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- Publisher
- Springer Journals
- Copyright
- Copyright © 2019 by The Author(s)
- Subject
- Dentistry; Dentistry
- eISSN
- 2056-807X
- DOI
- 10.1038/s41405-019-0010-3
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- See Article on Publisher Site
Abstract
BDJOpen www.nature.com/bdjopen ARTICLE OPEN Multidisciplinary perspectives to prevent occupational health- related conditions among dental practitioners 1 2 Rajeshree Moodley and J. Van Wyk INTRODUCTION: The prevalence of occupational health conditions is high among dental practitioners and this study investigated the role which occupational health plays in dental training. PURPOSE/OBJECTIVES: This study was conducted to explore occupational health and to determine the topics to include from an occupational health perspective into the dental curriculum. METHODS: A descriptive qualitative study was conducted to explore the perceptions of dental practitioners, dental academics, physiotherapists, occupational therapists, occupational health specialists, ergonomists, optometrists and audiologists about dental training from an occupational health perspective in KwaZulu- Natal, South Africa. The interdisciplinary and multidisciplinary approach was used in this study. RESULTS: Three main themes became evident that hinged on varying understanding of occupational health-related conditions to dental practice, how practitioners experience practising in the resource-poor settings and its impact on the dental practice. There was also a lack of awareness of the occupational health policies and practices, which could inform safe dental practice. CONCLUSION: Dental academics should gain input from a multidisciplinary team. An occupational health course with a student- centred approach would enrich the dental curriculum and make dental practitioners more aware of occupational health issues. BDJ Open (2019) 5:6 ; https://doi.org/10.1038/s41405-019-0010-3 INTRODUCTION Pain is also prevalent among dental students. Even more The number of dental practitioners in South Africa (SA) is 12,904, disconcerting was the finding that revealed the prevalence of pain which consists of 9541 dentists, 1094 dental therapists and 2269 among dental students and the fact that the percentage of pain oral hygienists serving a population of 55.91 million people. among students steadily increased from the first (41%) to their Eighty-six percent of the dentists in SA are employed in the non- fourth year (71%). Incorrect postures with sudden flexure of the 2 6 public or private sector. There is an unequal distribution of dental neck and cervical twisting puts students at risk of muscle pain. practitioners within the public and private sector placing Eighty percent of dental students at the University of Cartagena, practitioners in the public sector at risk of occupational health- South America reported pain due to clinical practice. Female 5,6 related conditions due to a higher workload and patient volumes. students were found to be at a higher risk of developing pain. There is a need for dental practitioners to be free of occupational Researchers in a South African study reported a high level of stress health-related conditions so that they can be productive, healthy among dental students with stress levels peaking in the fourth and serve the population for a longer time. year of study. Dental practitioners are at risk of various occupational health- Statistics among students and young practitioners indicate a related conditions. The systemic diseases of concern in the South need for greater awareness in dental curricula to prevent African setting specifically relates to HIV, TB, hepatitis C and occupational health-related conditions among dentists. It is thus hepatitis B. In addition, they are exposed to allergies including clear that training about primary prevention of the many monomers, latex and solvents that cause dermatitis and occupational hazards is a necessity to ensure that students respiratory diseases. They are also exposed to physical hazards become more aware of their body position and work habits. due to radiation and noise. A previous study on dental Occupational health-related conditions are prevalent among practitioners in KwaZulu-Natal, South Africa reported on ergo- dental practitioners. Stress, musculoskeletal disorders and percu- nomic factors that impacted on practitioners’ health that included taneous injuries are issues that are common among both young musculoskeletal disorders, carpal tunnel syndrome and other and experienced dental practitioners. To include occupational overuse disorders. That study highlighted how a lack of health in a dental curriculum required perspectives of various awareness of occupational health principles and safety impacted disciplines and in this study, the researcher engaged in a focus on the health and productivity of dental practitioners. Occupa- group discussion to get multi-stakeholder input into the dental tional health is defined by the World Health Organisation as curriculum. Physiotherapists, occupational therapists, occupational “all aspects of health and safety in the workplace and has a strong health specialists, ergonomists, optometrists and audiologists focus on primary prevention of hazards”. were also part of these discussions. This team would input from 1 2 Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa and Discipline of Clinical and Professional Practice, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa Correspondence: R. Moodley (moodleyra@ukzn.ac.za) These authors contributed equally: R. Moodley, J. Van Wyk Received: 9 July 2018 Revised: 7 October 2018 Accepted: 15 October 2018 © British Dental Association/Macmillan