One morning I was taking a shower to get ready for work. I noticed I could not raise my left hand, and my left clavicle and the shoulder socket were positioned forward compared to the right side. I was scared and worried about what happened to my arm and shoulder. I had no pain or discomfort. I went to work and was able to work without any problem. I saw a shoulder specialist a week after and, sure enough, I had musculoskeletal issues.
A dental hygiene job requires physical demands that will cause musculoskeletal problems, such as carpal tunnel syndrome and cubital tunnel syndrome. This is due to repetitive work, incorrect posture, and non-ideal instruments. In this paper, the issues regarding these physical demands will be explained and how to solve them. We will also examine why these two syndromes have been overlooked.
What are musculoskeletal disorders?
Musculoskeletal disorders are injuries that affect the musculoskeletal system, which includes muscles, nerves, tendons, ligaments, discs, blood vessels, and joints. (Middlesworth, 2019). This issue is very common among people who work in the dental industry, especially dental hygienist, because of the repetitive work and poor posture for a prolonged time when treating a patient. A study by Guignon (2013) reported that 70% of dental hygienists reported neck pain and shoulder pain, 30% complained about pain in their lower backs and dominant hands, and “27% have mid to upper back issues and 20% have problems with their nondominant hand or thumb” (para. 2). Furthermore, a study by Yochim (2018) found that 96% of dental hygienists reported Musculoskeletal related problems (para. 2).
These statistical numbers have driven hygienists and researchers to take the issue into consideration and to find ways to solve or control them. Musculoskeletal disorders have a wide range of symptoms. These symptoms include pain, tingling, numbness, and weakness in the hands, shoulders, elbows, and wrists. This is referred to as musculoskeletal syndrome (Rempel, Azevedo, & Rapel, 2015). These symptoms happen “due to the injuries to muscles, tendons, nerves, joints, or ligaments” (Rempel, Azevedo, & Rapel, 2015, p. 3).
Physical problems and issues
Dental hygienists have reported different types of musculoskeletal conditions; however, this paper focuses on the carpal tunnel and cubital tunnel syndromes because of 20% of dental hygienists experiencing issues related to their hands and wrists (Guignon, 2013). According to Michalak-Turcotte (2000), dental hygienists “use different wrist movements 30 times or more per minute” (As stated in Taft, 2014, p. 20). Among the many musculoskeletal disorders, the two mentioned syndromes may cause more difficulties with a dental hygienist job that is mainly done by hand (Guignon 2013). These injuries need to be acknowledged, managed, and treated before they limit a hygienist’s profession and cause serious health issues.
Carpal tunnel syndrome
In a survey of 2,447 dental hygienist in Southern California, 6.4% reported that they were diagnosed with carpal tunnel disorder, and one third disclosed that they have been experiencing the signs and symptoms of carpal tunnel (Lalumandier & McPhee, 2001, p. 130). Additionally, Lalumandier and McPhee (2001), discussed that 75.1% of hygienists reported persistent hand problems, with 56.5% experiencing symptoms of carpal tunnel (p. 131). Carpal tunnel happens because of the compressor of the median nerve in the wrist (Jennings & Faust, 2016). The median nerve is located between the carpal bones of the wrist and flexor tendon sheaths (Jennings & Faust, 2016). The inflammation of the tendon sheaths will cause a narrower passage for the median nerve (Jennings & Faust, 2016). In other words, when the nerve gets compressed, the person may feel the following signs and symptoms (a combination of any or all of them). These signs and symptoms are:
- Tingling, numbness, pain, weakness, and discomfort in the thumb, index, middle finger, and ring finger (Jennings & Faust, 2016)
- Radiating shock-like sensation in the fingers (Jennings & Faust, 2016)
- Incoordination in the hand and dropping things due to loss of the grasp (Jennings & Faust, 2016)
Dental hygienists are at a higher risk of developing carpal tunnel syndrome when compared to other dental professions (Lalumandier & McPhee, 2001). Removing tenacious calculus, the number of hours working in a week as a clinical dental hygienist, and the number of years as a clinician are the reasons for developing carpal tunnel syndrome amongst dental hygienists (Lalumandier & McPhee, 2001). Cubital tunnel syndrome is another issue that dental hygienists may experience, since it is caused by compression of the ulnar nerve that travels from the neck to the fingers (Keener, 2015). In the next paragraph, cubital tunnel syndrome will be discussed in more detail.
