HEALTH AND SAFETY IN DENTAL LABORATORY Postgraduate THESIS L. Koutsopodis DDT, Msc, V. Drakopoulos, T.C.C.Konstantinidis, M.D. 1.

Dental Technologist (TEI), Master of Science in Health and Safety in Workplace Medical School Democritus University of Thrace. 2. Occupational Physician, ELINYAE 3. Adjunct Professor, Occupational Physician, Supervisor of the Laboratory of Hygiene and Environmental Protection, Medical School Democritus University of Thrace.

SUMMARY INTRODUCTION: It is a well- known fact that employees on a daily basis face many hazards concerning their health and safety. Every employee confronts a series of safety risks (lack of safety measures, poor building structures, lack of literature) and health risks (exposure to biological chemicals and natural hazards). It is considered highly important to evaluate workplace hazards in order to deal with them effectively. It could be said that to evaluate professional or workplace risks, a combined effort is needed by a) the professionals of a business so that the risks of the production process are determined b) by specialized individuals (ex. safety engineeroccupational physician) to analyze the possibility or coincidence and c) by the manager or supervisor to decide on the necessary measures to be taken. [2] Some sources of hazards which may threaten ones health or physical well-being are as follows: Work materials (ex. Chemical substances which in many cases are great hazards due to their composition and handling, etc. To what degree the equipment in the workplace is in accordance with rules and regulations legislated by the state. Basic rules and demands should be met regarding the surrounding and work conditions so that an individual may work safely. The method and manner in which work is conducted: In any form of work potential risks may rise. It is therefore important there exist a proper outline, work protocol and preparation (techniques, methods, measures) in order for employees health to be protected and accidents be avoided. Many activities performed by the worker may potentially put at risk their physical well-being. Some examples are a) not complying with the safety measures required by the employee to clean a device b) the careless handling of a substance or not using proper protective gear. The structure and organization of a business: A highly important factor affecting the safety of the workplace is considered the manner in which it is set up, ex. if there is a safety engineer and occupational physician, if there are measures to deal with excess stress in the workplace, if there is the possibility of exchanging responsibilities among the workers so that their job does not become tedious or monotonous. [3] The natural surroundings of the workplace cause great, if not grave, danger to employees health: - Extensive noise over many years leads to lack of concentration while working and deafness to employees. - Poor ventilation in the workplace forces employees to inhale dust, toxic steam and gasses from solvents when refining basic materials such as pyrite, metal shavings and resin dust. - Poor lighting also reduces the employees efficiency as it fatigues the employee and may lead to an increase in work related accidents. - Vibrations or frictions from moving instrument parts cause long lasting swelling of the arteries, bruising of the hands, agitation and damage to the nervous system.

Non-ionized radiation (electromagnetic, micro-waves, laser beams) cause injuries to the eyes, skin cancer, inflammation of the retina, etc. [8] Chemical factors in the workplace are quite many and may lead to serious work related illnesses. This of course depends on the structural design of the workplace and to what extent the employees are exposed to these factors. [9] It is estimated that over the past few years more than 80,000 chemical substances have been used in industry, and every year 200-700 new ones are added which are massproduced. Many of these are caustic, toxic, carcinogenic or explosive. Pneumoconiosis, contact dermatitis and acute allergies are very common work related illnesses for employees who handle chemical substances and solvents. Oils, resins, plasters, medicines and more which cause work related pulmonary disease and skin related diseases. It is also well known that heavy metals cause work related illnesses especially to the nervous, reproductive and respiratory systems. Lead, leads to lead poisoning, anemia, and nerve disturbances. Beryllium causes beryllium poisoning, cadmium causes, lung disease, renal function impairment and prostate cancer. Finally, asbestos leads to mesothelioma and pulmonary cancer. Biological factors (germs, bacteria, viruses, etc) are considered responsible for a significant number of work related diseases, such as hepatitis A-B and tetanus. Adhering strictly to health regulations in the workplace plays a determining role in limiting the detrimental effects of biological factors. Poor psychological, social and financial factors which exist in the workplace are considered serious causes of health problems especially when referring to a psychosomatic level. The hustling pace, overtime, lack of literature regarding work related hazards, appreciation of the produced work, business relations and other factors can directly affect the quality of the work. [14,15] PURPOSE: Is the study and objective evaluation of dental technologists regarding the health and safety of their workplace, reaching conclusions and forming suggestions in order to improve their health. The dental technology laboratory is a business which undertakes every nature of prosthodontics and orthodontics appliances. These undertakings are done solely in the laboratory based on the impressions and the instructions given by the dentist. Creating the necessary appliances requires the use of specific dental materials along with the technical experience and skills used by professional dental technologists. Skills, as well as a great amount of creativity, are also needed so that the final product satisfies scientific and aesthetic demands. [4] The practice of this profession demands mental, physical and psychological effort which in combination with the working conditions, leads to getting tired early, the occurrence of work related health problems or the causing of a work related accident. Most common illnesses are possible infections, dermatitis, allergies, chronic poisoning, lung cancer, musculoskeletal disorders and pneumonoconiosis. [5][6] The workplace which includes: facilities, machinery, materials, transport means, etc, plays a significant role due to the fact that it comprises the area where professionals spend a great deal of time in. Determining the conditions as to whether or not health and safety exist in the workplace is thus important, as they affect the efficiency and disposition of the employees. [7] METHOD: In order to investigate work related conditions and its effects on the health of dental technologists, a prototype questionnaire (12pages) for objective evaluation was drawn up according to international models and was distributed to 230 dental technologists in the city of Athens, regarding the science of health and safety in