Publishers Limited 2019 Multidisciplinary perspectives to prevent occupational health-related. . . R. Moodley and J. Van Wyk a coordinated range of skill, expertise and clinical experience as specialists, ergonomists, optometrists and audiologists. The third discussed by Young, 1998 who further stated that such a team focus group consisted of dental practitioners with clinical allows input for a common goal. experience and clinical supervision experience (n = 13). The last Focus group discussions were conducted to determine what group consisted of dental academics who had been involved in could be included in the dental curriculum to make dental clinical supervision, curriculum development and who taught on students aware of self-care in terms of their occupational health. the undergraduate programme (n = 7). A facilitator conducted the The interdisciplinary and multidisciplinary approach was used in focus groups while the researcher played the moderator’s role to this study. A multidisciplinary approach to dental education would reduce bias. The focus group used semi-structured open-ended be to draw from different academic disciplines to redefine an questions. The discussions centred on personal experiences, approach or understanding and, in the case of this study, it would experiences in academia, challenges in dental training and be to design a course by getting multidisciplinary input. The recommendations for dental training and curriculum content. rationale for the use of this approach is that occupational health- Each focus group discussion lasted between 60 and 90 min. This related conditions are treated by a team of health care workers qualitative approach using semi-structured focus group discus- and their input was required. sions rather than questions allowed us to investigate broader The dental curriculum prepares a student for work placement areas of concern and was relaxed as it was semi-structured. In the and traditionally dental curricula focuses on the core competency end, the participants themselves gave positive input about the of graduates. Education and training is vital to ensure safe and focus group. In addition three interviews were conducted with healthy working. Alli, 2001 suggested that health and safety stakeholder participants who were unable to attend the discus- principles be incorporated into student training relating to the sions of their particular focus group and the data were added to needs of the profession. that collected from the group. One of the major health issues that emanates from students as This phase of the study was part of a larger study that they progress in academic years is stress, which impacts on investigated the role of occupational health in dental training. students’ and dental practitioners’ well-being. A study conducted Ethical clearance was obtained from the Humanities & Social in a dental school in Karnataka, India reported that stress levels Sciences Research Ethics Committee (UKZN)—reference no: HSS/ among dental students showed a marked increase from first to 1490/015D. All participants were informed of the study through an the fourth year with stress peaking in the second and third year. information letter; they completed an anonymous demographic Fear of failure was the highest stressor. Similar results can be sheet and signed written consent prior to participation. They also seen in the Jordanian study where fourth and fifth-year students consented to an audio recording. They were given the option to displayed higher levels of burnout. Senior students in a Saudi withdraw from the study at any stage. The anonymity of Arabian study showed higher levels of stress than first-year participants was assured and maintained throughout the study students. For students at a South African University, stress by using participant codes instead of names. All data were kept in peaked in the fourth year (47.9%) with stressors including lack of a locked password protected e-file. effective teaching/lectures in the first year (49%) and lack of The audio recordings were transcribed verbatim and checked motivation in the second year (39.2%). A lack of student input into for accuracy. The transcripts were sent to a participant in each management decisions and the non-response by management to focus group for member checking or respondent validation. This the needs of students were issues with fourth and fifth year was conducted to establish rigour and validity. The data were students (40 and 50%). The research displays that there is a need then thematically analysed. All transcripts were read and the to teach stress prevention at universities. It needs to be reinforced researchers made written notes and noted patterns. Broad themes at universities where it is already being done. were identified, according to the main aim, then further refined This study, reports on a qualitative case study conducted in the and coded after which the final analysis was done. University of KwaZulu-Natal, South Africa to elicit the occupation- related challenges experienced by dental practitioners in dental practice. This study also provided recommendations for a multi- RESULTS AND DISCUSSION disciplinary team including other health care workers. The input The demographic details of the participants are summarised in included specific curriculum content/topics to ensure a more Table 1. All participants (n = 36) were qualified with an under- occupationally responsive dental training programme. graduate degree (in either health science, dentistry, dental therapy or oral hygiene) and some participants had postgraduate qualifications (n = 14). The table shows the years of experience as RESEARCH METHODS a practitioner. The average age of