48.2
percent reported feeling tired for no apparent reason.
Levels of minor psychiatric symptoms were
high, with 32.0 percent of cases identified [62]. The
other study found that gender was associated with
depression in two specialties: periodontics and pediatric
dentistry [55].
The important thing is that only 15 percent of
depressed dentists receive treatment [55].
Job-related stress and all psychological impairments
it has led to affects dentists personal as well
as dental family life. The effect of the dentist's office-
related stress is directly felt in the family, especially
by the spouse. Strong coping patterns result
when dentists and spouses maintain a balance
of time and responsibility, satisfaction in work and
family activity, regular communication, sharing of
decision making, good physical health, and the inclusion
of an active exercise program within multiple
demands on their time [64].
A study of Sweden general practice dentists revealed
that females constitute one-quarter of all dentists.
These female dentists suffer from many problems
relating to their psychosocial working conditions.
There are wide discrepancies between their
perception of the ideal job situation and reality [38].
Physicians, who report high levels of work
stress, also report lower levels of marital satisfaction
and a higher prevalence of psychiatric symptoms
[52].
Dentists are much like physicians in their reports
of overall work stress, and the similarities and
differences regarding specific stressors suggest
these professions are very alike in reporting the
stresses of professional practice. [52].
Taking into account dental students, it must be
assumed that the level of emotional exhaustion was
higher in dental students than medical students; and,
second, that general psychological distress and
course related stress levels were associated with
the nature of the course and the immediate living
conditions of the students [42].
In our day remuneration system has led dentists
to long working hours, leaving little time to relax
from work, participate in family life [56,61]. A
huge study in Canada showed that more than 10
percent of dentists see equally or more than 30 patients
per day [56]. These factors may all be considered
to be part of current general dental practice
and they really affect dentist's health.
It is very interesting that particular traits are common
among those who decide to pursue careers in
dentistry. And these traits make dentists prone to professional
burnout, anxiety disorders and clinical depression
[21]. And that differences in approach to
work and perceived workplace climate mainly reflects
stable, long-term individual differences in doctors
themselves, reflects in measures of personality and
learning style [58]. In many cases the psychological
variables (distress, emotional exhaustion or intensity
of stressors) were influenced by gender [25,42].
A. Puriene et al. REVIEW
1 6 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
Although dentists suffer from psychical impairments,
they do not seem to be using alcohol,
tobacco and other potentially addicting drugs in
numbers greater than the nonprofessional population
[6,46,84]. But alcohol use is related to stress
among dental professionals [62]. The media repeatedly
portrays dentists and other health professionals
as being at risk of committing suicide
[1,83,87]. While this message often is accepted
without question, there are little reliable data available
that verifies this alleged risk. There is little
valid evidence that dentists are more prone to
suicide than the general population, although some
related data suggest that female dentists may be
more vulnerable [4,34,35,78,83]. It is very interesting
that male doctors seem to be at less risk than
men in the general population. The excess risk of
suicide in female doctors highlights the need to
tackle stress and mental health problems in doctors
more effectively [1,34].
On the contrary, the other study [36] revealed
that the physicians as a whole still had a higher suicide
rate than other university graduates and the general
population, both among men and women compared
to 23.5 per 100.000 person-years and 8.0 per
100.000 person-years among male and female no
graduates, respectively. The suicide rate among female
physicians was twice as high as that of the
general population as well as other female graduates,
even in the 1990s. Of interest, suicide rates
increased steeply by age among physicians and other
graduates, whereas for no graduates, the rate was
highest among those ages 40-60 years [36].
Also analysis of death distribution according to
underlying causes indicated the absence of significant
differences that might suggest increased risk
of death for dentists. Dentists' deaths did not present
worse indications for global and specific categories
of infectious diseases, central nervous system or circulatory
diseases [4]. There is only a slight tendency
of a favorable risk pattern for lung cancer
and overall cancer occurrence [85]. All these observations
suggest that dentistry can be considered
a safe profession, at least regarding exposure to
systematic risk of death. It may be because of dentists
report immediate results and aesthetics, and
long-term results of working with patients to be the
most rewarding aspects. All job resources showed
a positive correlation with job satisfaction [27].
Slightly less than half of the dentists were satisfied
with their profession and the personality types over
represented in dentistry tended to have a higher level
of satisfaction and a lower level of burnout compared
to their cohort group [7,9].
The philosophy inherent in the remuneration system
raises issues of quantity and quality. The combination
of a fee per item system of payment combined
with a fixed pool of available money witch is
not forecast to increase has strong implications related
to burnout, poorer mental health, stress
[6,9,68,80,98]. Short term increases in profit for individuals
can be achieved by higher work output,
but in the longer term as the system adjusts the increases
are eroded, though the increase work load
and therefore stress levels have been sustained. This
also has implications for quality, where quality is
poorly defined, if at all and only rewarded negatively
with retrospective punitive action. Practitioners who
feel unfairly penalized may have a greater tendency
to burnout. Furthermore, in systems of low profitability,
the ability of dentists to reinvest in their practices
and thereby improve the working environment,
increase their patients confidence and decrease their
anxiety levels is limited [68].
A study in Sweden describes how the female
general practice dentists think of the dimensions that
the dentistry profession should contain. It concluded
that the gulf between ideal and reality is wide, especially
concerning the dentist's influence on important
decisions. There must be good communication
and democracy at work, and based on freedom and
the employees influence, could bring ideal and reality
closer [37].
