Original Article Braz J Oral Sci. January/March 2009 - Volume 8, Number 1 Relationship between orofacial pain and absenteeism among workers in Southern Brazil Anderson Nardi1, Edgard Michel-Crosato2, Maria Gabriela Haye Biazevic3, Edgard Crosato4, Eduardo Pizzatto5, Dagmar de Paula Queluz6 1MS, Universidade do Oeste de Santa Catarina (Unoesc), Joaçaba (SC), Brazil 2 DDS, MS, PhD, Assistant Professor, Department of Community Dentistry, Faculdade de Odontologia, Universidade de São Paulo (USP), São Paulo (SP), Brazil 3DDS, MS, PhD, Post-doctored student, Department of Community Dentistry, Faculdade de Odontologia, USP, São Paulo (SP), Brazil 4 DDS, MS, PhD, Professor, Department of Community Dentistry, Faculdade de Odontologia, USP, São Paulo (SP), Brazil 5DDS, MSPH, PhD, Professor, Faculdade de Odontologia, Universidade Positivo, Curitiba (PR), Brazil 6 DDS, MSPH, PhD, Professor, Department of Community Dentistry, Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil. Received for publication: July, 17, 2008 Accepted: February 04, 2009 Correspondence to: Edgard Michel Crosato Departamento de Odontologia Social da Faculdade de Odontologia da USP Avenida Professor Lineu Prestes, 2.227 – Cidade Universitária CEP 05508-000 – São Paulo (SP), Brazil E-mail: michelcrosato@usp.br Abstract Aim: To verify the relationship between orofacial pain and absenteeism in workers of slaughter and meat processing industries in the Southern region of Brazil. Methods: A cross-sectional study, with the random sample of 401 workers of slaughter and meat processing industries in the Southern region of Brazil, was carried out. A questionnaire referred to the situation of absenteeism caused by nine different types of orofacial pain and also the amount of time the employee was kept from work. Results: Only 60 workers (15%) reported having missed work due to orofacial pain in the six months prior to the study. The prevalence of absenteeism resulting from orofacial pain was of 15%. The types of orofacial pain that resulted in absenteeism were: spontaneous toothache (9.7 %); toothache caused by cold or hot liquids or by sweet foodstuff (6.5%) and pain around and behind the eyes (3.2%). There was a predominance of absen- teeism in half and full work shifts for the types of orofacial pain experienced. Associations between absenteeism from induced toothache and gender (p < 0.05), absenteeism and spontaneous toothache and family income (p = 0.011), and between absenteeism and the self awareness of their oral health condition, as well as the nine types of orofacial pain (p < 0.001) were observed. Conclusions: The prevalence of absenteeism as a result of orofacial pain was low. Keywords: absenteeism, facial pain, facial pain/epidemiology, oral health. Introduction Absenteeism is an issue of growing interest as a result of the economic importance of com- petitiveness, driving companies to seek means to reduce its occurrence and, consequently, to increase the profitability and achieve sustained growth1,2. Various epidemiological studies have demonstrated that the prevalence of absenteeism resulting from dental reasons varies from 10 to 35%, and the average number of working hours lost varies from 1.24 to 6.20 working hours/workers/years3-9. The pain is a private percept that arises in a conscious brain, typically in response to a noxious provoking stimulus, but, sometimes, in the absence of a stimulus. The relation of the percept to the stimulus is variable, and depends on the individual’s prior expectations and beliefs, and on his/her cognitive and emotional state – not just on the nature of the stimulus itself. While acute pain is, by definition, a brief and self-limiting process, chronic pain comes to dominate the life and concerns of the patient, and often also family, friends and other care- givers. In addition to the severe erosion in quality of life of the pain sufferer and those around 51Relationship between orofacial pain and absenteeism among workers in Southern Brazil Braz J Oral Sci. 8(1): 50-4 him/her, chronic pain imposes severe financial burdens on many levels. These include: costs of healthcare services and medication, job absenteeism and disruption in the workplace, loss of income, non-productivity in the economy and in the home, financial