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Special Article

Dental ergonomics: Basic steps to enhance


work efficiency
Abdul Rahim Shaik
Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al Majmaah, Riyadh,
Kingdom of Saudi Arabia

ABSTRACT
The nature of the dental profession and the postures assumed by the dental surgeons during their professional work has a huge impact
on the dental surgeon’s body and carries with it a high risk of musculoskeletal disorders (MSDs). To perform efficiently and effectively,
they shall always like to attain a position that allows them to achieve optimum access, visibility, comfort, and control at all times. Good
ergonomic design of the workplace is a basic requirement for facilitating the balanced musculoskeletal health that will enable longer,
healthier career, enhance productivity, and minimize MSDs among dental surgeons. While treating the patients, they are concerned
about patients’ comfort and pay little attention to their own health till they begin to experience discomfort in their body. With a little
attention and creativity, dental surgeons can improve their comfort on the job during the course of their career.

Key Words: Dental surgeon, dentistry, ergonomics, musculoskeletal disorders, neutral position, risk factors, static postures,
work efficiency, workplace

Introduction epidemic of MSDs. These epidemics served as the catalyst to


investigate the causative factors of MSDs and the extent to
Musculoskeletal disorders which technological or societal changes may have impacted
Musculoskeletal disorders (MSDs) are among the most the occurrences of MSDs.[1]
common causes of long-term disability. Due to spiraling
incidences of MSDs over a period of time and their Musculoskeletal disorders are a wide range of inflammatory
subsequent impact on industrial profits and quality of and degenerative disorders of muscles, tendons, and nerves.
individual lives, the MSDs have received considerable These disorders can result in pain and functional impairment
attention since 1990s from ergonomists, researchers and affecting the neck, upper back, lower back, shoulders,
other healthcare professionals. MSDs were first described elbows, wrists, and hands.[2] Examples are carpal tunnel
in 1700 A.D. and were only documented in the 19th and 20th syndrome, tendonitis, thoracic outlet syndrome, and tension
centuries as many countries worldwide reported a so-called neck syndrome. Epidemiologic literature has grouped these
disorders as clinically well-defined (such as tendonitis and
Access this article online carpal tunnel syndrome), less clinically well-defined (such as
Quick Response Code: tension neck syndrome) and nonspecific (such as repetitive
Website: strain injury, cumulative trauma disorder, and overuse
www.amhsjournal.org
syndrome).[3] Nonspecific disorders are not considered
a diagnosis, but rather an umbrella term for a disorder
DOI:
10.4103/2321-4848.154966 developing from various risk factors.[4] Work activities
which are frequent and repetitive or activities with awkward
postures cause these disorders which may be painful during

Corresponding Author:
Dr. Abdul Rahim Shaik, Assistant Professor, Department of Physical Therapy and Health Rehabilitation, College of Applied Medical
Sciences, Majmaah University, Al Majmaah, Riyadh, Kingdom of Saudi Arabia. E-mail: shaikarahim11@gmail.com

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Shaik, et al.: Dental ergonomics: Enhance work efficiency

