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Ergonomics: A pain free dentistry for professionals

Article · August 2014

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Orthodontics
O rthodontics
Ergonomics: A pain free dentistry for professionals
Dr. Mayuresh J Baheti Dr. Nandlal Girijalal Toshniwal
P.G. Student Professor & Head
Dentistry is a social interaction between helper and recipient in
their limited job setting and with personal characteristics. It is a
profession where performance is restricted to an area covering only
a few tens of millimeters (the mouth), and that it requires repeated,
precise force applications. These situations demand a fixed posture
that can create occupational hazards in both dentists and dental
students.1 A healthy dentist is one of the most important component
in a successful dental practice. Despite the fact, that though 88%
of dentists report good or excellent health,2 some studies show that
one out of ten dentists reports having poor general health and three
out of ten dentists report having poor physical state.3 Dentists can,
and do experience illnesses and problems that can disrupt or impair
a practice. Yet, there are growing evidences that suggest increased
vulnerability within the profession to certain disorders and afflictions
that can only be categorized as practice related.
These problems can be avoided by increasing awareness of the
postures used during work, redesigning the workstation to promote
neutral positions, examining the impact of instrument use on upper
extremity pain, and following healthy work practices to reduce the
stress of dental work on the practitioner’s body.4
Recently, “Ergonomics” has become a popular term. The term
has been used with most professions but increasingly in the
dental profession. It is a discipline that studies workers and their
relationship to their occupational environment. This includes many
different concepts such as, how dentists position themselves and
their patients, how they utilize equipment, how work areas are
designed and how all of this impact the health of dentists.5
In Greek, “Ergo,” means work and, “Nomos,” means natural laws
or systems. Ergonomics, therefore, is an applied science concerned
with designing products and procedures for maximum efficiency and
safety. It is also a study of the relationship among the personnel,
54 GUIDENT  |  Your Guide on the path of Dentistry
Aug 2014
Department of Orthodontics & Dentofacial Orthopedics,
Rural Dental College, Pravara Institute of Medical Sciences,
Loni Maharashtra, India
One of the most prevalent types of work-related
injuries are musculoskeletal disorders. Work-related
musculoskeletal disorders (WRMDs) result in persistent
pain, loss of functional capacity and work disability,
but initial diagnosis is difficult because they are mainly
based on complaints of pain and symptoms. “An ounce
of prevention is better than pounds of cure” ……That’s
what dental health care workers spend their day telling
their patients, but it also applies to working conditions
that can cause pain in the neck, shoulder and hand to
a dentist. Dentists and dental students often assume
awkward physical positions while providing treatment
to (a) get a better view of the intraoral cavity; (b) provide
a more comfortable position for the patient; and/or
(c) operate equipment and reach for instruments and
supplies. This update reviews various causes, signs,
symptoms of musculoskeletal disorder and their
preventive measures and various exercises to work with
comfort, efficiency and ease.
KEY WORDS: Ergonomics Exercises, Dentistry, Work-
related musculoskeletal disorders
equipment and environment in the work area.6,7 Proper ergonomic
design is necessary to prevent repetitive strain injuries, which
can develop over time and can lead to long-term disability. Dental
ergonomics is concerned with the ‘fit’ between people and their
 Aug 2014

work. It takes account of the worker’s capabilities and limitations

in seeking to ensure that tasks, equipment, information and the
environment suit each worker (Fig.1).8
Orthodontics
O rthodontics
tendonitis, tenosynovitis,epicondylitis
5. Hand-Arm Vibration Syndrome: Raynaud’s disease.
6. Low Back Disorders: chronic low back pain.