burden on family, friends and employers, worker compensation costs and welfare payments. The workers can reduce absenteeism and health- care utilization from the risks from dental disease by incorporating dental education into workplace wellness. The aim of this study was to verify the relationship between oro- facial pain and absenteeism in workers of slaughter and meat pro- cessing industries in the Southern region of Brazil. Material and methods The study population was composed of a sample of 401 workers of slaughter and meat processing industries in the Southern region of Brazil. The company workforce was composed of 1,187 employees. Sample size calculation was done using the following criteria: con- fidence level 95%, sample mistake 4% and unknown prevalence, and estimated prevalence 50%. The selection process of the samples was realized through simple random drawings. An observational and cross-sectional study de- sign was used. Data collected referred to absenteeism resulting from orofacial pain, as well as social and economic characteristics of the study population (gender, age, marital status, area of work, address, edu- cational level and family income). A questionnaire developed by Locker & Grushka6-7 was used as an instrument for the survey, which was validated in Brazil in the Bambuí Health and Ageing Study (BHSA)10. The questions in the survey instrument referred to the situation of absenteeism caused by nine different types of orofacial pain and also the amount of time the employee was kept from work. The question- naire was prepared to gather information about orofacial pain and absenteeism at present or in the recent past. All questions referred to the period encompassing the six months prior to the survey. This relatively short period of time is normally used to minimize bias due to possible lapse of memory of the surveyed study population11,12. About the family income, low means until two minimum wage, and high means two or more minimum wages. The oral health, it was self related good or poor. The questionnaire was first applied to 15 employees. Thereafter, it was applied by duly trained surveyors to the employees that agreed to be enrolled as volunteers after granting authorization from the company management and after the participants had signed an in- formed consent form to take part in the study. The research project was approved by the Research Ethics Committee of the Universidade de Passo Fundo (UPF) under the protocol number 194/03. Data were analyzed by the chi-square test using the Stata 8.0 software and presented in tables, according to the frequency distri- bution. A 5% significance level was adopted for all analyses. Results The social and economic status of the studied population is shown on Table 1. Among the participants in the study, 60 employees declared hav- ing lost working hours due to orofacial pain in the six months prior to the survey. Consequently, the prevalence of absenteeism due to orofacial pain in this study was of 15%. The types of orofacial pain that cause more absenteeism were: spontaneous toothache (9.7%); toothache caused by cold or hot liquids or sweet foodstuff (6.5%) and pain around and behind the eyes (3.2%). Table 2 shows the percentage of loss of working hours for each of the nine types of orofacial pain described. The predominance of loss of half and full work shifts was observed for all types of orofacial pain experienced. A half work shift was considered as a period of four hours, in other words, half a day’s work. The types of orofacial pain that caused two and three days or more of absence from work were the spontaneous toothache, toothache caused by hot or cold liquids or sweet foodstuff, pain in front of the ears and pain around and be- hind the eyes. Considering the prevalence of absenteeism according to the num- ber of types of pain experienced by workers, 26 employees informed having been absent from work due to one type of orofacial pain (6.5%), 18 employees informed having been absent as a result of two types of orofacial pain (4.5%), nine employees informed having missed work as a result of feeling more than three types of orofacial pain and only one worker informed having missed working days as a result of feeling the nine types of orofacial