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Dental practitioners and ill
health retirement: causes,
outcomes and re-employment
J. Brown,1 F. J. T. Burke,2 E. B. Macdonald,3 H. Gilmour,4 K. B. Hill,5
A. J. Morris,6 D. A. White,7 E. K. Muirhead8 and K. Murray9
who might be considered an equivalent
group in terms of qualifi cations and train-
ing. It may be considered that examina-
tion of reasons for premature retirement
would provide information on diseases
which incapacitate dentists, but contem-
porary comprehensive data regarding the
reasons for premature retirement due to
illness among dentists has proved diffi cult
to obtain. Data presented by Burke and co-
workers in April 1997, representing only a
small proportion of the dental population,
identifi ed reasons for premature retirement
of dental practitioners on health grounds,
with musculoskeletal disorders and stress-
related illnesses being the most frequently
cited groups of conditions.2 In this respect,
statistics collected almost two decades
ago suggested that dentistry was the most
stressful of healthcare professions.3 Cooper
and co-workers, in 1987, suggested that
dentists face a set of unique problems such
as time-related pressures, fearful patients,
INTRODUCTION
Data published in 1999 from the
Government Actuary on the National Health
Service Pension Scheme (1989-1994) have
indicated that the frequency of premature
ill health retirement (IHR) was four times
more prevalent among dentists at age
42 years compared with medical doctors,1
Aim The aim of this project was, by means of a questionnaire to ill health retirees, to determine the factors which have
contributed to the premature retirement of general dental practitioners (GDPs) due to ill health. Methods A questionnaire
was designed to determine the effects of illness and ill health retirement (IHR) on the lives of those dentists who were
affected. This was distributed to 207 dentists who were known to have retired because of ill health but were not suffer-
ing from serious, debilitating or life-threatening illnesses. Results A total of 189 questionnaires were returned. The mean
age at retirement of respondents was 51.5 years, with a range of 31 to 62 years. Of the respondents, 90% selected general
dental practitioner as their last job title. The most common cause of IHR was musculoskeletal disorders (55%), followed by
mental and behavioural disorders (28%). A majority of respondents (90%) considered that their ill health was work related.
Sixty-three percent of respondents stated that they were able to keep working until their retirement, 34% of respondents
stated that they would have liked to have been offered part-time work as an alternative to full retirement, and 27% of
dentists reported to have found re-employment since their retirement. In univariate analyses, re-employment of dentists
after IHR was signifi cantly associated with age, having dependants, cause of IHR, health having improved and wanting
to work again. Multiple logistic regression analyses showed that a combination of age, having dependents and cause of
IHR was predictive of re-employment status (p = 0.024). Conclusion This study used a database of dentists who were ill
health retired and who were not suffering from life threatening illnesses The results confi rmed that the majority were able
to work up to their retirement and a similar number would have liked to continue working, particularly if part-time work
had been possible. It seems likely that many of the ill health retirees could have been retained in the dental workforce with
better support or opportunities for more fl exible working.
fi nancial worries and staff problems, along
with the repetitive nature of the job.4 They
also found that dentists had signifi cantly
lower mental well-being than a compa-
rable group from the general population.4
On the other hand, a US study published
in 1976 indicated that dentists’ mortality
rates were lower than other professional
groups for the most common causes of
death, with 73% of deaths occurring after
the age of 64.5 In the UK, dentists have
the lowest mortality rates for all cancers,
heart disease, cerebrovascular disease and
chronic lung disease among healthcare
professionals.6 Nevertheless, the results of
an evaluation of UK general dental prac-
titioner stress levels indicated that one in
three of the respondents were considerably
dissatisfi ed with their job.3 Negative patient
perceptions and scheduling problems
were noted as the primary factors relat-
ing to poor job satisfaction. More recently,
Gilmour and colleagues assessed the level
1Research Fellow, Healthy Working Lives Group, 3Head
of Healthy Working Lives Group/Honorary Profes-
sor, 9Research Fellow, Healthy Working Lives Group,
4Senior Lecturer in Medical Statistics, Public Health and
Health Policy Section, Division of Communit y Based
Sciences, 1 Lilybank Gardens, University of Glasgow,
Glasgow, G12 8RZ; 2*Professor of Primar y Dental Care,
5Lecturer in Dental Public Health and Behavioural Sci-
ence, 6Senior Lecturer, 7Associate Professor of Dental
Public Health, 8Research Assistant, Primary Dental Care
Research Group, University of Birmingham School of
Dentistry, St.Chad’s Queensway, Birmingham, B4 6NN
*Correspondence to: Professor Trevor Burke
Email: f.j.t.burke@bham.ac.uk;
Tel: +44 (0)121 237 2767
Online article number E7
Refereed Paper - Acc epted 19 February 2010
DOI: 10.1038/sj.bdj.2010.813
©British Dental Journal 2010; 209: E7
• The most common cause of IHR was
musculoskeletal disorders. A majority
of respondents considered that their ill
health was work related.
• The majority were able to work up to
their retirement and a similar number
would have liked to continue working.
• It is likely that many of the ill health
retirees could have been retained in the
dental workforce with better support or
opportunities for more fl exible working.
