It’s a tough conversation, but it’s a conversation we need to have as a profession. With more than 42% of the population clinically obese and 72% overweight, we have a new obstacle in our dental chairs, and it’s not just the significant increase in chronic inflammatory conditions we see intraorally.1,2 This new, highly correlated obstacle is the size of our patients, and even the size of many of us.
As a dental ergonomic assessment specialist, one of the first office items I look at when I conduct an assessment is the patient chair. I’ve spent years warning practice owners and clinicians about the dangers of using wide-backed patient chairs. The wider the chair back, the more difficult it is to see into the mouth, causing a clinician to lean forward to obtain access. Working in an awkward position is one of OSHA’s top risks for injury in the workplace.3 The chairs used to be too big for the average patient, but now people often fill the entire chair, and then some.
The need to safely get through treatment is not a luxury, it’s a requirement. It’s also just one part of the patient care process. Large patients often need nutritional guidance, and many have underlying health conditions such as diabetes, hypertension, hypothyroidism, and increased inflammatory oral conditions. These patients take more time before we ever put the chair back, which reduces our time for clinical treatment and adds to the tricky part: treating a mouth that is outside of our reach while maintaining neutral posture.
The difficulty in treating large patients is about geometry. Our safe working distance is dependent on our ability to see and access the oral cavity. Our reaching distance should not exceed 12 inches from our torso. When a patient is 36 to 46 inches wide at the shoulders, this extended reaching with contraction of the musculature in the arms while leaning forward puts a clinician at increased risk for injury.4 We must protect ourselves while serving these patients. Since we can’t magically make a person smaller, we should employ ergonomic strategies, so we don’t fall into an injury-promoting cycle.
Chances are more of our patients will be large, according to currently predicted increases in obesity.5 At some point, it may be less common to have a patient who is not obese or overweight. We must protect ourselves as best we can from any workplace injury that will inevitably occur if we don’t use ergonomics.
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Strategies to work around large patient size
Indirect vision: This is by far the most underused strategy that we have in our ergonomic armamentarium, and it has a huge ergonomic impact when we use it. It doesn’t prevent reaching, but it certainly aids in forward leaning at the hips, hunching of the back, and forward head posture with twisting in the neck. Live it. Breath it. Use it.
Train the patient: Saying “Turn toward me,” followed by a quarter-inch nod in our direction, is not going to cut it. We have got to train our patients to move their head (and our field of vision) so that we can safely and successfully provide treatment. Use phrases such as “Turn way toward me” or “Put your chin way up to the ceiling,” while applying gentle pressure to the chin so they know what we need from them.
Use a properly fitted saddle stool: With the legs angled down at about 135 degrees rather than 90 degrees, clinicians can get in closer to the chair because their legs aren’t in the way. In addition to proximity from less obstruction, clinicians tend to sit higher in a saddle. The higher we sit, the more torso length we can use to gain access to a mouth that may be attached to a deeper head, allowing us to practice without hunching our shoulders. For torso deficient and vertically challenged clinicians, we need all the help we can get!
Use the headrest: An articulating headrest is a vital piece of ergonomic equipment because it puts the patient’s head back, even if the upper body is somewhat forward. Put it back before the patient enters the room. They won’t have to lean as far back, but access will be there.
Get assistance: Often, large intraoral structures (cheeks and tongues) are found in overweight and obese patients. Trying to hold back or isolate anatomy can be almost impossible. Rather than putting the patient or operator through an energy sucking battle, ask for retraction assistance.
Take time to look at ourselves
This is often uncomfortable, but we must look at the risk we place ourselves in as we work within our own bodies. Having a large middle circumference puts a person in danger in a similar fashion. When a patient is further away, there’s a need to lean over and reach higher, and this puts more strain on an already taxed musculoskeletal system. This doesn’t mean we must all be a size two. And it has nothing to do with self-image or self-acceptance. This is about having the ability to perform a vital part of our job without injury.
For those who face this dilemma, consider standing more. The distance from the belly to the patient decreases due to the length of available area for the belly to exist. Wear supportive footwear with plenty of cushion, and compression socks to help promote adequate blood flow and foot fatigue. When sitting, a saddle stool is even more important for overweight clinicians. Practicing ergonomics is also a priority for those facing a bigger distance from their workspace, especially if it comes from both ends.
Finally, it’s imperative to refrain from judgement. We all want to create a story that makes sense in our curious mind for why things are the way they are. Before jumping to conclusions when a patient comes in, look to the medical history. Ask, “How’s your health? Anything new going on like medication changes, diagnoses, surgeries?”
As we connect the dots between medical history and the status of the oral condition, we may find that our initial conclusions are wrong. Maybe someone just had a baby, is going through depression from a death in the family, or is struggling with an autoimmune disorder. We can never know why people come in the way they do, but we can be compassionate. Always come to work with kindness and from a position to serve.
Editor's note: This article appeared in the March 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
- The state of obesity: Better policies for a healthier America. Trust for America's Health. September 21, 2023. https://www.tfah.org/wp-content/uploads/2023/09/TFAH-2023-ObesityReport-FINAL.pdf
- Adult obesity facts. Centers for Disease Control and Prevention. Last reviewed May 17, 2022. Accessed December 9, 2023. https://www.cdc.gov/obesity/data/adult.html
- Prevention of musculoskeletal disorders in the workplace. Occupational Safety and Health Administration. Accessed December 9, 2023. https://www.osha.gov/SLTC/ergonomics/
- Identify problems. Occupational Safety and Health Administration. Accessed December 9, 2023. https://www.osha.gov/ergonomics/identify-problems#risk-factors
- Ward ZJ, Bleich SN, Cradock AL, et al. Predicted US state-level prevalence of adult obesity and severe obesity. N Engl J Med. 2019;381:2440-2450. doi:10.1056/NEJMsa 1909301.
Katrina Klein, RDH, CEAS, CPT, is a 17-year practicing registered dental hygienist, national speaker, author, competitive bodybuilder, certified personal trainer, certified ergonomic assessment specialist. and biomechanics nerd. She’s the founder of ErgoFitLife, where ergonomics and fitness are a lifestyle to prevent, reduce. or eliminate pain for dental professionals.
