Med Oral Patol Oral Cir Bucal. 2011 May 1;16 (3):e425-9.

Ergonomics and musculoskeletal pain in dentists

Journal section: Community and Preventive Dentistry doi:10.4317/medoral.16.e425

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.16.e425

Ergonomics and musculoskeletal pain among postgraduate students

and faculty members of the School of Dentistry of the University
of Barcelona (Spain). A cross-sectional study

Karmen Harutunian 1, Jordi Gargallo-Albiol 2, Rui Figueiredo 3, Cosme Gay-Escoda 4

1
DDS. Fellow of Oral Surgery and Implantology, School of Dentistry, University of Barcelona (Spain)
2
DDS, PhD. Master of Oral Surgery and Orofacial Implantology. Professor of the Master in Oral Surgery and Implantology.
School of Dentistry, University of Barcelona. Investigator of the IDIBELL Institute. Barcelona (Spain)
3
DDS. Master of Oral Surgery and Implantology. Associate professor of Oral Surgery and professor of the Master in Oral Surgery
and Implantology. School of Dentistry of the University of Barcelona. Investigator of the IDIBELL Institute. Barcelona (Spain)
4
DDS, MD, PhD. Chairman and Professor of Oral and Maxillofacial Surgery. Director of the Master in Oral Surgery and Im-
plantology. School of Dentistry of the University of Barcelona. Investigating coordinator of the IDIBELL Institute. Oral and
Maxillofacial Surgeon of the Teknon Medical Center, Barcelona (Spain)

Harutunian K, Gargallo-Albiol J, Figueiredo R, Gay-Escoda C. Ergo-

Correspondence:
nomics and musculoskeletal pain among postgraduate students and fa-
Centro Mdico Teknon
culty members of the School of Dentistry of the University of Barcelona
Instituto de investigacin IDIBELL
(Spain). A cross-sectional study. Med Oral Patol Oral Cir Bucal. 2011
C/ Vilana 12
May 1;16 (3):e425-9.
08022 Barcelona (Spain) http://www.medicinaoral.com/medoralfree01/v16i3/medoralv16i3p425.pdf
cgay@ub.edu
Article Number: 16972 http://www.medicinaoral.com/
Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: medicina@medicinaoral.com
Received: 12/03/2010 Indexed in:
Accepted: 14/03/2010 Science Citation Index Expanded
Journal Citation Reports
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Mdico Espaol

Abstract
Objectives: To evaluate the intensity and location of musculoskeletal pain suffered by students and professors
from different postgraduate programs of the School of Dentistry of the University of Barcelona (Spain), to identify
the variables related to the occurrence of musculoskeletal symptoms and signs, and to establish possible preven-
tive measures for such disorders.
Materials and Methods: A cross-sectional study was made among students and faculty members from different
postgraduate courses of the School of Dentistry at the University of Barcelona between May and June 2007. A
total of 74 dentists (54 postgraduate students and 20 faculty members) completed an anonymous questionnaire
containing 19 questions. The variables were divided into three main groups: sociodemographic information, ergo-
nomic features and musculoskeletal pain arising from professional practice.
Results: Most of the dentists (79.8%) had experienced some kind of musculoskeletal pain in the last 6 months. On
comparing the different locations of pain (lumbar, cervical, dorsal, wrist, shoulder and others), the neck was found
to be the most commonly affected location (58% of all subjects), and only 34% of the respondents took some pre-
ventive measures against musculoskeletal disorders. Women showed a higher frequency of intense pain involving
the cervical, lumbar, dorsal and wrist areas (p<0.05). A higher incidence of wrist pain was recorded in professio-
nals exclusively dedicated to oral surgery (p<0.05). No statistically significant correlation was found between the
workload (hours) and pain in the different anatomical locations (p>0.05).
Conclusions: An important incidence of pain symptoms secondary to musculoskeletal disorders was observed,
particularly in the cervical region. Females and younger dentists showed a higher frequency of such symptoms.
The implementation of preventive measures is necessary, in view of the high incidence of these disorders.

Key words: Musculoskeletal disorders, ergonomics, preventive measures, dentists.

