Abstract

This cross-sectional study examined factors associated with occupational stress among 384 dentists working in the private sector in the first year of the COVID-19 pandemic in Brazil. Data were collected from August to October 2020 through an online form. Two outcomes - (1) anxiety and worry and (2) preparation and safety for work during the pandemic - constituted a proxy for occupational stress. The independent variables were grouped according to the explanatory theoretical model into individual, organisational and extra-organisational factors. Associations were tested by bivariate and multivariate logistic regression. Although prepared and confident, dentists felt anxious and worried about providing clinical care. Women, younger respondents and those who received no guidance on safety measures were more likely to report insecurity and unpreparedness. Younger professionals, those who did not participate in decision-making and who only sometimes had an assistant for four-hand work, were more likely to feel anxious and worried. In addition to individual factors, work organisation factors were associated with occupational stress among dentists in the first year of the pandemic.

Key words:
COVID-19; dentists; private sector; occupational stress

Introduction

COVID-19 caused irreparable damage to various sectors of society and is considered the greatest health challenge of the past 100 years¹1 Farooq I, Ali S. COVID-19 outbreak and its monetary implications for dental practices, hospitals and healthcare workers. Postgrad Med J 2020; 96(1142):791-792.. Furthermore, the high capacity for adaptive mutations of the etiologic agent, the Sars-CoV-2 virus, and the emergence of new variants heighten the uncertainties regarding vaccine coverage and the end stage of the pandemic²2 Aleem A, Samad ABK, Vaqar S. Emerging variants of SARS-CoV-2 and novel therapeutics against coronavirus (COVID-19). In: StatPearls. Treasure Island: StatPearls Publishing; 2022. PMID: 34033342..

In 2020, the first year of the pandemic, guidelines issued by Brazil’s national health surveillance agency (Agência Nacional de Vigilância Sanitária, ANVISA)³3 Brasil. Agência Nacional de Vigilância Sanitária (Anvisa). Nota Técnica GVIMS/GGTES/Anvisa no 04/2020 [Internet]. 2020. [citado 2021 out 13]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/nota-tecnica-gvims_ggtes_anvisa-04-2020-09-09-2021.pdf/view
https://www.gov.br/anvisa/pt-br/centrais... recommended that the main measures to be taken in dental services include suspending elective care, placing restrictions on emergency care, applying new biosecurity protocols and acquiring personal protective equipment (PPE), such as face shields and N95 or similar masks, as well as encouraging teleworking, distancing in waiting rooms and others³3 Brasil. Agência Nacional de Vigilância Sanitária (Anvisa). Nota Técnica GVIMS/GGTES/Anvisa no 04/2020 [Internet]. 2020. [citado 2021 out 13]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/nota-tecnica-gvims_ggtes_anvisa-04-2020-09-09-2021.pdf/view
https://www.gov.br/anvisa/pt-br/centrais... .

In private dental practice, it is up to the dental employer or employee to make organisational decisions and changes, and to purchase the necessary PPE for safe care. These professionals were directly affected by the suspension of elective treatment: their earnings depend daily on their performance in carrying out procedures to maintain the profitability of their establishments⁴4 Schwendicke F, Krois J, Gomez J. Impact of SARS-CoV2 (COVID-19) on dental practices: economic analysis. J Dent 2020; 99:103387.. The biosafety measures to be taken⁵5 Franco JB, Camargo AR, Peres MPS. Cuidados odontológicos na era do COVID-19: recomendações para procedimentos odontológicos e profissionais. Rev Assoc Paul Cir Dent 2020; 74(1):18-21. entailed higher expenses and economic consequences of major concern to the profession⁶6 Cavalcanti YW, Silva RO, Ferreira LF, Lucena EHG, Souza AMLB, Cavalcante DFB, Meneghim MC, Pereira AC. Economic impact of new biosafety recommendations for dental clinical practice during COVID-19 pandemic. Pesqui Bras Odontopediatria Clin Integr 2020; 20(Supl. 1):e0133.

