The Struggle for Musculoskeletal Health

The practice of dentistry and dental hygiene requires physical endurance. Thirty to 40 years ago, all procedures were performed while the patient sat in the dental chair and the practitioner stood bent over the patient. Daily stress and strain were placed on the practitioner’s back, neck, legs, and arms. In the 1960s, a new innovative approach was introduced. Oral health care providers provided patient care while seated on a newly designed dental stool next to the patient. The seated position created an environment in which there was more stability for the body of the practitioner and less strain on the legs.¹ But the seated position presented other physical compromises and challenges. In order to reach for required equipment and instruments or to adjust the overhead light, the clinician had to twist the torso in new ways.

Oral health care providers are affected by musculoskeletal pain more than any other occupational hazard.² Musculoskeletal disorders including carpal tunnel syndrome, tendonitis, and upper extremity problems affect nerves, tendons, and muscles. Reported symptoms may be mild, severe, or chronic, and may include pain, swelling, or burning. Cramping, lower back stiffness, weakness, decreased range of motion, or tingling and numbness may also be a problem. As the work day progresses, the physical discomfort to the practitioner increases, resulting in significant stress. Even when the practitioner rests between patients, these breaks do not allow for full recovery from the cumulative effects of the work.^2,3

STRATEGIES FOR HEALTH AND WELLNESS

Musculoskeletal disorders represent more than 60% of occupational injuries—accounting for more than a third of lost work time among workers in this country.⁴ The associated costs of these disorders are estimated in excess of 20 billion dollars per year for workers’ compensation.^5,6

When designing the optimal work station, the practitioner’s comfort should be the top priority. The design of an office, the equipment, and the hand instruments selected should facilitate the application of proper ergonomics. The procedure rooms should have the equipment and instruments placed within easy reach of the practitioner. The curly tubing on all dental equipment should be replaced, thus creating an environment with decreased resistance.⁷ Repeatedly twisting, pulling, and tugging at resistant dental unit cords increases fatigue of the hand, arm, and shoulder. Solid, straight uncurled tubing and longer cords are easier to access and provide for easier mobility and less resistance and stress.

The high and low speed handpieces and lathes create vibrations that are harmful to the hand, arm, and shoulder, causing fatigue and muscle strain. To minimize these, the clinician should evaluate the equipment, modify its use, and use alternative treatment methods. The change of speed, force, and direction of the slow speed handpiece is recommended. Reduce the use of equipment that causes excessive vibrations. Selectively polish patients with minimal staining or substitute the use of air polishing when indicated. Ultrasonic and sonic instruments may be used to reduce repetitive motion required by hand scaling only.⁸

Choosing an ergonomically designed chair with arms for support or a saddle-style stool is an important factor when purchasing dental equipment.¹⁰ In a traditional clinician chair, the hygienist may incur undue strain on the lower back. Newly designed clinician chairs help place the practitioner in the proper working positions. While turning or reaching for an object, the entire body is rotated as a single unit. Rotating only the upper extremities such as the hands and arms should be avoided, since these movements may also cause lower back pain.⁹

Sharpened hand scaling instruments are essential. Correctly sharpened instruments require less pressure and force in their application resulting in reduced stress on the hand, wrist, and shoulder. Dull instruments require the use of additional pressure, which results in clinician fatigue and patient discomfort. Lighter, balanced instruments with thicker, larger, and textured or cushioned grips are helpful in reducing the force and pressure required for instrumentation. A larger handle will enable the clinician to open the grasp on the instrument resulting in less muscle tension. Alternating the use of larger and smaller instrument sizes in the course of the work day will enable various muscle groups to rest.^7,10

The proper fit of gloves will further reduce fatigue and tension of the hand, palm, and wrist and allow for unimpeded blood circulation. The gloves should feel comfortable without being too loose or tight. Gloves with textured fingers can reduce slipping and sliding of instruments, while ill fitting gloves may cause loss of control.⁷

In the past decade, the use of magnification loupes has greatly increased. Loupes aid in better visualization of the treatment area and may provide auxiliary lighting. Loupes can improve visual acuity, decrease eye strain, and increase ergonomic benefits and improved posture of the clinician.^1,11

THE COMPUTER AGE

An additional change within the dental profession is the use of computers. In creating a stress free environment, the computer monitor and keyboard should be located so its use permits the clinician to assume an ergonomically correct posture. For office staff, the use of a hands-free telephone will improve neck posture and reduce neck and shoulder strain.

