PHYSICAL AND ERGONOMIC OCCUPATIONAL RISKS FOR DENTISTS AT DENTISTRY CLINICS IN HOSPITALS: A CASE STUDY IN A HOSPITAL IN BRASÍLIA-DF

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1 PHYSICAL AND ERGONOMIC OCCUPATIONAL RISKS FOR DENTISTS AT DENTISTRY CLINICS IN HOSPITALS: A CASE STUDY IN A HOSPITAL IN BRASÍLIA-DF Teresa Cristina Villamarin Lopez (UCG) tecrisvillamarin@yahoo.com.br LENITA VILLAMARIN LOPEZ LESSA (UFPB) lenitalessa@yahoo.com.br At private clinics in public or private hospitals, surgeon-dentists are subject to several occupational risks. The present article intends to accomplish an evaluation of the surgeon-dentists physical and ergonomic occupational risks at thee dentistry clinic of a hospital in Brasília-DF. For such, a qualitative study was accomplished, of exploratory and descriptive character, with the aid of a field research and a case study. Data were collected by the application of programmed questionnaires, with closed questions, to all surgeondentists at the hospital dentistry clinic, thus obtaining full representativeness. The research evidenced some points susceptible to immediate improvement, especially in what concerns the use of complete IPE, divulgation of individual dosimeters reading results, radioprotection, ergonomic aspects at the working place and stressing factors such as rigid productivity control and long working periods. In order to minimize the occupational risks among the surgeon-dentists at the studied clinic, it s suggested to the hospital to implant lecture cycles regarding risk awareness, as well as give widespread information about individual dosimeters reading results, rearrange physical working places and provide auxiliary personnel to help dentists. Palavras-chaves: dentistry; occupational risks among dentists; physical risks; ergonomic risks

2 INTRODUCTION The accomplishment of the most varied tasks can lead to direct or indirect health disturbances, known as occupational diseases. Surgeon-dentist's profession is subject to a wide spectrum of occupational risks, among which the most common are the ones of biological character, which may bring contaminations through direct contact with infectious lesions or with blood and contaminated saliva. Occupational risks are regarded as the possibility of loss or damage and the probability that such loss or damage happens, which implicates in the probability of occurrence of an adverse event. The most frequent risks under which surgeon dentists are subject when giving attendance to patients are the physic, chemical, ergonomic, mechanical, of accident, as well as the ones caused by lack of comfort and hygiene and, also, the biological ones. Physical risks are those that happen due to exposure to physical agents such as noise, vibration, ionizing and no-ionizing radiations, extreme temperatures, deficient or excessive illumination, humidity and others. The causes of such risks are high speed hand pieces, air compressors, X-ray and laser equipments, curing lights, autoclave sterilizers and air conditioning devices, amongst other agents (ANVISA, 2002). The exposure of those professionals to chemical agents such as dusts, fogs, steams, gases, mercury and chemical products in general, meets its main causes in the amalgam devices, chemical disinfectants as alcohol, glutaraldehyde, sodium hypochlorite, peracetic acid and chlorhexidine, as well as the medicinal gases, as the nitrous oxide, for instance (SAMARANAYAKE, 1995). Ergonomic risks are those caused by incorrect positioning, inexistence of auxiliary technician staff or deficient staff training, constant attention and responsibility demands, bad planning or no planning at all, excessive work rhythm or repetitive actions, amidst other causes. Mechanical and accidents risks are characterized by the exposure of dentists to mechanical agents or those that can drive to accidents and most concurrent causes are the subdimensioning of physical space, inadequate physical arrangement, existence of inappropriate procedure instruments, fire or explosions danger, problems in the physical building construction, improvisations in the hydraulic and electric net and no adoption of IPE (individual protection equipment). Lack of comfort at work leads to risks in situations in which there are, for instance, sanitariums in insufficient number and without gender separation, lack of personal hygiene items at the lavatories such as liquid soap and disposable towels, absence of drinking water, no supply of uniforms, absence of airy atmospheres for leisure and comfortable for rest, absence of dressing rooms with closets or inexistence of adequate places for snacks and meals. Biological risk is the probability of occurrence of an adverse event due to a biological agent's presence. The occupational exposures to biological potentially polluted materials may turn to a serious risk to dentistry professionals at the working places. Studies developed have shown that accidents involving blood and other organic fluids are related to the exposures more frequently told (APECIH, 2008). When working at dentistry clinics in hospitals, dentists many times accomplish workload periods superior than 40 hours, that including night work and weekends. Such factors increase 2

