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Occupational Hazards in Dentistry

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Review Article
___________________________________________________ ____________________
J Res Adv Dent 2017;6:2:110-122.

Occupational Hazards in Dentistry

Kommuri Sahithi Reddy1* Dipak Sadhan Paul Majumder2 Dolar Doshi3 Suhas Kulkarni4 B.
Srikanth Reddy5 M. Padma Reddy6

1Senior Lecturer, Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, India.
2Professor and Head, Department of Dentistry, Agartala Govt Medical College, Agartala, Tripura, India.
3Professor, Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, India.
4Professor and Head, Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, India.
5Reader, Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, India.
6Professor, Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, India.

ABSTRACT

Background: Dental professionals are predisposed to a number of occupational hazards. These include
exposure to infections (including Human Immunodeficiency Virus and viral hepatitis); percutaneous exposure
Incidents, dental materials, radiation, and noise; musculoskeletal disorders; psychological problems And
dermatitis; respiratory disorders; and eye insults. Therefore, the aim of the paper is to increase the level of
awareness of occupational hazards among the dental surgeons and also to provide information on the ways in
which hazards can be reduced.

Keywords: Hazards, dentistry, health.

INTRODUCTION study by brooks SL et al6 reported that dentists,

more frequently have worse health problems than
Occupational hazards refer to a risk or other high risk medical professionals. The present
danger as a consequence of the nature or working scenario of dentistry in India is greater work hours,
conditions of a particular job1. Carrying out their huge competition and fewer economic returns
professional work, dentists are exposed to a which had become an integral part of dental
number of occupational hazards. These cause the practice7 which leaded to dis-satisfied aspects such
appearance of various ailments, specific to the as their level of stress and limited amount of
profession, which develop and intensify with years. personal time8.
In many cases they result in diseases and disease
complexes, some of which are regarded as The reports of other countries on
occupational illnesses2. occupational hazards in dentistry are, the survey
carried out in the United Kingdom and United States
Dentistry is known to be a demanding of America9 found that the most common
profession and a wide variety of deleterious work manifestation of organic diseases included
environmental factors are proved to affect the backache, haemorrhoids, chronic indigestion, and
physical health of the dentists or even aggregate circulatory system diseases occurred among
their pre-existing disorders3.occupational health dentists. Similarly a study in Lithuanian dentists
hazards are not uncommon4 , Even-though, Modern revealed that more than half of the dentists
dentistry has been described as probably among the experienced work psychological complaints10. The
least hazardous of all occupations5. Likewise, many occupational hazards found among dentists and
risks still challenge the status of this occupation. A other clinical dental workers are similar worldwide.
_______________________________________________________________________________________

Copyright ©2017
The practice of dentistry exposes dental 2) Chemical
professionals to a variety of work-related hazards, 3) Physical
they include: Working long hours at a high level of 4) Psychological
concentration, Working in a sedentary state,
Working with anxious patients, Exposure to Babaji P et al stated that dentists during during
microbial aerosols generated by high-speed rotary clinical practice exposed to variety of work related
hand pieces, Exposure to various chemicals used in hazards. These occupational hazards can be
clinical dental practice and Other hazards. These classified into five types15:
hazards can pose significant risks to dental
1) Physical
practitioners9.
2) Chemical
HISTORY11 3) Biological
4) Psychological
BERNADINO RAMAZZINI is referred as father of 5) Musculoskeletal disorders
occupational medicine in 18th century published
his systemic study of occupational diseases in a PHYSICAL HAZARD 15
book entitled “DE MORBIS ARTIFICUM DIATRIBE”
The dentists are at risk of physical injuries during
in the year 1713. The book had three principles
many dental procedures. Physical hazards includes
causing occupational hazards which he recognised
they are as follows: Poor illumination:

1. fixed working posture Causes- eye pain, eye strain, headache and eye
2. A continuous repetitive motion fatigue
3. Psychological stress
Excessive brightness
These would now be referred to as repetitive
“strain injuries”. Hence, he recognised the role Causes- discomfort and visual fatigue
of occupation in the dynamics of health and
diseases. The study16 done in Norway reported that public
health dentists complained 13% of eye problems.
DEFINITION 11-13 An investigation done on Flemish dentists in
Belgium revealed a similar problem that 52% had
➢ Occupational hazard can be defined as a risk to vision problems 22, eye injuries among dentist may
a person usually arising out of employment. be as high as 10%23. The study in Australia
➢ It can also refer to a work, material, substance, suggested continuing but low prevalence of eye
process, or situation that predisposes, or itself injuries amongst dental students and assistants17.
causes accidents or disease, at a work place.
Prevention of poor illumination and excessive
CLASSIFICATION brightness-