IN BRIEF
RESEARCH
BRITISH DENTAL JOURNAL 1
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
of job satisfaction among 297 general
dental practitioners in Staffordshire,
England, with the results indicating that
57% were satisfi ed with their career in
dentistry but that job-related stress was
associated with the greatest proportion of
dissatisfaction.7
Regarding stress and burnout in general
dental practitioners, sources of stress have
been identifi ed by Blinkhorn as being the
payment system, a feeling of being under-
valued and the feeling of being trapped in
a practice until retirement,8 while Osborne
and Croucher, when assessing burnout
among dental practitioners in South East
England, concluded that general dental
practice had characteristics which were
likely to produce high levels of job-
related stress, and with 11% of practition-
ers exhibiting high overall burnout levels.9
In general it would be expected that the
incidence of disease among dentists would
be lower compared with that from other
groups within the population since dentists
belong to a higher socio-economic group-
ing.10,11 In a study of gender-related differ-
ences in burnout among Dutch dentists,
Te Brake and co-workers found no gender
differences in work stress or health-related
aspects but that male dentists worked
longer hours than female dentists.12 Scully
and co-workers11 compared standardised
mortality ratios (SMRs) among dentists and
demonstrated that dentists had lower SMRs
than the general population in the UK and
USA, with 73% of dentists living beyond
the age of retirement. It would therefore
appear that dentists are not, in general, at
increased risk from illnesses, but, never-
theless, a proportion of these physical and
mental illnesses result in IHR.
A small number of studies have exam-
ined the impact of musculoskeletal
problems among dentists. Shugars and
colleagues reported the results of a 1985
survey of 2,000 US dentists. Sixty per-
cent of respondents reported that they had
experienced some type of musculoskeletal
pain during the previous year. Of those who
reported musculoskeletal pain, the location
of the pain with the highest incidence was
lower back (37% of respondents), followed
by neck (17%).13 In addition, respondents
who reported having pain stated that pain
was present from 65 to 125 days per year
and almost a third of those who experi-
enced pain indicated that physical and
leisure activities were interrupted because
of pain. Pain was found to cause the can-
cellation of one day of practice per year,
extrapolated by the authors to mean 1.3
million cancelled patient appointments
per annum.13 More recently, Finsen and
co-workers investigated musculoskeletal
disorders among 115 dentists in Denmark
who were members of the Danish Society
for Craniomandibular Disorders. Two thirds
of the respondents reported pain or discom-
fort in the neck and/or shoulder region in
the year preceding the survey, with a simi-
lar fi gure being reported for low back pain.
Older dentists were found to have fewer
reported neck problems than younger den-
tists, but hours worked had a signifi cant
impact, with dentists who worked longer
hours reporting more neck problems.14
Lastly, Lake, in a review of the literature
on musculoskeletal problems associated
with the practice of dentistry, concluded
that musculoskeletal dysfunctions such as
tendonitis, muscular strains, carpal tun-
nel syndrome, Raynaud’s phenomenon and
cervical arthroses are associated with the
practice of dentistry.15 She advised that the
dentist must take responsibility for their
own physical wellbeing, monitoring symp-
toms and taking advice early.
Despite these studies, there is a paucity
of information on the predisposing factors
which initiate a dentist’s decision to retire
on health grounds, since this was not their
focus. In addition, little is known about
the alternative career choices made to den-
tists concerning IHR, such as employment
outside of clinical dentistry or reduced
hours of work. Accordingly, in view of the
information contained in the Government
Actuary’s report1 and the shortage of den-
tists identifi ed by the Primary Care Dental
Workforce Review published in 2004,16 it
was considered appropriate to investigate
these factors.
The aim of this project was to determine
the factors which have contributed to the
premature retirement of general dental
practitioners (GDPs) due to ill health. The
objectives were to obtain a sample of den-
tists who had retired through IHR and use
a questionnaire to determine:
The effect of premature retirement
•
upon their life
Any potential remediable factors which
•
might have led to their remaining in
the workplace, and
Assess rehabilitation needs which may •
not have not been met.
Specifi c research questions included:
What factors are associated with, and 1.
possibly predispose, to premature
retirement on health grounds from
dental practice?
What is the effect of IHR upon 2.
the health and quality of life of those
who retire?
What potential remedial factors 3.
might prevent or forstall premature
retirement?
Was any rehabilitation offered to the 4.
ill health retirees which would have
enabled them to continue in work?
What are the predictors of returning 5.
to work after IHR?
METHODS
The questionnaire
A questionnaire was designed to deter-
mine the effects of illness and ill health
retirement (IHR) on the lives of those den-
tists who were affected. It was derived
from one used successfully by Macdonald
and co-workers in recent research into
Scottish teachers’ and healthcare work-
ers’ premature retirement due to ill
health.17–19 In addition, the questionnaire
also addressed work ability of the partici-
pants. In this respect, the concept of work
ability can be defi ned as the ability of a
worker to perform his/her job, taking into
account the specifi c work demands and
mental resources.20
The questionnaire also included the
questions from the HADS (Hospital Anxiety
and Depression Scale) questionnaire,21 a
validated questionnaire consisting of 14
items and yielding two measures, one for
anxiety and one for depression. Scores on
both scales can range between 0 and 21. A
higher score indicates a more severe con-
dition. A score of 7 or less is considered
‘normal’, a score between 8 and 10 ‘mild’,
a score between 11 and 15 ‘moderate’,
and a score greater or equal to 16 ‘severe’.
Moderate and severe scores indicate ‘case-
ness’, that is individuals who would be
considered anxious or depressed. A large-
scale (n = 1,792) normative study carried
out on a non-clinical sample of the UK
population found an average score of 6.14
for anxiety and 3.68 for depression.21
2 BRITISH DENTAL JOURNAL
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
to take part in a telephone interview. The
data from the completed questionnaires
were collated and analysed.
