Introduction

In the context of dental care, vision is our dominant sense accounting for about 75% of all sensory information we receive [1]. The all the visual sensory information we process in whatever task we are engaged with in dentistry, whether it be detecting caries, performing endodontic procedures, or completing surgery, good vision is essential to success [2,3]. Dental professionals also face various physical hazards including aerosols, splatter, flying objects, sharp instruments, and optical radiation that increase the potential for ocular injury [4]. The potential for ocular injury included acute injuries to the eye whereby bloodborne pathogens (Hepatitis B, Hepatitis C, and HIV) could easily be transmitted from client to dental professional [5,6]. Regular exposures to chemicals such as sodium hypochlorite, phosphoric acid, methyl methacrylate and radiation from curing lights and laser emitters also increase ocular injury risk [7–9].

To deal with this risk, supranational best practice recommendations from the WHO, ADA and OSHA for use include always wearing impact resistant protective eyewear with side shields or full-face shields, during every dental procedure [10]. Despite these recommendations, ocular injuries have been documented among dental professionals in various countries, including Greece [11], Nigeria [12], the United Kingdom [13], and Saudi Arabia [14,15], with frequencies of 38% to 73% and ongoing reports of ocular injuries still occurring. The ongoing report of ocular injuries, and the large frequency of ocular injuries in these studies, especially in high-income countries where recommendations are established, suggest a large gap between knowledge and practice.

In India, the disparity may be even greater due to systemic, educational, and infrastructural barriers. The Dental Council of India (DCI) does not require ocular safety training as either an undergraduate component or postgraduate training outcome, nor does the DCI impose any national policy requiring dental institutions to follow protective equipment protocols. Therefore, the implementation of safety practices varies from institution to institution, and region to region. A recent survey by Uppal et al. [16] in the National Capital Region showed that while 77% of dental professionals reported ocular protection was important, only 23% reported using protective eyewear consistently. Likewise, Arvind et al. [17] demonstrated that, although knowledge about ocular infections among Indian dentists was of moderate quality, actual practice of eye protection was poor.

Further research in other Indian states supports these findings. A cross-sectional survey of 150 dental practitioners in Bengaluru identified that just over half of respondents indicated wearing protective eyewear, while others did not wear any protection—this indicates a significant knowledge–practice gap [18]. In Maharashtra, a recent survey of dental students identified that only 15.5% could identify that it was essential to use eye protection for aerosol-generating procedures—still indicating a knowledge--practice gap in safety [19]. On a national scale, Nimma et al. [20] conducted an audit of eye safety protocols among dentists in India and found that 69% of respondents wore eye safety protection consistently, 21.6% wore it some of the time, and 9.6% indicated they did not wear any eye protection. These are clear systemic gaps in institutional enforcement; more importantly, even for practitioners who are aware of ocular hazards, there are major behavioural gaps.

Educational gaps may don’t help the situation. Malandkar et al. [21] investigated the knowledge, attitudes and practices associated with PPE in a cross-sectional study of 390 dental practitioners from India. Out of their findings it was 85% thought their work efficiency was affected by PPE use, and 89% stated diagnosed communication problems which illustrates strong barriers practically and educationally to be able to work safely.

Given a multitude of contributory factors—including poor training, lack of mandates and variation in access to equipment—there is an evident need to conduct an extensive national survey of ocular safety practices across the field of Indian dentistry. While mini regional studies exist, no large multicenter studies have been conducted to date which document self-reported awareness, injury events and compliance behaviour of the entire professional continuum—from faculty to students to supporting staff.

This investigation is, therefore, intended to explore knowledge, awareness and clinical practice regarding ocular safety measures across dental professionals and clinical career support staff in the entire Indian context. This study considers the breadth of knowledge–practice gaps across regions and professional roles in order to underpin targeted educational reform, institutional staff training plans and to provide the basis for a national safety-related policy to help lessen the incidence of avoidable occupational ocular injuries and incidents experienced in dentistry.

