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Slide 1-

USAF Dental Evaluation & Consultation Service Musculoskeletal Disorders and Ergonomics in Dentistry: An Introduction
Slide 2-

USAF Dental Evaluation & Consultation Service Musculoskeletal Disorders (MSDs) Include a group of conditions that involve nerves, tendons, muscles, and supporting structures such as intervertebral discs Severity of Symptoms Mild periodic Severe chronic & debilitating conditions
Slide 3-

USAF Dental Evaluation & Consultation Service MSDs = Ergonomics Musculoskeletal problems are the problem and ergonomics is a solution.
Slide 4-

USAF Dental Evaluation & Consultation Service Types of MSDs Neck and Shoulder Disorders Myofascial Pain Disorder Cervical Spondylolysis Thoracic Outlet Syndrome Rotator Cuff Tendinitis/Tears Back Disorders Herniated Spinal Disc Lower Back Pain Sciatica Hand and Wrist Disorders DeQuervain’s Disease Trigger Finger Carpal Tunnel Syndrome Guyon’s Syndrome Cubital Tunnel Syndrome Hand-Arm Vibration Syndrome Raynaud’s Phenomenon
Slide 5-

USAF Dental Evaluation & Consultation Service MSDs Signs Symptoms Decreased range of motion Deformity Decreased grip strength Loss of muscle function Pain Numbness Tingling Burning Cramping Stiffness
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USAF Dental Evaluation & Consultation Service Contributing Factors for Work-Related MSDs (WMSD) Routine exposure to: Forceful hand exertions Repetitive movements Fixed or awkward postures Vibrating tools Unassisted frequent or heavy lifting
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USAF Dental Evaluation & Consultation Service What Factors Contribute to WMSDs? Forceful hand exertions Grasping small instruments for prolonged periods Forceful squeezing/release of instruments Repetitive movements—e.g., scaling, root planing, polishing
Slide 8-

USAF Dental Evaluation & Consultation Service What Factors Contribute to WMSDs? Fixed or awkward postures Neck, back, shoulder posture Hand/wrist positions Standing/sitting Operatory organization Patient positioning
Slide 9-

USAF Dental Evaluation & Consultation Service What Factors Contribute to WMSDs? Prolonged use of vibrating hand tools—dental handpieces, laboratory equipment
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USAF Dental Evaluation & Consultation Service Contributing Factors for WMSDs A risk factor is not always a causation factor The level of risk depends on Length of time a worker is exposed to these conditions How often they are exposed Level of exposure Usually a combination of multiple risk factors (vs. a single factor) contributes to or causes a MSD
Slide 11-

USAF Dental Evaluation & Consultation Service Contributing Factors for WMSDs Do not focus solely on the workplace Risk factors may be experienced during non-occupational activities (e.g., certain sports, exercising, working with computers, needlework, playing musical instruments)
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USAF Dental Evaluation & Consultation Service Contributing Factors for WMSDs Not everyone exposed to any or all of the risk factors will develop a MSD Individuals do not respond to them in the same way Predisposing factors such as age, arthritis, renal disease, hormonal imbalances, diabetes, and hypothyroidism may play a role
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USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Risk factors associated with dentistry Prolonged static neck flexion and shoulder abduction or flexion Lack of upper-extremity support Inadequate work breaks
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USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Dental health-care personnel (DHCP) commonly assume awkward work postures To obtain better views of the intraoral cavity To provide a more comfortable position for the patient To coordinate their position relative to the dentist or assistant While operating equipment and reaching for instruments and supplies
Slide 15-

USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Examples Myofascial Pain Disorder Cervical Spondylolysis Thoracic Outlet Syndrome Rotator Cuff Tendinitis/Tears
Slide 16-

USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Myofascial Pain Disorder Pain and tenderness in the neck, shoulder, arm muscles Painful trigger points—may twitch upon touch or massage Restricted range of motion Possible causes: overloaded neck/shoulder muscles
Slide 17-

USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Cervical Spondylosis Intermittent/chronic neck and shoulder pain or stiffness Headache Hand and arm pain, numbness, tingling, clumsiness may occur Possible causes: age-related spinal disc degeneration leading to nerve compression and spinal cord damage; arthritis
Slide 18-

USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Thoracic Outlet Syndrome Pain in the shoulder, arm or hand (can be all three) Numbness, tingling of fingers Muscle weakness/fatigue Cold arm or hand Possible causes: compressed nerves or blood vessels passing into arms; trauma; slouching forward or dropping shoulders
Slide 19-

USAF Dental Evaluation & Consultation Service Neck and Shoulder Disorders Rotator Cuff Tendinitis/Tears Pain and stiffness in the shoulder associated with backward and upward arm movements Weakness of rotator cuff muscles Possible causes: swelling or tearing of rotator cuff soft tissue; shoulder joint bone spurs/abnormalities; poor shoulder posture
Slide 20-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Risk factors associated with dentistry Chronic repetitive movements of the hand and wrist Abnormal or awkward positions of the wrist Mechanical stresses to digital nerves such as sustained grasps on instrument handles Forceful work Extended use of vibratory instruments Inadequate work breaks
Slide 21-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Examples DeQuervain’s Disease Trigger Finger Carpal Tunnel Syndrome Guyon’s Syndrome Cubital Tunnel Syndrome Hand-Arm Vibration Syndrome Raynaud’s Phenomenon
Slide 22-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders DeQuervain’s Disease Pain in thumb and wrist area when grasping, pinching, twisting Swelling in thumb area Decreased range of motion of thumb with pain Possible causes: synovial sheath swelling; thickening of tendons at base of thumb; repeated trauma or twisting hand/wrist motions
Slide 23-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Trigger Finger (Tenosynovitis) Pain during movement that place tendons in tension Warmth, swelling, tenderness of the tendon when palpated Possible causes: sustained, forceful powerful grip and/or repetitive motion
Slide 24-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Carpal Tunnel Syndrome Hand or finger numbness, pain, tingling, burning, clumsiness Eventual muscle weakness and atrophy Symptoms often worse with increased activity Pain or tingling that awakens the patient at night with relief via shaking/massaging the hand is considered a hallmark symptom for diagnosis Possible causes: compressed median nerve in wrist via trauma, forceful exertion, repetitive and awkward movements that deviate from near-neutral positions
Slide 25-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Carpal Tunnel Syndrome All hand pain does not mean carpal tunnel syndrome DHCP do not appear to be at greater risk compared to the general population for developing carpal tunnel syndrome Hamann C, Werner RA, Franzblau A, Rodgers PA, Siew C, Gruninger S. Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J Am Dent Assoc 2001;132:163-170. Werner RA, Hamann C, Franzblau A, Rodgers PA. Prevalence of carpal tunnel syndrome and upper extremity tendinitis among dental hygienists. J Dent Hyg 2002;76:126-132.
Slide 26-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Guyon’s Syndrome Pain, weakness, numbness, tingling, burning in the little finger and part of the ring finger Symptoms may worsen at night or early morning Possible causes: compressed ulnar nerve in Guyon’s canal at the base of the palm; repetitive wrist flexing; excessive pressure on palm/base of hand
Slide 27-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Cubital Tunnel Syndrome Pain, numbness, tingling and impaired sense of touch in the little and ring fingers, side and back of hand Loss of fine control Reduced grip strength Possible causes: compressed ulnar nerve in elbow due to trauma or repeated use; prolonged use of elbow while flexed
Slide 28-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Hand-Arm Vibration Syndrome Intermittent or chronic finger and hand numbness and blanching Reduced dexterity, grip strength, and sensation Greater sensitivity to cold Possible causes: vibrations may injure nerves leading to decreased blood flow and lower oxygen supply to surrounding tissues
Slide 29-

USAF Dental Evaluation & Consultation Service Hand and Wrist Disorders Raynaud’s Phenomenon Intermittent spasm of finger and toe blood vessels causing blanching, numbness, and pain Increased sensitivity to cold temperatures Possible causes: carpal tunnel syndrome, connective tissue diseases, repeated vibration or use of tools that vibrate
Slide 30-

USAF Dental Evaluation & Consultation Service Back Disorders Risk factors associated with dentistry Awkward posture Examples Herniated Spinal Disc Lower Back Pain Sciatica
Slide 31-

USAF Dental Evaluation & Consultation Service Back Disorders Herniated Spinal Disc Back and leg numbness, tingling, pain, weakness Worsens with coughing, sneezing, sitting, driving, bending forward Possible causes: bulging or fragmenting of intervertebral discs into spinal canal compressing and irritating spinal nerves; excessive heavy lifting without adequate rest
Slide 32-

