4.1. Possible Explanations for the Study Findings
In March 2020, the World Health Organization (WHO) released a statement characterizing the COVID−19 outbreak as a pandemic [24
]. Drastic changes have been seen in the general well-being of the population, but the impact on the work well-being of dentists has not been extensively studied, much less in Latin American countries. Few studies have been published regarding the impact of COVID-19 on dentists in Central and South America [13
], the largest number of publications being from countries in Europe and Asia [4
]. Most of the published studies were carried out in 2020. Although few publications allow us to compare the evolution of the pandemic impact on the dentistry profession, we can attempt to show the outlook after a year and a half following the start of the pandemic.
This study has data from eleven Latin American countries, being the only one that incorporates so many countries in the region for 2021, gathering a total of 2214 surveys of oral health professionals. The study by León-Manco et al. is the most similar to this research study. It was carried out in the first six months of the pandemic, included various countries in Latin America and the Caribbean, had a total of 2036 surveys of dentists and dentistry students in the region, and evaluated the stress perceived due to the pandemic. These authors found a significant impact on the financial situation, career prospects, and personal lives of dentists and career students. Despite including a nongraduate population, this study proves that even in the initial stages of the pandemic there was already a considerable impact on important aspects of both personal and work life. Additionally, one year after this analysis it can be observed that this stress remains within the Latin American population [13
]. Another complementary analysis carried out in Latin America and the Caribbean involving 1195 dentists between May and August 2021 found that the subjective perception of well-being had an average score of 56.83 out of a maximum possible score of 100 (maximum well-being) [14
There are other studies such as that by Dávila-Torres et al., which was carried out in Ecuador between May and June 2020. This study evaluated the existence of anxiety caused by the pandemic and concluded that the Ecuadorian dentistry population experienced a state of moderate anxiety as a consequence of the pandemic. In accordance with our study, the results displayed greater female participation (74%) [25
], which concurs with the results of various studies [26
], and could be explained by the feminization that has been occurring in the profession for several decades.
The labor well-being of dentists is analyzed considering two dimensions: psychosocial well-being and collateral effects. A higher collateral effect suggests a lower well-being in dentists [9
]. Somatization, wear, and alienation were the collateral effects evaluated. The ones that occurred most frequently were back pain and muscle tension as a consequence of the somatization experienced by dentists, as well as physical exhaustion and work overload within the wear component. However, these findings should not be attributed exclusively to the COVID-19 pandemic since dentists are prone to musculoskeletal disorders resulting from inadequate work ergonomics [34
While this study was taking place, restrictions on the practice of dentistry had already decreased and most of the dentists were performing clinical activities. Even though a large percentage of the dentists were already vaccinated, the stress of working in the patient’s mouth with the high risk of contagion and with all of the biosafety equipment (aprons, double masks, and face shields, among others) makes clinical management more complex, which may explain the perception of higher overload and physical exhaustion, as well as the ailments reported. A Romanian study conducted on 83 dentists analyzed preventive dentistry behaviors related to the fear of COVID-19 contagion [35
]. The main findings complement our results, considering the stress and anxiety that presented for dental health workers who had to adapt to all the dental practices in private and public health services. One study, conducted on 5370 dentists in Colombia, shows that COVID-19 has strongly impacted the practice of dentistry, leading to changes in clinical activities and career prospects [36
]. However, although the contagion risk perception was high, self-reported contagion was very low and biosafety measures compliance was high. That situation means that the dentistry practice is safe and there is a need for policies and strategies for improving the quality of labor life of dentists, considering their actual situation. In addition, the findings raise an important question regarding the dentists working in hospitals. Conceivably, the workload of such dentists was extremely high, especially in the first months of the pandemic, because most private practices were closed. Complementary qualitative analyses should be conducted on those dentists involved in hospitals and health centers to understand the changes during the pandemic in labor well-being and its relationship with physical, mental, and psychosocial health.