Some Symptoms of Musculoskeletal disorders (MSDs):

XX Excessive fatigue in the shoulders and neck
XX Tingling, burning, or other pain in arms
XX Weak grip, cramping of hands
XX Numbness in fingers and hands
XX Clumsiness and dropping of objects
XX Hypersensitivity in hands and fingers

Some Signs of MSDs

XX Decreased range of motion
XX Loss of normal sensation
Fig.1 – Ergonomics
XX Decreased grip strength
Dentists and dental hygienists are at a greater risk of work-related XX Loss of normal movement
musculoskeletal disorders (MSDs) than is the general population. XX Loss of co-ordination
These disorders can result in pain and dysfunction of the neck,
back, and hands and fingers. It has been estimated that work- Some Risk Factors for MSDs
related musculoskeletal injuries occur in 54% to 93% of dental XX Repetition
professionals, with the most frequent injuries occurring in the spine
XX Forceful exertions
(neck and back), shoulders, elbows and hands. Dental hygienists in
one study reported neck pain associated with working in a bent neck XX Awkward postures
position, and neck symptoms were reported by 72% of a sample of 94 XX Contact stress
experienced hygienists (mean age: 46 years). While the occasional
XX Vibration
backache or neck ache is not a cause for alarm, if regularly occurring
XX Poorly designed equipment workstation
pain or discomfort is ignored, the cumulative physiological damage
can lead to an injury or a career-ending disability.9 XX Improper work habits
Many work related MSDs are cumulative, building up over years or Lake in 1995 implicates several mechanisms in the generation of
4

decades. A poor ergonomic choice may not have an impact today or
even a few years down the road. But over a lifetime, it could result
in pain or injury, affecting the productivity and earning potential of
the dental professionals. Good habits, adopted early, are your best
strategy when it comes to posturedontics (ergonomics). This update
reviews the various causes, signs, symptoms of musculoskeletal
disorder and their preventive measures and various exercises to
work with comfort, efficiency and ease.
Classification of MSDs10
1. Nerve Entrapment Disorders: carpal tunnel syndrome, ulnar
neuropathy.
2. Occupational Disorders of the Neck and Brachial Plexus: tension neck
syndrome, cervical spondylosis, cervical disc disease, brachial plexus
compression.
3. Shoulder disorders: trapezius myalgia, rotator cuff tendonitis, rotator
cuff tears, and adhesive capsulitis.
4. Tendonitis of the Elbow, Forearm and Wrist: deQuervain´s disease,
pains and soreness in dentists, such as:
a. Elevated work area with permanent static positions of more than 30
degrees, which would produce a reduction of blood flow in the supra
spine tendon and would also originate high muscle tension on the
trapezoids.
b. Lack of support of the forearms during repetitive holding of instruments
which would compromise different body segments such as spine,
shoulder, and wrists.
c. The handling of vibrating instruments is associated with specific
lesions such as nerve trapping, early arthrosis and even, with Raynaud
syndrome.
d. Forced cervical static postures.
e. Poor posture when seating. The flexion of the lumbar spine, when
seating forward, produces marked pressure increments between the
interdiscal spaces.
f. Lighting at the work place: the lack or excess of light can generate
myopia and irreversible retinal lesions, among others.
g. Temperature, ventilation and humidity at the work place. If the

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Your Guide on the path of Dentistry 55
Orthodontics
O rthodontics
temperature is high and the air is saturated with humidity, there
Aug 2014