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Introduction - Consequences of pain: sick leaves, need for analge-

Musculoskeletal disorders are characterized by the sics.
presence of discomfort, disability or persistent pain in - Preventive or mitigating measures: physiotherapy,
the joints, muscles, tendons and other soft parts, caused swimming, others.
or aggravated by repeated movements and prolonged - Intensity of work, workload (days and hours of work
awkward or forced body postures. Dentists are usually per week), number of patients seen per week.
included among the professionals with a higher inci- Statistical analysis
dence of musculoskeletal diseases in the course of their A descriptive and bivariate analysis (Pearson chi-
professional life (1,2). squared test, Student t-test and Pearson correlation co-
Important advances in the field of ergonomics in den- efficient) was performed with the SPSS version 11.5 sta-
tistry have been made in recent years. These advances tistical package (SPSS, SPSS Inc., Chicago, IL, USA).
have focused on furnishing and the working environ- Statistical significance was accepted for p<0.05.
ment, though preventive measures related to the den-
tal professional have not been adopted. The main risk Results
factors involved must be identified in order to design The questionnaire was completed by 74 professionals
adequate prevention strategies (3,4). (54 students and 20 teaching faculty members) out of an
The objectives of this study were to assess the inten- initial sample of 100 subjects. Regarding the sociodemo-
sity and location of musculoskeletal pain suffered by graphic variables, 53% of the dentists who participated
students and faculty members from different graduate in the study were women, and the average age was 28.9
programs (Oral Surgery, Pedodontics, Periodontics, years (range 23-52 years). The professionals worked an
Prosthodontics, Endodontics and Integrated Adult Den- average of 4.6 days and 31.6 hours a week, and attended
tistry) of the School of Dentistry of the University of an average of 45.8 patients during that time.
Barcelona (Spain); to identify variables associated with In relation to the ergonomic features, practitioners sat
the onset of symptoms and signs of musculoskeletal dis- 77.5% of their working hours, and 89.2% were right
orders; and to establish possible preventive measures. handed. All of the respondents claimed to have a chair
with a back, though 28% did not use it. In turn, 52.7%
Materials and Methods of the dentists were not involved in any activity between
A cross-sectional study was conducted between May successive visiting patients.
and June 2007 among 54 students and 20 teaching facul- With regards to the musculoskeletal disorders, 79.8% of
ty members from various postgraduate programs (Oral the participants reported musculoskeletal pain during
Surgery and Implantology, Pedodontics, Periodontics, the past 6 months. The neck region was the most fre-
Prosthodontics, Endodontics and Integrated Adult Den- quently affected area (58% of the participants), followed
tistry) of the School of Dentistry of the University of by pain in the lumbar area (52.7%), back pain (40.5%),
Barcelona (Spain). Participant perceptions of symptoms wrist pain (27.1%) and pain in the shoulders (24.3%)
were established with an anonymous questionnaire (Table 1). In turn, 17.6% of the participants suffered
containing 19 questions that had been used in an earlier pain in a single location, 20.3% in two locations, and
study (2). The study variables were divided into three 42% in three or more locations (mean = 2.16; SD = 1.7).
groups according to the classification described by Bu- Although the incidence of musculoskeletal pain was im-
garin (2): portant, only 15% of the dentists included in the study
1. Sociodemographic information: applied for sick leave, and 12% had to use nonsteroidal
- Age and gender, duration and type of professional antiinflammatory drugs (NSAIDs). In turn, 33.8% of
practice, and leisure activities. the respondents claimed to perform some preventive ac-
2. Ergonomic features: tivity (sports 52%, correct postures 16%, physiotherapy
- Dominant limbs, weight and height. 16%, stretching 8%, yoga 4% and sports and massage
- Working hours in the sitting position. Characteristics 4%). (Table 2) shows the relationship between the inci-
of the working chair. dence of pain and other variables. Pain in the cervical
- Characteristics of the instrument holder. and lumbar regions was associated with the presence
- Others: activity between successive visiting patients, of pain in other locations, with statistically significant
work with or without an assistant. values (p<0.05). Wrist pain was more frequent in pro-
3. Musculoskeletal disorders resulting from profession- fessionals who also had shoulder pain (Pearson cor-
al practice: relation; p<0.05). The participants who did stretching
- Locations of pain. Additionally, within each region, a or other preventive actions between patients suffered
visual analog scale (VAS) was included for the quantifi- lesser low back pain, though no significant differences
cation of pain. A set of closed or semi-closed questions were found (Student t-test; p = 0.398). Oral surgeons re-
was added for assessing the following points: ported a higher incidence of pain in the wrist than the