These hazards can be grouped into11: ➢ Sufficient and suitable lighting

➢ Natural or artificial is advised
1) Physical
2) Chemical The study done in UK revealed that the Use of eye
3) Biological protection by dentists was found to be as low as
4) mechanical 57% when using laboratory cutting machines24.
5) social aspects
EXPOSURE TO SOUND 25, 26Air driven, high speed
Handbook of Occupational Hazards and hand pieces operating from 3900 to 12,500 Hz and
Controls for Dental Workers by government of electric engines are main contributing factors
Alberta in year 2011 classified occupational towards sound pollution.
hazards into14

1) Biological

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Hearing loss, acoustic stress and impaired power of Prevention
concentration first affect the individual who are
regularly exposed to frequencies above 3000 Hz, ➢ Protective eye wear during usage
therefore Use of high speed compressors and
Ionising radiation injury - Exposure to radiation
suction ultrasonic scaler.
Causes- acute erythema, dermatitis, chronic skin
Causes- temporary and permanent hearing loss
cancer, bone marrow suppression, damaged to eye
Prevention including cornea. Radiation effects are cumulative
and this damage is totally painless yet life threating.
➢ Personal protection by using ear plugs and Ionising radiation is a well established risk factor
muffs which reduce high intensity sounds by 30 for cancer. The study conducted among Canadian
to 35 dB. dentists reported that occupational doses of
ionizing radiation among dentists and dental
➢ The noise levels of modern dental equipment workers have decreased markedly since 1950s31.
have now generally fallen below 85 Db, the
widely used benchmark standard, below which Prevention
the risk of hearing loss is believed to be
minimal and negligible ➢ Lead gloves and lead apron.

An investigation done on Flemish dentists in The risk from ionising and non-ionising radiation
Belgium revealed that 20% of dentist had auditory appears to have been effectively reduced by most
problems22. dentists in a study done in Thailand32.

Kadanakuppe S et al 27 (2011) done a study in Following are the recommendations for safety of
dental practical classes, the acoustic environment is the practitioner 33, 34
characterized by high noise levels in relation to
Buying of standard radiographic equipment, which
other teaching areas, due to the exaggerated noise
rigidly follows the National Council on Radiation
produced by some of these devices and use of dental
Protection and Measurements (NCRP) and ISI
equipment by many users at the same time.
recommendations .Well-collimated and filtered
FernandesJCS et al28 (2005) measured and beam of at least 1.5 mm of aluminium filtration,
analysed the noise levels in the learning– teaching should be available. Special conch shell designs are
activities at the Dental School of the University of recommended for the X-ray departments. During
Porto (Portugal). The study Results revealed that construction use a special barium plaster, which
the noise levels registered vary between 60 and 99 absorbs the scattered radiation. Lead aprons should
dB(A) and are similar to the data of other be routinely used for all patients, and for all
international studies. The results recorded children special thyroid shield should be used. Use
differences in sound levels when the equipment was of fast films, i.e. Ekta (E) speed to lower exposure
merely turned on and during cutting operations. time’s .Dental surgeons must use a film badge
Differences between brand new and used service provided by the Baba Atomic Research
equipment were also noted. It appears that hearing Centre (BARC), Mumbai for personnel monitoring.
damage risk may be lesser amongst dentists who Justification of radiographic examination:
use brand new equipment.
a. Operator should leave the room or take a
Radiation 29, 30 position behind a suitable barrier or wall during
exposure of the film.
Dental personnel are exposed to both ionizing and
non-ionizing type of radiations b. Walls must be of sufficient density or thickness.

Non- ionising radiation injury - Exposure to c. The operator should stand at least 6 feet from
Dental Curing Light and Lasers the patient, at an angle of 90° to 135° to the central
ray of the X-ray beam.
Causes- conjunctivitis and keratitis

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 d. Films should never be held in place by the opera- AEROSOLS 41-43 Aerosols is Defined as particles less
tor (use film holding instruments). than 50 micrometers in diameter. These are ejected
from operating site and suspended in the air and
e. The radiographic tube should never be stabilized are airborne infection in dentistry. Therefore,
by the operator or patient during the exposure. Aerosols are contaminated with bacteria and blood.