3 the level of demands and attention and drive to time reduction during and among procedures, which may be considered another a specific cause of accidents risk. In all situations, may it be at private clinics or public and private hospitals clinics of any type or size, dentists are subject to several acquired diseases caused by direct contact (hands or skin) or indirect contact (working surfaces), due to proximity and exposure period during procedures, and standardized precaution measures should be adopted when dealing with all patients. The regulating organisms of the profession, as well as the Brazilian National Agency of Sanitary Surveillance (ANVISA) offer studies and prescriptions regarding the correct methods of protection and prevention from occupational risks to which dentists are subject, giving larger emphasis to biological risks aspects. Once general attention turns, at first regulation level, to biological risks, as a consequence, physical, chemical, ergonomic and mechanical risks use to appear without much notice and often become a common cause of problems with high occurrence which are most of the time little reported as an occupational risk. Thus being, the problem regarded in the present study finds its central axis in trying to understand which physical and ergonomic occupational risks dentists are subject when working at dentistry clinics in a hospital. Academic-theoretical contributions could be given on the theme, especially in what concerns physical and ergonomic risks may guide professionals and hospital managers to the easiest identification of critical points of risks, with the aid of an updated and useful conceptual base for decision making, when necessary. Additionally, knowledge concerning the current levels of dentists occupational safety may turn into an important technical contribution to a better control of the risk variables involved. When reducing occupational risks, it may be possible for dentistry clinics to offer higher quality and reliability services, thus granting as much well-being to dentists team as well as to patients. The present article intends to evaluate the occupational risks, in their physical and ergonomic aspects, to which dentists that work at a dentistry clinic of a hospital in Brasília, DF, Brazil, are subject. For such, a case study was accomplished, with data collected in field and through the application of programmed questionnaires to all dentists in the clinic. 2 METHODOLOGICAL PROCEDURES The present study is of qualitative nature and presents an exploratory and descriptive character. According to Vergara (1997, p. 53), "the descriptive research exposes characteristics of certain phenomenon or establishes correlation among variables and it defines its nature". As for the means, it is a bibliographical, documental and field research, as well as case study. The documental research was accomplished through the analysis of the official documents at the studied hospital and by researching the Brazilian regulation and normalization organisms that specify occupational risks for dentist, as well as Federal and Regional Council of Dentistry, ANVISA. 3

4 Data were obtained through the application of programmed questionnaires with closed questions, to 29 surgeon-dentists, among a population of 29 of those professionals, which reached a representativeness of 100% of dentists at active work. In accordance with the bibliographical revision regarding the theme, the variables used as reference for the present study are defined below: DEPENDENT VARIABLE INDEPENDENT VARIABLES DEPENDENT VARIABLE INDEPENDENT VARIABLES PHYSICAL RISK (description) ARISES FROM EXPOSURE TO PHYSICAL AGENTS Noises Vibrations Ionizing radiations No-Ionizing radiations Extreme Temperatures Inadequate Illumination Humidity ERGONOMIC RISK (description) AFFECTS MENTAL INTEGRITY Inadequate Positioning Auxiliary technical staff missing Technical auxiliary staff training Constant attention and responsibility Excessive working rhythm AFFECTS PHYSICAL INTEGRITY Frame 1: Investigation Variables Source: Accomplished research, 2009 Working space conditions Physical Arrangement inadequate Improvised instrumental and equipments Results were treated in both qualitative and quantitative ways, with the aid of descriptive statistic tools and discretionary analysis and also with the analysis of the logical correlations among results, which were all presented in graphs and tables so as to allow a broad understanding. 3 ANALYSES AND RESULTS DISCUSSION a) Dentists profile at the studied hospital Among the interviewees, 87% are women and 13% are men, with medium age 30 years old, and most (40%) have been working at the clinic for less than a year. From the remaining, 20% have been working for a period between 2 and four years, 20% have been working for 5 to 7 years and 20% have been working at the clinic for more than 7 years. From 5 to 7 years 20% More than 7 years 20% From 2 to 4 years 20% Up to 1 year 40% 0% 50% 100% Male Female 4