Cubital tunnel syndrome
Besides carpal tunnel syndrome that may cause issues for the wrists and hands, cubital tunnel syndrome is caused by the compression of the ulnar nerve (Keener, 2015). The ulnar nerve travels from the neck to the elbow to the wrist and finally to the hand (Keener, 2015). The ulnar nerve passes through cubital and Guyon canals, which are the two most common areas that the nerve entraps due to the already narrow space of the canals (Keener, 2015). The ulnar nerve is responsible for most of our fine movements and our sturdy grasp (Keener, 2015). It gives sensation to the small finger and half of the ring finger (Keener, 2015). Constant elbow bending positions will irritate the nerve and cause pain when straightening and bending the elbow (Keener, 2015). When the ulnar nerve is compressed in the cubital or Guyon canal, the following may occur:
- Tingling and numbness on the small and ring finger (Keener, 2015)
- Losing grip is common especially if the nerve is over irritated (Keener, 2015)
Dental hygienists' hands are bent during treatment, which will put pressure on the ulnar nerve; also, constant wrist movement will aggravate the ulnar nerve and can cause tingling and numbness in our fingers (Keener, 2015). Therefore, it is important to notice which fingers are affected by this disorder for proper treatments. Hygienists should take note of the times that they are experiencing any of the symptoms, as well as how long each symptom last and which areas where affected. Perhaps a journal will help a physician with better diagnosis and a physical therapist with more suitable exercises.
The mentioned physical syndromes can change one’s life. There are many ways to prevent these musculoskeletal disorders from happening or to manage the symptoms. The solutions for these issues that are related to the physical requirements of the dental hygiene profession are correcting ergonomics, having the right equipment, choosing the right instruments, balancing the schedule, exercising, and maintaining overall health (Rempel et al., 2015). Each of the mentioned solutions can have a positive effect on avoiding these disorders or stopping them from progressing.
The first point would be having the correct ergonomics. According to Rempel et al. (2015), “ergonomics is the study of how to design work to be efficient and to prevent injuries [as well as guiding principles for the] dental hygienists and other workers to avoid sustained awkward postures, sustained high muscle loads, or repeated forceful hand exertions” (p. 3). To correct ergonomics, one should avoid twisting while bending forward, raising the shoulders, lifting arms, and squeezing the instruments during dental hygiene care (Rempel et al., 2015). Besides the position of the body during the cleaning, a hygienist should remember to use the proper operating positioning. These include adjusting the operator’s chair and the patient’s chair height as necessary before the start of the day and between each patient (Rempel et al., 2015). To hold the proper chair positioning, the knees should be a little lower than the hips with the feet flat on the ground and at a straight angle with the knees (Rempel et al., 2015). Additionally, “the operator’s Knees should be able to slide under the patient’s chair to avoid working with a twisted spine and torso” (Rempel et al., 2015, p. 4). Moreover, the operator’s elbow and the patient’s mouth should be at the same level to the shoulders close to the body (Rempel et al., 2015). To adjust that, the operator should move for the correct clock positioning throughout the treatment (Rempel et al., 2015). Therefore, maintaining the right ergonomics can maintain our physical health at work.
So far, the focus was mostly on the ergonomics and fixing it. There are other factors that can relive the associated discomfort with musculoskeletal disorders. Besides ergonomics, use of the proper equipment, such as dental loupes with lights, gloves, right instruments, balancing the schedule, and exercise can significantly reduce the issues related to musculoskeletal problems. Use of the right equipment will help the hygienists to work for more years comfortably.
