Review of literature for occupational pain in dental hygiene notes some statistical trends
BY Lori Gallon, RDH
As dental hygienists, we are at risk for work-related musculoskeletal disorders (MSDs). Our care of patients' oral health requires us to work in awkward positions and use repetitive motions. We become friends and confidants to our patients, and twice per year, we tell them to "floss, floss, floss." We have taken an oath to promote oral health and overall well-being regardless of the risk of an MSD.
The unfortunate reality is that our jobs place us at risk for injuring our bodies and ultimately for chronic pain. By incorporating complementary and alternative medicine (CAM) (see related article) and proper body positioning, we may be able to reduce our susceptibility to musculoskeletal disorders caused by poor ergonomics, repetitive motions, and demanding work schedules.
Musculoskeletal disorders are a widely acknowledged health and safety issue. According to the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC), musculoskeletal disorders are defined as: "... injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and disorders of the nerves, tendons, muscles, and supporting structures of the upper and lower limbs, neck, and lower back that are caused, precipitated, or exacerbated by sudden exertion or prolonged exposure to physical factors such as repetition, force, vibration, or awkward position."
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Other articles on ergonomics
- Where do you stand with your dental ergonomics?
- Ergonomics and your practice's bottom line
- Ergonomics and dental hygiene: It's all in how you say it
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We spend the majority of each dental appointment physically exposed the repetitive motion of using dental instruments, using the force needed to grasp the instrument, and the contorted body positioning needed to access the patient's mouth - all of which are causative factors for acquiring an MSD. A case study by Sanders and Turcotte indicated that 96% of all hygienists developed symptoms in at least one body part and that 95% reported physical findings consistent with MSDs, while 57% were actually diagnosed with an MSD. In other words, the study found that over half of us are experiencing and being diagnosed with injuries of the musculoskeletal system.
These therapies use non-mainstream approaches in addition to conventional medicine, whereas alternative medicine uses non-mainstream approaches in place of conventional medicine. Due to the growing disbelief in conventional medicine (particularly in prescription medications), Complementary medicine (CAM) therapy is becoming a more popular option for wellness.
According to Chismark et al., 80.7% of dental hygienists are more likely to utilize CAM therapy, versus 38.3% of the general public. Yoga, massage therapy, acupuncture, mind-body therapy, osteopathy, and meditation are all examples of CAM therapies that may help to reduce the pain associated with acquired musculoskeletal disorders.
A person may seek the use of CAM therapy after traditional medicine does not alleviate the pain and symptoms of an MSD. A study conducted by Chismark et al. surveyed 617 dental hygienists who were current members of the American Dental Hygienists' Association in California and North Carolina:
• 76.5% reported having an MSD
• 14.2% used CAM therapies alone
• 3.6% used conventional therapies
• 1.5% used no treatment
Of the 472 hygienists who reported an MSD, over 60% favored massage, almost 60% used herbs and supplements, and fewer than 40% practiced chiropractic care. Although the researchers only surveyed hygienists in North Carolina and California, the results of the study show that massage is a popular option for hygienists with MSDs - probably because it is widely available and offers a variety of different modes of therapy. Moreover, in addition to providing relief from existing MSDs, body-based medicine such as massage therapy can help to prevent the occurrence of MSDs.
The neck, wrists, hands, and shoulders are the locations of the body most commonly affected, and 63% to 95% of hygienists have reported having an MSD with combined lower back, neck, shoulder, arm, and hand pain (Sanders and Turcotte). Another study, conducted by Hayes, Cockrell, and Smith, found that: 69.5% of U.S. dental professionals reported pain in the wrist and hand region with 44.2% experiencing carpel tunnel syndrome; 68.5% reported that they experienced symptoms in the neck region; and 60% reported shoulder pain. Hayes et al. also noted that Swedish dental hygienists reported an even higher complaint of shoulder pain of 81%. This finding suggests that musculoskeletal pain in dental hygiene is a worldwide problem.