7 Chamorro-Petronacci C, Martin Carreras-Presas C, Sanz-Marchena A, A Rodríguez-Fernández M, María Suárez-Quintanilla J, Rivas-Mundiña B, Suárez-Quintanilla J, Pérez-Sayáns M. Assessment of the economic and health-care impact of COVID-19 (SARS-CoV-2) on public and private dental surgeries in Spain: a pilot study. Int J Environ Res Public Health 2020; 17(14):e5139.^-88 Consolo U, Bellini P, Bencivenni D, Iani C, Checchi V. Epidemiological Aspects and Psychological Reactions to COVID-19 of Dental Practitioners in the Northern Italy Districts of Modena and Reggio Emilia. Int J Environ Res Public Health 2020; 17(10):e3459..

COVID-19 brought diverse changes to the global scenario and had strong impact on dental practice, especially during the first year of the pandemic⁹9 Abdelrahman H, Atteya S, Ihab M, Nyan M, Maharani DA, Rahardjo A, Shaath M, Aboalshamat K, Butool S, Shamala A, Baig L, El Tantawi M. Dental practice closure during the first wave of COVID-19 and associated professional, practice and structural determinants: a multi-country survey. BMC Oral Health 2021; 21:243.. Also, private sector dentists¹⁰10 Ranka MS, Ranka SR. Survey of mental health of dentists in the COVID-19 pandemic in the UK. J Int Soc Prev Community Dent 2021; 11(1):104-108. have shown greater emotional impairment than those in the public sector⁹9 Abdelrahman H, Atteya S, Ihab M, Nyan M, Maharani DA, Rahardjo A, Shaath M, Aboalshamat K, Butool S, Shamala A, Baig L, El Tantawi M. Dental practice closure during the first wave of COVID-19 and associated professional, practice and structural determinants: a multi-country survey. BMC Oral Health 2021; 21:243.

10 Ranka MS, Ranka SR. Survey of mental health of dentists in the COVID-19 pandemic in the UK. J Int Soc Prev Community Dent 2021; 11(1):104-108.^-1111 Novaes TF, Jordão MC, Bonacina CF, Veronezi AO, Araujo CAR, Olegário IC, Oliveira DB, Ushakova V, Birbrair A, Costa Palacio D, Heller D. COVID-19 pandemic impact on dentists in Latin America's epicenter: São-Paulo, Brazil. PLoS One 2021; 16(8):e0256092., possibly due to the numerous uncertainties and insecurity of employment in the private sector.

In view of the atypical problems experienced by these professionals and the concept of occupational stress (which can be defined as a physiological and psychological response to pressures and demands unrelated to workers’ knowledge and skills¹²12 Babatunde A. Occupational stress: a review on conceptualizations, causes and cure. Econ insights - Trends Challenges 2013; 2(3):73-80.), it became important to identify possible factors causing job stress in the private sector during the pandemic period. Accordingly, this study examined for individual and organisational factors associated with occupational stress among dentists working in the private sector in the first year of the COVID-19 pandemic in Brazil.

Methods

This cross-sectional study used data from a multicentre, observational, cross-sectional study to evaluate the COVID-19 prevention and control measures adopted by dental surgeons, technicians and oral health assistants in Brazil’s southern states (Paraná, Santa Catarina and Rio Grande do Sul) in response to the ANVISA recommendations for health services. Data for Paraná were obtained under the responsibility of the Universidade Estadual de Ponta Grossa and the Universidade Federal do Paraná. The study was approved by the research ethics committees of the Universidade Estadual de Ponta Grossa (CAAE certificate: 31720920.5.1001.0105, opinion 4,024,593) and the Universidade Federal do Paraná (CAAE certificate: 31720920.5.3001.0102, opinion 4,312,933).

The design followed a methodological framework for online studies (websurveys), within the limitations of a non-probabilistic, convenience sample. The research and reporting of results were guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)¹³13 Eysenbach G. Improving the quality of web surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6(3):e34..

A research form of open and closed questions was drawn up, subjected to face and content validation, assessment by eight experts in the field and a pilot study with oral health professionals from states not participating in the research. The construction and validation of the data collection instrument used for this research are described in detail in another publication¹⁴14 Ditterich RG, Baldani MH, Warmling CM. Rede Colaborativa - Biossegurança em Odontologia - Pesquisa Multicêntrica para o enfrentamento do Covid19. Ponta Grossa: Ed. UEPG: 2021..

