Introduction
Work-related skin lesions are known to commonly occur in dental professionals (dentists, dental assistants, dental technicians) and dental students, possibly leading to occupational skin diseases which rank second among occupational diseases in this profession, following musculoskeletal disorders (1-3). In most cases, work-related skin lesions are manifested as contact reactions (e.g. irritant contact dermatitis, allergic contact dermatitis, contact urticaria), commonly on hands but also on other body parts (e.g. forearms, face and neck) (4, 5). Skin contact reactions may be characterized by different clinical features including itching, erythema, papulovesicles, fissuring, hyperkeratosis and lichenification but also as urticarial lesions (2, 3). In contact dermatitis a patients’ skin is in contact with irritants and/or allergens, which can lead to non-allergic (irritant or toxic) or allergic contact dermatitis (2, 6, 7). Irritant contact dermatitis is more common and is related to skin barrier damage due to friction and various environmental/occupational factors (i.e. cold, dental materials, gloves, excessive or prolonged exposure to water or chemicals such as acids, alkali, detergents, cleaning agents, disinfectants, solvents, lubricants, dust etc.) (2, 4, 8). In patients with work-related skin lesions, the lesions recede, but relapse again after renewed exposure (2).
We should not neglect the fact that geographical, occupational, economic and even social factors can result in different exposures to irritants/allergens and, consequently, patterns of contact dermatitis which can differ from one part of the world to another (5).
According to an extensive Polish study of occupational skin disease frequency among dentists and physicians, dentists rank first, possibly due to the use of different chemicals, gloves, drugs, etc. in their everyday work (3). Moreover, recent Croatian research showed that occupational skin diseases among dentists are often related to glove use (35%) mostly due to high exposure to latex gloves as dentists may wear gloves 8 to 10 hours every working day (1, 9, 10). In a recent Japanese study among dental workers, 46.4% of dentists self-reported chronic hand eczema which was commonly reported by atopics, those who frequently washed their hands, and those who did not use alcohol-based hand rub disinfectants (11).
In order to ensure appropriate diagnostics, workup and treatment, dental professionals and students should see a dermatologist in particular. The most common diagnostic procedures in cases of work-related skin lesions are allergy tests (patch test and/or skin prick test) (2, 6). It is necessary to take care of skin adequately by use of protective hand creams, soaps for sensitive skin, and receive appropriate therapy. Although this is widely known fact, protective measures are not sufficiently taken.
Subjects and methods
Prior to the researching, ethical approval from the Ethics Committee of the School of Dental Medicine, University of Zagreb (Ref. No. 05-PA-26-6/2015) was obtained. Participation in the survey was voluntary and the respondents were included regardless of their history of work-related skin lesions.
The research included 444 subjects (dentists, dental assistants, dental technicians, dental students) who filled out a questionnaire (244 filled it out online and 200 on paper).
The respondents were 301 dental professionals (261 dentists, 37 dental assistants, 3 dental technicians) from different dental institutions and 143 dental students (second, fourth, and sixth-year) of the Zagreb School of Dental Medicine. Those who stated they had noticed work-related skin lesions were singled out (249 of them).
Questionnaire
It was requested that respondents specify if they had observed any lesions (itchy rash) on their skin and, if they had, where they were localized; had they undergone any treatments and in what way; were any allergy tests performed; and had they used any soaps for sensitive skin and any protective hand creams (Table 1).
Results
Out of 444 respondents, 249 (56.1%) observed skin lesions. Figure 1. shows their localizations.
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Analytic results regarding treatment showed no statistically significant difference between the number of those who had sought assistance and those who had not (Table 2.). As regards subjects who undertook some treatment-related measures, we found that the number of those who took self-prescribed therapy was significantly higher than the number of those who sought assistance from a dermatologist or, at least, from a general practitioner (p=0.006).
| Number of respondents | Ways of treatment | ||
|---|---|---|---|
| No treatment | n % | 113 45% | |
| Underwent treatment | n % | 90 36% | Self-treated |
| n % | 8 3% | General practitioner | |
| n % | 38 15% | Dermatologist |
*In the cases where several ways of treatment had been applied, the more specialized ones were entered.
The analysis of respondents’ histories of allergy tests showed that only 83 subjects (33%) had undergone such tests (without statistical significance p<0.001).
The analysis of sensitive skin soaps use by persons who had observed lesions showed that only 39 respondents (16%) used them regularly, 112 respondents (45%) used them sometimes and 98 (39%) never (without statistical significance p<0.001). Nevertheless, there was a significantly higher number of those who had used a soap for sensitive skin daily or at least occasionally than the number of those who had never used one (p=0.017).