To ensure the above, advice to use film badges. Procedures Shown To Produce Airborne Bacterial
These badges contain a piece of sensitive film or Contamination44
radiosensitive crystal by which the quantity of
radiation exposure or dose can be determined. The Ultrasonic and sonic scalers - Shown to be the
instrument used to measure radiation dose is greatest source of airborne contamination. The use
known as dosimeter. of a high volume evacuator will reduce airborne
contamination by greater than 95%.
Exposure to cuts from sharp medical instrument
✓ Air polishing - Bacterial counts show that
Includes – needle prick injuries and injuries from airborne contamination is nearly equal to
sharp objects and spicules of bone and teeth ultrasonic scalers. Commercially available
suction/barrier devices will reduce airborne
Needle cut injuries are also known as precutaneous
contamination by greater than 95%.
injuries; they are most efficient method of
transmitting blood-borne infections. ✓ Air-water syringe - Bacterial counts indicate
that airborne contamination is slightly less than
• Fasunloro A and Owatade FJ in 200413 done a
ultrasonic scalers. High volume evacuator will
survey on occupational hazards among clinical
reduce airborne bacteria by nearly 99%.
dental staff in Nigeria reported that 1-15% of
surgical procedures like suturing cause’s needle ✓ Tooth preparation with an air turbine hand
stick injuries and cuts from sharp objects. piece - Minimal airborne contamination if a
rubber dam is used.
• A study done in United States reports that more
than 800,000needle stick injuries occur each Azari RM et al 45 (2008) conducted a study on
year inspite of continuing education and efforts Occupational risk of dental personnel to microbial
to prevent them35. Also, the studies in United airborne contamination and reported increased
kingdom23 and Thailand 32 also revealed that prevalence of respiratory infections. Therefore,
precutenaous injuries are mostly due to needle study concludes that there are no standards for
prick. acceptable levels of indoor air contamination with
pathogenic microorganisms and since pathogenic
• A survey in South Africa only 14% of dentists
Streptococcus haemolyticus and opportunistic
reported needlestick injuries 36.
Staphylococcus species were found in some areas of
the dental school, the need for management of
• The two studies in Australia from brisbrane and
possible risk of infective hazards is recognized.
sydeny revealed that 72% of dental students
indicated injury from sharps objects during Chemical Hazards 42
their training37.
Dentists are exposed to many various types of
• 70% of the injuries occurred during chemicals that are hazardous while providing care.
administration of the local anesthesia38. They include beryllium, silica, powdered natural
rubber latex (NRL), formaldehyde and most
Prevention: Safe working procedures and wearing
dangerous mercury.
of double gloves. National and international
guidelines, such as the Needle stick Safety Act in Silica: Inhalation of dust containing free silica or
2001 were developed to help minimize the risk of silicon dioxide in ceramic laboratories leads to
blood borne pathogen exposure to health care silicosis
workers including dental settings39, 40.

113
Beryllium: Some of the dental alloys contain population.54, 55 therefore, dental personnel should
beryllium and if it inhaled while working on items be familiar with the major signs and symptoms of
such as dental crowns, bridges, and partial denture allergic reactions, including anaphylaxis. Dentistry
framework, they can cause chronic beryllium uses variety of different polymer materials. The
disease (CBD). As per Occupational Safety and setting of restorative materials and adhesives is
Health Administration (OSHA) specification, initiated chemically by mixing two components or
employees cannot be exposed to more than 2 by visible light. In both cases, polymerization is
microorganisms of beryllium per cubic Meter of air incomplete and monomers not reacted are released.
for an 8 hour time weighted average These free monomers may cause a wide range of
adverse health effects such as irritation to skin, eyes
Formaldehyde1: is one of the chemical agents or mucous membranes, allergic dermatitis, asthma
routinely used in the clinical set up mainly for and parasesthesia in the fingers. Additionally,
disinfection of operatory area. Liquid and vapour disturbances of the central nervous system such as
forms of formaldehyde may cause severe abdominal headache, pain in the extremities, nausea, loss of
pain, nausea, vomiting and eye irritation. appetite, fatigue, sleep disturbances, irritability, loss
of memory, and changes in blood parameters may
Natural Rubber Latex (NRL) 46-53: Latex gloves
also be noted.57 The Asthma Due to Acrylate
(dusted with cornstarch powder) form an efficient
Compounds Allergic respiratory problem due to
barrier against most pathogens. Unfortunately most
dental materials is also an important occupational
of the professionals are allergic to latex content of
hazard.58
gloves. The powder in latex gloves itself is not the
allergen. It only provides binding sites for latex NITROUS OXIDE60, 61 The National Institute for
protein, and aids in carrying the protein into the Occupational Safety and Health (NIOSH) in 1994
skin. It has also been reported that airborne powder issued a warning to hundreds of thousands of
particles can cause asthmatic allergic reactions or medical, dental professionals who work with
even anaphylaxis. Dental personnel should also note nitrous oxide (N2O). The Institute warns that even
that latex is present in other personnel protective with preventive measures such as scavenging
equipments like masks, eyewear, and clinical systems in place these workers may be at risk for
gowns. serious health effects due to their exposure. N2O
commonly called as laughing gas, is an anesthetic
Clinical symptoms of latex allergies include:
agent used in operating rooms. Workers are
urticaria, conjunctivitis accompanied by lacrimation
exposed to N2O while administering the anesthetic
and swelling of eyelids, mucous rhinitis, bronchial
gas to patients. To protect workers from the health
asthma and anaphylactic reaction.
risks associated with N2O, operating rooms are
Prevention often equipped with scavenging systems that vent
unused and exhaled gas away from the work area. If
Most allergic reactions can be managed by self used in high concentrations during anesthetic
medication, prescribed medication. Sufferers from administration, it may cause increased absorption
latex allergy are advised to work in latex free and thereby liver and kidney damage with
environment and use vinyl, nitrile or 4H gloves. neuralgic disease and congenital abnormalities.