Data analysis
Analysis of the completed questionnaires
was undertaken on SPSS version 15.0. We
investigated the likelihood of taking up
employment after IHR in relation to seven
factors recorded in the questionnaire. The
possible predictors were sex, age, depend-
ants, managerial responsibility, cause of
IHR, health improvement and wanting to
work again. Age was recoded into three
categories (less than 50, 50-54 and 55+).
Cause of IHR was recoded as either mental
disorder or all other diseases. The relative
chance of re-employment was initially
estimated by odds ratios (ORs) calculated
for each predictive variable separately.
Multiple logistic regression models exclud-
ing ‘health improvement’ and ‘wanting to
work again’ provided adjusted OR and
their confi dence intervals.
Telephone interviews
A sample of 29 respondents was selected
from those subjects who agreed, in their
replies to the questionnaire, to either a tel-
ephone interview or a face-to-face inter-
view with a researcher who was trained in
interview techniques. The fi ndings from
these interviews are presented in a sepa-
rate paper.
RESULTS
A total of 189 questionnaires were
returned, 28 from female dentists and 161
from male dentists. This represents a 90%
response rate from the dentists who agreed
to participate in the project, but a 50%
response rate from those retirees who were
originally contacted by WMS.
Demographic details
The mean age at retirement of respond-
ents was 51.5 years, with a range of
31 to 62 years. Of the respondents, 90%
(n = 170) selected general dental practi-
tioner as their last ‘job title’, with 108 of
these being mainly National Health Service
(NHS) and the others being mixed NHS/
private or wholly private. Of the general
dental practitioners, 70% reported being
practice owners.
Data on IHR are as follows:
Regarding the number of years for
•
which respondents worked as a dentist,
the mean was 27.4 years, with the
shortest time being 5 years and the
longest being 39 years
Seventy-seven percent (n = 146) of
•
respondents reported that they worked
full-time at the time of their retirement
and 76% (n = 142) reported that their
job involved supervisory or managerial
responsibility
Sixty-three percent (n = 116) of
•
respondents stated that they were able
to keep working until their retirement,
and, of those who were off work before
retirement, this was for a mean time of
10.9 months
When asked if they felt that their ill
•
health was work related, 10% (n = 19)
replied that it was not work related,
while 42% (n = 80) replied that their
retirement was ‘partly work related’
and 48% (n = 90) ‘completely work
related’
Ninety-fi ve percent of respondents
•
(n = 179) stated that they had
consulted their general practitioner
because of the illness that led to their
retirement.
Causes of IHR
It should be noted that this study addresses
IHR in dentists who retired with non life-
threatening illnesses and Table 1 illustrates
the causes of IHR of these respondents.
The most common cause of IHR was mus-
culoskeletal disorders, followed by mental
and behavioural disorders and disease of
the nervous system/sense organs. ‘Other’
included diseases of the respiratory system,
digestive system, endocrine and skin.
Interestingly, results from the HADS part
of the questionnaire indicated that, while
28% of dentists retired early because of
The questionnaire was piloted with ten
dentists who had retired prematurely due
to ill health. A number of changes, includ-
ing deletion of several sections, were made
following feedback from these dentists. The
fi nal questionnaire contained a total of 77
questions, 13 of which included subsec-
tions requesting additional information.
The subjects
Previous correspondence with a dental sick-
ness insurance company indicated that a
proportion of their members who had retired
prematurely on health grounds would be
prepared to co-operate in this research.
Accordingly, following contact with a
company specialising in health insurance
for dentists (Wesleyan Medical Sickness:
WMS), it was agreed that they would send
a letter to their members who had retired
prematurely due to ill health, since, because
of the need to protect confi dentiality, it was
not appropriate for the researchers to con-
tact the retirees directly. The letter requested
the co-operation of the retired dentist in
responding to the questionnaire; it also
stated that that WMS would have no further
involvement in the project.
Analysis of the WMS database of reti-
rees who were known to have retired
through ill health indicated that 207 (of
594) members were suffering from serious,
debilitating or life-threatening illnesses as
defi ned by the insurance arrangements. It
was decided jointly between WMS and the
research team that it would be inappropri-
ate to ask these dentists to respond to a
questionnaire. Accordingly, the letter from
WMS requesting help was distributed, in
September 2006, to 387 retired dentists. Of
these, 210 replied positively and provided
their names and addresses. The question-
naire was sent by post to these dentists,
with a reply-paid envelope and a covering
letter explaining the aims of the project.
The letter requesting participation in the
research explained that this would be car-
ried out by way of completion of a detailed
questionnaire designed to examine the
dentist’s life history and job satisfaction,
issues involved in the decision to retire,
whether alternatives to retirement were
offered, and changes in quality of life since
retirement. The dentists were informed that
they would be reimbursed for the time
taken completing the questionnaire. They
were also asked if they would be prepared
Table 1 Reported cause of IHR in dentists
who retired with non-life-threatening
illnesses
Cause Number (%)
Musculoskeletal 104 (55%)
Mental and behavioural disorders 54 (28%)
Nervous system/sense organs 17 (9%)
Circulatory 4 (2%)
Neoplasms 3 (2%)
Other 7 (4%)
BRITISH DENTAL JOURNAL 3
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
mental health problems, the data from the
completed HADS questions indicated that
only 20% were anxious and 10% depressed
on completion of the questionnaire.