Considering care with protective hand creams, of those who had observed skin lesions the majority (61%) had used them 1-2 times per day, while only 7% respondents had not. Statistically, the number of persons who had observed skin lesions and used protective hand creams was significantly higher than those who had observed lesions and had not used them (p<0.001). Of those who had used protective hand creams, there were significantly more of those who used them daily than those who used them only a few times a month (p<0.001). The frequency of the protective hand cream use is shown in Table 3.
| After every hand washing | 1-2 times a day | Several times a month | ||
|---|---|---|---|---|
| N | 25 | 152 | 55 | |
| % | 10% | 61% | 22% | |
Regarding gender and the assistance-seeking and sensitive-skin soap use factors, no statistically significant differences between genders were established. However, as regards the protective hand cream use factor, the following differences were observed: women used protective cream more often than men (97% vs. 73%; p<0.001).
Discussion
Skin lesions in dental professionals and students, connected to exposure at the workplace, are relatively common. Dental professionals and students appear to pay little attention to them and, consequently, their professional etiology can remain unrecognized (2). Apart from dentists, assistants and technicians, dental students should particularly be cautious because skin lesions can occur as soon as they start working in dental offices (which is often attributed to a latex allergy although this is only one possible cause). Thus, a recent study of dental students established that 5% of them had manifested a latex allergy, mostly as hand itching (64.5%), hand eczema (19.4%) and contact urticaria (16.1%) (12). Similarly, our recent results showed that only 7% of dental professionals and students were allergic to latex in skin prick test, which corresponds well to the subjects in the above mentioned study (13).
According to our survey results, the skin of the hands requires particular care and protective measures as most of the lesions (96%) occurred on the hands, corresponding to a Greek survey of dental professionals, which is expected since hands are highly exposed to irritants and allergens due to the nature of dental work (14).
However, when lesions occur, it is important to recognize them on time and take adequate protective measures (such as personal protective clothing, work-related precautionary measures and consistent stage-related treatment) (4). Also, the previously mentioned Japanese research showed a lack of knowledge among dental workers about skin protective measures, pointing to the need for education on skin protective measures (11). According to our results, a notable number (45%) of surveyed dental professionals and students with skin lesions had not been treated adequately or had not been to a dermatologist, with a significantly higher number of those who had taken self-prescribed therapy than those who sought a dermatologist′s assistance. It seems that lack of awareness among dental professionals and dental students of the services available within healthcare system and how to effectively access them was another barrier.
Also, regarding allergy testing, only 33% of our respondents underwent such tests (before our questionnaire), despite having observed lesions. However, it is important to determine whether and which allergens are responsible for the exacerbation and perpetuation of skin lesions so that they can be avoided. Unfortunately, according to the results of other study, the individuals with occupational contact allergic dermatitis are not fully aware of the importance of allergy testing: one study showed that some had failed to recall the allergy test results after two years (15).
Dental professionals and students are also insufficiently aware of the need to protect their skin with protective soaps and creams. Our results showed that respondents who had observed undesirable skin lesions mostly used soaps for sensitive skin only sometimes (45%) even though it is recommended that healthcare workers use them. It is also recommended they disinfect their hands with alcohol-based disinfectants containing moisturizers and, if using latex gloves, use powder-free gloves or cotton under (13, 16, 17).
Our study showed that 61% of respondents only rarely apply protective creams (1-2 times per day) despite the fact that their condition requires it. This can be explained by inadequate educational measures (18, 19). It is necessary to be aware of the need for protection of the skin barrier with protective creams, especially in case of irritant contact dermatitis wherein future occurrence of lesions or exposure to irritants can be prevented (20). Likewise, a significantly higher number of individuals who had observed skin lesions used protective hand creams than those who had not (p<0.001). Also, our results showed that women used protective hand creams more often than men (97% vs. 73%), possibly because women generally pay more attention to skin care. An adequate use of suitable skin barrier creams can be helpful especially considering the prolonged influence of glove use, which has an occlusive effect (4).
Additionally, preventive measures and skin care are also outlined by the World Health Organization (WHO) – including the avoidance of certain bad habits (excessive hand washing, use of hot water, inadequate procedures when drying hands and putting gloves on, excessive rubbing-in of disinfectants, etc.) (17). We also highlight the importance of preventive measures and their implementation, along with the inclusion of educational programs and the provision of hand moisturizers, which are useful for prevention of occupational contact dermatitis and hand eczema (21). There are evidence-based guidelines for preventing healthcare-associated diseases that can be useful for healthcare workers with hand eczema and, also, effective skin care educational prevention programs and individual counselling (for allergic persons based on allergy testing). The adequate measures are potentially useful in both the clinical encounter and in quality improvement. They have a positive effect on skin lesion severity and skin protective behavior (hand washing, glove use) (22). However, they cannot always be implemented, for example, because of the economic capacity of a country. (13, 18, 23).
Conclusion
Since dental professionals and students often fail to undertake adequate measures or diagnostic procedures and are commonly not trained in taking necessary preventive and protective measures, initial skin lesions can sometimes lead to chronic occupational skin diseases and eventually affect their efficiency and productivity. To ensure adequate training of dental professionals and students and those in related fields, extensive campaigns and public-health efforts are required to improve their knowledge of skin care and occupational diseases.
