Jpmer

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10.5005/jp-journals-10028-1140
An Ounce of Prevention is Worth a Pound of Cure: Ergonomics in Dental Practice
review article

An Ounce of Prevention is Worth a Pound of Cure:

Ergonomics in Dental Practice
1
Praveenkumar Ramdurg, 2Vijaylaxmi Mendigeri, 3Surekha Puranik

ABSTRACT applied science concerned with designing products and

Dentists and dental hygienists are at risk for work-related procedures for maximum efficiency and safety.1 It is also a
musculoskeletal disorders compared to the general popula- study of the relationship among the personnel, equipment
tion. The most frequent injuries occur in the spine (neck and and environment in the work area.2 The International
back), shoulders, elbows and hands. While specific procedures
Ergonomics Association defines ergonomics as follows:
place the clinician at increased risk for finger and hand injuries,
poor posture is a risk factor with all procedures. Sitting in an Ergonomics is the scientific discipline concern with the
appropriate chair, using magnification for visualization, and the understanding of interactions among human and other
selection of ergonomically-friendly equipment are essential elements of a system, and the profession that applies
for the health of dental clinicians. Ergonomics is the science
of designing jobs, equipment and workplaces to fit workers.
theory, principles, data and methods to design in order
Proper ergonomics design is necessary to prevent repetitive to optimize human well being and overall system per-
strain injuries, which can develop over time and can lead to long formance. Ergonomics first entered the modern lexicon
term disability. This article includes musculoskeletal disorders when Wojciech Jastrzebowski used the word in his 1857
(MSDs) and the signs, symptoms and risk factors of these types
of injuries, so that one can be aware of developing problems article ‘The Outline of Ergonomics, i.e. Science of Work,
and can change his /her approach to work or alter the worksta- Based on the Truths Taken from the Natural Science’.
tion setup to prevent further injury. The article discusses the The coining of term Ergonomics, however, is now widely
applications of ergonomics in dental clinic set up and offers
attributed to British psychologist Hywel Murrell, at the
different exercises to work with comfort, efficiency and ease.
1949 meeting at the United Kingdom’s admiralty, which
Keywords: Ergonomics, Musculoskeletal disorders, Work leads to foundation of The Ergonomic Society.3
station, Exercise, Risk factors.
The musculoskeletal health of dental professionals
How to cite this article: Ramdurg P, Mendigeri V, Puranik S.
has been the subject of numerous studies worldwide,
An Ounce of Prevention is Worth a Pound of Cure: Ergonomics
in Dental Practice. J Postgrad Med Edu Res 2015;49(1):37-42. and their focus has been on the pain experienced by the
practitioner. Because their work area is narrow, perfor-
Source of support: Nil
mance of dental treatment results in a very inflexible work
Conflict of interest: None posture.4 Literature suggests that the prevalence of musculo­
skeletal disorders (MSDs) in dentist, dental hygienists and
introduction dental students ranges between 64 and 93%.5 Some other
studies indicate that back, neck, and shoulder or arm pain
Visit any shopping center and you will find a number of
is present up to 81% of dental operators.6 Researchers
products labeled, ‘ergonomic,’ from can openers bearing
have found symptoms of discomfort for dental workers
squishy handles, to dog food bowls on elevated platforms
occurred in the wrists/hands (69.5%), neck (68.5%), upper
so that spot does not need to stoop for breakfast. What
back (67.4%), low back (56.8%) and shoulders (60.0%).7
does ‘ergonomics’ mean and why should dental pro­­-
fe­ssionals care? What Are MSDs?
In Greek, ‘Ergo,’ means work and, ‘Nomos,’ means
Musculoskeletal disorders (MSDs) are described as
natural laws or systems. Ergonomics, therefore, is an
disorders of the muscles, nerves, tendons, ligaments,
joints, cartilage or spinal disks. The term ‘work-related
1,2
musculoskeletal disorders’ (WMSDs) refers to MSDs
Assistant Professor, 3Head
that are made worse or longer lasting by work condi-
1,3
Department of Oral Medicine and Radiology, Pmnm Dental tions. Dental professionals are among the workers
College and Hospital, Bagalkot, Karnataka, India
who are more often susceptible to MSDs; they often
2
Department of Orthodontics, Pmnm Dental College and cannot avoid prolonged static postures. Even in optimal
Hospital, Bagalkot, Karnataka, India seated postures, more than one half of the muscles of
Corresponding Author: Praveenkumar Ramdurg, Assistant the body are contracted statically and there is a little
Professor, Department of Oral Medicine and Radiology, Pmnm movement of the vertebral joints. This may result
Dental College and Hospital, Bagalkot, Karnataka, India, Phone: in many pathologies, such as tendinitis, synovitis,
8861593975, e-mail: [email protected]
tenosynovitis and bursitis (Table 1).8,9 Occupational
Journal of Postgraduate Medicine, Education and Research, January-March 2015;49(1):37-42 37
Praveenkumar Ramdurg et al