pain (0.2%) in the last six months (Table 2). The association between absenteeism and gender indicated that the prevalence of absenteeism resulting from toothache caused by hot or cold liquids or sweet foodstuff (p = 0.043) was higher for male workers (Table 3). Variable Category n % Gender Male 285 71.1 Female 116 28.9 Age 18 to 21 91 22.7 22 to 31 191 47.6 32 to 41 99 24.7 42 to 51 20 5.0 Marital status Single 178 44.4 Married 223 55.6 Education level Cannot read or write 1 0.2 Incomplete Elementary School 75 18.7 Complete Elementary School 78 19.5 Incomplete High School 73 18.2 Complete High School 142 35.4 College Education 32 8.0 Family income From 1 to 2 minimum wages 180 44.9 From 3 to 5 minimum wages 182 45.4 From 6 to 10 minimum wages 33 8.2 From 11 to 20 minimum wages 6 1.5 Table 1. Percentage of gender, age, marital status, education level, family income among workers of a meat processing industry. Joaçaba (SC), Brazil, 2003 52 Nardi A, Michel-Crosato E, Biazevic MGH, Crosato E, Pizzatto E, Queluz DP Braz J Oral Sci. 8(1): 50-4 Table 4 shows that the prevalence of absenteeism resulting from spontaneous toothache was higher among workers with the worst level of family income (p = 0.011). An association was also observed between absenteeism result- ing from orofacial pain and self awareness of oral health (p < 0.001). Employees who declared having poor oral health conditions present- ed a higher prevalence of absenteeism resulting from orofacial pain, in the nine types of orofacial pain studied, than those who declared having a good oral health status (Table 5). Discussion The prevalence of absenteeism due to orofacial pain for the workers of the meat processing industry was of 15%, and the average number of lost working hours as a result of dental causes was of 0.88 working hours/employee/year. When comparing the results of this study to those of various epi- demiological studies3-9, it was noted that the prevalence of absentee- ism for dental reasons in the study population matched the previous- ly found values. However, the average number of working hours lost by the employees of the meat processing industry was below those results previously presented. The orofacial pains that caused the highest levels of absentee- ism were: spontaneous toothache (9.7%); toothache caused by cold or hot liquids or sweet foodstuff (6.5%) and pain around and behind the eyes (3.2%). These pains have the characteristic of acute cases with a relatively short duration and that can be rapidly treated, reestablish- ing the workers’ capabilities to perform their functions and enabling their prompt return to their jobs. Considering the amount of time absent from work as a result of orofacial pain, there was a predomi- nance for the loss of half or a full work shift as shown in Table 2. The average number of leave-of-absence days due to dentist certificates was of 1.5 days/employee/year. These results are consistent with those presented in previous studies11-14. Absenteeism caused by dental reasons in this meat process- ing industry was smaller than absenteeism resulting from medical causes in both average length and total number of leaves of absence, being these data similar to the survey by Reisine15. Employees who declared having poor oral health status pre- sented a higher prevalence of absenteeism due to orofacial pain than those who declared having a good oral health status. In this sense, Type of orofacial pain No absence (%) Absent on half a shift (%) Absent for a full shift (%) Absent for 1 day (%) Absent for 2 days (%) Total (%) Spontaneous toothache 90.7 5.2 1.4 2.2 0.5 100.0 Induced toothache 93.5 3.7 1.4 1.2 0.2 100.0 Burning sensation on the tongue 98.8 0.5 0.2 0.5 0.0 100.0 TMJ pain 97.5 1.2 0.8 0.5 0.0 100.0 Pain on chewing 98.0 1.0 0.5 0.5 0.0 100.0 Pain on opening the mouth 99.0 0.5 0.3 0.2 0.0 100.0 Pain in front of the ears 97.5 1.5 0.0 0.5 0.5 100.0 Pain in the face or cheeks 97.3 1.5 1.0 0.2 0.0 100.0 Pain around or behind the eyes 97.0 1.3 1.4 0.3 0.0 100.0 Table 2. Percentage of working hours lost for each type of orofacial pain among workers of a meat processing industry. Joaçaba (SC), Brazil, 2003 Causes of absenteeism Gender Odds Ratio Confidence interval (95%) p Male Female Spontaneous toothache No 253 109 