It is estimated that 2.8-17% of the employees of XYLENE62-64

health service are allergic to latex51. 8.8% of
dentists were found to be allergic52. The frequency In dentistry, xylene is used in histological
of occupational related dermatosis varied from 21% laboratories for tissue processing, staining and
to 43% depending on the prevailing material used cover slipping and also in endodontic retreatment
in the various specialties.50 as a guttapercha solvent. Exposure to xylene can
occur via inhalation, ingestion, eye or skin contact.
Dental Products - such as acrylics, resins and It is primarily metabolized in the liver by oxidation
polymer materials used in restorative dentistry of a methyl group and conjugation with glycine to
represent a major advance in dentistry; but these yield methyl hippuric acid, which is excreted in the
products may act as allergens in part of the

114
115
urine. Smaller amounts are eliminated unchanged in permanently damage the brain, kidneys, and
the exhaled air. There is a low potential for immune system of children.69, 70
accumulation
Biological Hazards 71-77 are constituted by
Effects: Dizziness, headache, mental confusion infectious agents of human origin and include
from inhalation of vapour.Acute: Eye and mucous viruses, bacteria and fungi. Therefore it is greatest
membrane irritation from vapour and liquid forms. concern to the dental professional. They are HIV,
HBV, HCV and Mycobacterium tuberculosis. A
Chronic: If xylene contains benzene as an impurity, dentist can become infected either directly or
repeated breathing of vapour for a long period may indirectly.
cause leukemia.
Prevention from contamination and cross-infection
PREVENTIVE MEASURES can be done by effective sterilization of instruments
using autoclave before and after use.
• Substitution
• Local exhaust ventilation Legnani et al 72 made an assessment of the aerosol
• Proper protective equipment contamination resulting from dental procedures. Air
contamination was measured by means of the
Mercury 65-70:
Surface Air System method and the “plate” method
By definition, an amalgam is a mixture of uncharged (Air Microbial Index). It was proved that during
metal powders in elemental form that is mixed with working hours the average air bacterial load
liquid mercury to form an emulsion that hardens increased over three times, and the air load levels
with time. were 1.5 times (aerobic bacteria) and 2 times
(anaerobes) greater as compared to the initial load.
Prevention: Use of precapsulated alloys, Good
ventilation, Excess and spilled mercury should be In the study done in United Kingdom73,74, the carrier
collected in fixer containing break resistant bottles. rate of HBV in the general population is 0.5%, while
Mercury caused the formation of "neurofibrillar dentists have a carrier rate of approximately 1.6%
tangles," which are one of the two diagnostic Several of the common viral agents that can cause
markers for Alzheimer's disease. In February, 1998, hepatitis.
a group of the world's top mercury researchers
Musculoskeletal disorder 78
announced that mercury from amalgam fillings can