Support
Regarding support before retirement, 37%
of respondents (n = 69) reported contact-
ing a support organisation (the British
Dental Association being an example),
with 71% (n = 49) fi nding that this was
helpful. Ninety-fi ve percent of respond-
ents (n = 176) considered that their general
medical practitioner was supportive, 94%
(n = 178) had been referred to a consult-
ant, with 95% (n = 174) of these being
considered supportive.
Occupational health advice
Twenty-eight percent of respondents
(n = 52) stated that they were offered occu-
pational health advice before their IHR, with
71% (n = 40) reporting this to be useful. This
advice was obtained from a wide variety of
sources, including consultants, advisers and
physicians in occupational health, general
medical practitioners and physiotherapists.
Of those respondents who reported not
receiving occupational health advice, 92%
(n = 140) stated that they would have liked
to have been offered such advice.
Most frequently quoted suggestions for
the advice that should be given included:
Advice on posture and better working
•
practices
Coping with (workplace) stress
•
Coping with the stress of being ill and •
managing recovery
Future career possibilities and
•
retraining.
One respondent suggested that everyone
should be allowed a sabbatical after being
in practice for a few years, as this might
improve long-term retention.
Alternative working patterns
When asked whether they were offered
the option of working part-time in the
period preceding ill health retirement, 13%
(n = 24) reported such an offer, although
28% (n = 52) replied that they were already
working part-time. Of those who reported
an offer of part-time work, 70% (n = 21)
took up this option. Thirty-four percent of
respondents (n = 44) stated that they would
have liked to have been offered part-time
work. Twenty-eight percent of respond-
ents (n = 52) replied that they investigated
alternative work before retirement, and of
those who did not, 45% (n = 63) replied
that they would have liked help in inves-
tigating alternative employment.
Effect of retirement
When asked ‘At the point of retirement did
you feel under strain?’
Six percent (n = 11) of respondents
•
stated ‘not at all’
Eleven percent (n = 21) stated ‘no more
•
than usual’
Sixteen percent (n = 31) stated ‘rather
•
more than usual’
Sixty-seven percent (n = 126) stated
•
‘much more than usual’.
Following IHR:
Fifteen percent (n = 29) of respondents
•
stated that they were less happy than
usual
Twenty-nine percent (n = 54)
•
responded that they were as happy as
usual
Fifty-six percent (n = 106) considered
•
that they were more happy than usual.
Forty-three percent of respondents
(n = 81) stated that they felt a loss of status
since IHR and this was considered to cause
Table 2 Possible predictors of re-employment of dentists after ill health retirement
Variable No.
retired
No. back to
work (%)
Unadjusted OR
(95% CI)a
Adjusted OR (95%
CI)b,c
Sex
Male
Female
161
27
41 (25)
10 (37)
p = 0.211
1.00
1.72 (0.73, 4.06)
Age-group
55+
50-54
<50
65
62
59
13 (20)
14 (23)
23 (39)
p = 0.038
1.00
1.17 (0.50, 2.73)
2.56 (1.15, 5.70)
p = 0.158
1.00
0.96 (0.40, 2.31)
1.94 (0.83, 4.51)
Dependants
No
Yes
96
92
20 (21)
31 (34)
p = 0.047
1.00
1.93 (1.00, 3.72)
p = 0.072
1.00
1.88 (0.95, 3.73)
Managerial responsibility
No
Yes
45
142
10 (22)
41 (29)
p = 0.383
1.00
1.42 (0.64, 3.13)
Cause of IHR
All other diseases
Mental disorder
135
54
31 (23)
20 (37)
p = 0.049
1.00
1.97 (1.00, 3.91)
p = 0.129
1.00
1.77 (0.85, 3.67)
Health improved
No
Yes
82
107
16 (20)
35 (33)
p = 0.043
1.00
2.01 (1.02, 3.96)
Want to work again
No
Yes
108
37
18 (17)
22 (59)
p <0.001
1.00
7.33 (3.20, 16.80)
aUnadjusted odds ratio (relative chance of fi nding re-employment after IHR) obtained from cross-tabulations
bAdjusted odds ratio obtained from a multiple logistic regression model
cThe overall multiple logistic regression model including age, dependents and cause of IHR was predictive of re-employment
tatus (p = 0.024)
Table 3 All probabilities of subsequent employment after IHR from logistic regression model
<50 50-54 55+
Dependants No
dependants Dependants No
dependants Dependants No
dependants
Mental
Health as
cause of
IHR
53.5% 38.0% 36.3% 23.3% 37.2% 24.0%
Cause of
IHR not
mental
health
39.4% 25.7% 24.4% 14.7% 25.1% 15.2%
4 BRITISH DENTAL JOURNAL
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
The estimated probability of a dentist aged
55+ returning to work, with no dependants
and who retired with an illness other than
a mental health problem, was 15%.
Views on career and employment
The respondents’ feeling about their career
before IHR is presented in Table 4, with a
majority (63%) presenting positive feelings
about their career. However, when asked
about their feelings on their past method
of employment, only 43% were positive
(Table 5).
Income protection
Ninety-four percent of respondents
(n = 177) reported that they had income
protection before retirement and 70%
(n = 131) made a claim on this. Of these,
97% (n = 127) reported that the claim was
successful. Regarding the attitude of the
NHS Pensions Agency, 81% of respond-
ents reported that they were helpful, while
the attitude of private insurance com-
panies was considered helpful by 69%
of respondents.
Self-help groups
Thirty-eight percent of respondents
(n = 71) considered that a self-help group
would have been advantageous.
Health and well-being
When asked to rate their present health,
respondents answered as shown in Table 6.