The questionnaire was organised on the Google Forms platform and the link to participate was sent out by email by the regional boards of dentistry (Conselhos Regionais de Odontologia, CROs). The CROs resent the email 14 and 45 days after the first sending, totalling three attempts. In the same period, a wide-ranging dissemination strategy was pursued through social media. Responses to the form were monitored at all times and further dissemination strategies were implemented as needed¹⁵15 Fielding NG, Lee RM, Blank G. The SAGE handbook of online research methods. New York: SAGE Publications; 2016..

The population of the multicentre study comprised 81,531 oral health professionals working in the three southern states in May 2020. With the study population size given by the number registered with the CROs, a non-probabilistic, convenience sample of 2,560 participants was obtained, representing a 3.1% response rate.

Participants from Paraná comprised 1,127 oral health professionals, of whom 435 worked in private dental clinics and surgeries. The sample selected for this study comprised the 384 dental surgeons in Paraná who responded with regard to their work process in these establishments.

The survey form addressed: sociodemographic characteristics; academic background and work; biosafety and COVID-19-related work process; access to information; and perceptions regarding anxiety, worry and emotional aspects of work. Response options for questions on biosafety and work process were organised on a five-point Likert frequency scale: (1) never, (2) almost never, (3) sometimes, (4) almost always and (5) always. There was also an ‘I don’t know’ option.

In this study, the two outcome items selected as proxy for occupational stress related to perceived anxiety and emotional aspects of work during the pandemic: (1) I feel informed and secure enough to practice dentistry properly during the COVID-19 pandemic and (2) I feel anxious and worried about working properly in my dental practice during the COVID-19 pandemic. Both offered response options on a five-point Likert scale of agreement: (1) strongly disagree, (2) partly disagree, (3) neither agree nor disagree, (4) partly agree and (5) strongly agree. They also offered the ‘I don’t know’ response option.

For purposes of analysis, in addition to the ordinal measure, responses to the two items were dichotomised and categorised as: a) ‘No’ - negative and neutral responses (completely disagree, partly disagree, neither agree nor disagree); and b) ‘Yes’ - positive responses (partly agree and totally agree). ‘I don’t know’ responses were considered missing (lost data). The outcomes of interest were the ‘No’ responses to feeling prepared and safe, and ‘Yes’ to feeling anxious and worried about working during the COVID-19 pandemic. These were considered proxy variables for stress symptoms.

This study is based on self-perceived stress assessment¹⁶16 Faro A, Pereira ME. Medidas do estresse: uma revisão narrativa. Psic Saude Doenças 2013; 14(1):101-124., and the choice of dependent and independent variables followed the explanatory theoretical model of occupational stress proposed by the World Health Organization (WHO)¹⁷17 Leka S, Jain A. Health impact of psychosocial hazards at work: an overview. Geneva: WHO; 2010. and adapted to dental surgeons working during the pandemic (Figure 1). The proxy variables for stress symptoms include psychological and emotional factors (anxiety and worry) and cognitive and behavioural factors (secure and knowledge). The independent variables identified from the answers were listed as individual factors and extra-organisational and organisational sources of stress connected with the work process, biosafety and access to personal protective equipment (PPE).

The theoretical model described here rests on three explanatory pillars:

Lastly, the responses identified as proxy for occupational stress constituted the study outcome were the resultant of, on the one hand, sources of stress which can foster anxiety and concern and, on the other, information and conditions for safe clinical care during the pandemic (Figure 1).

The data were organised in a Microsoft Excel spreadsheet and analysed using the SPSS for Windows (version 16.0) Package for the Social Sciences statistics programme. The sample’s sociodemographic, education, work and health characteristics were analysed using descriptive statistics. Absolute and percentage frequencies were measured for categorical variables, and medians (± interquartile intervals), for numeric variables.