116
Musculoskeletal disorders are common health short rest breaks in which you change posture and
problems reported among dentists. Therefore, it has relax the upper extremities
been reported that young and less experienced
dentists experience more musculoskeletal disorders Wazzan al et al81 in their study, reported that only
compared to older and experienced one. Common 37% of those suffering back and neck pain sought
musculoskeletal problems are, low back pain, medical treatment and concluded that these
shoulder pain, headache, hand and wrist pain. symptoms among dental personnel are not severe
Low back pain is more prevalent than other types. enough to ask for medications.
The cause of musculoskeletal problem is due to,
Visser and Straker 82 also showed the dentist
repeated unidirectional twisting of the trunks,
experienced significantly greater levels of lower
working in one position, prolonged static periods
back discomfort than dental assistants.
and operators flexibility.
Onycholysis and nail pitting are of occupational
Prevention of Neck, Shoulder and Back
dermatitis of manicurists and people whose jobs
Disorders
relate to vibrating machines but have not been
Ergonomic recommendations for minimizing the
mentioned in dentistry. Here we report a unique
risks of back injuries focus on improving working
case of this object. A 29-year-old right-handed
posture and equipment design. These include:
female dentist who had been carrying out
1) Change Posture - Alternate between sitting and endodontics for 5 years , was visited in Qaem
standing to reduce postural fatigue and maximize dermatology clinic with complaint of nail deformity
postural variety, which helps to reduce static .There was not any evidence of dermatologic
muscle fatigue. disease and allergy in her medical history. Clinical
examination revealed onycholysis in internal angle
2) Use Support - When sitting or standing, don’t of right thumbnail and pitting in the ipsilateral
lean forwards or stoop in an unsupported posture index finger, with 6 months duration. Besides, nail
for prolonged periods. If you are sitting, sit up bed biopsy ruled out other differential diagnosis of
straight or recline slightly in a chair with good back dermatologic disease with nail manifestations. She
support, and use a good footrest if necessary. If you reported exacerbation of the condition with longer
are standing for prolonged periods try to find occupation time and relative improvement in
something to help you lean against. vacations.

3) Safe reaching - Avoid having to reach The possibility of occupational onycholysis with a
awkwardly to equipment and work close to the none-allergic aetiology was considered.
patient. Keep the items used most frequently within Improvement was noted when she stopped her
a distance of about 20 inches (50 cm). Use assistants career. This is the first report of occupational
to help move equipment into this zone. onycholysis due to dentistry.83

4) Normal arm posture - Keep elbows and upper Psychological Hazards 83 Dentists encounter
arms close to the body and don’t raise and tense the numerous sources of professional stress, anxiety,
shoulders when working. Also, ensure that hand and depression, beginning in dental clinic.
postures are not deviated because this could lead to
wrist problems. Stress can be defined as the biological reaction to
any adverse internal or xternal stimulus physical,
5) Use Comfortable Equipment - Use equipment mental or emotional that tends to disturb the
that isn’t too heavy, that can be used without organism’s homeostasis
awkward upper body posture, and that feels
comfortable to use. Ergonomically designed Meslach and Jackson84 (1986) define burn out as:
equipment helps to minimize stresses on the upper “A syndrome of emotional exhaustion,
extremities and the back. depersonalization and reduced personal
accomplishment that can occur among individuals
6) Manage Time - Avoid long appointments who do people work of some kind. Burn out may
where possible, or intersperse these with frequent

117
lead to depression, so early recognition of the periodically to update their knowledge and,
symptom is important. hopefully, influence their work practices. Precaution
has to be taken while practicing to prevent
Humphris et al85 reported that general dentists occupational hazards. Dental clinic design has to be
and Oral surgeons had the highest levels of burnout made with, sufficient lighting, ventilation,
and that orthodontists had the lowest levels of engineering control measure and equipped with
burnout. appropriate personal protective. More effort should
be made by management officials to educate the
Anxiety Disorders84 are chronic and relentless and
staff about the importance of Hepatitis B
can grow progressively worse if not treated. Two
vaccination. All staff members should also be
common and potentially overlapping anxiety
alerted to the danger of chronic mercurial poisoning
disorders are panic disorder and generalized
and its prevention.
anxiety disorder, or GAD.
CONCLUSION
Good communication between the doctor and the
patient has a positive influence upon a stricter Occupational health hazards are present in
observance of the doctor’s recommendations by the every profession. Dentists are one such professional
patient. The course of doctor patient relations group. In spite of these hazards we cannot refrain
significantly reflects patient’s health action and from providing care and serving community.
result of treatment86 Sufficient knowledge and adequate information
regarding occupational hazards and its prevention
Prevention
will contribute in providing quality care to patients
The goal of coping with stress is to offset the without any doubt.
negative effects of stress by using appropriate
CONFLICT OF INTEREST
coping strategies. Coping can be done by,
participating in activities that make to feel better, No potential conflict of interest relevant to this
going to movies or participating in religious, social article was reported.
or other activities. Stress management workshops
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