Of the respondents, 52% considered that
they were ‘limited a lot’ in doing vigor-
ous activities, 24% (n = 45) were ‘limited
a little’ and 25% (n = 46) not ‘limited at
all’. On a similar theme, 18% of respond-
ents (n = 33) were ‘completely satisfi ed’
with their physical ability to do what they
wanted to do, 16% (n = 31) being ‘very
satisfi ed’, 28% (n = 52) being ‘somewhat
satisfi ed’, 29% (n = 54) being ‘somewhat
dissatisfi ed’, and 9% (n = 17) being ‘very’
or ‘completely dissatisfi ed’. A small propor-
tion of respondents (16%: n = 29) stated
that they needed help with mobility and
a further 7% were confi ned to a bed or a
chair for most or all of the day because of
their health.
HADS scores
The mean anxiety score was 6.39 and
the mean depressive score was 4.37 (very
near the normative study referenced ear-
lier). Table 7 shows the percentage of
stress to 35% (n = 29) of these. Fifty-four
percent of respondents (n = 102) reported
that they enjoyed things that they used
to enjoy more than they could before IHR
and half reported that they laughed more
after they retired.
Current health
and re-employment status
Regarding health post-retirement, 57%
(n = 107) of respondents reported that
their health had improved since retire-
ment. Twenty-seven percent of respond-
ents (n = 51) stated that they would like to
work again, with 27% (n = 51) reporting
that they had obtained other work since
IHR, with a majority of this work being
reported as being voluntary. Twenty-three
percent (n = 44) of respondents chose not
to answer this question.
Predictors of re-employment
On univariate (unadjusted) analyses, re-
employment of dentists after IHR was
signifi cantly associated with age, having
dependants, cause of IHR, health having
improved and wanting to work again. No
signifi cant association was found with
gender or having managerial responsibil-
ity (Table 2).
Although health having improved and
wanting to work again were included as
possible predictors of returning to work,
they would not be particularly useful at
the decision point of IHR and therefore
were not included in subsequent analy-
ses. Multiple logistic regression analyses
showed that, in the fi nal model, none of
the three variables individually were sig-
nifi cant after adjusting for the others, but
the combination of these three variables
is predictive of re-employment status
(p = 0.0.24) (Table 2).
Table 3 shows four examples of prob-
abilities of returning to work after IHR
based on the fi tted logistic regression
model. The estimated probability of a
dentist aged <50 years, having dependants
and retiring with a mental health problem
obtaining work after IHR was 54%. The
estimated probability of a dentist aged
55+ returning to work, having depend-
ants and who retired with a mental health
problem, was 37%. A dentist aged 50-54,
having dependants and retiring because of
a mental health problem has an estimated
probability of returning to work of 36%.
Table 4 Feelings about work before IHR
Feeling %
respondents
Number of
respondents
Very positive 30 58
Positive 33 62
Neutral 13 24
Negative 12 23
Very negative 12 23
Table 5 Respondents’ feelings about their
past method of employment
Feeling %
respondents
Number of
respondents
Very positive 18 33
Positive 25 46
Neutral 23 44
Negative 20 38
Very negative 14 27
Table 6 Respondents’ assessments of their present health
Good Bad
12345
17% (n = 30) 33% (n = 60) 32% (n = 58) 14% (n = 26) 3% (n = 5)
Table 7 Results from HADS questionnaire
Anxiety score Depression score
Normal 60% 80%
Mild 20% 10%
Moderate 16% 8%
Severe 4% 2%
BRITISH DENTAL JOURNAL 5
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
respondents scoring normal, mild, moder-
ate or severe scores. Moderate and severe
scores indicate ‘caseness’. In this study
20% of respondents were anxious and 10%
were depressed.
DISCUSSION
Internationally, research has demonstrated
that dentistry may be a stressful occupa-
tion, with studies from as far afi eld as
Denmark,22 the United States,23 Israel,24
the United Kingdom2–4,8,9 and Southern
Thailand25 confi rming this. A lack of career
perspective has been found to be a stress
factor most related to burnout in a survey
of Dutch dentists.26 However, the evidence
is by no means equivocal5,6,11 and a reason-
able proportion of a group of UK dentists
appear to be satisfi ed with their careers.7
Results of research into musculoskel-
etal disorders, again covering much of the
world, has shown a prevalence of muscu-
loskeletal problems among dentists, with
research among dentists in Sweden indi-
cating that female dental health workers
are at special risk of development of musc-
uloskeletal disorders of the upper extremi-
ties,27 that dentists in Poland worked in
conditions which produced disorders of the
musculoskeletal system,28 and that muscu-
loskeletal problems are a common source
of premature retirement in the US29 and the
UK.2 Droeze and Jonsson30 have described
the effect of introducing ergonomic inter-
ventions as a means of reducing muscu-
loskeletal disorders (MSD) among dentists
in the Netherlands, fi nding that the imple-
mentation of recommendations effected a
reduction in MSD. However, it was con-
cluded that, even in a highly motivated
group, the implementation of recommen-
dations will only be partly successful.
The response rate to the questionnaire in
this study, especially in view of its length,
may be considered satisfactory at 90% of
those retirees who agreed to take part and
50% of those who were considered suit-
able to take part. The response rate may
also be considered to indicate an interest
in the subject, a view reinforced by the
fact that a number of respondents wrote
letters or made telephone calls compli-
menting the researchers on examining
this subject. The views of the retirees who
declined to participate are not known. It is
possible that non-respondents, compared
to respondents, were enjoying life and did
not wish to re-open old feelings related
to their retirement, or, alternatively, that
they were unhappy and/or depressed and
did not wish to take part in the research.