Associations between outcome variables were quantified using Spearman’s correlation test. Bivariate associations between outcomes (proxy for occupational stress) and explanatory variables (individual, extra-organisational and organisational factors) were measured using Pearson’s chi-square test, to a 5% level of statistical significance. Variables associated with each outcome with p-value ≤ 0.20 were eligible for multivariate analysis, which was performed by binary logistic regression. Results for the variables included in the multivariate explanatory model are displayed by crude and adjusted odds ratio with respective 95% confidence intervals. Years since completion of undergraduate course showed multicollinearity with age and was excluded from the analysis. Variables were included in the regression analysis by the enter method. Goodness of fit of the final model was assessed using the Hosmer and Lemershow test, with p ≥ 0.05 indicating fit.

Results

The sample characterisation (Table 1) revealed that participants were predominantly female (74.7%) and 39 years old or less (51.0%). Most reported no risk factors for the development of severe forms of COVID-19 (90.9%) and had not yet been tested for COVID-19 (71.6%). On the other hand, most participants declared having left off working in a dental clinic during the pandemic (84.4%), having had access to official COVID-19 prevention and control guidelines (84.4%) and having received workplace guidance on measures to be taken during the COVID-19 pandemic (77.5%). Table 1 also shows that, despite the high frequency of reports of feeling prepared and safe to work properly in dentistry during the COVID-19 pandemic (78.1%), most participants reported feeling anxious and worried (64.8%).

The measure most often adopted to prevent and control the spread of COVID-19, as reflected in the response ‘always/almost always’, was to investigate for symptoms of respiratory infection when scheduling appointments (83.4%) and the measure least applied was to suspend elective procedures and restrict care to emergencies (29.7%) (Table 2).

The biosafety measure most often taken in dental clinics, as given by ‘always/almost always’ responses, was for a trained professional, with appropriate PPE, to clean and disinfect the environment (80.5%), while the least applied was to avoid aerosol-generating procedures (26.6%), to use a rubber dam in high-speed treatments (32.0%), four-hand dentistry (40.1%) and to use sterile handpieces at each appointment (42.7%) (Table 2).

The PPE most commonly available and used was the face shield (85.4%) and N95/PFF2 masks were available in sufficient quantity for most participants (76.6%) (Table 2).

Table 3 shows the bivariate associations between explanatory factors of the theoretical model and the dichotomised outcome variables. As regards the individual factors, participants who felt prepared and confident were mostly male (p = 0.018), over 39 years old (p < 0.001), trained more than 20 years ago (p < 0.001) and had some risk factor for severe forms of COVID-19 (p = 0.044). Women (p = 0.015), younger participants (up to 39 years old) (p < 0.001) and more recent graduates (qualified up to 10 years previously) (p = 0.055) reported greater anxiety and concern (Table 3).

In the block of extra-organisational work-related factors, professionals who stopped working during the pandemic were more anxious and concerned (p = 0.020), while those who had access to official COVID-19 prevention and control guidelines were more prepared and confident (p = 0.050) (Table 3).

With regard to organisational factors, participants who declared they were more prepared and confident reported receiving workplace guidance on measures to be taken during the pandemic (p < 0.001), always or almost always suspending elective care (p = 0.035) and participating in decision-making (p < 0.001), as well as those who reported ‘always/almost always’ investigating for respiratory infection symptoms when scheduling appointments (p < 0.001), specifying emergencies on the basis of established protocols (p < 0.001) and using digital tele-guidance and tele-monitoring tools (p < 0.001). As regards workplace biosafety measures, participants who reported feeling better prepared and safer responded that ‘always/almost always’: a) the environment was cleaned and disinfected by a trained professional with appropriate PPE (p < 0.001); b) suction hoses were cleaned at each appointment (p < 0.001); c) sterile pens and handpieces were used at each appointment (p < 0.001); d) four-hand dentistry was performed (p = 0.002); e) aerosol-generating procedures were avoided (p = 0.005); f) doffing followed the recommended sequence (p < 0.001); g) enough N95/PFF2 masks were available (p = 0.018); and h) enough waterproof aprons were available (p = 0.046) (Table 3).