In the present study, we found low professional fulfillment, which could have been caused by the situation of uncertainty created by the pandemic because, in spite of dentistry activities having restarted, patients still appear to be reluctant and consult almost only for emergency situations out of fear of contagion. Similarly, owing to biosafety protocols and capacity restrictions, dentists have reduced the number of patients they see per day. This altogether produces an economic impact and brings about the perception that the profession does not allow them to meet their economic needs. A study in Iranian dentists showed that 57% could face financial problems in the future [4
]. Similarly, in studies carried out in Poland, Turkey, and Romania, a significant decrease in the income of dentists was found during the pandemic [35
When stress exceeds the individual’s coping capacity, it can lead to wear. High levels of stress, exhaustion, anxiety, and psychological distress were associated with decreased personal well-being [38
Labor well-being was lower in women, which concurs with various studies [13
], where a higher level of stress and anxiety was reported in this group. Mekhermar et al. found higher levels of anxiety and stress in women and in middle-aged individuals [33
]. Gasparro et al., in Italy, found that women were more afraid of COVID-19 and showed more depressive symptoms than men [30
]. In Spain, women, in comparison to men, reported being more concerned about contracting COVID-19 for not having adequate protection measures, as well as being possible SARS-CoV-2 transmitters for patients [29
]. Circumstances such as stress, depression, and concern about contagion lead to a decrease in well-being, which is evident in these groups. According to a recent study, perceived well-being was lower in Latin American female dentists compared to males [14
]. In the Latin American background, women tend to have more responsibility in the household, which results in more work overload. Similarly, the fear of being infected and infecting their patients and their family contributes to a higher level of worry, stress, and even less well-being [29
Regarding age, in the psychosocial well-being dimension, no significant differences were found. However, they were found in the collateral effect dimension, where a lower collateral effect and consequently a higher perceived well-being were evidenced in the older age groups and in individuals with more years of professional practice. This could be a result of this group being more mature and having more professional stability, as opposed to the younger ones, many of whom are just starting their professional careers and who have not reached a level of employment and economic stability that could provide them with a certain degree of peace of mind to face a limiting situation such as the COVID-19 pandemic. At the Latin American level, Garcés-Elías et al. [14
] and Ortega-López et al. [15
], respectively, found greater well-being and a lower level of perceived stress in older individuals, which is consistent with our results. When interpreting the results of people over 60 years of age showing less stress and anxiety, Mekhermar et al., in Germany, attributed it, among other aspects, to the fact that the elderly have gone through strong experiences in the past such as wars, crises, and pandemics, together with the fact that they spend less time on social networks exposed to ample information concerning the pandemic, which can ultimately be a stressor [33
Labor well-being was lower in those who worked in clinical care compared to those who work in teaching and research. In a study carried out in the United Kingdom at the beginning of the pandemic, it was found that dentists who worked in clinical care in hospitals were more stressed compared to those who performed other types of activities [18
]. It is very known that dentists in clinical practice face a higher risk of contracting SARS-CoV-2 and thus, they face all the consequences this entails, such as fear of becoming infected, taking the infection from the clinic to their families, being quarantined if they become infected, and even closing their clinics until the number of COVID-19 cases drops significantly [39
]. Another consideration that favors the idea of higher well-being in dentists who work in teaching and research is the possibility of having an economic income, product of this activity, which grants more stability and economic ease. Furthermore, these activities provided the opportunity to keep working; despite the restrictions in most countries, they continued remotely, which allowed dentists to remain active and lessened their chances of experiencing feelings of anxiety, anguish, and worry. In the United Kingdom, it was found that dentists who were not working showed more depressive symptoms compared to those who did work [32
]. The level of stress linked to the concern about their professional future in Turkish dentists was higher in those who worked in private practices compared to those who worked in hospitals [31
]. To match this with our results, those who work in teaching and research in the Latin American context work mainly in university centers or hospitals, with a fixed economic income that may have been less affected in comparison with income from clinical care practice.
When performing the multivariate analysis, the three models presented were significant. It can be seen that in the adjusted model where all the variables were incorporated, age was not significant in any dimension. Some regional differences amongst dentists were found and labor well-being tended to be better in Central American countries and Mexico than in South American countries, which allows us to deduce the resemblance of the South American context.