Nevertheless, the data contained in the
responses may be considered to represent
the fi rst examination of the factors infl u-
encing IHR among a group of dentists and
the effect of this on their lives.
The mean age of respondents at IHR
was 51.5 years, having worked for a mean
time of 27 years, with 90% being general
dental practitioners at the time of retire-
ment, 77% being employed full-time and
70% being practice owners. These retire-
ments represent a considerable loss from
the profession in the UK, with the loss of
potential trainers and skilled practitioners,
arguably at the top of their experience. In
this respect, this paper provides evidence
that there is a potential to retain many
more of the highly skilled dental work-
force who take IHR. This could be consid-
ered to indicate that at least some of the
retirements were potentially unnecessary
had there been occupational support or
alternative work available. Furthermore,
as 63% of respondents were able to keep
working until their retirement, there must
be a question as to whether this group
actually needed to retire. These results
therefore reinforce a view that steps should
be taken to offer potential ill health reti-
rees alternative or reduced employment
within the profession in order to prevent
their total retirement. However, few were
offered the option of working part-time
and, of those who were, 70% took up this
option. In this respect, it appears clear that
working is good for well-being – ‘good
work is good for you’.31
At the time of IHR, 83% of respondents
reported that they were under strain and
90% considered that their ill health was
work-related. After retirement, more than
half stated that they were more happy
than usual and 63% had positive views
about their career. In addition, 63% were
able to continue working until the point
of IHR but only 43% were positive about
their method of employment. Given that
a majority of the respondents’ work was
within the NHS regulations, it could be
conjectured that it was not dentistry per se
which resulted in the retirees’ ill health, but
that it was the system under which they
worked that was the stressor.
The all or nothing attitude to retirement
and working, in which ill health retirees are
forced to retire fully without the option of
taking part of their retirement package and
working part-time, may result in the loss
of a potentially effective part of the work-
force and may be associated with increased
dissatisfaction among ill health retirees
and represents a poor use of the resources
available. In this respect, 28% and 34% of
respondents, respectively, stated that they
would have liked to have been offered
alternative or part-time employment, with
just over a quarter of respondents stating
that they investigated alternative work
before retirement. It would therefore be
reasonable to assume that, at retirement, a
majority of respondents retained suffi cient
work ability to be able to continue to work
in some capacity. Perhaps the lesson here
for the National Pensions Agency, sickness
insurance companies and organisations
is that a proportion of ill health retirees
would be content to remain in employ-
ment, albeit in a different or part-time,
role. There should therefore be a greater
focus on support and rehabilitation rather
than the current ‘stay or go’ choices that
many respondents reported. Indeed, it
could be argued that the whole IHR proc-
ess is not fi t for purpose and, as a result,
dentists are leaving the workplace unnec-
essarily. Furthermore, there is a systemic
lack of employability advice and a lack of
creativity in fi nding alternative work for
dentists. There may also be perverse incen-
tives within the insurance system by which
dentists are put off seeking alternative
careers because their insurance payments
would be affected if they started earning
another income.
Only a small proportion of respond-
ents reported being offered advice around
the time of their IHR. Of those who did
report receiving advice, 71% found it help-
ful, indicating a need for more advice to
those who are suffering work-threatening
illnesses. Regarding support, just over one
third of respondents reported contacting
an organisation for support before retire-
ment, perhaps a surprisingly low fi gure.
This might be considered to indicate that
the retirees had come to terms with their
premature retirement when it happened.
Another surprisingly low fi gure is the pro-
portion (28%) of respondents who reported
being offered occupational health advice
6 BRITISH DENTAL JOURNAL
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
NHS staff and mental disorders for teach-
ers, both of which were prevalent among
dentists. Seventeen percent of NHS staff
and 36% of teachers subsequently found
employment (26% of which was teaching-
related), a higher proportion than indicated
by the results of the present study. This
may suggest a different potential set of
outcomes between teachers, and NHS
staff and dentists. There is no bar to a
return to teaching under the regulations
of the Scottish Teachers’ Superannuation
Scheme, and, under the provisions of the
scheme, the employment can be pension-
able, whereas dentists who return to work
under the NHS after receiving their pen-
sion following IHR may have adjustments
to their pension.
The results of this research from
Scotland19 also indicate other differences
with the fi ndings of the present study, prin-
cipally in the use of occupational health
services and rehabilitation. Ninety-six per-
cent of NHS staff who took IHR had access
to an occupational health advisor, while
only 16% of teachers stated that an occu-
pational health advisor was available to
them. Forty-eight percent of NHS staff and
37% of teachers were offered rehabilitation
to help with ill health before retirement.
Why there is such a comparative dearth of
occupational health advice available to or
taken up by dentists is a matter for debate,
but it could be considered that the example
from these other professions must be fol-
lowed by those who administer dentistry in
the UK. Similarly, the fact that a proportion
of dentists in the present study would have
liked to return to work part-time is echoed
by the results from the Scottish NHS work-
ers and teachers. This may be considered to
point to a need for consideration of a two-
tier pension scheme, in which the criteria
for the lower tier includes permanency of
ill health for the current job but for the
upper tier any gainful employment.