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Table 1. Intensity and frequency of pain according to anatomical location.

Mean* Professionals with Mean* Mild Moderate Severe

Location Gender
(0-100) pain (0-100) n (%) n (%) n (%)

Female 29.3
43 25 16 2
Cervical 20.9
(58.1%) (33.8 %) (21.6 %) (2.7 %)
Male 13.4

Female 20.1
30 17 10 3
Dorsal 14.9
(40.5 %) (22.9 %) (13.5 %) (4.1%)
Male 10.1

Female 25.2
39 22 13 4
Lumbar 19.8
(52.7 %) (29.7 %) (17.6 %) (5.4 %)
Male 14.9

Female 13.2
20 15 3 2
Wrist 8.8
(27.1 %) (20.3 %) (4.1 %) (2.7 %)
Male 4.8

Female 9.7
18 11 3 4
Shoulder 9.6
(24.3%) (14.8 %) (4.1 %) (5.4 %)
Male 9.6

* Intensity scored by VAS: mild <40 mm; moderate 40-70 mm; severe >70 mm. Significant differences were found between males
and females regarding pain in all locations except the shoulders (Student t-test; p<0.05).

Table 2. Pain and its association to different variables (Pearsons correlation).

Work No. patients Male Female Specialty oral Correct body

Pain Age Sports Stretching
hours attended gender gender surgery posture

Cervical NS NS -- NS ++ NS NS NS NS

Dorsal NS NS NS NS ++ NS NS NS NS

Lumbar NS NS NS NS ++ NS NS NS -

Wrist NS NS NS NS ++ ++ NS NS -

Shoulder NS NS NS NS NS NS NS NS NS
++ significant direct relationship (p<0.05); -- significant inverse relationship (p<0.05); + direct relationship (p>0.05); - inverse relationship
(p>0.05); NS nonsignificant relationship.

rest of the professionals (Student t-test; p = 0.043). No Discussion

significant correlations were found between workload Almost all published studies on musculoskeletal prob-
(weekly days and hours of work and number of attended lems in dentistry have an observational design. Despite
patients) and pain in the different anatomical locations their limitations (difficulty in identifying risk factors
(Pearson correlation; p>0.05). and questionable utility for diseases of low incidence
and short duration), studies using questionnaires, as in