diseases have not only physical, psychological, and social of force is low and the work postures are not awkward.
consequences, but also economic10 and security impacts Repetitive motions are extremely prevalent in clinical
when they reach a level of severity that directly affects practice, particularly when performing scaling, root
work capacity, cau­sing absences and early retirement.11 planning and polishing.
• Contact stress: results from occasional, repeated, or
Risk factors for MSDs
continuous contact between sensitive body tissues
Musculoskeletal disorders are associated with a number and hard or sharp objects like resting the wrist on the
of strains that are often combined in a single job, edge of a desk, or tool handles pressing into palms.12-14
including strains related to holding various positions,
force or repetitive movements. The problems vary Application of Ergonomics
according to the parts of the body affected. One or more
factors may be involved. The presence of simultaneous Through ergonomic advances made over the years, dental
strains increases the level of risk. Injuries may be sus- professionals have been able to modify and optimize
tained either by repeating the same movements or by a their working environments. Ergonomic improvements
lack of movement. in work station layout, seating, selection of instruments,
Many ergonomic analyses of the work done by hygie­ magnification and lighting have offered a proactive
nists, dentists and dental assistants have made it possible measure for ensuring a proper balance between job
to identify a certain number of risk factors. requirements and worker capabilities.
• Awkward postures: Refers to positions of the body that
significantly deviate from the neutral position while Work Station Layout
performing job tasks, such as working over head According to ergonomists, a person’s work area should
reaching, twisting, squatting or kneeling. be close to and in front of him/her. A work area that
• Static postures: Static postures are defined by those respects the length of the arms is safe for the shoulders,
which are held for a long period of time and may neck and back. As can be seen in the following figure,
result in fatigue and injury. When a posture is held the usual work area should be within the length of the
for a prolonged period of time there is a reduction in
forearm, or 25 cm (10 inches) (Fig. 1).15
blood flow to the tissues. This results in a reduction
To be able to work behind the patient’s head (12:00
of nutrient and oxygen supply with lactic acid and
position), the dentist and hygienist have to be able to
other metabolites accumulating, which can result in
move easily between the back of the patient’s chair and
pain and tissue damage.
the rear counter or wall of the room. A minimum of 46 cm
• Force: The amount of physical effort required to main-
(18 inches) is necessary.16
tain control of equipment or tools, or to perform a task,
Instruments are placed above the patient so that
such as heavy lifting, pushing, pulling or carrying.
the distance for the clinician is minimized and there is
• Repetitive movements: The risk of developing an MSD
significant reduction in his neck and left shoulder pain.
increases when same or similar parts of the body are
Negatoscope should be installed in front and on the
used continuously, with few breaks. Highly repetitive
dominant side. So, it makes possible to maintain the neck,
tasks can lead to fatigue, tissue damage, discomfort,
the upper and lower back in a straighter position.
and, eventually injury. This can occur even if the level
A counter or table should be placed on the dominant
Table 1: Understanding musculoskeletal disorders side to allow taking notes without twisting the body.
Some signs of MSDs
•   Decreased range of motion
•  Loss of normal sensation
•  Decreased grip strength
•  Loss of normal movement
•  Loss of coordination
Some symptoms of MSDs
•  Excessive fatigue in the shoulders and neck
•  Tingling, burning, or other pain in arms
•  Weak grip, cramping of hands
•  Numbness in fingers and hands
•  Clumsiness and dropping of objects
•  Hypersensitivity in hands and fingers
MSDs: Musculoskeletal disorders Fig. 1: Work station layout