The most anxious and concerned were women (p = 0.015), young people (up to 39 years old) (p < 0.001), participants who had completed their professional training within 10 years earlier (p = 0.055), who withdrew from clinical work during the pandemic (p = 0.020) and who “always/almost always” suspended elective care (p = 0.037) and used a face shield (p = 0.001). The most anxious and concerned declared that they “never/almost never” took part in decision making (p = 0.010). Also more anxious and worried were those who answered “sometimes” with regard to a trained professional’s cleaning and disinfecting the environment (p = 0.009) and four-hand dental care (p < 0.001) (Table 3).

Table 4 shows the results of multivariate analysis for feeling individually prepared and safe with regard to, and anxious and concerned about, working in a clinic during the pandemic. The final model revealed that the preparedness and safety outcome was associated with individual and organisational biosafety-related factors. Participants were less likely to feel prepared and safe regarding clinical care because of individual factors (being female and younger) and organisational factors (not receiving workplace guidance on measures to be taken during the pandemic and “almost never/never” doffing in the recommended sequence). COVID-19-related factors, such as risk factors for severe forms of the disease and laboratory testing to detect COVID-19, were of borderline statistical significance and adjusted the explanatory model.

In the multivariate model, feelings of anxiety and concern about working were found to be associated with only one individual factor - age - and with factors relating to work process organisation and biosafety in the clinic. Younger dentists, those who “almost never/never” participated in decision-making and who “sometimes” performed four-handed dental procedures were more likely to feel anxious and worried. Less likely to be anxious and worried were those who “almost never/never” suspended elective care and who “sometimes” used a face shield (Table 4).

Discussion

This study showed that most dentists reported feeling anxiety and concern about working during the COVID-19 pandemic, and that individual and organisational factors were associated with occupational stress among dentists in the private sector in the state of Paraná during the COVID-19 pandemic. Studies have shown that the pandemic affected mental health adversely in the population at large¹⁸18 Ren X, Huang W, Pan H, Huang T, Wang X, Ma Y. Mental health during the COVID-19 outbreak in China: a meta-analysis. Psychiatr Q 2020; 91(4):1033-1045., and especially among health personnel¹⁹19 Silva DFO, Cobucci RN, Soares-Rachetti VP, Lima SCVC, Andrade FB. Prevalência de ansiedade em profissionais da saúde em tempos de COVID-19: revisão sistemática com metanálise. Cien Saude Colet 2021; 26(2):693-710. , including private-sector dentists¹⁰10 Ranka MS, Ranka SR. Survey of mental health of dentists in the COVID-19 pandemic in the UK. J Int Soc Prev Community Dent 2021; 11(1):104-108., who were more affected as compared with the emotional state of public-sector dentists¹⁰10 Ranka MS, Ranka SR. Survey of mental health of dentists in the COVID-19 pandemic in the UK. J Int Soc Prev Community Dent 2021; 11(1):104-108.^,1111 Novaes TF, Jordão MC, Bonacina CF, Veronezi AO, Araujo CAR, Olegário IC, Oliveira DB, Ushakova V, Birbrair A, Costa Palacio D, Heller D. COVID-19 pandemic impact on dentists in Latin America's epicenter: São-Paulo, Brazil. PLoS One 2021; 16(8):e0256092., possibly because of the unpredictability inherent to economic and work conditions in the former sector.

Women are a majority among dental professionals in southern Brazil and the mostly-female sample was similar to those of most studies of dentists there, corroborating the feminisation of the profession²⁰20 Costa SM, Durães SJA, Abreu MHNG. Feminização do curso de odontologia da Universidade Estadual de Montes Claros. Cien Saude Colet 2010; 15(Supl. 1):1865-1873.^,2121 Moraes RR, Correa MB, Daneris A, Queiroz AB, Lopes JP, Lima GS, Cenci MS, D'Avila OP, Pannuti CM, Pereira-Cenci T, Demarco FF. Email vs. Instagram recruitment strategies for online survey research. Braz Dent J 2021; 32(1):67-77.. Although studies have shown women to be more perceptive of mental health, the only outcomes with which gender was found to associate in this study were preparedness for, and safety at, work: more women reported feeling less prepared and safe. Although, in this study, gender was not retained in the multivariate analysis as a factor associated with anxiety, in the literature, women have been found at greater risk of anxiety during the COVID-19 pandemic¹⁹19 Silva DFO, Cobucci RN, Soares-Rachetti VP, Lima SCVC, Andrade FB. Prevalência de ansiedade em profissionais da saúde em tempos de COVID-19: revisão sistemática com metanálise. Cien Saude Colet 2021; 26(2):693-710.^,2222 Tysiac-Mista M, Dziedzic A. The attitudes and professional approaches of dental practitioners during the COVID-19 outbreak in Poland: a cross-sectional survey. Int J Environ Res Public Health 2020; 17(13):4703.. That age showed greater impact than gender may be explained by the professional experience gained with age’s fostering feelings of being informed and safe in clinical practice and, consequently, resulting in less anxiety and concern at work and mitigating the influence of gender.