work or at rest. Almost all work requires the use of the arms and neutral position. Postures other than this neutral position
and hands. Therefore, most MSDs affect the hands, wrists, are likely to cause musculoskeletal discomfort. Fostering and
elbows, neck, and shoulders. Work using the legs can lead to implementing good musculoskeletal health in dentistry is
MSDs of the legs, hips, ankles, and feet. Some back problems a real challenge for the physiotherapists and other allied
also result from repetitive activities.[2,3] health care professionals. Dental surgeons are prone to
unique muscle imbalances and require special exercises and
Musculoskeletal disorders were a leading cause of worker ergonomic interventions to maintain optimal health during
impairment, disability, compensation costs, and loss of the course of their career.[8]
productivity in industrialized countries. The aging of the
workforce and presence of physically demanding jobs Ergonomics
contribute to the widespread occurrence of MSDs. Tasks Ergonomics, as a discipline, has its formal beginnings
that require forceful exertions place higher loads on the immediately after the Second World War. During this time,
muscles, tendons, ligaments, and joints. Increasing force the focus of concern expanded to include worker safety, as
means increasing body demands such as greater muscle well as productivity. The studies of efficiency carried out by
exertion along with other physiological changes necessary psychologists on Pilots, Radar, and Sonar operators in Great
to sustain an increased effort. Prolonged or recurrent Britain during the war and immediately after it, showed the
experiences of this type can give rise to not only feelings importance of designing technologies that should adapt
of fatigue but may also lead to musculoskeletal problems sizably, statically, and dynamically to the human body and
when there is inadequate time for rest or recovery. Force that should stimulate the physical and mental status of the
requirements may increase with:[3] human beings.[1]
• Use of an awkward posture,
• The speeding up of movements, International Ergonomic Association defines Ergonomics
• Increased slipperiness of the objects handled (requiring (or human factors) as “the scientific discipline concerned
increased grip force), with the understanding of the interactions among humans
• Use of the index finger and thumb to forcefully grip an and other elements of a system, and the profession that
object (i.e., a pinch grip compared with gripping the applies theoretical principles, data and methods to design,
object with the whole hand) and in order to optimize human well-being and overall system.”
• Use of small or narrow tool handles that lessen grip Ergonomics is the science of matching working conditions
capacity. and human capabilities. The goal is to allow people to
perform work and other activities safely and efficiently. The
Most of the dental surgeons today perform their work in basic principle in ergonomics is to match tools, equipment,
the sitting position while treating the patients in the supine and work methods to the needs of the worker in order to
position. Invariably the dental surgeons often have to enable him/her perform comfortably to his/her best. Thus,
perform their professional work in prolonged static postures. the need is to recognize conditions that lead to discomfort
[5]
Even in optimal seated postures more than one-half of and implement changes to minimize or eliminate those
the muscles of the body are contracted statically, and there conditions.
is little movement of the vertebral joints. These result in
physiological changes that can lead to back, neck or shoulder Modern ergonomics is an interdisciplinary applied science
pain or MSDs. If regularly occurring pain or discomfort is that studies the optimization possibilities of the man-
ignored, the cumulative physiological damage can lead to machine system design by knowing the human’s physical
an injury (macro change) or a career-ending disability.[6] In and mental possibilities and limits, his/her capacity to learn,
dentistry, bad working environment, repetitive tasks-such as the factors generating errors, the work, the physiology,
scaling, root planning, and uncomfortable physical postures the human behavior as an individual and within a team,
contribute greatly to MSDs, stress and loss of productivity. To the managerial possibilities, the organizational culture
perform efficiently and effectively, the dental surgeons shall (interdisciplinary study of anatomy, physiology, psychology,
always like to attain a position that allows them to achieve management), and the technical and designing possibilities
optimum access, visibility, comfort, and control at all times.[7] (engineering, design).[9]

Basic operating posture is considered to be an important Dental work poses some interesting ergonomic challenges.
occupational health issue for dental surgeons. It is generally While performing normal professional work, the dental
agreed that the physical posture of the dental surgeon should surgeons have to repeatedly change their positions like
be such that all the muscles are in a relaxed, well - balanced, sitting, standing, and sometimes in one position (static

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Shaik, et al.: Dental ergonomics: Enhance work efficiency