5 Graph 1 Gender of studied population Graph 2 Service time The research revealed a relatively young team of professionals, in which women are in greater amount, and that has been working at the hospital for a period not superior to 7 years but with significant occurrences of less than a year working period. As to the occupational risks the dentists team pointed, they are explained as follow. b) Physical risks Radioprotection - radiographies Regarding the adopted measures for radioprotection, 7% of the interviewees make use of lead shields combined with thyroid protector, 13,3% don't adopt any protection at all and 80% use to keep a distance of two meters from the X-ray device. Graph 3 Adopted protection measures in radiographies Considering that radiation use in dentistry diagnoses procedures is a frequent practice, and that ionizing radiations are imperceptible, invisible and dangerous because they are unnoticeable, when surgeon-dentists don t adopt some radioprotection measures against daily radiation doses, they will be threatened by the inherent risks of that exposure. There is evidence of risk associated with radioprotection measures at the studied dentistry clinic, once a representative percent (13, 3%) of professionals relate to adopt no protection measures at all. That suggests the need of a more intensive training and control, so as to offer wide awareness to the professionals involved. Zamata et al (2002) say that several laws and rules were elaborated with the intent of reducing current exposure doses during diagnostic radiology, among which the most important one is the Rule 453 from General Sanitary Surveillance Office (SVS)/ Health Ministry, from June 1 o, 1998, that establishes Radiologic Protection Guidelines for Medical and Dentistry Radio Diagnoses in the whole national territory. Ionizing radiations are treated as physical risks and there are recommendations on the subject also at the Prevention of Environmental Risks Program - FOR, NR-9 mentioned in the 5

6 Dentistry Bio-Safety Manual, which is a technical regulation that establishes the basic requirements of radiologic protection for radio diagnoses and disciplines the x-ray practices for diagnose and intervention purposes, so as to grant patients and professionals health. Radioprotection - individual dosimeters and access to results Although the respondents' totality (100%) say to make use of individual dosimeters, only 40% of that professionals admitted to know its readings results. Such fact strongly suggests an individual uncertainty as to the possibility of dose restrictions being exceeded. Although the results are said to be monitored by the hospital, it is advisable that all professionals have wide access to radiologic dosimeters readings, so as to trace and control the risks to which they are subject. Thus being, communication is another evidenced need, and can help avoid concerns and insecurity feelings among professionals. The follow-up of the received ionizing radiation dose to which dentists are exposed is done usually with the use of an individual dosimeter which is used in the position of the most exposed part of body: the trunk. The main objective is to monitor the exposures to which dentists are submitted, so as to grant that they are low and that dose restrictions are not exceeded. Rule MS/SVS no. 453, from June 01, 1998 disposes about the use of x-rays diagnoses, medium doses and the control of the doses in the following way: Each individual exposure, current from all the practices, should be controlled so that the values of the established limits stated at Resolution-CNEN n.º 12/88 are not exceeded. In the practices included by this Regulation, control should be accomplished in the following way: (i) the effective annual average dose should not exceed 20 msv in any period of 5 consecutive years, nor can exceed 50 msv in any year. (ii) the annual equivalent dose should not exceed 500 msv for extremities of the body and 150 msv for the crystalline lens. Still regarding the use of the individual dosimeter, The Rule for Radio protection NE 3.03, from CNEN Resolution 12/1988 instructs about radioprotection activities and workers' individual controlling. The permanent reading and evaluation of individual dosimeter is of obligatory use for anybody during permanence in controlled areas. b) specifications of the compatible individual dosimeters with the exposure conditions, such as radiation type, energy, geometry of irradiation of the body, time of exposure and dose taxes c) use of so many dosimeters as necessary for the evaluation of doses at separate areas of the body, when exposure risk is not homogeneous for the human body. d) possibility of individual dosimeters to allow evaluations in separate in doses due to exhibitions to x-rays and range, neutrons and beta radiation, when they happen. e) use of periodic and compatible evaluation procedures for individual dosimeters under the exposure conditions. [...] h) establishment of a quality control program for individual dosimeters (inspections, readings and adjustments) and calibration and, when necessary, for the evaluation of the individual dosimeters by authorized institutions ( CNEN- National Committee for Nuclear Energy). Finally, CNEN Resolution Nr. 12/1988 states that individual radiation control should be accomplished through dosimeters, in order to detect exposures, making possible for professionals to evaluate if their work conditions are satisfactory and, still, that the personal dosimeter results readings should be accomplished monthly by laboratories accredited by the State Secretary of Health. That implies that professionals should have wide access to results. 6