workplace. The questions targeted work related conditions, materials used, lab procedures and musculoskeletal problems. RESULTS: The results of this research showed that the 169 dental technologists who replied had a mean age of 37,4 years (11 years). 61,5% of the participants were male and 38,5% female, as opposed to the study of G.Drakonakis [16] who were 88,2% and 11,8% accordingly. In addition, a relatively similar percentage can be seen in Roms et al. 1984 study [17] which is in contrast however to the Sherson et al. 1988[18]. 51.2%of the participants were smokers, a percentage which is lower than that of the dental technologists who were questioned in Crete, which was 62,7%. Average age of smokers was 16 (9,5) and a mean number of cigarettes smoked daily was 18,1 (10). Previous years of experience in this specific lab was 10,3 (9,3) and in other labs 6,9 years of experience (6,4) and in other fields was 4,2 years (5,2) though average weekly work hours was 45 (10,4) hours. The percentage of workers employed by dental technologists is 79,8% with average rate SD employees, 6,9 (6,3) which seems in accordance with the study of Choudat D et al 1994[19] which mentions an average of 2 and a range of 1-12 employees. 75,1% of the participants worked in a general prosthodontics lab and on average 8,9 hours (2) a day. It is noteworthy that though 58,6% report that there is a safety engineer employed in the lab that they work in, only 35,4% recognizes the MSDS of materials used and that only 42,5% have been trained on matters of health and safety in the workplace. A great percentage (74,7%) replied sometimes/often having problems with the noise while working metallic frameworks. Rarely/hardly ever were earplugs used by 95,2% of the participants. This percentage is exceptionally greater than the 15% percentage which was reported in Jacobsen N, et al, 1996 [20] who conducted his study among Sweedish dental technologists in and is the sole report which includes a number of issues concerning the health of dental technologists. The fact that 69,6% suffer from punctures often/sometimes and that 69,7% suffer serious cuts is very significant as such injuries allow pathogenic microorganisms as well as toxic chemicals to enter the body. 97,6% report that work is at an intense pace, due to the great degree of responsibility one has (88,6%). It is possible for someones mental status to become affected (mental fatigue 64,8%) and a reduction in the level of concentration while at work can occur leading to an increase in injuries which has already been observed[23]. We could compare our studies to the work related fatigue experience by those in the field of health as in the study of Xirotiri-Koufidis, 1991[24] in which the fast pace of work and great sense of responsibility leads to work burnout. A significant percentage of dental technologists 77,7%, report anxiety during work and 58,2% feel they receive little appreciation. Moreover, 57,4% of the participants claim they sometimes/often receive pressure by dentist offices when accepting orders. We can concur that the job of a dental technologist is one of great stress. These findings agree with the Park NG et al study 2003[14], which was conducted in Korea. Their results mention that better organization, cooperation with the dentist and business management may bring about a reduction of stress in the workplace. 12,1% of dental technologists report having allergies to methacrylic methyl. This percentage is less compared to the clinical study of Ingrid E et al 2009 [25]. It is however an important finding that 17,8% of dental technologist report symptoms of contact dermatitis or eczema. While manufacturing orthodontics appliances vinyl gloves are rarely/hardly ever used ( which is recommended when handling acrylic resin) by 91,7% of the participants. 94,8% of