Our physical and administrative responsibilities may help to explain the causes of musculoskeletal pain in our profession. We spend the majority of each dental appointment, which lasts 45 to 60 minutes on average, providing oral health services in an awkward position. According to Simmer-Beck and Branson, 25 to 35 minutes of that time is spent physically removing plaque and calculus. Throughout the workweek, there are few breaks for relief from this kind of physical stress. In a four-week case study, Branson, Black, and Simmer-Beck determined that 29.7 of the 31.6 hours worked, on average, by a dental hygienist were spent in patient contact, and 57% of the time spent in patient contact was spent scaling teeth. The limited time for physical breaks, the repetitive motions required for cleaning, and the force needed to grasp the instruments are all proven factors contributing to MSDs.
Another factor increasing our risk for MSDs is the length of time spent practicing. A longer length of time spent working in the profession is correlative with the increased likelihood of a musculoskeletal disorder. Chismark et al. state that hygienists who practice clinically for 10 years or more are more likely to report MSDs than someone who has been working in the field for five years or less. Due to clinical responsibilities, working in dental hygiene requires us to adopt prolonged static postures and physical burdens, so repeated stresses become worse and more prevalent with time. Nicholas Warren conducted a longitudinal study in Connecticut, involving 94 dental hygienists and 66 dental hygiene students, to address the high prevalence of MSDs in hygienists. The average age of the students was 26.1 years old and of the hygienists, 45.5 years old. The students were in their first year and second semester of hygiene school. Interestingly, Warren found the students were not asymptomatic when he began the study and that they had acquired their symptoms during the first year of school. While being in the profession for a longer length of time may increase the likelihood of reporting an MSD, the physical demands of practicing dental hygiene have damaging effects to the body, regardless of age.
Daily hygiene schedules are often extremely busy, creating a fast-paced workday. Hygiene appointments are typically scheduled consecutively, lasting about 45 minutes to one hour per patient, without any scheduled breaks in between. The case study conducted by Sanders and Turcotte concluded that more clinical hours with limited or no breaks contribute to the discomforts associated with MSDs. Patients seen per day can vary from five to 14, on average, and studies have shown that those of us who treat more than 11 patients per day and work more than 34 hours per week are at a higher risk for developing MSDs. Coupled with the debilitating schedule, the actual mechanics of performing the responsibilities of the job can cause physical discomfort.
The repetitive motion of scaling the dentition requires strength and perseverance. The characteristics of clinical work are the basis for static neck positions, extended neck flexion, and poor posture (Hayes et al.). Using job analysis studies, Sanders and Turcotte concluded that the highly repetitive motions of instrumentation, consisting of more than 30 strokes per minute, are related to the increased incidence of MSDs. These repetitive motions can contribute to carpel tunnel syndrome, as well as neck and shoulder pain. Scaling requires repetitive motions of both hands - not to mention the constant gripping of instruments. Exerting pressure on instruments, writing utensils, and mirrors can cause trauma to the underlying tendons, tendon sheaths, and ligaments. The process of continually removing plaque and calculus for extended periods of time contributes to the numerous reports by dental hygienists of hand, wrist, and neck pain. But it's not always just the hand using the instrument that is affected. While the dominant hand is used to clean the teeth, trauma can also occur to the opposite hand and arm. Incorporating proper ergonomics into our practices may help to reduce work stress, resulting in a lower risk of MSDs.
Ergonomic Resources
Proper ergonomics are essential; however, they are not always feasible. Research indicates that 90% of the time, hygienists hold their heads at forward angles, ranging from 17 to 39 degrees; 10% of the time, they hold their heads at angles greater than 40 degrees (Branson, Black, Simmer-Beck). The natural and reported consequence of these angles is neck pain, the second most-reported MSD by hygienists. As clinicians, we can adjust the positions of our chairs for appropriate working angles and body positioning on a patient-to-patient basis, but there are other tools, too, that may help us to decrease the discomfort.