posture) for long periods. They bend forward or to the side It has been seen that the dental surgeons practicing over
while working on patients. While treating the patients, the the years expose themselves to the increased risks of MSDs
dental surgeons are concerned about patients’ comfort due to adopting either repetitive or awkward positions
and pay little attention to their own health till they begin during their work. This has resulted in a high incidence of
to experience discomfort or pain in their body. With a little musculoskeletal and circulatory conditions such as scoliosis,
attention and creativity, dental surgeons can improve their kyphosis, lordosis, varicosities, and other leg and foot
comfort on the job.[10] problems. While it may be impossible to completely eliminate
all ergonomic exposures in dentistry, the detrimental effects
The muscular effort can be either static or dynamic. In of these hazards can be minimized through engineering
static muscular effort, the length of the muscle remains controls such as workstation design/adjustment and through
unchanged called as an isometric contraction, whereas administrative controls such as creative scheduling and rest
in dynamic muscular effort, there are rhythmic changes breaks. The variety of tasks performed by a dental surgeon
of lengthening and shortening of the muscles known as provides the opportunity for “musculoskeletal relief” offered
isotonic contractions. The posture is the complex term by alternating task assignments.
used as reference for a number of movements and posture
concepts. The posture has been defined in various ways - a Dental surgeons and other allied healthcare professionals
posture or a body position, the relative postures of the body trained in ergonomics awareness programs are able to
parts for a specific activity. Pain, fatigue and disorders of recognize early signs of discomfort or MSDs. Training
the musculoskeletal system may result from sustained also increases awareness of ergonomic risk factors, body
inadequate working postures and poor working conditions. mechanics, and helps them develop possible solutions to
ergonomic concerns. Early reporting of symptoms gives
Musculoskeletal pain and fatigue may influence posture
the employer the opportunity to respond quickly, address
control which can increase the risk of errors and may result
concerns, and to head-off or alleviate potential MSDs
in low work efficiency.
problems. With the availability of highly sophisticated dental
equipment, the potential for improving the occupational
Good ergonomic design of the workplace is a basic
health of dental surgeons has expanded. But in spite of this
requirement for improving musculoskeletal health. The
development, dental surgeons continue to experience chronic
nature of the dental profession and the positions assumed
back, neck, and shoulder pain as occupational hazards,[12,13]
by the dental surgeons during an average work day have a
often resulting in early retirement from the profession.[14]
huge impact on the dental surgeon’s body and carries with it
a high prevalence of MSDs. The effects of MSDs will manifest
Using Sports Medicine approach, dentistry may be
themselves not only in the reduction of working hours of
viewed as a profession much like a “sport.” There is
efficiency of the dental surgeons but shall also result in a an abundance of dental surgeons with work-related
reduction in quality time spent with their family members pain and dysfunction. Dentistry poses a huge challenge
and friends. Although the dental surgeons rarely miss their because of the ergonomics of dental work. The biggest
work due to the MSDs, it is more likely to lead to severe risk factors are the awkward prolonged seated postures
disability and a subsequent impact on the quality-of-life. It with no back support and the limited range of motion
is further observed that the most common complaint among and isometric muscle contraction created by working in a
dental surgeons is how MSDs are impeding their personal confined area, namely the mouth. The physiologic effects
life and the lack of leisure time between working periods of these elements are patterns of muscle imbalance
for recovery.[11] and neuromuscular inhibition causing dysfunction and/
or pain. Advances in ergonomics continue to ease the
A poor ergonomically designed workplace may not show physical challenges of the dental profession. Use of office
immediate ill health effect, because the human body has ergonomics does not replace the basics of a body being
the capacity for adapting to a poorly designed workplace physically conditioned. However, one must try to learn
or structured job. However, the compounding effect of job how to work around the various risk factors. The ultimate
and workplace deficiencies will surpass the body’s coping goal should be to prevent injuries and maintain the health
mechanisms causing MSDs. The successful application of of the dental surgeons by rehabilitative exercises.[15]
ergonomics assures high productivity, avoidance of illnesses
and injuries and increased satisfaction among workers. In an effort to reduce the physical fatigue of standing and the
Unsuccessful application of ergonomics, on the other hand, resultant adverse effects on health, dental stools began to be
can result in MSDs.[8,10] used in the 1950s and thus the term “sit down” dentistry was

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Shaik, et al.: Dental ergonomics: Enhance work efficiency