In this study, most participants were in the younger age groups (median age, 39; 75% percentile, 47 years). Younger people tend to use social networks more and are more likely to respond to online surveys. With social isolation, however, the population as a whole began to make more use of these tools²³23 Farooq A, Laato S, Islam AKMN. Impact of online information on self-isolation intention during the COVID-19 pandemic: cross-sectional study. J Med Internet Res 2020; 22(5):e19128., which may justify the similar participation by different age groups. Age was the only individual factor retained in the theoretical model in both outcomes, in which younger professionals felt less prepared and safe, and more anxious and concerned about working during the pandemic. In Turkey, recent dentistry graduates seemed to be the most affected during the pandemic²⁴24 Maden EA, Özen B, Altun C. The effect of COVID-19 pandemic on life quality of dental professionals. J Health Sci Med 2022; 5(1):274-281. and a study in Paraíba State in Brazil showed greater confidence in working during the pandemic among older dentists, which can be explained by their being longer in practice and more stably established in the profession²⁵25 Braga MLA, Medeiros FLS, Costa LED, Penha ES, Queiroz FS. Biossegurança no ambiente odontológico e prevalência de COVID-19 em cirurgiões-dentistas do estado da Paraíba. Res Soc Dev 2021; 10(15):e294101521813..

As regards the organisational factors, participants who received workplace guidance on COVID-19 reported greater confidence and preparedness for work, highlighting the importance of continuing health education for practitioners. A study in São Paulo state showed that more than 80% of dentists received no specific training to control COVID-19 transmission in the healthcare environment, although several courses were available and widely publicised¹¹11 Novaes TF, Jordão MC, Bonacina CF, Veronezi AO, Araujo CAR, Olegário IC, Oliveira DB, Ushakova V, Birbrair A, Costa Palacio D, Heller D. COVID-19 pandemic impact on dentists in Latin America's epicenter: São-Paulo, Brazil. PLoS One 2021; 16(8):e0256092..

Participants who did not follow the recommended sequence for doffing PPE felt unprepared and more insecure in providing care during the pandemic. Given that doffing is one of the main routes for contamination of health personnel, this procedure is as important as donning³3 Brasil. Agência Nacional de Vigilância Sanitária (Anvisa). Nota Técnica GVIMS/GGTES/Anvisa no 04/2020 [Internet]. 2020. [citado 2021 out 13]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/nota-tecnica-gvims_ggtes_anvisa-04-2020-09-09-2021.pdf/view
https://www.gov.br/anvisa/pt-br/centrais... . Adequate access to, and proper use of, PPE have been associated with not only physical health protection, but greater job satisfaction and lesser emotional distress²⁶26 Zhang SX, Liu J, Afshar Jahanshahi A, Nawaser K, Yousefi A, Li J, Sun S. At the height of the storm: Healthcare staff's health conditions and job satisfaction and their associated predictors during the epidemic peak of COVID-19. Brain Behav Immun 2020; 87:144-146..

Organisational factors relating to adherence to COVID-19 protocols were associated with anxiety and concern about working. Lack of participation in decision-making was associated with a greater likelihood of participants’ being anxious and worried, suggesting that those employed in clinics, with fragile employment relationships, were adversely affected. This underlines the importance of team dialogue, as well as managers’ role in guiding targeted measures.