Loupes - With the flexed and bent neck position required while providing oral health services, loupes may help decrease the risk of injury by increasing magnification and helping to improve posture. Because loupes are individually fitted, based on a precise measurement of the proper working distance between the patient and the hygienist, they make it easier to maintain a straighter back and proper working position. Branson, Black, and Simmer-Beck conducted a study using dental hygiene students to confirm or deny the evidence that suggests loupes can improve the posture of dental clinicians. They found the greatest change in the students' posture was a more upright position with "less unnatural bending of the neck," and they concluded (based on the students' journals and on real-time observance) that loupes improved their posture. Although loupes aid in proper ergonomics and help to alleviate back and neck pain, they are expensive - with the average cost ranging from approximately $600 to $1,300. Fortunately, however, there are less expensive avenues for alleviating the symptoms of MSDs.
Seating - Consciously improving posture can help to decrease the risk of developing a musculoskeletal disorder. Using a proper clinician chair that is set to an appropriate height and sustaining a neutral seated position - with limited side-bending, relaxed shoulders, elbows flexed at 90 degrees, feet supported by the floor, and knees below the level of the hips - may help to alleviate musculoskeletal pain. Beyond chairside improvements, outside intervention may sometimes be necessary to help with the discomforts of MSDs.
Medical therapy - Conventional methods of treatment, such as over-the-counter medication, splints, stretching exercises, and physical therapy, are often the first line of defense to help alleviate the symptoms. For chronic pain issues, 67.2% of the general population reported seeing their general practitioner and dental hygienists reported using conventional medicine, such as splints (Chismark et al.). Alternative and complementary medicine (CAM) therapies can also be used to manage pain in addition to or in place of conventional medicine. According to the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, complementary and alternative therapies are "a group of diverse health-care systems and practices that are not considered to be part of conventional medicine" (see related article).
Musculoskeletal disorders can be detrimental, but for many hygienists, the desire to be well and continue to work outweighs any desire to leave the profession. Studies have shown that it's common for hygienists to attempt to prevent MSDs and to stay in the profession. In 2007, 53.8% of U.S. dental hygienists reported being very satisfied in their current position, and 90.6% were satisfied with their overall work hours (Chismark et al.). Furthermore, the average length of employment in Nicolas Warren's survey was 21.8 years, which is a lengthy career. Many of us may stay in the profession because we like to help patients have teeth that feel fabulous and clean, or we stay because we find the profession to be personally rewarding.
The truth of the matter, however, is that there is a cost to the work that we do. If the proven risks for developing a musculoskeletal disorder were presented to prospective hygiene students prior to enrollment, would they have the same desire to pursue this career? Because of the overwhelming personal reward of working with the public in a medical setting, most would. Nonetheless, MSDs can cause chronic pain. We must be aware of our risk for MSDs and take measures to protect ourselves. If we don't, who will help our patients? RDH
Lori Gallon, RDH, is a 2008 graduate of Tunxis Community College and is currently pursuing a bachelor's degree in health care administration. After working full-time for five years in private practice, she changed employers and currently works for a fully grant-based organization treating local elementary public school children in a school-based health center.
References
Branson B, Black M, Simmer-Beck M. Changes in posture: A case study of a dental hygienist's use of magnification loupes. Work 35 (2010): 467-476.
Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. Musculoskeletal Disorders. Atlanta, 2012.
Chismark A, et al. Use of complementary and alternative medicine for work-related pain correlates with career satisfaction among dental hygienists. Journal of Dental Hygiene: JDH / American Dental Hygienists' Association 85.4 (2011): 273-284.
Grazio S, Balen D. Complementary and alternative treatment of musculoskeletal pain. Acta Clin Croat (2011): 513-530.
Hayes MJ, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. International Journal of Dental Hygiene 7 (2009): 159-165.
National Institutes of Health. National Center for Complementary and Alternative Medicine (NCAAM). Complementary, Alternative, or Integrative Health: What's in a Name? (NCAAM Publication No. D347). Bethesda, 2008.
Sanders MA, Turcotte CM. "Strategies to reduce work-related musculoskeletal disorders in dental hygienists: Two case studies." Journal of Hand Therapy 15.4 (2002): 33-674.
Simmer-Beck M, Branson B. "An evidence-based review of ergonomic features of dental hygiene instruments." Work 35 (2010): 477-485.
Warren N. "Causes of musculoskeletal disorders in dental hygienists and dental hygiene students: A study of combined biomechanical and psychosocial risk factors." Work 35.4 (2010): 441.