coined. However, the initial stools were single pedestaled surgeon has to handle a variety of tools while simultaneously
and often tilted and rotated, presenting a safety problem. having a good general view.[18]
Since then the design of the stool has been greatly improved.
Despite these changes, dental surgeons experienced frequent Postures assumed by the dental surgeons during
their professional work
musculoskeletal complaints.
In dental work, the majority of awkward positions are held
Dentistry in 21st century for a longer time without moving. The postural rigidity
The 21st century tends to give greater importance to the imposed on the shoulder girdle (neck, shoulder, upper back)
human factor, neglected frequently before in favor of the and lower back muscles are a major problem. The areas
technological factor. The transition from the ergonomics affected depend on their role:
centered on technology to the human-centered ergonomics • The shoulders and upper back are contracted to
is also now the major preoccupation of the industry, which stabilize the arms and to allow greater precision of
eventually has decided to optimize the quality of the activity hand movements
in parallel with the reduction of the risks which generate • The neck muscles (extensors) are contracted to keep the
conditions specific to the occupation. Unlike the initiatives head tilted to one side
in the past, the human-centered ergonomics gives priority • The lower back muscles (spinal extensors) are contracted
primarily to the patient, secondarily to the practitioner, and to hold the torso in a forward leaning position.
finally to the working place design. The design of the working
environment that has to be adapted both for the patient and For dental surgeons, holding awkward postures without
for the practitioner’s requirements can be conceived only moving, or with little movement for prolonged duration,
after establishing a correct relationship between the dental generally have more serious consequences on the joints of
surgeon and the patient.[16] the neck, shoulder, upper and lower back, than repetitive
movements, which have more of an impact on the elbow
Despite numerous technical advances in recent years, and wrist joints.[19]
many occupational health problems still persist in modern
dentistry. These include percutaneous exposure incidents, In order to see into the far reaches of a patient’s mouth,
exposure to infectious diseases (including bioaerosols), dental surgeons have to bend their heads forward. The
radiation, dental materials and noise, MSDs, dermatitis angles of flexion of the neck required in dental work far
and respiratory disorders, eye injuries, and psychological exceed safe angles of flexion for the neck when they are
problems. Apart from biological hazards, dental surgeons held for longer periods.
continue to suffer a high prevalence of MSDs, especially of
the back, neck, and shoulders. Although modern dentistry The following changes occur when the head is bent forward
has been described as probably among the least hazardous as shown in Figure 1:[20]
of all occupations, many risks remain in dental practices • The weight of the head (approximately 9% of the body’s
which continue to challenge this status.[17] weight) is pulled downward
• The rotation point of the head is the first cervical vertebra
Today, most of the dental surgeons work with patients
Figure 1: The muscles of the neck and upper back are under pressure
seated in a reclining position. From chair side and with
to support the weight of the head and keep it from falling down
the continuous assistance of a dental nurse, “four-handed”
dentistry is usually practiced. The dental surgeon is usually
on the right of the patient and the dental nurse on the left.
High and low-speed handpieces, ultrasonic scalers, and
water and air syringes are usually placed on a platform
over the patient’s chest while the suction equipment is on
the left side. Hand tools are on a movable tray that can
be placed in front of, alongside or behind the patient, as
needed. The work is usually carried out while seated, with
elevated and unsupported arms, frequently away from the
body, for example, when reaching for an instrument at arm’s
length. The requirements of vision and accuracy in the work
cause forward bends and rotated positions of the body. The
patient’s mouth is a small surgical area where the dental

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Shaik, et al.: Dental ergonomics: Enhance work efficiency