Materials and methods

Results

Demographic details

When demographic factors were considered and compared across genders, no statistically significant differences were found among average age (males: 31.6 ± 10.2 years; females: 30.4 ± 9.6 years; t = 1.55, df = 510, p = 0.12) or years of professional experience (males: 7.8 ± 9.2 years; females: 6.9 ± 8.6 years; t = 1.70, df = 510, p = 0.09). On the contrary, since their professional role distribution was significantly different across males and females (χ² = 34.7, df = 4, p < 0.001), males were more likely to be practitioners (33.3%) or technicians (24.9%) and females were more likely to be hygienists (13.7%) or assistants (12.5%). The distribution of faculty members was more equal, with 37.3% of them being women and 39.5% being men. Notwithstanding similarities in age and experience, this data shows a clear gender disparity in dental occupations (Table 1).

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Table 1. Demographic details and professional characteristics of the study participants (n = 512).

https://doi.org/10.1371/journal.pone.0350450.t001

Gender distribution in categories of qualification

To gain a better understanding of demographic variation the gender distribution of occupational roles was assessed. The distribution of gender across six categories is presented in Table 2. Although females represented most of the total survey respondents, the ratio in which they represented each of the different types of qualification varied. For example, females appeared most often in their numbers as dental hygienists and assistants, while dental practitioners presented as being more evenly distributed between gender. Since descriptive attributes of occupational representation weren’t considered statistically significant, no statistical tests were performed.

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Table 2. Gender-wise distribution of respondents based on qualification.

https://doi.org/10.1371/journal.pone.0350450.t002

Geographical distribution of participants

The survey included responses from dental professionals and auxiliaries from various states of India, indicating a wide geographic dispersion. As shown in Fig 1, the state-wise distribution of respondents demonstrated broad geographic participation across India. The highest number of responses was received from Maharashtra (100; 19.5%), followed by Tamil Nadu (66; 12.9%), Karnataka (60; 11.7%), and Delhi (52; 10.2%). Other states contributing responses included Gujarat (38; 7.4%), West Bengal (36; 7.0%), Uttar Pradesh (34; 6.6%), and Kerala (28; 5.5%). Fewer responses were received from Rajasthan (22; 4.3%), Andhra Pradesh (20; 3.9%), Madhya Pradesh (18; 3.5%), Punjab (14; 2.7%), Odisha (8; 1.6%), and Bihar (6; 1.2%). In addition, 10 responses (2.0%) were received from other states and Union Territories, including Assam, Goa, Himachal Pradesh, and Chandigarh. The broad geographical administration of the survey highlights the national relevance and the generalizability of results to the dental community across India. No significant differences were observed in gender distribution between high- and low-response states (p = 0.21).

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Fig 1. State-wise bar chart illustrating the geographic distribution of survey participants by state.

https://doi.org/10.1371/journal.pone.0350450.g001

Awareness and importance of ocular safety guidelines pertaining to dental professionals

The analysis of eye safety awareness among the 512 participants revealed that 441 individuals (86.1%) affirmed their awareness of eye safety protocols when working with patients. Conversely, 13.9% of participants were not aware of such protocols (Fig 2). Notably, all 512 participants (100%) acknowledged the importance of eye safety protocols. A mean score of 9.1 ± 1.4 was observed when asked to rate the importance of ocular safety on a scale from 1 to 10, with 10 being the highest importance, which was fairly consistent value across participants with no significant difference by gender (p = 0.28) or role (ANOVA, p = 0.33).