Professionals who understood the importance of the adjustments were more affected emotionally, as they were more aware of the risk of infection and possibly more concerned about the consequences of contamination, as evidenced in the association between use of face shield and anxiety and concern. Lax adherence to protective measures, reflected in the “sometimes” responses with regard to four-hand care, showed that uncertainty regarding the workplace support structure can generate anxiety and concern among health personnel. Private sector care teams do not always include oral health assistants and technicians, although this can optimise the work, possibly because they represent an additional financial burden for the clinics. Nonetheless, four-hand dentistry is highly recommended and stressed during pandemics because it helps reduce the generation of aerosols, speeds up care and, consequently, reduces the risk of contamination²⁷27 Vicente KMS, Silva BM, Barbosa DN, Pinheiro JCP, Leite RB. Diretrizes de biossegurança para o atendimento odontológico durante a pandemia do COVID-19: revisão de literatura. Rev Odontol Araçatuba 2020; 41(3):29-32..

On the other hand, participants who did not suspend elective care were less anxious and worried. With time, they had possibly grown used to the inappropriate conditions or this may even suggest carelessness and denial of the severity of the pandemic, both of which are associated with a lesser likelihood of occupational stress. A study in Poland showed that dentists who suspended their clinical work reported greater anxiety than those who continued their practice without interruption²²22 Tysiac-Mista M, Dziedzic A. The attitudes and professional approaches of dental practitioners during the COVID-19 outbreak in Poland: a cross-sectional survey. Int J Environ Res Public Health 2020; 17(13):4703.. In general, however, dentists seem to have a good command of knowledge of COVID-19 and the adjustments necessary in services to minimise the risk of contamination²⁸28 Sotomayor-Castillo C, Li C, Kaufman-Francis K, Nahidi S, Walsh LJ, Liberali SAC, Irving E, Holden AC, Shaban RZ. Australian dentists' knowledge, preparedness, and experiences during the COVID-19 pandemic. Infect Dis Health 2022; 27(1):49-57..

Patient flow, in both urgent and elective care²⁹29 Villarim NLS, Muniz IAF, Perez DEC, Martelli Junior H, Machado RA, Cavalcanti YW, Bonan PRF. Evaluation of the economic impact of COVID-19 on Brazilian private dental clinics: a cross-sectional study. Work 2022;71(1):79-86., has been seen to decrease in private dental services worldwide, entailing financial losses for practitioners. Also, the impact of COVID-19 on dentists’ financial situation is determined by factors beyond those inherent to suspending care during a critical period of the pandemic, because the economic situation of patients who attend private dental clinics is intrinsically bound up with the country’s economic situation. Accordingly, the current economic crisis in Brazil, which involves reduced purchasing power, high rates of unemployment and food insecurity, has heightened the impacts of the pandemic and aggravated this problem³⁰30 Alpino TMA, Santos CRB, Barros DC, Freitas CM. COVID-19 and food and nutritional (in)security: action by the Brazilian Federal Government during the pandemic, with budget cuts and institutional dismantlement. Cad Saude Publica 2020; 36(8):e00161320..

The findings of this study, in which participants under most occupational stress were younger, women and more recent graduates, demonstrate the existence of precarious work relations in the private dental sector. In practice, it is increasingly common for employment situations not to assure favourable conditions of care and adequate PPE, but subject dental workers’ wage gains to their quantitative performance of procedures, which diminished or were abruptly stopped during the pandemic period. This thus resulted in substantial financial losses and, consequently, affected these workers’ emotional health. Also, informal employment lacking guarantees has devalued and impaired working conditions. That dental practice in the supplementary health market is precarious is recognised in the literature³¹31 Moraes DA, Maluf F, Tauil PL, Portillo JAC. Precarização do trabalho odontológico na saúde suplementar: uma análise bioética. Cien Saude Colet 2019; 24(3):705-714., and in Brazil, it has to be acknowledged that the labour market is over-supplied with dental surgeons, as a result of the excessive number of schools of dentistry across the country, plus a lack of market regulation and State control³¹31 Moraes DA, Maluf F, Tauil PL, Portillo JAC. Precarização do trabalho odontológico na saúde suplementar: uma análise bioética. Cien Saude Colet 2019; 24(3):705-714..