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An Ounce of Prevention is Worth a Pound of Cure: Ergonomics in Dental Practice

Operator chair The patient’s head must be at the end of the headrest
so that the clinician can keep his/her back supported
For right-handed clinicians, working in the range from
on the lumbar support and also limit forward flexion of
7 to 9 o’clock is commonly associated with twisting of the
back and neck.
trunk and neck as well as working with an elevated elbow
Sling or low profile arm rests should be incorporated
posture in order to gain access. The mirror image (3 to
to help the clinician to work in 8:00 to 10:00 positions
5 o’clock) is equally problematic for left-handed clini-
without hitting their knees on a fixed metal arm rest.
cians. In an attempt to reduce such postural deviations
Large knobs should be absent. They hit the edge of
a conservative range from 10 o’clock to approximately
operator chair, preventing close positioning.
12:30 is preferred.
Finally, when the patient is properly positioned; your
The risk for low-back pain is associated with work
shoulders, elbows, and wrists should be in a neutral
undertaken for prolonged periods of time in a seated
position, meaning that:
position. Continual seating for a prolonged period
• Your upper arms are close to your body.
results in activation of the upper and lower erector spinae
• Your elbow/forearm angle is close to 90º.
muscles and in significantly greater low-back compre­
• Your wrists are in line with the forearm with no more
ssive loading in the lumbar spine region.17
than 20 to 30º extension.
Posture varies depending on the dental stool selected,
so careful selection is crucial. The dental stool must fit
Rheostat positioning
correctly; it must offer neutral back, neck and shoulder
support for optimal posture; must be at the correct height Place it close to the operator so that the knee is at about
and tilt; and must offer optional arm and elbow support. 90 to 100º angle. If placed outside this zone, the dentist
Important design considerations include the back rest, must shift weight to one side, leading to asymmetrical
height of the stool cylinder and armrests. stresses on back, hence low back pain. Switch it from one
– Backrest: Back support is obtained by selecting a foot to another 2 to 3 times a day.
chair with a backrest that can be correctly adjusted
for height and angulation. Lumbar support is helpful
in avoiding any damaging spinal compression and
muscular activity, by maintaining an ergonomic
spinal curve of the seated person (Fig. 2).6
– Height of the stool cylinder: The height of the stool from
the floor to the base of the seat is critical. If the stool
is too high, it will cause the operator to perch on the
edge of the seat, losing contact with the backrest of
the chair. If too short, the clinician’s pelvis will tend to
roll backward, causing flattening of the lumbar spine
(Fig. 3).6
– Armrests: Offer benefits by providing support during
procedures. Shoulder support is aided by armrests,
which help prevent back, shoulder and neck pain. Arm­-
rests are particularly useful if the clinician is staying
in one position for an extended period of time.18
Fig. 2: Lumbar support
Patient Chair
When seating a patient optimal results will be achieved
when their oral cavity is positioned at a height equal to
the mid chest level of the clinician.19 Positioning the oral
cavity above mid chest level will limit vantage and
increase the rate of shoulder fatigue. On the other hand,
positioning the oral cavity below the recommended
height will result in non-neutral working postures inclu­
ding over declination of the head, forward and/or lateral
bending of the torso, and inability of the clinician to
access free movement in the clock positions. Fig. 3: Height of the stool cylinder

Journal of Postgraduate Medicine, Education and Research, January-March 2015;49(1):37-42 39