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Fig 2. Participants’ awareness and perception of the importance of eye safety guidelines.

https://doi.org/10.1371/journal.pone.0350450.g002

A gender analysis of ocular injuries indicated a significantly larger percentage of males (69.5%) reported ocular insults compared to females (58.8%). This difference was borderline for significance (χ² = 3.41, p = 0.065). Regarding the frequency of injuries, males more often reported recurrent injuries, particularly at monthly or weekly frequencies, while females categorized their injury as having occurred “rarely” (χ² = 8.92, p = 0.012). The cause of reported incidents also varied by gender (χ² = 11.47, p = 0.042), with males most frequently attributing incidents to foreign bodies and laboratory procedures, while females most often attributed incidents to splatter or aerosols and removal of old restorations. Generally, first aid practices were similar across genders and irrigating with water immediately was the most frequently selected option (76.1% overall), although males were somewhat more likely to seek further care compared to females and this was not statistically significant (χ² = 2.37, p = 0.124). These results suggest modest but notable gender differences in the incidence, frequency, and etiological profile of ocular injuries among dental professionals; thus, it is important to all consider targeted injury prevention strategies (Table 3).

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Table 3. Experience, frequency, causes, and first aid responses to ocular insults among participants.

https://doi.org/10.1371/journal.pone.0350450.t003

Ophthalmologic consultations and surgical history

Analysis of ophthalmologic care patterns indicated there were no meaningful differences between males and females in terms of visit frequency, reasons for contact and surgical history. Males reported seeing an ophthalmologist monthly (12.4%) compared to females (6.9%) but the majority of each group reported visiting infrequently (74.6% males, 77.9% females (χ² = 2.14, p = 0.343)). With respect to the purpose of visits both males and females exhibited comparable patterns, with 24.3% of males and 20.6% of females reported visiting only because of an injury, and having an exam or check-up was slightly more common for females (43.9 vs. 45.8%; χ² = 1.92, p = 0.289). Surgical history was also comparable with 11.9% male and 9.7% female reported a previous minor or major ocular surgical procedure (χ² = 0.48, p = 0.487). Overall, it appears that the patterns of utilization of ophthalmologic care were similar for males and females without meaningful differences (Table 4).

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Table 4. Ophthalmologist visits, reasons for visits, and history of eye surgeries among participants.

https://doi.org/10.1371/journal.pone.0350450.t004

Awareness of ocular safety pertaining to patients

The results showed 70.5% of participants reported awareness of eye safety practices for patients, and there was a statistically significant difference in participant awareness levels (faculty = 81.6794 and auxiliaries = 72.7272) (χ² = 10.2, p = 0.006). Almost all participants (94.9%) felt that patient eye safety was an important concept, with a mean rating of 8.35 ± 1.98 (Fig 3).

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Fig 3. Awareness and perceived importance of patient eye safety protocols.

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Statistically significant differences were found in the provision of type of patient eye protection (χ², p < 0.001). Safety glasses were the most common patient eye protection offered (58.0%) and were offered more than spectacles, or visors (post-hoc, p < 0.001). As such, very few participants offered the patient with prescription spectacles (1.9%, p = 0.04), or visors (1.7%, p = 0.08). In addition, an alarming 38.4% of participants stated they did not provide patients with any eye protection when conducting dental procedures, which also was statistically significant (p = 0.001). These findings suggest an overwhelming reliance on safety glasses whilst highlighting a major risk to patient safety and share the concern for patient safety with a considerable amount of patients clearly without any patient eye protection (Table 5).

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Table 5. Patient ocular injuries, provided eye protection, and frequency of eye safety glasses use.

https://doi.org/10.1371/journal.pone.0350450.t005

Discussion

The study presents a striking contradiction: more than four out of five participants stated they knew about ocular safety practices, yet less than half stated they routinely wore eye protection. Knowledge-practice gaps are common, but our study demonstrates that they are deeply engrained in India. The lifetime incidence of 62.5% ocular injuries was observed, which is greater than reported from Pakistan (60%) [22] and some areas of Saudi Arabia (38%) [23], but less than was reported from Riyadh (86.8%) [15], Greece (73%) [11] and Nigeria (72.3%) [12]. Almost half of participants with injuries reported “rare” injuries, while 14.5% reported injuries on a monthly basis. These findings provide evidence that even occasional non-compliance in wearing protective eyewear has real clinical implications. The major causes of ocular injuries were scaling and polishing, cavity-preparation, and laboratory procedures. These findings reinforce previous findings that high-speed rotors and laboratory procedures produce debris and aerosols that can lead to ocular insults [24]. Additionally, retinal damage from curing lights indicates that injury risks not only included projectile injuries but also phototoxic exposures [25].