7 Still concerning physical risks, the surgeon-dentists pointed repetitive movements (93%), followed by lack of intervals during work period (80%), inexistence of acoustic protection in the equipments (73%), occurrences of external noises (60%), vibrations (33%) and heat (20%) and cold (5%). No perception of physical risk was pointed by 7% of interviewees Graph 4 Physical risks detected It is important to emphasize that physical risks are classified as Group 1 in Occupational Risks in Dentistry Services Manual (ANVISA, 2006). Some of the physical risks mentioned at the Manual are noise, heat, cold, abnormal pressures, humidity, ionizing and no ionizing radiations and vibrations. Individual protection - use of EPI Regarding the use of complete EPI, 20% of the interviewees only adopt protection glasses for patients, 53% only adopt EPI for themselves and 27% adopt as much complete EPI for themselves as protection glasses for patients. 27% 20% 53% only EPI only protection glasses for patient practice both 7

8 Protection glasses against halogen light Graph 5 Use of EPI by dentists When considering the habit of using protection glasses in operations that involve halogen light equipment, 73% of dentists affirmed to use them while 27% say not to make use of them. 80% 70% 60% 50% 40% 30% 20% 10% 0% use don t use Graph 6 Protection glasses against halogen light Once near 30% of professionals don t adopt eye protection during procedures, it s important to stress the point that, according to Duffy (2002), direct eye exposure to ultraviolet rays may cause temporary conjunctivitis, burning of retina and permanent blindness due to the high intensity of energy and to cumulative effects and, for such reasons, it is essential the eyes protection. Halogen curing lights emit a great component of ultraviolet radiation, which may be minimized by filters, although not eliminated at all (CCAHUANA-VÁSQUEZ, 2004). Ears protection A fact that was evidenced, and that it is worthy registration, is the non-use of ears protection (all professionals say not to adopt it), specially because 33% of the respondents pointed vibrations and 60% pointed external noises as physical risks noticed at the working place. According to Reston et al (2001), professional exercise of the dentistry tasks implies some severe occupational risks. Among them, the hearing problems originating from noises at the clinical environment are quite frequent, causing irreversible damages to active professionals. The Hearing Loss Induced by Noise (HLIN) is a gradual neuro sensory decrease of the hearing sharpness due to continuous exposure to high levels of noise, being a disease of great prevalence among dentists (FELIX,2005). 8