Praveenkumar Ramdurg et al

Fig. 4: body stretching exercise

Lighting Dental Hand Pieces

Light positioning is a critical factor affecting clinician’s When selecting hand pieces, look for the following:
posture during clinical operation. The goal of proper • Lightweight, balanced models (cordless preferred)
lighting is to produce even, shadow-free, color-corrected • Sufficient power
illumination concentrated on the operating field. Typi- • Built-in light sources
cally, a single light source can provide sufficient unsha­ • Angled vs straight-shank
dowed viewing for a supine patient. For both mandibular • Pliable, lightweight hoses (extra length adds weight)
and maxillary treatment, the light source should be • Swivel mechanisms
directly above and slightly behind the patient’s oral • Easy activation
cavity. This not only serves to increase visibility but can
also reduce awkward working postures.20 Ultrasonic Tools
Instrumentation While ultrasonic tools can serve to reduce prolonged
pinch gripping they do expose the clinician to hand-arm
The design of dental instrumentation can play a key role
vibration. Research has been controversial regarding the
in the prevention of negative health effects for its users.
relationship between the use of ultrasonic scalers and the
Dental clinicians are typically responsible for selecting
development of musculoskeletal problems. While some
and maintaining their own instruments and equipment.
studies indicate that prolonged use of this equipment can
The goal of proper instrument selection should be to
be hazardous due to the negative effects associated with
reduce force exertion while allowing for neutral joint
vibration, other researchers suggest that its use is prefer-
positioning. Critical areas to consider when selecting
able to the heavy hand forces experienced during manual
new or evaluating existing instruments, which is sum-
scaling. As result, educators suggest using ultrasonics for
marized21 in Table 2.
Additional tips for instrument selection are as follows: heavy calculus build-up, but limiting the overall usage
• Hollow or resin handles are preferred of this vibrating tool.22
• Round, textured/grooves (knurled) or compressible
Cord Management
handles are preferred
• Color-coding may make instrument identification easier. The added weight of cords can often influence the level of
• Carbon steel construction (for instruments with sharp muscle fatigue experienced by a clinician. Additionally,
edges) is preferred. coiled hoses can cause the hands and wrists to do more
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An Ounce of Prevention is Worth a Pound of Cure: Ergonomics in Dental Practice

Table 2: Instrumentation
Handle shape and • Dental instrument diameter ranges from 5.6 to 11.5 mm. Larger handle diameters reduce hand muscle load
size and pinch force.
• ‘No. 4’ handle lessens pinch gripping and can be purchased for most instruments.
• A round handle, compared to a hexagon handle will reduce muscle force and compression.
Weight • Lightweight instruments (15 gm or less) help reduce muscle workload and pinch force (Dong, 2006).
Balance/ • The instrument should be equally balanced within the hand so that the tendency to deviate the wrist is reduced.
maneuverability • Balancing an instrument is improved using a third digit rest compared a fourth digit rest since it does not engage
the wrist as much while guiding and positioning the hand piece. The second digit (index finger) can detect very
fine movements and should be placed close to the operating point. By not using the fourth digit as a stabilizer
of the hand piece reduces the number of fingers in the oral cavity, improves the ability to position instruments,
and involves as few joint segments as possible thereby improving the degree of control and providing enhanced
tactile ability.
Ease of operation • The easier it is to operate a tool, the better. Less time is spent searching for buttons, thereby reducing the risk
of error. Less time is also spent learning how to use the device. Simple activation is also important, such as
using a foot pedal or handle turn to activate the tool as they do not require the operator to hold a button in a
sustained pinch grip for extended periods of time.
Sharpness • As a tool becomes dull, additional force is required to perform tasks. As a result, it is important to maintain
sharpness of the instruments.
Texture • Knurled handles such as diamond-shaped or crisscross patterns serve to reduce pinch grip force due to an
increase in tactile sensation as a result of the knurl.