The contradiction is in why there is such a high level of awareness of risk but a lack of consistent protective behavior. Our finding is similar to that of Malandkar et al. [21] who report, 85% of dentists feel PPE impairs their efficiency. When asked what those barriers were, PPE discomfort, fogging and communication were notable. Similar barriers were reported by hygienists in the United States [26]. In other words, these ergonomic and psychosocial factors contribute to a perceived obstacle that protection interferes with clinical performance. In situations like this it seems a workshop and continuing education to reframe safety as a facilitator of professional efficiency could be worthwhile.

The findings of this study regarding ocular safety compliance and awareness fall in line with overall trends seen throughout other healthcare fields and professions. Just as dental healthcare practitioners can be at risk for injuries due to high-velocity projectiles as well as aerosol exposure that is contaminated, there are multiple studies that show that other Healthcare Workers (HCWs), also experience serious risk of injury through occupation hazards while not having a high level of compliance with safety standards [27,28]. A paradoxical aspect of infection control is that although dental providers and dental students consistently show greater compliance than nursing or medical staff, their perception of overall occupational risk is often lower than their medical or nursing colleagues [27].

Generally, nurses in all medical fields express high awareness when dealing with biological dangers. However, because they occur so often at the bedside, nurses will have a greater chance of having a percutaneous injury from handling these biological dangers [29]. However, ocular exposure through infectious splash effects is still a common threat to workers in all health care fields. Data suggests that a substantial portion of physicians and nurses underutilize ocular protection, frequently attributing this to physical discomfort or a perceived lack of necessity during non-invasive procedures [27,28]. This indicates that the safety gaps identified among dental professionals in the current study are emblematic of a systemic healthcare challenge, where theoretical awareness does not always manifest as consistent protective behavior [28,30].

These issues are exacerbated by systemic challenges. It is important to note that the present study did not directly assess or stratify institutional safety policies across participating sites. However, given the wide geographic distribution of respondents and inclusion of multiple institutional types, it is likely that variability in local safety protocols, enforcement practices, and availability of protective equipment existed. This heterogeneity may have influenced individual compliance behaviors and could partly explain the observed inconsistencies in ocular safety practices. Unlike infection control, ocular protection is not required by the Dental Council of India nor woven into training curricula as a core competency. The lack of systematic policy leads to commoditized institutional levels of variability and individualization of ocular safety. In contrast, compliance in contexts of stated policy exceeds to 60% [14], significantly above Indian rates. Without federal audits or accreditation requirements, eyewear protection is optional and unsafe behaviors continue.

Cultural and behavioral systems can provide more explanations. Dentistry in India has hierarchical systems: senior practitioners do not wear eyewear and students and aides follow suit. Arvind et al. [17] identified that clinicians may acquire knowledge but do not model safe practice to their patients, and this leads to a continual cycle of non-adherence. Youthful dentists may also underestimate risk associated with their own behaviors — the “invulnerability bias” — in models of Greek [11] and Nigerian [12] dentists. People also consider appearance in their decision-making process: most individuals will purposely not use bulky eyewear as they feel it diminishes their professionalism, consistent with behavioral studies illustrating that aesthetic and matters of social concern will take precedence over rational and systematic safety behaviors [31].

In addition to personal factors, practical obstacles also need to be addressed. The expense for quality visors or prescription glasses that ensure safety for work practice, is high especially for small independent practices. Practitioners in Bengaluru consistently cited as barriers, estimated to be just over 40% of practitioners indicating that price is a barrier [18]. While financial concerns also play a role, there are also misconceptions. Many dentists feel safe with regular spectacles, however, the work by Farrier et al. [32] has shown that rates of injury among spectacle users are higher than those wearing actual safety glasses. These misconceptions create barriers requiring educational and other initiatives to not only raise awareness, but to correct false beliefs and showing a cost-benefit of appropriate prevention.