The findings of this study may thus be reflecting the effects of problems existing in the dental sector labour market prior to the pandemic, especially in southern Brazil, where this study took place and where, after the southeast, most of Brazil’s dentists are concentrated³²32 Martin ASS, Chisini LA, Martelli S, Sartori LRM, Ramos EC, Demarco FF. Distribuição dos cursos de odontologia e de cirurgiões-dentistas no Brasil: uma visão do mercado de trabalho. Rev ABENO 2018; 18(1):63-73.. The findings, which are grounded in the concepts of the theoretical models applied³³33 Cooper CL, Willians S, Sloan SJ. Occupational stress indicator management guide. London; Windsor: 1988.^,3434 Griffiths A, Leka S, Cox T. La organización del trabajo y el estrés: estrategias sistemáticas de solución de problemas para empleadores, personal directivo y representantes sindicales [Internet]. 2004. [citado 16 de setembro de 2021]. Disponible en: https://apps.who.int/iris/handle/10665/42756
https://apps.who.int/iris/handle/10665/4... , help to explain, in part, socioeconomic points of view on occupational stress among dentists, which was aggravated during COVID-19.

Having been tested for COVID-19, although not associated at the 5% level, was an important variable in fitting the final explanatory model. This finding may be connected with uncertainty about possible infection by the disease, which would affect dentists emotionally, especially at a time when there were no proven effective drugs nor vaccines available for the disease. The sample comprised liberal professionals from the private sector, most of whom had only one job and were thus not only concerned over their own health with regard to this newly-arrived installed infectious disease, but were suffering direct impact on their financial situation from the necessary period of isolation, quarantine and resulting absence from work, which left them apprehensive and worried about the future of the profession³⁵35 De Stefani A, Bruno G, Mutinelli S, Gracco A. COVID-19 Outbreak Perception in Italian Dentists. Int J Environ Res Public Health 2020; 17(11):e3867.^,3636 Noushi N, Oladega A, Glogauer M, Chvartszaid D, Bedos C, Allison P. Dentists' experiences and dental care in the COVID-19 pandemic: insights from Nova Scotia, Canada. J Can Dent Assoc 2021; 87:l5..

Vaccination has been highly effective in controlling COVID-19³⁷37 Zheng C, Shao W, Chen X, Zhang B, Wang G, Zhang W. Real-world effectiveness of COVID-19 vaccines: a literature review and meta-analysis. Int J Infect Dis 2022; 114:252-260. and may impact the responses of participants who answered the questionnaire early in the pandemic. Accordingly, the multicentre research team plans to conduct a further wave of data collection. Although the instrument used to measure occupational stress was a proxy for occupational stress and the validation of the research instrument has yet to be published, the data obtained here are consistent with findings in the literature on the subject¹⁹19 Silva DFO, Cobucci RN, Soares-Rachetti VP, Lima SCVC, Andrade FB. Prevalência de ansiedade em profissionais da saúde em tempos de COVID-19: revisão sistemática com metanálise. Cien Saude Colet 2021; 26(2):693-710.^,2424 Maden EA, Özen B, Altun C. The effect of COVID-19 pandemic on life quality of dental professionals. J Health Sci Med 2022; 5(1):274-281.. Note that the data were collected between August 10 and October 7, 2020 and, given the spread of the pandemic into new phases, accentuated by the emergence of new variants of the virus, the findings should be interpreted with caution, as they may not be representative of the whole pandemic period. One limitation of this study is the bias inherent to participation in an online questionnaire by a convenience sample. However, sample calculation found that the study sample was of sufficient sise to represent the state of Paraná.

The findings of this study underline the need to build strategies to minimise the emotional impacts suffered by private sector dentists during the COVID-19 pandemic. It is the job of Brazil’s federal and regional boards of dentistry to enable and encourage dental caregivers to qualify through permanent health education to afford them effective preparation and safety for working in clinical practice. It is the function of the regulatory bodies to supervise and seek to improve labour relations and working conditions in the private dental sector, so as to guarantee dentists’ rights, given that these conditions are intrinsically related to the occupational stress suffered by workers, which may potentially affect their mental health.

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