In the population in the present study
the factors that were associated with re-
employment were age, having dependants,
cause of IHR, health having improved and
wanting to work again. Identifying health
improvement and the desire to work again
may not be possible at the point of IHR
and these were excluded from the multiple
logistic model. Although the combination
of the three variables age, having depend-
ents, and cause of IHR was predictive of
re-employment status (p = 0.024), none of
the variables individually were signifi cant
predictors of re-employment after IHR after
adjusting for the others. Stepwise selection
of variables was not used in the multiple
logistic regression analysis because for-
ward selection and backward elimination
gave contradictory results. Forward selec-
tion resulted in only the age-group being
included in the model, while backward
elimination resulted in age-group being the
only variable eliminated from the model.
The model including all three predictors
was used since this combination was pre-
dictive of re-employment status (p = 0.024)
and there was no strong rationale for fi t-
ting a simpler model. Younger age, hav-
ing dependants, and retiring because of a
mental health problem could prove useful
in identifying dentists who are more likely
to respond to rehabilitation and job reten-
tion initiatives. Mental health problems,
in particular anxiety and depression, tend
to improve with treatment32,33 and many
ill health retirees may have a manageable
health condition where the outcome could
be predicted to improve. In this respect,
in the present study, 60% of respondents
scored ‘normal’ for anxiety and 36% ‘mild’
or ‘moderate’. These retirees could there-
fore be considered to have a good chance
of being able to return to the workplace,
a similar fi nding to that in a study in
IHR among teachers17. Early retirement
need not therefore be the fi nal outcome
in such cases.
CONCLUSIONS
The mean age at retirement of the •
premature retirees was 51.5 years, with
a range of 31 to 62 years and the mean
number of years for which respondents
had been employed as a dentist was
27.4 years
Sixty-three percent of respondents
•
stated that they were able to keep
working until their retirement
Eleven percent of respondents
•
considered that their IHR was not work
related
Regarding support before retirement,
•
37% of respondents contacted an
organisation
Fifty-four percent of respondents
•
either obtained work after IHR or
would like to work again
A minority (28%) of respondents were
•
before their retirement, with the majority
of these being given advice on posture and
coping with stress.
The present study examined the effects
of IHR on a group of dentists who had
retired because of illnesses which were not
life-threatening. The results did not iden-
tify particular stressors within the dental
surgery practising environment which may
have contributed to premature retirement
due to ill health in the group studied.
Nevertheless, work appears to have played
a large part in IHR of the respondents, given
that only 11% of retirees stated that their
IHR was not work related and at the time
of IHR, 83% of respondents reported being
under strain. The lesson here is, perhaps, to
identify those members of the profession
who feel under work-related stress before
it results in illness and IHR. Improved
occupational support could therefore be
considered an obvious fi rst step. Who
should provide that is another matter, but a
partnership between the employers and the
sickness insurance providers would seem
to be the way ahead. This could improve
workforce numbers and would result in
cost savings as there would be no need
to reimburse the ill health retirees and,
moreover, the pension and sickness insur-
ance providers would continue to receive
their subscriptions.
Could there be a link between mus-
culoskeletal problems and stress among
dentists? The content and happy dentist
may manage to work through the problems
caused by musculoskeletal problems and
receive treatment for stress; the unhappy
dentist may not be prepared to do so.
Since 90% of respondents reported that
their retirement was work-related and over
half reported that their health improved
after retirement, there would appear to be
a need to investigate this further.
The results of the present study have
similarities to those from an earlier inves-
tigation of return to work of Scottish NHS
staff and teachers who had taken IHR,17,18
despite the occupations being dissimilar.
Of 1,500 who were sent a questionnaire
containing elements similar to that used
in the present work, 282 teachers and 424
NHS staff completed the questionnaire. The
mean age of retirement of NHS staff was
53.9 years and teachers 52.2 years. The
most common cause of premature retire-
ment was musculoskeletal disorders for
BRITISH DENTAL JOURNAL 7
© 20 Macmillan Publishers Limited. All rights reserved10
RESEARCH
offered occupational health advice
before their IHR, but this appeared to
be of a reactive nature
Thirty-four percent of respondents
•
stated that they would have liked to
have been offered part-time work
Following IHR, 56% of respondents
•
considered that they were happier
Regarding health post-retirement,
•
57% of respondents reported that their
health had improved since retirement
Regarding the respondents’ feeling
•
about their career before IHR, 63%
of respondents presented positive
feelings about their career, but, when
asked about their feelings on their
past method of employment, only 43%
were positive
Thirty-eight percent of respondents
•
considered that a self-help group
would have been helpful
Twenty-seven per cent of IHR dentists
•
reported having found re-employment
since their retirement. In univariate
analyses, re-employment of dentists
after IHR was signifi cantly associated
with age, having dependants, cause
of IHR, health having improved and
wanting to work again. Multiple
logistic regression analyses showed
that a combination of age, having
dependents and cause of IHR was
predictive of re-employment status
(p = 0.024).
Finally, these conclusions point to a
need to reconsider the terms and condi-
tions of IHR in the UK and there is a need
to improve the provision of occupational
health and rehabilitation and employabil-
ity advice to dentists.
The authors wish to express their thanks to the
following, without whose support this project
could not have been undertaken: Wesleyan
Medical Sickness and COPDEND (Committee of
Postgraduate Dental Deaneries) for their fi nancial
support; the dentists who piloted the questionnaire
and provided feedback; the dentists who agreed to
take part and gave their time to complete the ques-
tionnaire and the interviews; and Professor Ruth
Freeman, of the University of Dundee, for advice
with the questionnaire.
1. Government’s Actuary Department. Report by the
Government Actuary on the National Health Service
Pension Scheme 1989–1994. London: The Stationery
Offi ce, 1999.