the participants was 40–50 Ethical clearance was obtained from the Humanities & Social years. Most of the participants had previous experience in Sciences Research Ethics Committee University of KwaZulu-Natal curriculum development with some reporting experience also in (UKZN)—reference no: HSS/1490/015D. curriculum review. Three main themes emerged in response to the A descriptive qualitative study was conducted to explore the questions explored (as indicated in Table 2). The themes were; perceptions and challenges of dental practitioners, dental varying understanding of occupational health-related conditions academics, physiotherapists, occupational therapists, occupational to dental practice and how practitioners experience practice in the health specialists, ergonomists, optometrists and audiologists resource-poor settings and its impact on the dental practice. There about dental training from an occupational health perspective. was also a lack of awareness of the occupational health policies All the practitioners were selected for having had more than and practices, which could inform safe dental practice. five years of clinical experience in dental practice or in practice in Practitioners also offered recommendations for curriculum their own field. A purposive sampling strategy was used to recruit content about self-care and occupational health to include during participants for the focus group discussions. Four focus group dental training (as indicated in Table 3). Table 3 also includes the discussions were conducted between May and June 2017. A total sub-themes, a basic description and the supporting evidence. of 36 participants participated in the four focus group discussions. The combined input of dental practitioners from multiple The participants in focus group one consisted of a group of dental disciplines was beneficial in the consideration of a dental practitioners all who had experienced an occupational health programme including occupational health principles. From the problem (n = 7). The participants of focus group two consisted of focus group discussions, it became clear that participants strongly a team of multidisciplinary professionals (n = 9) representing supported the inclusion of an occupational health course. They physiotherapists, occupational therapists, occupational health suggested that it be introduced in dental training and for an BDJ Open (2019) 5:6 1234567890();,: Multidisciplinary perspectives to prevent occupational health-related. . . R. Moodley and J. Van Wyk interdisciplinary approach to be followed during the curriculum design process. Participants of focus group one recommended that input is sought from audiologists, occupational therapists, physiotherapists, ergonomists and occupational health specialists. CHALLENGES Understanding occupational health One of the participants highlighted the psychosocial aspect of occupational health. Both physical and psychosocial stressors are prevalent in dentistry. The participants highlighted the physical aspects of dental practice. Participants of this study, had a perception that musculoskeletal disorders (MSD) was the only occupational related health condition among dental professionals. An explanation for this is that MSD is the most prevalent and most reported among dental practitioners. This can be seen in Phase 2 of this larger study where the occupational health-related problems were investigated among dental practitioners in KwaZulu-Natal South Africa, where MSD has the highest pre- valence among the occupational health-related issues. To reduce the prevalence there must be a change in dental training as MSD symptoms start in dental school and progress into practice. Dental practice in South Africa The focus group three discussions revealed that dental training prepares students for private practice and not public practice. This was seen in an American study where the researchers recom- mended that more topics related to public health and practice be included in the dental training. There were mixed feelings on whether dental training should prepare students for public practice as most of the students are employed in the private sector. Those who are employed in the public sector faced with high patient volumes for which they were not prepared causing stress. According to Baldwin et al., there is a significant difference between those working in public and private practice in terms of workloads and financial burden. Stress management should be introduced at first- year level so that students learn to manage their stress. Dental training in South Africa Recommendations. An occupational health medical at the beginning of preclinical years will make students aware of the prevention of occupational health problems and should be followed twice a year when employed. Dental curriculum includes posture in preclinical years as seen in the results of these focus group discussions. Clinical supervisors pay attention to the tasks at hand rather than the posture of the student. The recommendations from dental practitioners in this study were to include a course on occupational health in the final year of training while there should be a link in each clinical module with clinical assessments. The patient position in relation to the operating position is important in the prevention of carpal tunnel syndrome. The hand and elbow in relation to shoulders should be lower. Stretching of the body and rotation of hips while working predisposes the operator to MSD. The inclusion of the causes of MSD, the muscles involved, the physiology of this kind of pain and its prevention should be included in this possible module. The selection of dental instruments, weight andgripinfluence the type of pain