USAF Dental Evaluation & Consultation Service Back Disorders Lower Back Pain Pain Stiffness in lower spine and surrounding tissues Possible causes: heavy lifting and forceful movements; whole body vibration; bending/twisting; awkward static postures
Slide 33-

USAF Dental Evaluation & Consultation Service Back Disorders Sciatica Pain from lower back or hip radiating to the buttocks and legs Leg weakness, numbness, or tingling Possible causes: prolapsed intervertebral disc pressuring the sciatic nerve; worsened with prolonged sitting or excessive bending/lifting
Slide 34-

USAF Dental Evaluation & Consultation Service Treatment and Management of MSDs Obtain an accurate diagnosis from a qualified health-care provider Early intervention is key Self-diagnosis is not recommended MSD origins are complex with a broad range of symptoms
Slide 35-

USAF Dental Evaluation & Consultation Service Treatment and Management of MSDs Diagnostic tests may include physical exams, provocative tests, and electromyography Treatment may range from pain-relief medications and rest to surgery, and ergonomic interventions both at work and home
Slide 36-

USAF Dental Evaluation & Consultation Service What is Ergonomics? “Ergo” means work “Nomos” means natural laws or systems Ergonomics is the science of work Ergonomics is much broader than preventing work-related musculoskeletal disorders Ergonomics plays an important role in preventing injury and illness
Slide 37-

USAF Dental Evaluation & Consultation Service What is Ergonomics? An applied science concerned with designing and arranging things people use so that the people and things interact most efficiently and safely Job Demands Worker Capabilities "fitting the job task to the person performing the job"
Slide 38-

USAF Dental Evaluation & Consultation Service Consequences of Poor Design Fatigue Discomfort Illness/Injury Absenteeism Errors Lower productivity Customer dissatisfaction
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USAF Dental Evaluation & Consultation Service Ergonomic Design Goals Enhanced performance by eliminating unnecessary effort Reduce opportunities for overexertion injury Improve comfort by curtailing the development of fatigue Job Demands Worker Capabilities "fitting the job task to the person performing the job"
Slide 40-

USAF Dental Evaluation & Consultation Service Goals Improved Productivity Safety Health Job Satisfaction Job Demands Worker Capabilities "fitting the job task to the person performing the job"
Slide 41-

USAF Dental Evaluation & Consultation Service Dental Ergonomic Stressors Sustained/awkward postures Repetitive tasks Forceful hand exertions Vibrating operational devices Time pressure from a fixed schedule Coping with patient anxieties Precision required with work
Slide 42-

USAF Dental Evaluation & Consultation Service Preventing Ergonomic Injuries Identify risk factors Educate DHCP about ergonomic hazards and preventing MSDs Identify symptoms as soon as they become apparent Intervene quickly
Slide 43-

USAF Dental Evaluation & Consultation Service Preventing Ergonomic Injuries Change human behavior Consider ergonomic features for dental equipment (e.g., patient chairs, operator stools, hand/foot controls, instruments) when purchasing new equipment Modify working conditions to achieve optimal body posture Achieve optimum access, visibility, comfort, and control at all times
Slide 44-