9 There are many prevention measures that help control or lessen hearing occupational diseases. One of them refers to the fact that dentists should include ears protection issues in their IPE ( individual protection equipment), as well as provide acoustic isolation and proceed to periodic technical maintenance of the rotating instruments, mainly of high rotation turbines, in order to minimize the noise at the clinic. Bending, refolding and retreating discharged needles Regarding the way surgery needles are discharged, when asked how they are retreated, bended or refolded, 53% of the respondents affirmed to do it with the hands, 40% revealed to use clinical tweezers and 7% accomplish the activity with the use of collector for perforatecutting material. 7% 40% 53% hands clinical tweezers collector Graph 7 Ways of discharging surgical needles When analyzing the expressive percent of dentists that use only the hands when discharging used needles, it is impossible not to figure out the amount of physical risks involved, especially because needle discharging is one of the most frequent activities among dentists. c) Ergonomic Risks The most related ergonomic risks were the absence of auxiliary personnel at the dentistry clinic (100%), followed by daily situations that cause physical or psychological stress (80%), long duration working periods (73%), needs of additional efforts and unnecessary movements when accomplishment the tasks (73%), absence of deliver unit and auxiliary table with height tuning (67%), auxiliary table or bench at difficult reach (67%)), area restrictions at the working place (53%), inadequate illumination conditions (53%) and finally, a rigid productivity control (33%). long working periods psychological /physical stress conditions rigid productivity control inadequate illumination ausence of auxiliary personnel unnecessary needs of effort and movement physical space restrictions auxiliary table and bench out of reach 9 need of equip. set and aux. table with height tuning

10 Graph 8 Ergonomic risks factors The working area should have both main and auxiliary equipments located within dentist's reach, thus allowing work to be accomplished in a comfortable way and without inadequate or unnecessary movements, leading to the smallest expense of time and energy and, with that, increasing the productivity (MEDEIROS, 1968; SCHÖN, 1973; ERGONOMICS, 1981; FIGLIOLI, 1996). As to dentistry equipment positioning at the working place, ISO 4073 (1980) offers an outline where the center represents the patient's mouth and starting from the center 4 concentric circles are drawn ( B, C and D), each one with a 0,5m distance from each other, indicating the exact position of each equipment. Picture 1 Equipment Location Scheme for Dentistry Treatment Rooms Source: Adapted from Figlioli, 1996 Circle A corresponds to the central movement space of work, where there should lay the deliver and the auxiliary units; circle B is the maximum movement amplitude recommended, from where should be possible to reach the auxiliary table and the drawers of the closet, when open. Circle C is the total area of the treatment room, where the sinks and fixed closets should lay. Figlioli (1996) also suggested space division in 2 areas through the axis 6-12 hours, and position 12 hours it is indicated by the patient's head. That division has as purpose to separate the space in two areas: to the right of the chair - the dentist's area and to the left of the chair - the auxiliary's area. Besides promoting the division of the treatment area, Figlioli (1996) emphasizes the need of the treatment chair to be located in front of a source of natural light and suggests that it should be placed in an oblique angle, so as to allow larger space at the work areas. As to the 10

11 auxiliary s chair, it should be tall enough to enable visualization of the oral cavity and have a metal ring to give support to the feet. The author also says that not only the equipments should be disposed correctly at the treatment room, but also that the door should be positioned in the ends of the walls, in order to reduce the unused areas and to make people's flow easier. Trainings on occupational risks At the appraised hospital there were registered no occurrences of lectures, trainings or awareness programs about occupational risks among dentists. Such a practice could mean a good contribution to reduce most of the risk situations detected and, also, give the basis for the building a prevention-guided organizational culture. The strengthening of a risk reduction culture is especially advisable due to the great amount of dentists that have been working at the dentistry clinic for periods of less than 1 year, once educative practices are most applicable, faster and cheaper when professionals join the corporation and are still acquiring their best practices and learning to follow the corporation regulations. 4 FINAL COMMENTS In the whole, some points that should be immediately improved were noticed at the hospital dentistry clinic, especially the ones regarding complete IPE use, information about individual dosimeters results, radioprotection and ergonomic aspects at the working places. Lectures and awareness cycles could be of help in reducing daily risk exposure situations to which dentists are subject, as well as broad studies involving all the items, standards and guidelines stated by ANVISA, ISO/Brazilian Agency of Technical Rules (ISO/ABNT) and other official agencies that consider the matter. The related stressing factors, such as rigid productivity control and excessively long working periods may be associated to the loss of attention that leads to increasing occupational accident risks that threaten all health care services professionals. It was also evidenced a relative overwork for the dentists, owing to the non-existence of auxiliary personnel at the clinic. It is essential to point out the fact that all the present circumstances related, when together, may lead to a high incidence of occupational risks at the studied hospital and that strong measures should be taken in order to reduce them. 5 RECOMMENDATIONS In order to minimize occupational risks detected among the dentists, it is suggested to the hospital: - To implant cycles of lectures, with explanation, sensitization and awareness intention, about the best practices for accidents prevention; - To standardize radioprotection procedures and supervise its adoption by all professionals; - To create, with the aid of trainings, information, awareness campaigns, supervising and control procedures, a risk prevention oriented organizational culture; - To communicate the results of individual dosimeters readings to the all professionals; 11