Dental Loupes. Magnifying loupes can help with excess neck bend and upper body flexion (Rempel et al., 2015). The loupes should be lightweight, focal fit customization, additional lighting, and 2.5x magnification. (Rempel et al., 2015). Some loupes company also offer the headlights with their loupes. Those will help the hygienist to see better and to avoid bending forward to obtain a better view of the area.
Gloves. In addition to the dental loupes, the right size gloves and the good quality gloves can help with the musculoskeletal syndrome. The appropriate gloves can have positive impacts on the way a dental hygienist practice. Everyone’s hands are different in size and shape; therefore, choosing the right brand is crucial (Guignon, 2013). The newer gloves are thinner and allow for better tactile sensitivity without excess pressure (Guignon, 2013). As a result, the operator can utilize them without applying extra pressure to feel something. The suitable gloves can assure the health of hygienists’ hands and their comfort. The gloves should not be tight since they can apply excess pressure to the nerves, tendons, ligaments, blood vessel, muscles, etc. and cause musculoskeletal problems (Rempel et al., 2015).
Saddleback Chair. Many different chair models have been introduced in dentistry such as the regular office chairs, the stools, and saddleback chairs. The normal chairs’ height has been determined based on average men height after World War II; therefore, the standard height is based on 5’11” tall man (Guignon, 2015). Many dental hygienists are women and having a smaller body size than men (Guignon, 2015). The traditional dental operator chairs are wider and deeper; as a result, the operator sits at the edge of the chair which will cause pain and discomfort in the lumbar area. As Guignon (2012) stated, the saddleback chairs can help with supporting the lumbar area since they place the body in a “sit/stand positioning [where the] benefits include sitting up higher, erect posture, deeper breathing, more stable reach, improved leg circulation, and a balanced pelvic position” (para. 4). Besides the lumbar and pelvic support, saddleback chairs are a better choice for the cervical comfort owning to the fact that it positions the body at a 45˚ angle (Annetts, Coales, Colville, Mistry, Moles, Thomas, & van Deursen, 2012). In short, choosing the right chair that removes the excess stress on a hygienist body, will help them to maintain a better body position which in turn will reduce the musculoskeletal issues.
Instruments. Another factor in preventing physical job-related problems for hygienist is using the right instruments. Hygienists work with their instruments all day long, so the quality of the instruments must be superior. In addition, using the right surface instrument is necessary to avoid wrist bending and excess pressure. According to Simmer-Beck and Branson (2010), “the literature suggests that the optimal diameter for dental instruments and mirrors is at least 10 mm, the optimal weight is 15.0 g or less, and padding decreases muscle activity” (Conclusion section). Furthermore, Rempel, Lee, Dawson, and Looner (2012), indicated that during their study, the clinicians who used lighter and wider instruments had a positive improvement on their upper extremities pain in comparison to the hygienists who used the heavier and thinner instruments. These studies emphasized on the best size and weight of the instruments; as a result, the lighter and thicker instruments are the best options to avoid musculoskeletal disorders. Alongside the diameter size and the weight of the instrument, using the sharp instruments is important to reduce the squeezing force during the scaling (Rempel et al., 2015).
Balancing the Schedule. One other aspect the dental hygienists can do to reduce the probability of the musculoskeletal disorders is balancing the schedule with the hard cases in between the prophylaxis to reduce hand fatigue (Rempel et al., 2015). To fulfill this, one may need to talk to the manager and the dentist to find the best solution that can work for the office and the hygienist.
Exercise. Lastly, exercise has shown to be effective in strengthening the muscles and torso as well as maintaining the weight (Yochim, 2018). Dental hygienists should incorporate exercise and weight control management in their weekly and daily schedule. A study done on 124 dental students revealed that students “who do not exercise, experience statistically significant higher incidences of pain in the shoulders (72.3%), neck (69.2%), lower back (43.0%), knees (43.1%), upper back (32.3%), and ankles/feet (7.7%)” (Yochim, 2018, p. 19). Stretching may help with the muscle tension; however, there is no evidence to support preventing musculoskeletal issues (Rempel, et al., 2015). Although stretching can alleviate the pain and discomfort associated with musculoskeletal disorders. Yoga showed to be the most effective exercise for musculoskeletal disorders (Yochim, 2018). Therefore, hygienists should incorporate yoga in their weekly exercises to strengthen their core muscles and to stretch their muscles.