XX Spinal Disk Herniation and Degeneration: In unsupported sitting,

is exhaustion, increased body temperature and, respiratory and
circulatory disorders.
h. Intermittent and continuous noise produced by high and low speed
instruments
i. Present dental chairs allow adaptation of the patient´s position in
height, inclination of the torso, flexion or hyper extension of the head
of the patient.
Mechanisms Leading to Musculoskeletal Disorders in
Dentistry
XX Prolonged Static Postures (PSPs): Dentists frequently assume static
postures. When the human body is subjected repeatedly to PSPs,
it can initiate a series of events that may result in pain, injury or a
career-ending MSD.11
XX Muscle Ischemia/Necrosis and Imbalances: During treatment,
operators strive to maintain a neutral, balanced posture and find
themselves in sustained awkward postures. These postures often
lead to stressed shortened muscles which can become ischemic and
painful, exerting asymmetrical forces that can cause misalignment of
the spinal column.8
XX Hypomobile Joints: During periods of PSPs or when joints are restricted
due to muscle contractions, synovial fluid production is reduced and
joint hypomobility may result.11
pressure in the lumbar spinal disks increases. During forward flexion
and rotation, a position often assumed by dental operators, the
pressure increases further and makes the structure vulnerable to
injury.8
XX Neck and Shoulder: Repetitive neck movements and continuous arm
and hand movements affecting the neck and shoulder demonstrate
significant associations with neck MSDs.11
XX Wrist and Hand: Carpal Tunnel syndrome (CTS) has been associated
with both repetitive work and forceful work. Symptoms can appear
from any activity causing prolonged increased (passive or active)
pressure in the carpal canal.11
XX Low Back Pain: Low-back discomfort has been associated with dental
work in numerous studies. Good posture correlated negatively with
back pain and dentists who sat 80 percent to 100 percent of the day
reported more frequent lower-back pain, than those that do not sit
as often.12
XX Psychosocial Factors: Dentists with work-related MSDs show a
significant tendency to be more dissatisfied at work and to be more
burdened by anxiety, experiencing poor psychosomatic health and
feeling less confident with their futures.13
Many MSDs can be treated conservatively by modifying activities
or using splints or anti-inflammatory drugs. Early intervention can
reduce the necessity of steroid injections or surgery (Table.1).

DISORDER SYMPTOMS POSSIBLE CAUSES TREATMENT OPTIONS

Hand Carpal tunnel Numbness, pain, tingling,
syndrome cluminess; reduced muscle/
grip strength, dexterity;
symptoms may be worse
at night
Compressed median nerve in the Night splint; increased frequency
wrist of rest/breaks;
change work patterns; use
large-handled instruments; anti-
inflammatory drugs, B6, diuret
ics; steroid treatment; surgical
intervention as a last resort

Hand Carpal tunnel Pain, numbness,
syndrome tingling in 4th and
5th fingers, the side and
back of the hand; reduced
dexterity and grip
Hand DeQuervain’s Pain around thumb
with grasping, pinching,
twisting; swelling of the
thumb area; decreased and
painful thumb motion
Hand & arm Tenosynovitis Pain, stiffness, swelling at
the wrist, shoulder, elbow,
hand, or finger joints;
painful gripping or grasping;
difficulty straightening
Compressed ulnar nerve in the
elbow
Swelling/thickening of the tendons
at the base of the tendons
Swelling/thickening of tendons and
related structures
Avoid extreme elbow flexion
and extension; ergonomic
intervention; physical therapy;
surgical intervention as a last
resort
Thumb spica wrist splint; Hand
rest; physical therapy; NSAIDs*;
steroid injection; Surgical
intervention
Worksite ergonomic
interventions; NSAIDs; minimize
aggravating movements;
physical therapy; steroid
injections, surgical intervention
as last resort

56 GUIDENT  |  Your Guide on the path of Dentistry

Orthodontics
O rthodontics Aug 2014

Arm Epicondylitis Pain or tenderness on either
side of the elbow; pain
increases during activities
Tearing of the tendons from
overuse of the forearm muscles
Worksite ergonomic
interventions; NSAIDs; physical
therapy; acupuncture; steroid
injections; surgical intervention
as a last resort

Arm Radial Dull aching pain
tunnel below the elbow and on
syndrome outside upper forearm; may
be worse at night; may
include hand pain
Shoulder Rotator cuff Pain, stiffness in shoulder
problems with backward and upward
arm joint movements;
weakness of the rotator cuff
muscles
Shoulder Thoracic outlet Pain in the shoulder, arm
syndrome and/or hand; numbness and
tingling of fingers; muscle
weakness And fatigue; cold
arm or hand
Hand Arm Shoulder Tendonitis Localized and/or diffuse
pain; loss of strength and
Motion
Neck Back Myofascial pain Pain in neck, shoulder and
syndrome arm; and painful “trigger
points”; restricted range of
motion
Compressed radial nerve
Swelling or tearing of rotator cuff
soft tissue; shoulder bone spurs or
abnormalities
Compressed nerves or blood supply
passing to the arms
irritation and loss inflammation of
tendons
Overloaded neck and shoulder
muscles
Worksite ergonomic
interventions; NSAIDs;
steroid injections; surgical
intervention as a last resort
Worksite ergonomic
interventions; NSAIDs; steroid
injections; surgical intervention
as a last resort
Worksite ergonomic
interventions avoid working
with hands above chest; Avoid
surgery due to high rate of
complications
NSAIDs; minimize aggravating
movements; physical therapy,
massage; steroid injections;
surgical intervention as a last
resort
Mechanical, thermal, and
chemical (eg, botulinum toxin)
treatments to reduce pain
and restore muscle function;
v muscle strengthening and
stretching