2. Burke F J T, Main J R, Freeman R. The practice of
dentistry: an assessment of reasons for premature
retirement. Br Dent J 1997; 182: 250–254.
3. Howard J H, Cunningham D A, Rechnitzer P, Goode
R C. Stress in the job and career of dentists. J Am
Dent Assoc 1976; 93: 630–636.
4. Cooper C L, Watts J, Kelly M. Job satisfaction, men-
tal health and job stressors among general dental
practitioners in the UK. Br Dent J 1987; 162: 77–81.
5. Orner G, Mumma R D. Mortality study of dentists:
fi nal report, prepared for the National Institute
for Occupational Safety and Health. Philadelphia:
Temple University Health Sciences Center, School of
Dentistry, 1976.
6. Balarajan R. Inequalities in health within the health
sector. Br Med J 1989; 299: 822–825.
7. Gilmour J, Stewardson D A, Shugars D A, Burke
F J T. An assessment of career satisfaction
among a group of general dental practitioners in
Staffordshire. Br Dent J 2005; 198: 701–704.
8. Blinkhorn A S. Stress and the dental team: a qualita-
tive investigation of the causes of stress in general
dental practice. Dent Update 1992; 19: 385–387.
9. Osborne D, Croucher R. Levels of burnout in general
dental practitioners in the south-east of England.
Br Dent J 1994; 177: 372–377.
10. Whitehead M. The health divide. In Inequalities in
health. London: Penguin Books, 1988.
11. Scully C, Cawson R A, Griffi ths M. Occupational
hazards to dental staff. London: British Dental
Association, 1990.
12. Te Brake H, Bloemendal E, Hoogstraten J. Gender
differences in burnout among Dutch dentists.
Community Dent Oral Epidemiol 2003; 31: 321–327.
13. Shugars D, Miller D, Willans D, Fishburne C,
Strickland D. Musculoskeletal pain among general
dentists. Gen Dent 1987; 35: 272–275.
14. Finsen L, Christensen H, Bakke M. Musculoskeletal
disorders among dentists and variation in dental
work. Appl Ergon 1998; 29: 119–125.
15. Lake J. Musculoskeletal dysfunction associated with
the practice of dentistry – proposed mechanisms
and management: literature review. Univ Tor Dent J
1995; 9: 7,9–11.
16. Department of Health. Report of the Primary Care
Dental Workforce Review. London: Department of
Health, 2004.
17. Brown J, Gilmour W H, Macdonald E B. Ill health
retirement in Scottish teachers: process, outcomes
and re-employment. Int Arch Occup Environ Health
2006; 79: 433–440.
18. Brown J, Reetoo N K, Murray K J, Thom W,
Macdonald E B. The involvement of occupational
health services before ill health retirement in NHS
staff in Scotland and predictors of re-employm-
nent. Occup Med 2005; 55: 357–363.
19. Brown J, Gilmour W H, MacDonald E B. Return to
work after ill-health retirement in Scottish NHS
staff and teachers. Occup Med 2006; 56: 480–484.
20. Ilmarinen J, Rantanen J. Promotion of work ability
during aging. Am J Ind Med 1999; 38: 21–23.
21. Crawford J R, Henry J D, Crombie C, Taylor E P.
Normative data for the HADS from a large non-
clinical sample. Br J Clin Psychol 2001; 40: 429–434.
22. Moore R, Brodsgaard I. Dentists’ perceived stress and
its relation to perceptions about anxious patients.
Community Dent Oral Epidemiol 2001; 29: 73–80.
23. Rada R E, Johnson-Leong C. Stress, burnout and
depression among dentists. J Am Dent Assoc 2004;
135: 788–794.
24. Al-Khatib I A, Ishtayeh M, Barghouty H, Akkawi
B. Dentists’ perceptions of occupational hazards
and preventive measures in East Jerusalem. East
Mediterr Health J 2006; 12: 153–160.
25. Leggat P A, Chowanadisal S, Kewdjarune U,
Kukiattrakoon B, Yapong B. Health of dentists in
southern Thailand. Int Dent J 2001; 51: 348–352.
26. Gorter R C, Albrecht G, Hoogstraten J, Eijkman
M A. Work place characteristics, work stress and
burnout among Dutch dentists. Eur J Oral Sci 1998;
106: 999–1005.
27. Lindfors P, von Thiele U, Lundberg U. Work character-
istics and upper extremity disorders in female dental
health workers. J Occup Health 2006; 48: 192–197.
28. Sxzymaska J. Disorders of the musculoskeletal
system among dentists from the aspect of ergo-
nomics and prophylaxis. Ann Agric Environ Med
2002; 9: 169–172.
29. Lalumandler J A, McPhee S D, Parrott C B, Vendemia
M. Musculoskeletal pain: prevalence, prevention
and differences among dental offi ce personnel.
Gen Dent 2001; 49: 160–166.
30. Droeze E H, Jonsson H. Evaluation of ergonomic
interventions to reduce musculoskeletal disorders
of dentists in The Netherlands. Work 2005;
25: 211–220.
31. Waddell G, Burton A K. Is work good for your health
and well-being? London: The Stationery Offi ce,
2006.
32. Bakish D. New standard of depression treatment:
remission and full recovery. J Clin Psychiatry 2004;
62: 5–9.
33. Whitty P, Gilbody S. NICE, but will they help people
with depression? The new National Institute for
Clinical Excellence depression guidelines. Br J
Psychiatry 2005; 186: 177–178.
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