4.2. Strength and Weakness of This Study
Regarding the instrument used, it is important to point out that, although it was validated in a sample of 1252 professionals from the health and education areas who worked in hospitals and universities [9
], it has not been standardized internationally in other contexts and samples. That is the reason why the researchers carried out a pilot test in all the countries included in the present study, to support the decision to use by means of the labor components that include the questionnaire. However, not having data collected before the pandemic using this same questionnaire is a limitation, as there is no point of comparison to know if the work well-being of Latin American dentists has improved or worsened. In addition, most of the current results, obtained by using other questionnaires, concern the initial stages of the pandemic and are placed in geographical and sociocultural contexts that may be very different from the Latin American one.
Concerning the wear scale that belongs to the collateral effects dimensions, the information provided is not enough to consider if the participants are at risk of burnout syndrome. For that purpose, specific questionnaires are strongly recommended. For instance, the Copenhagen Burnout Inventory was validated in health care workers during the COVID-19 pandemic [40
], and one study conducted in UK dentists considered the Oldenburg Burnout Inventory [38
]. Further research could elucidate specific factors and conditions related to the burnout syndrome in Latin American Dentists.
The results of this study should be interpreted considering the nature and limitations of cross-sectional studies that use self-report questionnaires. Although it is not possible to determine causality, important associations and relationships between the variables can be established in this type of design considering bivariate and multivariate analyses. Precisely this type of study has an interest in exploring unknown or not studied in-depth situations. From a public health perspective, the study of self-perceptions in different social groups considering social phenomena constitutes broad measures transcending restrictive biomedical views in health research.
Owing to the lack of updated lists in the different countries of dentists registered in government databases, it was necessary to carry out a quota sampling and this means that the population size of each country was not considered. The results cannot be inferred from the total population of dentists, since a probabilistic sample was not possibly obtained. At this point, it is important to mention that, at the beginning of the study, we had planned to have a minimum sample of 200 participants for each country; however, in the final sample, some countries surpassed the participation quota and, on the contrary, others such as Uruguay and Costa Rica had the lower participation. The research team decided to keep this sample. Possible reasons for this low participation lie in the low motivation of the dentists’ associations and their reluctance to complete the online questionnaire, among other circumstances related to the fieldwork in each country. This situation did not affect the general findings shown in this study because the statistical power considering the nature of the main study variables was greater than 80%, as calculated by EPIDAT 3.1 (free distribution program developed by Dirección Xeral de Saúde Pública da Consellería de Sanidade, Xunta de Galicia, with the support of the Pan American Health Organization (PAHO–WHO) and the CES University of Colombia.
Considering these limitations, this study provides initial evidence of how the different measures that the governments implemented to control the pandemic affected these professionals who were studied, and it is the starting point for other studies that want to assess occupational well-being, a very important aspect to address since at least one- third or one-half of their time is spent at work.
4.3. Scope and Research Recommendations Derived of This Study
This research offers a general panorama of the general labor well-being of Latin American dentists in the context of the COVID-19 pandemic. It is important to emphasize that the findings of this research should be compared while always keeping in mind that each country has a different political and socioeconomic context and that the perceived impact of the pandemic in each varies according to the policies that have been deployed, the moment of implementation, the biosafety protocols, social groups, and the population responsibility to comply [41
]. It should kept in mind that although most countries adopted the recommendations provided by the Pan American Health Organization (PAHO) [42
], some assumed specific measures of a governmental nature. For example, the Ministry of Health and Social Protection of Colombia established the document entitled: Biosafety guidelines for the provision of services related to oral health care during the period of the SARS-CoV-2 (COVID-19) pandemic [43
]. The Ministry of Health of Argentina published some recommendations for the dental practice [44
], which were adjusted following WHO and PAHO recommendations. Other documentary studies should explore the adaptation of biosafety protocols proposed by international organizations, and the implementation of other restrictive measures and their acceptance by dental health care professionals.
The results obtained open the need to carry out individual research for each of the Latin American countries and to establish comparative studies through strong samples for each of them. For that purpose, exploring specific topics related to the impact of the pandemic in personal, familiar, and social lives by incorporating new contextual variables is recommended.
Similarly, dental specialties were not equally touched by the pandemic. In our study, the participation of postgraduate dentists (clinical, MSc, and PhD) in the sample was 61.7%. Further research through quantitative, qualitative, and mixed methods should be conducted in specific clinical and other specialties, and by following other labor, physical, mental, and psychosocial indicators that permit an explanation of the impact of the COVID-19 pandemic in dental health care workers.