To promote a less stressful work environment, the use of music and comfortable room temperature are advised. A cold room contributes to muscle tension and spasm and may lead to pain. Soothing music and keeping noise levels to a minimum help further reduce stress and create a calm relaxed atmosphere for both clinician and patient.

The daily application of proper ergonomics by the practitioner will contribute to reduced risk for work-related injuries. The goal is to achieve an unstressed neutral position and relaxed hands, arms, and back posture. Keeping muscles stretched, loose, and relaxed and remaining aware of body posture as the clinician moves, reaches, sits, or stands are important in the prevention of aches and pains. Repetitive movements, forceful exertion, physical stress, poor posture, and vibrations are risk factors for musculoskeletal disorders. Duration and frequency of intense repetitive movements must be modified. To reduce postural strains while treating a patient, the clinician should vary positions from sitting, to standing, to moving around the dental unit. The patient may be requested to change his/her head position to accommodate the clinician’s ergonomic needs.

KEEP MOVING

A daily routine of exercise is recommended for oral health care providers in order to prevent musculoskeletal work-related disorders. Exercise increases agility, decreases stress, and improves overall mental and physical health. Warm-up stretching exercises can easily be performed at chairside or in between patients to help reduce pain, increase limberness, and muscle flexibility.⁴ Daily in-office exercises should be accompanied by routine physical activity and stress reduction regimens outside of the workplace. Weight training will reduce tension and stress and help achieve a pain-free practice and improve the body’s ability to resist strain injuries.⁷ Education must be offered to all oral health care providers on the risk of musculoskeletal injuries to enable them to prevent or alleviate muscular tension and work-related pain, which are common to dental hygienists.⁴

REFERENCES

1. Osuna T. Magnification in dental hygiene. Access. 2003;1(17):2-8.
2. Michalak-Turcott C. Controlling dental hygiene work related musculoskeletal disorders: the ergonomic process. J Dent Hyg. 2000; 74:41-48.
3. Visser J, Straher L. An investigation of discomfort experienced by dental therapists and assistants at work. Australian Dent J. 1994;39:39-44.
4. Valachi B. Managing muscles: neck and shoulder pain among dental hygienists. Contemporary Oral Hygiene. 2004;4(12):8-13.
5. Montgomery K. Preventing carpal tunnel syndrome and other upper-body musculoskeletal injuries. Access. 2003;10(17):28-36.
6. NIOSH: Elements of Ergonomic Programs. Rockville, Md: US Dept of Health and Human Services, Centers for Disease Control, Public Health Service, National Institute for Occupational Safety and Health; March 1997. Publication 97-117.
7. Darby M, Walsh M. Dental Hygiene Theory and Practice. 2nd ed. St Louis: Elsevier Science; 2003: 123-133.
8. Morse T, Michalak-Turcott C, Atwood-Sanders M, et al. A pilot study of hand and arm musculoskeletal disorders in dental hygiene students. J Dent Hyg. 2003;77:173-179.
9. Valachi B, Valachi K. Preventing musculoskeletal disorders in clinical dentistry: strategies to address the mechanisms leading to musculoskeletal disorders. J Am Dent Assoc. 2003;134:1604-1612.
10. Kunselman B, Mann G, Mauriello S. Task analysis of the gracey 17/18 curet. Journal of Practical Hygiene. 1999; 8(6):11-16.
11. Morris G, Kokott M. A clear view no longer means a stiff neck. Dental Economics. 1999;89(7):82-86.

From Dimensions of Dental Hygiene. September 2007;5(9): 24-25.