USAF Dental Evaluation & Consultation Service Workplace Intervention “Make the job fit the person” not vice versa Minimize extreme joint position Keep wrist in neutral (i.e., straight) position Keep joints held at midpoint of range of motion Reduce the use of excess force Reduce highly repetitive movement
Slide 45-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Provide Sufficient Space Awkward bending, twisting, and reaching places stress on the musculoskeletal system and can lead to discomfort
Slide 46-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Provide Sufficient Space Permanently place equipment used in every clinical procedure within comfortable reach (within 20 inches of the front of the body) Use mobile carts for less commonly used equipment Allows convenient positioning when required
Slide 47-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Provide Sufficient Space Provide a clear line of sight to the oral cavity and all required equipment Maintain a neutral, balanced position—position of an appendage when it is neither moved away from nor directed toward the body’s midline; it also should not be laterally turned or twisted
Slide 48-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Accommodate Individual Preferences Individuals vary in size, shape, training, and experience Ensure equipment and work areas allow flexibility; examples may include: Allows right- or left-handed use Allows different working postures Provides a choice in methods used
Slide 49-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Reduce Physical Effort Avoid bent or unnatural postures Ideally, equipment should allow work in a relaxed and well-balanced position DHCP should adjust equipment to the appropriate height Position the patient to allow easy access from the desired position
Slide 50-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Reduce Physical Effort Use reasonable operating forces and minimal repetitions reduces overall physical effort required by a task Minimize sustained effort Brief but frequent rest pauses can minimize fatigue and enhance productivity Try to incorporate a variety of different activities to shift musculoskeletal demands from one part of the body to another
Slide 51-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Instrument Design Goal: reduce force exertion; maintain hand/wrist in neutral position (no wrist bend) Considerations Overall shape/size Handle shape/size Weight Balance Maneuverability Ease of operation Ease of maintenance
Slide 52-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Hand Instruments When selecting instruments, look for Hollow or resin handles Round, textured/grooves, or compressible handles Carbon-steel construction Color-coding may make instrument identification easier
Slide 53-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Dental Handpieces When selecting handpieces, look for Lightweight, balanced models Sufficient power Built-in light sources Angled vs. straight-shank Pliable, lightweight hoses (extra length adds weight) Swivel mechanisms Easy activation Easy maintenance
Slide 54-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Syringes and Dispenser When selecting look for Adequate lumen size Ease in cleaning Textured/grooved handles Easy activation and placement
Slide 55-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Lighting Goal: produce even, shadow-free, color-corrected illumination concentrated on operating field Overhead light switch readily accessible Hand mirrors can be used to provide light intraorally Fiberoptics for handpieces add concentrated lighting to the operating field
Slide 56-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Magnification Goal: improve neck posture; provide clearer vision When selecting magnification systems consider Working distance Depth of field Declination angle Convergence angle Magnification factor Lighting needs
Slide 57-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Operator Chair Goal: promote mobility and patient access; accommodate different body sizes Look for: Stability Lumbar support Hands-free seat height adjustment Fully adjustable
Slide 58-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Patient Chair Goal: promote patient comfort; maximize patient access Look for: Stability Pivoting or drop-down arm rests (for patient ingress/egress) Fully adjustable head rest Hands-free operation
Slide 59-

USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Posture/Positioning Goal: avoid static and/or awkward positions Potential strategies Position patient so that operator’s elbows are elevated no more than 30 degrees Adjust patient chair when accessing different quadrants Alternate between standing and sitting
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USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Work Practices Goal: maintain neutral posture; reduce force requirements Potential strategies Ensure instruments are sharpened, well-maintained Use automatic handpieces instead of manual instruments wherever possible Use full-arm strokes rather than wrist strokes
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USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Scheduling Goal: provide sufficient recovery time to avoid muscular fatigue Potential strategies Increase treatment time for more difficult patients Alternate heavy and light calculus patients within a schedule Vary procedures within the same appointment Shorten patient’s recall interval
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USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Personal Protective Equipment Glasses Lightweight, clean, well-fitted Magnifying lenses and head lamps are encouraged Clothing Fit loosely, lightweight, pliable
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USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Personal Protective Equipment Gloves Be of proper size, lightweight, and pliable Should fit hands and fingers snugly Should not fit tightly across wrist/forearm
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USAF Dental Evaluation & Consultation Service Applying Ergonomics to Dentistry Personal Protective Equipment Gloves Ambidextrous (i.e., non-hand specific): exert more force than fitted gloves across palmar region of hand and may exacerbate symptoms of carpal tunnel syndrome Hand-specific (i.e., right vs left) is recommended Fit better Place less force on hand
Slide 65-

USAF Dental Evaluation & Consultation Service References Ergonomics and Disability Support Advisory Committee (EDSAC) to the Council on Dental Practice (CDP). An introduction to ergonomics: risk factors, MSDs, approaches and interventions. American Dental Association;2004. Grant KA. Ergonomics: is it optional? PowerPoint presentation. Murphy DC. Ergonomics and the Dental Care Worker. American Public Health Association, United Book Press, Washington, DC;1998. NIOSH. Work-related musculoskeletal disorders. 1997. SmartTec. Musculoskeletal disorders: their symptoms and possible causes. Smartpractice;2002.