Encouragingly, 93.6% of participants were aware of face shields and safety glasses and 42.6% indicated consistent use of either — higher than survey results from Nigeria (7.4%) [12], Saudi Arabia (24.5%) [23], or the National Capital Region of India (23%) [16]. However, compliance remains lower than other areas of the world with stronger institutional restrictions. For example, compliance is greater than 60% for regular face shield and safety glasses use in parts of Saudi Arabia [14]. Most often used were safety glasses (48.8%) and we again saw similar NCR survey results (47%) [16]. Visors remained rare (14.3%), and a few surveyed acknowledged they used no eye protection at all. Overall, these results reaffirm that compliance is dependent on organizational policy, cultural perceptions, and barriers to access.

Patient protection is arguably the most concerning finding. While 94.9% recognized the significance of patient protection, almost 40% of respondents indicated they had never provided any ocular protection and 13.3% had witnessed ocular injuries to patients. This reflects international trends: Oleksiak et al. [33] found that while 96% of dental students knew how ocular transmission occurs, fewer than 1 in 5 dental students routinely provided ocular protection. Our findings confirm that in the absence of a systemic level of enforcement, patient safety is left to the discretion of the clinician – not a viable approach.

These results together point to the need for multi-tiered interventions. On the educational level, workshops, simulated training, and integrating ocular protection into the curriculum would help normalize ocular protection as a feature of professionalism. On the institutional level, mandatory policies, annual audits, and the provision of affordability and standardization of the eyewear could enforce compliance. On the regulatory level, the Dental Council of India including ocular protection as part of its inspection and accreditation on the training institutions and private clinics would support this. Structural support, along with a cultural change, is needed to help raise awareness into ongoing safe practice.

When interpreting the findings of this study, several limitations should be acknowledged. First, due to the cross-sectional design of the study, no cause-and-effect relationships can be established. Second, self-reported data can result in self-report bias (i.e., participants may choose to report socially desirable responses). Third, participants’ recollections of their ocular injuries/clinical practices may also present a problem with recall bias and affect the accuracy of their reported frequencies and behaviours. Finally, since a snowball sampling technique was used, caution should be taken when generalizing the results beyond this sample to the overall dental community.

However, this research project has some strengths. The size of the sample, the geographic representation of the sample, and the agreement among respondents across groups increase the confidence in these results. Thus, the conclusions drawn from this study are based on the study data (e.g., the sizeable difference between awareness and compliance and the large incidence of ocular injuries) and indicate that targeted, systemic, and educational interventions should be made for dentists in the future.

Conclusion

This research indicates that there is a continued gap between knowledge and compliance regarding ocular safety protocol among many Indian dentists, students, auxiliaries and patients, thus both, dentists and patients are exposed to harm that could be prevented. Future research needs to go beyond cross-sectional surveys to longitudinal and interventional designs testing the impact of educational programs and workshops (based on simulation) that are ergonomic driven as well as cost- subsidized personal protective equipment. Comparative studies across geographical regions and within institution will be useful in describing systemic barriers, such as cost, habits of the culture and any form of institutional leadership in hindering compliance.

Ocular safety must be part of policy at the various levels of the curriculum and an integrated competency for both undergraduate and postgraduate education. This education must also be supported by enforceable national standards, routine audits, and accreditation. More crucially, along with supporting affordability initiatives, institutional leaders should also consider investing in ocular safety training to make it a requirement annually. By taking a multi-faceted approach to address both behavioural and systemic barriers through education, policy, and institutional action, dentistry in India has the ability to combat the risk of ocular injuries and develop sustainable behaviour around ocular safety for both providers and patients.

Supporting information