Table 1. Symptoms, Possible Causes, and Treatment Options for Common Musculoskeletal Disorders caused due to improper ergonomics in Dentist14,15

ERGONOMICS FOR DENTAL STUDENTS:
According to an article published in the January 2005 issue of JADA,
more than 70 percent of dental students reported neck, shoulder and
lower back pain by their third year of dental school. Dentists and
dental students often assume awkward physical positions while
providing treatment to (a) get a better view of the intraoral cavity;
(b) provide a more comfortable position for the patient; and/or (c)
operate equipment and reach for instruments and supplies.7
The Ergonomic Standard mandated by the Occupational Safety
and Health Administration (OSHA) recommended that the most
efficient and effective way to remedy “ergonomic hazards” causing
musculoskeletal strain should be through engineering improvements
in the workstation.16,17 Posturedontics have one primary objective
– the prevention of work-related musculoskeletal disorders, or
the symptoms that aggravate these disorders. In dentistry, bad
working habits, repetitive tasks – such as scaling, root planning,
and uncomfortable physical postures contribute greatly to
musculoskeletal disorders, stress, and loss of productivity.18
Four-handed dentistry is ergonomically the most favorable way to
provide dental services since it minimizes undesirable movements
of the operating team and expedites the progress of most dental
procedures.19 Available research supports the idea that ergonomic
hazards can be managed or alleviated effectively using a
multifaceted approach that includes preventive education, postural
and positioning strategies, proper selection and use of ergonomic
equipment and frequent breaks with stretching and postural
strengthening techniques. This represents a paradigm shift for daily
dental practice.20
Research shows that maintaining the low back curve-the lumbar
lordosis-when sitting can reduce or prevent low back pain.18 Proper
selection, adjustment and use of magnification systems have been
associated with decreased neck and low back pain, as they allow
operators to maintain healthier postures. Operators also need to
know how to adjust the features of their chairs to obtain maximal
ergonomic benefits and take the time to position their patients
properly for mandibular and maxillary procedures. When possible,
dentists should position instruments within easy reach.

58 GUIDENT  |  Your Guide on the path of Dentistry

 Aug 2014

To prevent injury of muscles and other tissues, the operator

should allow for rest periods to replenish and nourish the stressed
structures. Operators may use various stress-reduction techniques
to decrease stress-related muscular tension.21 It is important that
dentistry incorporate these strategies into practice to facilitate
balanced musculoskeletal health that will enable longer, healthier
careers; increase productivity; provide safer workplaces; and prevent
work related MSDs.16
Orthodontics
O rthodontics
Some Tips for Working with Good Posture22
1. Maintain an erect posture: by positioning chair close to the patient,
one can minimize forward bending or excessive leaning over the
patient. Place feet flat on the floor to promote a neutral or anterior
tilt to your pelvis, which keeps back aligned and promotes the natural
curvatures of back (Fig. 3).

Importance of posture
The elements of an improper workstation setup force the dental
practitioner to assume many harmful postures when performing
various procedures on the patient (Fig.2). These positions put
pressure on nerves and blood vessels, cause excessive strain on
muscles, decrease circulation and cause wear and tear on the joint
structures.