experienced by dental practitioners and should also be included. A practitioner will select instruments based on funding rather than what is ideal. Feng et al. concluded in their study on the prevalence of work- related musculoskeletal symptoms of the neck and upper extremity among dentists that the inability to select new instruments places dental staff at a higher risk of shoulder, wrist and hand pain Hand injuries are due to high pinch forces when working with a gloved hand and the textured appearance of dental instruments plays a role in the force applied to the instrument which invariably affects the grip. Regular aerobic, BDJ Open (2019) 5:6 Table 1. Demographic information and experience (teaching and clinical) of participants Average age Profession Post held Qualification Average years of Average years of Involvement in curriculum design experience as a experience as an practitioner academic Focus group 1- dental 40.7 Dentist, dental therapist and Lecturers and clinicians Undergraduate degree 19 6.7 Two participants had experience practitioners with oral hygienists (n = 5) with curriculum design and occupational health Master’s degree (n = 1) development problems (n = 7) PhD (n = 1) Focus group 2- 43.7 Optometrist, physiotherapist, Lecturers, senior Undergraduate degree 20.8 years 12.1 All participants except for one multidisciplinary team (n = ergonomist, audiologist, lecturers, professors and (n = 2) Master’s degree had experience with curriculum 9) occupational therapist, dentist, clinicians (n = 2) design and development. Three dental therapist, dentists PhD (n = 5) participants were involved with curriculum reviews at other universities Focus group 3- dental 41.6 Dentists, dental therapist and Dentists, dental Undergraduate degree 17.5 All participants are Two participants had experience practitioners (n = 13) oral hygienists therapists and oral 9(n = 13) clinical supervisors with curriculum design and hygienists that have with 2 having development honorary clinical teaching experience supervision posts Focus group- 4 dental 49.1 Dentists, dental therapist and Senior tutors, lecturers Undergraduate degree 23.1 12.1 All participants had experience academics (n = 7) oral hygienists and senior lecturers and (n = 2) with curriculum design and clinical supervisors Master’s degree (n = 2) development. Two participants PhD (n = 3) were involved with curriculum reviews at other universities Multidisciplinary perspectives to prevent occupational health-related. . . R. Moodley and J. Van Wyk Table 2. Themes emanating from focus group discussion Main theme Sub-themes Description Quotation/supporting evidence Challenges Understanding occupational There were different views on what “pain relating to the work that you basically experienced in dental health. This occupational health entails do” (focus group 4, participant 1) practice and training “the first thing that comes to your mind when you hear occupational health, that it is not just not purely physical it is the psychosocial aspects and that congruence between what you experience physically and what you experience psychologically.” (focus group 3, participant 2) There was a lack of holistic understanding “So, I understand it to be the procedures we of what occupational health entails do, the physical activity and how it affects your quality of life. That’s what I perceive it to be” (focus group 1, participant 1) “I never really thought about it until I started working, and then I kind of wised-up in terms of my posture, my surroundings” (focus group 1, participant 2) Lack of understanding occupational health “I would say it is divided into two it is strictly risks and hazards inherent in the dental work-related and strictly human factor practice related. For the work-related it seems your chair your equipment…” (focus group 4, participant 5) Perception that muscoloskeletal disorders “I think for me I just consider the physical.” (MSD) was the only occupational hazard (focus group 3, participant 3) Dental practice in SA. Some were First world versus third world. Resource- “When I moved to Australia I worked in a aware that high-income poor settings were experienced as very clinic there where part of our regime was at countries instituted better limiting. Lack of equipment and resources quarter to ten you would stop working and policies. in low-income countries you would take your tea break and do stretching exercises. Just stretching and then before lunch we do the same before you went on lunch and that was enforced even if you had a patient you had to stop go and do you exercise.” (focus group 4, participant 5) “Sometimes we use the visors for week, two weeks. I had a visor for like three weeks and I couldn’t even see properly.” (focus group 4, participant 5) Dental Training under resource Lack of resources is common as dental “We start off wrong and that is the biggest restricted conditions training or dentistry is not seen as priority problem. This is where it starts when you are in SA not sitting properly everything else goes wrong because it is your positioning because we have chairs that are not working properly not adjustable properly they do not roll properly…” (focus group 4, participant 5) “I also agree with what……. is saying is that if you want to make something a habit the environment has to be conducive. So, where we are teaching it not in the pre-clinic there we have typists, chairs and the one head will be right down and the other head on the top. So, we are teaching them in a wrong environment if we have the right equipment.” (focus group 4, participant 1) Lack of awareness of Participants do not know if principles and “what lacks in private practice is policy and occupational health policy/ policies were in place. procedure” (focus group 1, participant 6) principles “Because only after I went through everything did I realise there’s a huge manual on what constitutes a hazard and repetitive strain injury. And I ticked every box and I thought oh my god, I have been through all this and I didn’t know this manual existed.” BDJ Open (2019) 5:6 Multidisciplinary perspectives to prevent occupational health-related. . . R. Moodley and J. Van Wyk Table 3. Recommendations for dental training Main theme Sub-themes Description Quotation/supporting evidence Recommendations for dental Recommendations for Participants added what they “Yes, so I think for me, the first step would be to training and curriculum content curriculum thought should be included in get an idea of exactly how these working dental training environments are set up. So, to have an understanding of how these working activities work, so we call that at-risk assessment. So that’s for a person who is going into a ready-made practice. But for someone who’s starting out, I’d certainly like them to have training in how to set up the optimal work environment. So, you make sure upfront that there will be no issues. For example, if you’re going to be mixing amalgam, you make sure it is done in a separate area that is adequately ventilated. If you are using noxious gases, you use it under controlled conditions. Either you have protection, if the levels are low or some extractive ventilation. So, the first step is understanding, or redesigning the work environment or designing it in a way that these are taken into consideration. It’s far better to build from scratch, bearing this in mind, than trying to fit the work to the premises. It requires more money etc. so that’s the first step. I would like dental professionals to get a sense of the risks in what they do and what health outcomes are associated with these risks are. If they can understand those three concepts—risk assessment, specific risks and broad health outcomes—they would have a better understanding of how these can be addressed” (interview one-occupational health specialist) Recommendations for Should occupational health be a “I think it should be a module on its own— clinical practice stand-alone module or occupational hazards. Like 10 or 20 sessions and incorporated into existing in each session, talk about a hazard” (focus modules? group 1, participant 3) “Firstly, I do not think there is a need for a module that is stand-alone because it is going to be based on everything else where the student will want to pass that module” (focus group 2, participant 5) “So sitting position is important and I would add to that some back exercises lower back exercises, the back to me is very important.” (focus group 4, participant 5) stretching and strengthening exercises should be undertaken to undergraduate training. They also identified that open commu- strengthen the musculoskeletal system. Dental students should nication with clients and colleagues, variability of required skills be taught self-care as the research has shown that regular and how to increase resources in practice should be included in 24 28 training can prevent MSD. dental curricula. The occupational health specialist in this study recommended that the work environment must be optimal and all risks must be Clinical practice. Safe work practice and infection control were avoided. He suggested that if students understood the concepts highlighted and discussed in this focus group discussion. It was of risk assessment and workplace design, then they would be able recommended by Alsabaani et al., that safe work practice be to prevent work-related conditions. The study conducted by Khan emphasised in the early years of dental education. The use of and Chew recommended that theory and practice of ergo- magnification should be introduced in the first year of training nomics should be taught in dental schools as their study, which and reinforced in all years of undergraduate training. First-year was conducted in Malaysian dental schools showed a 93% students should be familiar with eye care, have regular eye checks prevalence of MSD among the student participants. Good and understand the prevention of eye injuries from level one. Eye ergonomic practices can prevent MSD and should be introduced safety and eye care awareness are compulsory in dentistry as 3,26 in the early years of training. Ergonomic training should focus dental practitioners work with sharp and rotary instruments. The on workstation design, physical job features, lifting, awkward splashes created have blood, saliva, particles of teeth, restorative postures and repetitive tasks. materials and oils from the headpiece and micro-organisms. This 29–31 Dental practitioners should mobilise their job resources and leads to injuries when the eye is unprotected. When wearing stay engaged in their work. Practitioners with good job control eye protection, these injuries do not occur but unfortunately 32,33 and those who constantly improve their work by being innovative compliance with eye protection is poor. Dosimeters to are the ones who best deal with their job demands. The monitor radiation exposure levels should be introduced. Staff researchers in the Hakanen study revealed that how to stay and students in dental radiography currently do not use engaged in your work is something that should be taught in dosimeters. When one draws from Singh’s article, a single BDJ Open (2019) 5:6 Multidisciplinary perspectives to prevent occupational health-related. . . R. Moodley and J. Van Wyk accidental exposure to high radiation may produce biological 13. Al-Sowygh, Z. H. 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Published: Apr 11, 2019