Many dental hygienists experiencing physical pain, which can be chronic or acute and occur throughout the body from the neck to the feet. In this paper, only carpal tunnel and cubital tunnel syndromes have been discussed. To prevent or manage these syndromes, one should follow correct ergonomics, choose the proper equipment and ideal instruments, as well as maintain the body with exercises. By following the discussed solutions, hygienists should not suffer from physical work-related pains.
- Annetts, S., Coales, P., Colville, R., Mistry, D., Moles, K., Thomas, B., & van Deursen, R. (2012). A pilot investigation into the effects of different office chairs on spinal angles. European Spine Journal, 21(2), 165-170. doi: 10.1007/s00586-012-2189-z
- Guignon, A. N. (2012). Saddle seating: Supporting healthy posture. RDH Magazine 32(7). Retrieved from https://www.rdhmag.com/career-profession/article/16405784/saddle-seating-supporting-healthy-postures
- Guignon, A. N. (2013). House of cards: A fragile balance in our health. RDH Magazine, 33(2). Retrieved from https://www.rdhmag.com/patient-care/article/16406545/house-of-cards-a-fragile-balance-in-our-health
- Guignon, A. N. (2015). Have a seat: Ergonomic conversations turn to dental clinician seating. RDH Magazine, 35(8). Retrieved from https://www.rdhmag.com/career-profession/students/article/16405433/have-a-seat-ergonomic-conversations-turn-to-dental-clinician-seating
- Jennings, C. D., Faust, K. (2016). Carpal tunnel syndrome. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/
- Keener, J. D. (2015). Ulnar nerve entrapment at the elbow (cubital tunnel syndrome). Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/ulnar-nerve-entrapment-at-the-elbow-cubital-tunnel-syndrome/
- Lalumandier, J. A., & McPhee, S. D. (2001). Prevalence and risk factors of hand problems and carpal tunnel syndrome among dental hygienists. Journal of Dental Hygiene,75(2), 130-134.
- Middlesworth, M. (2019). The definition and causes of musculoskeletal disorders. Retrieved from https://ergo-plus.com/musculoskeletal-disorders-msd/
- Rempel, D., Azevedo, S., & Raider, F. (2015). Dental hygiene work: Pain is not in the job description. CDHA Journal, 33(2). Retrieved from https://www.safetyandhealthmagazine.com/ext/resources/images/news/Dental-MSDs.pdf
- Rempel, D., Lee, D. L., Dawson, K., Loomer. P. (2012). The effects of periodontal curette handle weight and diameter on arm pain: a four-month randomized controlled trial. Journal of American Dental Association, 143(10), 1105-1113. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23024308
- Simmer-Beck, M., & Branson, B. G. (2010). An evidence-based review of ergonomic features of dental hygiene instruments. Work 35(4), 477-485. doi:10.3233/WOR-2010-0984
- Taft, S. (2014). Hand function evaluation for dental hygiene students. Retrieved from https://dc.etsu.edu/cgi/viewcontent.cgi?article=3681&context=etd
- Yochim, A. S. (2018). CE course: Musculoskeletal disorder prevention in dental hygiene. Journal of the California Dental Hygienists' Association, 36(2), 19-23. Retrieved from http://eds.a.ebscohost.com.proxy.wichita.edu/eds/pdfviewer/pdfviewer?vid=2&sid=0524c588-f63a-4ef4-a83b-faa38537e74d%40sdc-v-sessmgr03
Sahar Attari, LDH, is a clinical provider in general practice settings. In December 2019, she will finish her bachelor's degree in dental hygiene with emphasis on teaching and education development. For more information, email her at [email protected].