Fig.3- Proper Posture

2. Use an adjustable chair with lumbar, thoracic and arm support: A good
chair is essential for maintaining good posture. A chair should have
important features like, adjustable height, width, tilt, backrest, seat
pan and armrests, because in most dental offices, many people of
different sizes use the same workstation.
3. Work close to your body: Position the chair close to the patient and
position the instrument tray close to the chair. This way, dentist does
not have to overextend himself to reach the patient or instruments,
putting excessive stress on back, shoulders and arms. Think of the
90° rule of having elbows, hips, knees, and ankles all forming 90°
angles.
Fig.2 - Improper Posture 4. Minimize excessive wrist movements: Try to keep them in a neutral
position (palms facing each other, shoulder width apart with wrists
Some Improper Postures That Dentists Take: straight), which puts wrist muscles and tendons in a much better
XX Working with the neck in flexion and tilted to one side. relationship to perform the work.
XX Shoulders elevated. 5. Avoid excessive finger movements: When one can combine the
excessive forces needed to hold the instruments with the amount
XX Side bending to left or right.
of repetitions that he/she can perform each day, one can see the
XX Excessive twisting. tremendous toll that this takes on the small muscles of fingers.
XX Forward bending/overreaching at waist. Retraining of shoulders and arms to position hands, rather than
making the small, forceful movements with fingers.
XX Shoulders flexed and abducted.
6. Alternate work positions between sitting, standing and side of patient:
XX Elbows flexed greater than 90°. Switching positions allows certain muscles to relax while shifting
XX Wrists flexed/deviated in grasping. the stress onto other muscles and increasing your circulation. Allow
each side of your body to share the stress rather than performing the
XX Thumb hyperextension. same motion in the same way which causes cumulative trauma in the
XX Position maintained for 40+ minutes per patient. overused side.

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Orthodontics
O rthodontics
7. Adjust the height of your chair and the patient’s chair to a comfortable
Aug 2014

level: If dentist’s chair is too low and the patient’s chair is too high,
this causes elevation of shoulders and can lead to neck problems
and can pinch nerves. Alternately, if dentist’s chair is too high and
the patient’s chair is too low, flexion of neck down and bend wrists
back to compensate can lead to neck and hand problems. Remember
the 90° rule and keep elbows at a 90° angle with wrists straight and
shoulders relaxed.
8. Consider horizontal patient positioning: If workstation allows the
patient to recline into a horizontal position, it will allow a dentist to
sit above the patient’s head with good ergonomic posture and he can
use each arm equally in more natural position.
9. Check the placement of the adjustable light: Position the adjustable
Fig.4 - Body stretching exercises
light to avoid strain on the neck
10. Check the temperature in the room: Temperature of workspace should Hand Exercises:
not be too cold because this will decrease the circulation and blood Slowly open and close hands from a completely open position
flow of extremities. Most often, the dental work environment is damp
(Figure 5a), to a completely closed position (Figure 5b), which ends
and cold, so be certain to wear gloves and warm up the hands before
with your fingers tucked into your palm; press the palms of your
working.
hands together and then relax them (Figure 5c); gently pull and relax
Prevention of Musculoskeletal Disorders among Dental each finger on each hand separately (Figure 5d); cross the wrists and
Professionals gently stretch and relax.5 Fig. 5a – d Various Hand Exercises
This can be achieved by implementing various strategies. These
have been summarized in Table 2.

Postural Awareness Techniques * Maintaining a low back curve

* Using magnification systems
* Adjusting operator chair properly

Positioning Strategies * Avoiding static postures

Periodic Breaks and stretching
* Alternating between standing and sitting
* Repositioning patients at the proper height
* Avoiding twisting
Fig. 5a Fig. 5b
* Chairside directional stretching
* Stretching during microbreaks
* Releasing trigger points

Table 2. Implementation of various strategies

Dentists should also perform specific exercises for the trunk and
shoulder girdle to enhance the health and integrity of the spinal
column; stretching exercises for the hands and head & neck; maintain
good working posture; optimize the function of the arms and hands;
and prevent injuries.24 The following exercises can be practiced and Fig. 5c Fig. 5d
performed by dentists on a regular basis in order to improve your Some of the remedies recommended include:7
posture and reduce muscle fatigue in a clinical environment:
Stretch your wrists and fingers, especially the area between the
Body Strengthening Exercises: thumb and index finger.
In a sitting position, extend one leg forward; bend and stretch hands Stabilize your hand by resting your elbow on the chair’s back or
as far as possible without bending the knee (Figure 4); repeat with arm.
the other leg. Stretch one leg and put the other leg over the stretched Use hand instruments with larger-diameter handles—a larger
leg; turn around as far as possible without changing the position of handle distributes pressure over larger surface area across a larger
the legs (Figure 4); repeat on the other side.24 group of hand muscles.