• The muscles of the neck and upper back are contracted Much dental work requires high precision and the muscles
to keep the weight of the head from falling down used in sustaining such activity are at the risk of becoming
• After certain amount of time, this constant pressure on fatigued and causing discomfort. Stability maintained
the neck muscles to hold up the weight of the head can through static muscle loading in the shoulder for prolonged
lead to pain. periods could lead to fatigue and discomfort. Prolonged
contraction of the upper trapezius during upper extremity
A forward-head posture can lead to muscle imbalances stabilization (without armrests) can cause compression
contributing to a rounded shoulder posture. [8] This of adjacent blood vessels and nerves making the upper
posture can predispose the operator to impingement of extremity susceptible to temporary ischemia.
the supraspinatus tendon in the shoulder (rotator cuff
impingement) when reaching for items. In addition, static Theoretical “ideal position” and its effect on neck
flexion
posture of the arms in an elevated or abducted state of
In a neutral-seated position as shown in Figure 3, the torso is
more than 30° impedes the blood flow to the supraspinatus
leaning back slightly between 100° and 110° (90° is vertical),
muscle and tendon. Prolonged arm abduction also can lead
the buttocks, thighs, and legs are supported and the back
to trapezius myalgia-chronic pain and trigger points in the
of the knee is free. The operative field (the patient’s mouth)
upper trapezius muscle.[21,22]
to be placed at the same height as the practitioner’s elbows
is held close to the body. This shows that the arms are at 0°
Dental surgeons are required to adopt nonneutral postures
from the horizontal axis or 90° to the shoulder.
for many of the clinical tasks they perform. These postures
frequently require prolonged static contraction of the trunk,
The theoretical “ideal position” as shown in Figure 4 is rarely
scapulothoracic, and scapulohumeral musculature, combined
observed in dental clinics because for many dental surgeons
with repetitive contraction of muscles in the wrist, hand, and
the eye-task distance is too great. Dental work requires
fingers during fine motor control work. Dental surgeons,
bending the neck and back in order to be able to see and to
for example, most commonly use a combination of a flexed
perform extremely precise work in the patient’s oral cavity.
and right-side flexion position of the neck with a head-down
position, often combined with shoulder abduction or flexion
Therefore, an inability to see is what makes a dental surgeon
as shown in Figure 2.[23]
bend his/her neck and back to be able to see and perform
Dental surgeons assume these positions for the quality work in his/her patient’s mouth. Extremely, bent-over
following reasons positions are frequently observed as illustrated in Figure 5.
• To coordinate the relative positions between dental Dental surgeons, therefore, have a great deal of difficulty
surgeon and assistant maintaining a straight back and neck position when their
• To obtain optimal view of teeth within the patient’s mouth arms are held at 0° from the horizontal axis.
• To provide a comfortable position for the patient
• To maneuver complex equipment and reach for Two examples of sequences [Figures 5-8] are given comparing
instruments. neck and back positions resulting from the angles of the
forearms in relation to the horizontal axis. By raising the
Figure 2: Typical position used by many dental surgeons with flexed
and twisted neck and torso Figure 3: Neutral seated position

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Shaik, et al.: Dental ergonomics: Enhance work efficiency

Figure 4: Theoretical “ideal position”: Shoulders in line with the ears Figure 5: Neck flexion (70°) and back flexion (20°) when forearms are
and arms at nearly 90°. The patient’s mouth is positioned at elbow at 15° from the horizontal axis. These are common positions when the
level, forearm angle at 0° from the horizontal axis. The eye-task patient is positioned low
distance is too great

Figure 7: Neck flexion (70°) and upper back flexion (45°) when the
Figure 6: Neck position is reduced (30°) when raising the height of patient is positioned low. The forearms are at 10° from horizontal. Leg
the patient’s head. There is less need to bend over to see into the oral movements are limited by the back of the patient’s chair
cavity. Forearms are at 30° from the horizontal axis

support on the dental surgeon’s stool, used as a lumbar


level of the patient’s mouth and holding dental surgeon’s support. Some of the older stools have a lumbar support
arms up, the dental surgeon can straighten both neck and that cannot be adjusted forward, which is usually necessary
back as illustrated in Figures 6 and 8. to be able to lean on it while working in the patient’s mouth.
Lack of support increases static load on the lower and upper
When raising the patient’s head, dental surgeons often have
back muscles required to maintain working positions.[19]
the impression that the patient’s mouth is much too close to
their eyes. However, when measured the distance between
the eye and the mouth in Figures 7 and 8, it is found that the
Conclusion
distance was almost the same. In many cases, the dental
Musculoskeletal disorders result in loss of work efficiency
surgeons had less difficulty getting used to working at this
among dental surgeons, and the prevalence and severity
new height when their arms were supported by free-motion
elbow supports. of these disorders decrease by adopting ergonomic
interventions. Interventions or prevention strategies require
Most of the dental work done by dental surgeons is performed an awareness of “how to fit the job to the worker and not
with the arms unsupported because the majority of stools do the worker to the job.” Applying ergonomics to the practice
not have arm rests. When a person’s torso is bent forward, of dentistry not only could provide safety benefits, but a
his/her back is usually not in contact with the narrow torso practice might also improve performance objectives through

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