1.970 0.843 - 4.599 0.111 Yes 32 7 Induced toothache No 262 113 3.307 0.973 - 11.236 0.043 Yes 23 3 Burning sensation on the tongue No 281 115 1.637 0.181 - 14.804 0.658 Yes 4 1 TMJ pain No 278 113 0.948 0.241 - 3.733 0.940 Yes 7 3 Pain on chewing No 279 114 1.226 0.244 - 6.164 0.805 Yes 6 2 Pain on opening the mouth No 283 114 0.403 0.056 - 2.894 0.350 Yes 2 2 Pain in front of the ears No 280 111 0.396 0.113 - 1.396 0.137 Yes 5 5 Pain in the face or cheeks No 277 113 1.088 0.283 - 4.175 0.902 Yes 8 3 Pain around or behind the eyes No 275 113 1.370 0.370 - 5.070 0.636 Yes 10 3 Table 3. Association between absenteeism resulting from facial pain and gender among the workers of a meat processing industry. Joaçaba (SC), Brazil, 2003 53Relationship between orofacial pain and absenteeism among workers in Southern Brazil Braz J Oral Sci. 8(1): 50-4 Causes of absenteeism Income Odds Ratio Confidence interval (95%) p Low High Spontaneous toothache No 155 207 2.385 1.200 - 4.738 0.011 Yes 25 14 Induced toothache No 166 209 1.469 0.662 - 3.261 0.342 Yes 14 12 Burning sensation on the tongue No 177 219 1.856 0.307 - 11.229 0.494 Yes 3 2 TMJ pain No 174 217 1.871 0.520 - 6.733 0.331 Yes 6 4 Pain on chewing No 176 217 1.233 0.304 - 5.000 0.769 Yes 4 4 Pain on opening the mouth No 178 219 1.230 0.172 - 8.822 0.836 Yes 2 2 Pain in front of the ears No 174 217 1.871 0.520 - 6.733 0.331 Yes 6 4 Pain in the face or cheeks No 174 216 1.490 0.447 - 4.963 0.514 Yes 6 5 Pain around or behind the eyes No 175 213 0.761 0.244 - 2.367 0.636 Yes 5 8 Table 4. Association between absenteeism from orofacial pain and family income among the workers of a meat processing industry. Joaçaba (SC), Brazil , 2003 Causes of absenteeism Oral health Odds Ratio Confidence interval (95%) p Good Poor Spontaneous toothache No 37 325 6.787 3.309 - 13.923 0.000 Yes 17 22 Induced toothache No 39 336 11.748 5.043 - 27.370 0.000 Yes 15 11 Burning sensation on the tongue No 50 346 27.680 3.033 - 252.646 0.000 Yes 4 1 TMJ pain No 47 344 17.078 4.269 - 68.321 0.000 Yes 7 3 Pain on chewing No 48 345 21.563 4.231 - 109.892 0.000 Yes 6 2 Pain on opening the mouth No 50 347 7.940 6.127 - 10.289 0.000 Yes 4 0 Pain in front of the ears No 49 342 6.980 1.950 - 24.984 0.001 Yes 5 5 Pain in the face or cheeks No 49 341 5.799 1.705 - 19.722 0.002 Yes 5 6 Pain around or behind the eyes No 45 343 17.150 5.073 - 57.980 0.000 Yes 9 4 Tabela 5. Association between absenteeism from orofacial pain and self-awareness of oral health among workers of a meat processing industry. Joaçaba (SC), Brazil, 2003 self-awareness of the oral health status coincided with the impact observed through the application of the instruments: work-related activities are more severely affected among employees who present- ed the perception of their poor oral health condition. This study did not demonstrate any associations between preva- lence of absenteeism due to orofacial pain and age, marital status, schooling, geographical area (rural or urban), company sector or work shift. There are two types of absenteeism: absenteeism through the ab- sence of work and physically present absenteeism. The first type can be measured and its costs can be calculated through the absence. The second type cannot be measured, since it represents the worker who cannot perform his/her normal working activities due to pain, despite being physically present to the workspace13. Labor is increasingly becoming effective and instrumental in the social-economical advancements in our society14. The attention of the authorities responsible for the implementation of the directives of a country that has its economy based on labor should be oriented towards the health and welfare. Consequently, workers should be the objective of measures and policies to preserve their physical, mental and social well-being. Therefore, maximum productive capacity is achieved when the worker is satisfied in his basic health needs11-16. 54 Nardi A, Michel-Crosato E, Biazevic MGH, Crosato E, Pizzatto E, Queluz DP Braz J Oral Sci. 8(1): 50-4 Studies have shown that oral problems caused difficulties or in- capacity to perform normal working activities, study or sleep in a percentage that ranges from 8 to 60%16-18. 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