In addition to the vulnerabilities of the human
condition – addictive disorders, psychiatric illnesses,
family and relationship problems, or the many varieties
of human misery – dentists have undergone a
powerful process of socialization into their professional
role that makes it difficult to seek help for
themselves. Stigma about addictive and psychiatric
illnesses continues to be a problem despite significant
advances in scientific understanding of these
disorders. Many people, especially those in positions
of community visibility as dentists are, still struggle
with shame when they associate problems with personal
failure [50]. One may find out, that the reasons
for leaving practice included financial problems,
stress, and external regulation concerns. Current
careers varied widely, with business, teaching, medicine,
and investing being the most common. Respondents
ranked their current careers as considerably
more favorable on measures of perceived creativity,
freedom, belonging, and whether they would
choose the same career again. These findings indicate
that there was a difference between the perception
of a dental career and the reality of clinical
practice for the study sample. Reasons to leave
dental practice are not health problems [75].
REVIEW A. Puriene et al.
Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1 1 7
There is a need to acknowledge the existence
of the problems within the dental profession and to
establish ways to prevent and alleviate stress and
other psychological disorders among dental practitioners
[16,30]. Higher patient expectations, higher
targets for provision of dental care will put increased
demands upon dentists [45]. The highest
ranked individual stressor: 61.9 percent, was 'running
behind schedule'. [98]. Discussion of the problem
could take place at appropriate points in the
professional training program and throughout the
career of a dentist. This may, in itself, be helpful
by allowing individuals to realize that their feelings
are not unique nor representing a personality defect.
Davidove maintains that healthy self-criticism
can help bolster the dentist's sense of self-esteem
and can work as a prophylaxis against depression
[16,45]. Researches offers supervision and support
groups as a simple and powerful mean to
ease the burdens of medical practice and prevent
disillusionment and subsequent impairment among
health care workers [18,66,68]. Occupational medicine
clinics also serve as occupational training and
consultative site [79]. Dental societies, family and
friends are also in an ideal position to provide resources
and support. Active membership in local,
state and national organizations can lessen the feelings
of professional isolation and can provide contacts,
which can help starting practitioners improve
their practice environments [97]. Even the Stress
Thermometer (an easily accessible Internet-based
instrument for feedback on work stress and burnout)
was made-up to effectively call attention to
sensitive personal issues concerning work-related
stress and burnout [12]. Furthermore, the risk of
female suicides requires particular monitoring in
the light of the very large increase in the numbers
of women entering medicine [34]. All these measures
should be strongly promoted and developed
to help to overcome all these dental society problems.
Emphasis on faculty training and clinical rotations
should be strongly placed also. With reservations,
it can be concluded that the prevention
program does have a positive effect on burnout
scores among dentists, while different forms of
self-initiated prevention activities also appeared to
be effective [26].
In order to improve dental staff work in the
USA, The White Coat Ceremony was established.
Many dental schools use to mark the transition to
patient care. It is an opportunity to reflect on the
values of dental practice. Eight principles are offered
for consideration: 1) patient care is the point
of practice; 2) the doctor-patient relationship is
essential; 3) discuss options and possibilities; 4)
mistakes will be made; 5) tell the truth; be assertive;
7) consult; and 8) manage your stress and
your life. It may also be a good point in preventing
dental staff from stress and problems in their lives
[69].
As mentioned above studies indicated the occupational
health knowledge gained from school is
erratic. The curriculum reform should be developed.
The practitioner is recommended to be actively concerned
about problems. Numbers of percutaneus injury
show that dental practices should have a comprehensive
written program for preventing needle
stick injuries that describes procedures for identifying,
screening and, when appropriate, adopting
safety devices; mechanisms for reporting and providing
medical follow-up for percutaneous injuries;
and a system for training staff members safe work
practices and the proper use of safety devices [15].
In order to avoid part of musculoskeletal disorders
among dentists altering position between sitting and
standing is recommended [71]. A thorough understanding
and controlling of the underlying physiological
mechanisms leading to them is necessary to develop
and implement a comprehensive approach to
minimize the risks of a work-related injury. Dentists
must be highly aware of the importance of maintaining
good physical and mental health to enjoy and
be satisfied with their professional and personal
lives.
CONCLUSIONS
In different countries dentists reported having
poor general health and suffer from various healthrelated
problems. The dentistry has always been
known as uneasy occupation therefore one must take
into account serious difficulties before attending
medical school. First of all, students must be aware
of the health risks in dentist's job. Talking about musculoskeletal
disorders it might be assumed that
knowledge in ergonomics may be of some use. Secondly,
all sorts of protection must be used during
treatment in order to prevent infectious diseases and
other injuries. Furthermore, dentists must be taught
about coping with stress patterns. There are some
points in preventing psychological discrepancies. To
enjoy and be satisfied with their professional and
personal lives, dentists must be aware of the importance
to maintain good physical and mental health.
It is important to enjoy their lives, exercise physically,
have a hobby, create a harmonious family,
communicate with colleagues and keep learning all
their lives.
A. Puriene et al. REVIEW
1 8 Stomatologija, Baltic Dental and Maxillofacial Journal, 2007, Vol. 9, No. 1
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Accepted for publishing: 27 03 2007
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