12 - To intensify communication in all aspects, especially in what concerns professional safety; - To reconsider the physical arrangement and urgently proceed to improvements; - To make available clinic auxiliaries to give support to the dentists; - To buy, distribute and control de use of protection lead shields, ear protection issues and perforate-cutting material collectors. BIBLIOGRAPHY ANVISA. Resolução RDC n0 50 de 21 de fevereiro de Regulamento técnico para planejamento, programação, elaboração e avaliação de projetos físicos de estabelecimentos assistenciais de saúde. Diário Oficial da União, Brasília, 20 de março de Disponível em: < APECIH. Controle de Infecção na Prática Odontológica. São Paulo: p. BRASIL. Ministério da Saúde. Controle de infecções e a prática odontológica em tempos de AIDS: manual de condutas. Brasília: BRASIL. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Serviços Odontológicos: Prevenção e Controle de Riscos / Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Brasília: Ministério da Saúde, CCAHUANA-VÁSQUEZ, R.A. et al. Influência do tipo de ponteira condutora de luz de aparelhos LED. Rev Odo UNESP, v. 2, n. 33, p , CNEN. Comissão Nacional de Energia Nuclear. Norma NE 3.02/1988. Resolução CNEN 12/1988 : Serviços de Radioproteção. DUFFY, V.; CHAN, A.. Effects of virtual lighting on visual performance and eye fatigue. Human Factors and Ergonomics in Manufacturing. v. 12, n. 2, p , Feb ERGONOMICS - Health of the dentist. In: Dent J, FÉLIX, S. Análise do Ruído Ocupacional em Odontologia: medidas de prevenção e implicações para a saúde de profissionais atuantes [Tese de doutorado]. João Pessoa: Universidade Federal da Paraíba; FIGLIOLI, M. Treinamento do pessoal auxiliar em Odontologia. Porto Alegre: RGO; INTERNATIONAL STANDARD ORGANIZATION. Dental Equipmnent - items of dental equipment at the working place: ISO Genebra: MEDEIROS, E. Princípios de racionalização do trabalho profissional. Estomat & Cult, 1968 jan./jun. PORTARIA MS/SVS nº 453, de 01 de junho de Aprova o Regulamento Técnico que estabelece as diretrizes básicas de proteção radiológica em radiodiagnóstico médico e odontológico, dispõe sobre o uso dos raios-x diagnósticos em todo território nacional e dá outras providências. Brasília: ANVISA, RESTON E. et al. Aferição do nível de ruído provocado por instrumentos de alta e baixa rotação. JBC SAMARANAYAKE, L. ; SCHEUTZ, F.; COTTONE, J. Controle da infecção para a equipe odontológica. 2. ed. São Paulo: Santos, SCHÖN, F. Trabajo en equipo en la prática odontológica. Berlin: Quintenssence Books; VERGARA, S. Projetos e relatórios de pesquisa em administração. São Paulo: Atlas, ZAMATA L, R.; ADISSI P. Proteção radiológica em procedimentos diagnósticos usando raios x. In: VII Congresso Latino-Americano de Ergonomia; XII Congresso Brasileiro de Ergonomia; I Seminário Brasileiro de Acessibilidade Integral, 2002, Recife.Anais. Pernambuco: ABERGO,

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