60 GUIDENT  |  Your Guide on the path of Dentistry

 Aug 2014
Use full-arm motions rather than wrist strokes when possible.
Avoid coiled cords and hoses—the tension transfers to the hand
when you stretch the cord
Wear gloves that fit and don’t restrict movement.
Neck Exercises:
Relax shoulders and tuck the chin into the neck, then raise the head
back; tilt head to the side as if trying to touch ear to the shoulder;
repeat on other side.5
Back Exercises:
A “full back release” should be practiced. Relax the neck, roll down
slowly letting the arms and head fall between the legs (Figure
6a); hold position for a while; raise slowly by contracting stomach
muscles and rolling up, bringing the head up last (Figure 6b).5
Fig. 6a -b Back exercises
Shoulder Exercises:
Raise shoulders up towards the ears and rotate head first in
clockwise direction and then in anti-clockwise direction.24
Points to Remember:
XX Perform a variety of stretches throughout the workday
XX Stretching should be gentle and gradual
XX Do not stretch a muscle to the point of pain
XX Stretches can be held up to 10 seconds and repeat 3-5 times
XX Breathe normally while stretching
XX Ifyou suffer from a musculoskeletal condition consult a Physician
before attempting new exercises which you are unfamiliar with
Ergonomics and Everyday Life
Stress is cumulative, so ergonomic principles are just as important
outside of the clinical environment. By making adjustments in
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Orthodontics
O rthodontics
everyday life as necessary to your work and play, you can reduce
the likelihood of MSDs.7
XX When sitting at a desk, adjust your chair so that your thighs are
parallel to the floor
XX When using a computer keyboard, use the padded wrist rest while
taking a break, not while typing.
XX Monitor your time spent text messaging or playing video games to
avoid “Blackberry Thumb.”
XX Holding your phone between your shoulder and ear can lead to a
host of upper body difficulties—use a hands-free device whenever
possible. But don’t talk on the phone while driving!
XX Use caution when carrying groceries— carrying multiple plastic bags
at once can strain fingers, wrists and elbows. A heavy, plastic bag
can concentrate stress in a small area of your hand, increasing the
likelihood of injury or damage.
Future of Ergonomics in Dentistry
Dental work requires considerable concentration and attention to
detail. Dental professionals are concerned about patients’ comfort,
but probably pay little attention to their own until they begin to
experience discomfort or pain.25 Today, more dentists are becoming
aware of occupational hazards and paying more attention to the
prevention of hazards. Ergonomics have come into the profession
in a big way. Further development of dental ergonomics must take
place on the basis of a coherent vision of the future. Aspects of
particular interest are the prevention of occupational diseases, legal
responsibility for protecting the health and safety of employees
and students, education in dental ergonomics for dental and oral
hygiene students, the academic development and research of dental
ergonomics, using organizational models in daily dental practice,
and the development of ergonomics at the global level.26
Conclusion
Ergonomics has come into the profession in a big way. Further
development of dental ergonomics must take place on the basis
of a coherent vision of the future. Repetitive strain injuries are
on the rise in dentistry. Many dentists and dental hygienists have
been diagnosed with MSDs, and majority have experienced some
type of musculoskeletal pain in their shoulders and neck, hands
and wrists, low back, or forearms and elbows. The importance of
following proper ergonomic principles should be realized so that
these problems can be avoided by increasing awareness of the
postures used during work, redesigning the workstation to promote
neutral positions, examining the impact of instrument use on upper
extremity pain, and following healthy work practices to reduce the
stress of dental work on the practitioner’s body. By practicing with
correct postures the working capacity and productivity of dental
professionals can be enhanced and thus can make a considerable
difference to earning and quality of dental practice.
References are available on request
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Your Guide on the path of Dentistry 61