those who participated rarely/hardly ever wear vinyl gloves when generally using acrylic resin. Pathologic symptoms may be due to allergic dermatitis from the acrylic resin or to an allergic reaction from the metals and dusts, or even ceramic fibers as mentioned in M. Kiec-Swierczynska and J.Wojtczaks study 2000[26] which was conducted among dental technologists in Poland. Dermatitis or eczema may also be due to biological factors as reported in Nayebzadeh A et al 1998[27], a project which also mentions skin disorders among Danish dental technologists. Regarding the effects of acrylic on the nervous system, dizziness (33.3%) is reported, a fact that is supported by Fabrizio E et al in his study 2007 [27] proving that the nervous system of dental technologists from exposure to steam and methacrylic dust becomes heavily burdened. 29,4% of the participants are employed in labs where special space is provided for impressions and workpieces. 43,9% of dental technologists replied that only 25% of the received impressions are disinfected in the lab though only 20,6% of the received impressions from dentists are disinfected. 69,8% rarely/hardly ever disinfect their instruments or equipment. 81,1% of the participants believe that there is a risk of infection. Though only 17,8% of the participants have had their first vaccination for tetanus, 11,2%the second and 17,2% the third required vaccination. As far as the hepatitis B vaccine is concerned, 20,1% of the participants have had the first and third required vaccine and 17,2% the second. Finally, 7,5% of the participants have undergone tests or other examinations which are connected to work related hazards or exposures. These findings are important as they prove the danger of contracting infections in the dental technologists lab as well as the danger of employees becoming infected. These findings exist in may other studies such as that of Vodjani M. et al 2006[29] and Verran J et al 2004 [30]. Symptoms which dental technologists frequently complain about are eyestrain 83,2% and headaches (48,8%). These symptoms may be because the job of the dental technologist demands detail as well as many hours of work in poorly lit (34%) or well ventilated (51%) workplaces. Other significant contributors are acrylic steam, as well as dust and metal shavings, which burden the working environment. The fact that 90,5% reported that air suction systems exist in the workplace is much higher than G. Drakonakis study [16] which reported only 37,3%, though 85,2% answered that dust was still present in their workplace. Only 30,4% replied having a similar suction system while producing with plaster-firestone. In the study by Herbert VS et al 2002[31] and Kim Tae Seok et al 2002 [32] it can be seen that the lack of air suction systems for plaster and firestone dust is a factor that increases the risk of inhaling materials which cause work related pulmonary disease. Respiratory symptoms such as dry cough (25,7%) and cough with sputum (23,7%) was also quite high as mentioned by dental technologists. These symptoms may be because ventilation systems are not used and self protection systems (masks) are not worn during procedures which involve dust or steam. It can be concluded that dental technologists have not understood the value of protective equipment even though they are in a lab from the beginning and are exposed for long periods. In previous studies, the use of beryllium-containing alloys by dental technologists is mentioned. In our study, dental technologists have not yet stopped using berylliumcontaining alloys. The development of chronic beryllium disease (CBD) may even happen while being exposed only for a few months to alloys containing little amounts of beryllium. 32,1% (55 out of 169) of the participants replied using Ni- Cr-Be alloys. Of these, 89,1% use them daily. Moreover, 37,9% (64 out of 169) replied using Cr-CoBe alloys of which 80% use them daily. 24,3% ( 41of 169) replied using Cr-Co, of

which 78% use them daily. Not wearing a special mask during the welding of alloys was seen in 86,1% of the participants which is a very high percentage. The steam from the alloys during the heating process (distilling-welding) affects the nervous system due to its toxicity, but on the eyes and skin as well, as they are also affected. In the study of T. Hannue et al. 2007 [35] the connection between work related asthma and the acuteness of the symptoms of employees in refineries who are exposed to steam from casting from 1994-2003 are investigated. It is pointed out that the employees (including the dental technologists) quite frequently present respiratory symptoms and it is noted that the risk of lung disease suffered by employees in this field must be extensively examined. As far as musculoskeletal strain, a high percentage of employees (44,7%) mention suffering from neck problems over the last 12 months. Furthermore, it can also be considered that a large percentage (42,1%) complain of shoulder pain, 28,4% complain of upper and 34,4% of lower back pain. Dental technology is a sedentary form of work, a fact we can see from the results since in an average working week one works an average SD of 45,0% 10,4 hours. In addition, poor body posture (25,5%) is a fact that weighs heavily on the musculoskeletal system of employees. This may also be related to the anxiety and stress of the intense pace of this profession. Out of the 40,3% of those asked, 37,1% complained about numbing of the digits and hands in general. These problems probably are related to ergonomic problems, stress while at work and generally muscuoskeletal strain of the upper limbs. In the Jacobsen N. et al study 1996 [20] conducted on Sweedish dental technologists similar complaints were reported as well as work related health problems such as skin disorders, musculoskeletal and neurological problems. Moreover, in the study by Lache S et al 2008[36] it is mentioned that vibrations while working also burden the employees musculoskeletal system. Given that 28,7% of the dental technologists who participated in our study complain about recurring problems suffered in the digits and hands as a result of the vibrations, we can concur that employees health and hands are affected and that it is therefore absolutely necessary to use dental lab micromotors or vibrating instruments with caution. CONCLUSION The dental technology lab is burdened with substances which come from the numerous varieties of materials used as well as by the instruments. The substances which are used by employees or dental technologists who participated in our study do not differ from those used by all dental technologists as seen by existent studies. These studies mention the discontinuing of toxic substances and replacing them with other less toxic. Moreover, it is suggested that proper equipment be readily used as well as abiding by the health and safety regulations. The health issues professionals face are many and significant, and of those observed quite grave. The improvement of health in the professional workplace requires better training and literature to be provided to the employers and employees. Systematic observation and handling of problems as well as adjusting the conditions of the working environment to those required internationally to improve health and safety. Further studies must be conducted so as to study working conditions and professional hazards dental technologists encounter. Educational programs must be designed regarding matters concerning health and work safety.