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our case, are useful for identifying the prevalence of a exception of those who performed stretching. These
disorder, determining the clinical features of patients, seemingly disappointing results must be analyzed with
and for designing possible preventive strategies. caution, since professionals showing a higher incidence
Dentists are normally included within the group of of pain are those who most frequently try to implement
professionals at risk of suffering musculoskeletal dis- preventive measures (9-12).
orders, due to prolonged awkward or forced postures According to some studies, improvement in the ergo-
at work and failure to adopt preventive measures (3). nomics of the dental equipment has not served to re-
Our study found that most professionals referred some duce the incidence of musculoskeletal disorders (9).
kind of musculoskeletal pain in the last 6 months, in The etiology of musculoskeletal disease is multifacto-
coincidence with the information found in the literature rial, with the involvement of biomechanical, individual
(3). In agreement with different studies, the region most and psychosocial factors related to work. Consequently,
commonly affected by pain was the neck, followed the the preventive strategy must be multifactorial and not
lumbar zone (3-5). It is important to underscore that the only focused on ergonomics (10-12). Any useful study
great majority of the respondents had mild symptoms, on musculoskeletal disorders among dentists should in-
and that only a small percentage suffered moderate or clude an analysis of preventive strategies. These strat-
severe pain. egies in turn should focus on the following areas: er-
Lalumandier et al. (4) reported that all dental specialties gonomics, breaks at work, general health and physical
show a high occurrence of musculoskeletal disorders, exercise (10-12).
but with variations in frequency and order in different The ergonomic factors to be taken into account could
locations. Ratzon et al. (5) found musculoskeletal dis- be summarized as supports of the upper limbs, the use
comfort to be more frequent in the oral surgeon than of instruments with large handles, and working with a
in other dental specialists, and attributed this to an mechanically adjustable chair presenting an adjustable
increased workload (4-6). In our study, oral surgeons backrest. The use of indirect vision and correct patient
suffered more pain in the wrist (p = 0.043), though no positioning in the dental chair to avoid awkward or
statistically significant association was found between forced neck postures are also important. Proper lighting
the pain and workload (Pearson correlations; p>0.05). and the use of systems such as magnifiers and micro-
The wrist pain in oral surgeons could be explained by scopes also help reduce fatigue and increase productiv-
specific activities of this specialty, such as suturing. ity (11-13).
Coinciding with our study, most authors find that fe- Repetitive movements and prolonged body postures can
males are more susceptible to this type of pain, though be expected to cause muscle damage, as well as ligament
the reason is unclear. In any case, this association is and joint injuries (9-12). Daily work planning should al-
not specific to dentistry. Some authors relate this dif- low a break for the alternating muscle groups in order
ference to a lesser muscle tone and a higher incidence to maintain productive work. In our study, 52.7% of the
of osteoporosis among women (6). The role of age is professionals did not take breaks between attended pa-
even more controversial. While there are studies that tients. The Applied Occupational and Environmental
claim that the frequency of pain remains stable with age Hygiene guidelines recommend at least 6 minutes of
(7), others believe that musculoskeletal discomfort is rest every hour for professionals who perform repetitive
maximum around the sixth decade of life (5). A third movements (5,11,12). The three types of breaks which
group of authors believe that discomfort is greater in are recommended for dentists would be the following:
young professionals. In our study, we found young pro- - Frequent stops and shaking exercises (relaxing of the
fessionals to have a higher incidence of neck pain. This arms, shaking and dropping them for periods of 15 sec-
could be due to incorrect working positions, since older onds).
dentists use more indirect vision and usually avoid neck - Breaks between successive patients (dentists should
overload (8). perform movements opposite to those done during
In this work we found that the professionals, although work, for 2-3 minutes).
experiencing musculoskeletal discomfort, did not take - Breaks to allow recovery (periods of 10-15 minutes
measures to prevent or lessen the symptoms. Specifi- every 2-3 hours).
cally, 33.8% of our respondents claimed to take some General health is another aspect to be taken into account
preventive actions. However, these actions were not the for the correct prevention of musculoskeletal disorders
most appropriate solution, since the main preventive (13). It is essential to dedicate the necessary time to lei-
measures should be changing posture, taking breaks, sure activities, and to implement other measures for the
and stretching between successive patients and these control of mental stress.
measures were little used by our subjects. However, Lastly, the preventive role of physical exercise is also a
no decrease in pain intensity was recorded among the key element to be taken into account. Dental profession-
dentists who practiced preventive measures, with the als should learn to avoid the various risk factors - the

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ultimate objective being the definition of personalized

rehabilitation exercises, stretching and regular aerobic
activity. Aerobic exercise has been shown to prevent
or improve general pain, facilitate weight loss, and
strengthen the torso. The stretching of the muscle and
tendon structures in turn appears to be helpful in reliev-
ing back pain (10-12).
It thus may be concluded that musculoskeletal pain is
common among dentists, with a higher incidence in
young women. The neck region is the most affected
area. Among the different professionals surveyed, the
oral surgeons showed a higher incidence of pain in the
wrist.
Regarding prevention, 66.2% of the respondents took no
measures to avoid such problems, while 33.8% claimed
to practice preventive activities, though these were gen-
erally performed incorrectly.

References with links to Crossref - DOI

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