work if the coils have too much resistance to deformation. Magnification system
So, it is recommended that retractable or coiled hoses be
Main goal of the magnification is to improve neck posture
avoided and replaced with a pliable hose which consists
and to provide clearer vision. Use of normal scopes necessi-
of a swivel mechanism in the barrel.
tates 20º forward head bending which leads to flatting
of low back curve and hence low back pain. In contrast,
Finger Rests
procedure scopes utilizes 0º forward head bending and
In addition to increasing hand stabilization, the use of extraoral camera to display image on a liquid-crystal
two-finger rests has shown musculoskeletal advantages display (LCD) screen, hence, better vision.23
when performing scaling procedures. When researchers
examined three different finger positions (no rest, 1-finger Exercises for clinician
rest, and 2-finger rests) they found significant reductions
Ergonomics problems in dentistry can be reduced by
in thumb pinch forces and muscle activity when using
implementing various strategies which are discussed
rests. More specifically, two-finger rests always produced
above. Dentists should also perform specific exercises
these reductions, as compared to not using any finger
for the trunk and shoulder girdle to enhance the health
rests, while one finger rest reduced thumb pinch force
and integrity of the spinal column; stretching exercises
and muscle activity most of the time.21
for the hands and head and neck; maintain good working
posture; optimize the function of the arms and hands;
Gloves
and prevent injuries.6 The following exercises can be
Gloves are commonly worn due to universal precau- practiced and performed by clinician on a regular basis
tions. Gloves must be of proper size, lightweight and in order to prevent MSDs.
pliable. Poor fitting gloves can cause pain in the hands,
particularly at the base of the thumb. This is often due Body Strengthening Exercises
to compression of the tissues when gloves are either too
Stretching and strengthening the muscles that support the
small or too loose as ‘bunching’ occurs. When used for
back and neck and those used in the forearm, wrist, and
extended periods of time, gloves must be pulled into a
hand will help them remain strong and healthy (Fig. 4).6
working position, which may compress the back of the
hand, strain muscles at the base of the thumb, and reduce
Hand Exercises
blood flow to the hand. Properly fitted gloves should
fit hands and fingers snugly, should not feel tight across Slowly open and close hands from a completely open
the wrists and be hand-specific (right vs left-hand position, to a completely closed position, which ends
design). with your fingers tucked into your palm; press the palms

Journal of Postgraduate Medicine, Education and Research, January-March 2015;49(1):37-42 41

Praveenkumar Ramdurg et al

of your hands together and then relax them; gently pull 6. Valachi B, Valachi K. Mechanisms leading to musculoskeletal
and relax each finger on each hand separately; cross the disorders in dentistry. J Am Dent Assoc 2003 Oct;134(10):
1344-1350.
wrists and gently stretch and relax.2
7. Anton D, Rosecrance J, Merlino L, Cook T. Prevalence of mus­-
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Neck Exercises dental hygienists. Am J Industrial Med 2002;42(3):248-257.
8. Carvalho MV, Cavalcanti FI, Miranda HF, Soriano EP. Partial
Relax shoulders and tuck the chin into the neck, then raise rupture of supraspinous tendon in a dentist: a case report.
the head back; tilt head to the side as if trying to touch FIEP Bull 2006;76:131.
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263(suppl):1-64.
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11. Hill KB, Burke FJ, Brown J, Macdonald EB, Morris AJ, White
the legs; hold position for a while; raise slowly by con-
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Ergonomic infogram/E-A01;1998. p. 2-37.
Every dental care facility has an opportunity for ergo-
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nomic improvement. While employers should always be kinematics during standing and unsupported sitting.
seeking ways to modify and optimize their workplace Ergonomics 2001;44(3):280-294.
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need to pay attention to body symptoms in order to office chairs on trunk kinematics, trunk extensor EMG and
spinal shrinkage. Ergonomics 2001;44(7):739-750.
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18. Parsell DE, Weber MD, Anderson BC, Cobb GW Jr. Evaluation
result, ergonomics should be a continuous and proactive of ergonomic dental stools through clinical simulation. Gen
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