Musculoskeletal Disorders in Dentists: A Systematic Review

Abstract

p> Background : Musculoskeletal disorders (MSDs) are the most important occupational health problems particularly in dentists. Technological advancements in the field of dental equipment and material- shave not fully eliminated the musculoskeletal problems of dentists.

Methods : This systematic review began with a search of a range of a relevant articles from May to July 2017 in Google Scholar with the key words musculoskeletal disorders, dental practitioners, dentist, risk factors. According to the inclusion and exclusion criteria of the manuscript a total 13 origi- nal articles were included for this review work.

Results : This review work observed the highest overall prevalence of MSDs among dental practition- ers were 92% with the most prevalent regions for pain in dentists have been shown to be the neck (41-75.7%), lower back (35–73.5 %) and shoulder (29–43.3%). Different risk factors have been identi- fied, including inadequate postures, long working hours without pause, direct inspection, physical load, repetitive movements etc.

Conclusion : Overall, the review emphasizes that MSDs represent a significant burden for the dental professionals. Further studies are required including large sample size to be able to reach valid conclusion and be able to generalize results.

Update Dent. Coll. j: 2017; 7 (2): 38-42</p

Full text

38
Musculoskeletal Disorders in Dentists: A Systematic Review
Sultana N 1, Mian M A H 2, Rubby M G 3, Banik P C 4
Received: : 14.08.2017 Accepted: 03.10.2017
Abstract:
Background: Musculoskeletal disorders (MSDs) are the most important occupational health problems
particularly in dentists. Technological advancements in the field of dental equipment and material-
shave not fully eliminated the musculoskeletal problems of dentists.
Methods: This systematic review began with a search of a range of a relevant articles from May to
July 2017 in Google Scholar with the key words musculoskeletal disorders, dental practitioners,
dentist, risk factors. According to the inclusion and exclusion criteria of the manuscript a total 13 origi-
nal articles were included for this review work.
Results : This review work observed the highest overall prevalence of MSDs among dental practition-
ers were 92% with the most prevalent regions for pain in dentists have been shown to be the neck
(41-75.7%), lower back (35–73.5 %) and shoulder (29–43.3%). Different risk factors have been identi-
fied, including inadequate postures, long working hours without pause, direct inspection, physical
load, repetitive movements etc.
Conclusion: Overall, the review emphasizes that MSDs represent a significant burden for the dental
professionals. Further studies are required including large sample size to be able to reach valid
conclusion and be able to generalize results.
Key words: Musculoskeletal disorders; Dentist; Dental practitioners; Occupational health
1. Dr. Nihar Sultana, Assistant Professor, Department of Oral Anatomy and Physiology, Mandy Dental
College, Dhaka; PhD Research Fellow ( Bangladesh University of Professionals).
2. Prof. Dr. Md. AnowerHussainMian, Professor and Head, Department of Community Dentistry, Faculty of
Public Health, Bangladesh University of Health Sciences (BUHS).
3. Dr. Md.GolamRubby, Associate Professor and Head, Department of Orthodontics, Mandy Dental College,
Dhaka.
4. Palash Chandra Banik, Senior Lecturer, Department of Noncommunicable Diseases, Bangladesh Universi-
ty of Health Sciences (BUHS).
Correspondence :
Dr. Nihar Sultana, Assistant Professor, Department of Oral Anatomy and Physiology, Mandy Dental College &
Hospital, PhD Research Fellow (BUP), Phone: 01712-843965, E-mail: nihard40@gmail.com
Review Article UpDCJ | Vol. 7 No. 2 | October 2017

Update Dental College Journal
Vol. 7 No. 2 | October 2017
39
Introduction:
Dentistry is a demanding profession involving high
degree of concentration and precision. Dentists
require good visual acuity, hearing, depth perception,
psychomotor skills, manual dexterity, and ability to
maintain occupational postures over long periods .
Diminution of any of these abilities affects the practi-
tioner’s performance and productivity. Despite
numerous advances in dentistry many occupational
health problems still persist in modern dentistry.[1]
Musculoskeletal symptoms are a major concern
among dental practitioners. Musculoskeletal disorder
is characterized by presence of discomfort, disability
or persistent pain in the joints, muscles, tendons, and
other soft parts, caused or aggravated by repeated
movements and prolonged awkward or forced body
postures.[2] Dentists are susceptible to develop this
disorder . The physical load among dentists seems to
put them at risk for the occurrence of musculoskeletal
disorders. These disorders are not the result of a
[3]
of MSDs and the risk factors for this disorders among
dental practitioners. The search strategy uncovered a
total 37 titles. After examining the titles, keywords and
abstracts (excluding any duplicates) the complete
manuscript of 21 potentially relevant articles were
gathered. The papers were chiefly excluded on the
basis that the study did not measure the prevalence
of MSDs or possible risk factors. Finally 13 articles
were included for this review.
Results:
Table 1 : Prevalence of musculoskeletal disorders
among dental practitioners by country, year of publi-
cation
single event, but develop over time. Despite numer-
ous advances in dentistry many occupational health
problems still persist in modern dentistry.[1] Different
studies have indicated awide variety of causative
factors associated with musculoskeletalpain in dental
professionals. The physical burden ofclinical work
has been established as having a strong association-
with MSDs in dental health workers [4,5]; however,
evidence ismounting which suggests that psychoso-
cial factors may also beassociated with the preva-
lence of MSDs.[4,6] The aim of this review work is to
analyze critically the literatures and reports on the
prevalence of musculoskeletal pain and possible risk
factors of this problem in dental practitioners who are
registered dental surgeons working in respective
area.
Methodology:
This systematic review began with a search of a
range of a relevant articles from May to July 2017 in
Google Scholar. The keywords were used in the
search strategy are –
1. Musculoskeletal disorders
2. Dental practitioners
3. Dentist
4. Risk factors
The papers identified by the search strategy were
considered for possible relevance to this literature
review work. The criteria for inclusion of manuscript
was the original articles published in English peer
reviewed journals, where researched the prevalence
Cro
ss -
questionnaire
Sl
No
Study title
Study
design
Sample s ize
Tools used
Country
MSDs prevalence (%)
Author
& year
Reference
1
Work-related
musculoskeletal
disorders among
dentists-A
questionnaire
survey
Cross-sectional s tudy
220 dentists
Semi s tructured
Questionnaire
consisting three
sections
Poland
More than 92% of the surveyed
dentistsexperienced MSDs,
especially in the neck (47%) and
lower back (35%). More than
29%
of the dentists experienced
trouble with fingers, 23% with
hip, whereas 20% demonstrated
problems in the midback, and
also in the shoulders (20%).
Anna K
et
al.2011
7
2
Prevalence of
work-related
musculoskeletal
complaints among
dentists in India: A
national cross-
sectional survey
Cross-
sectional
survey
646 dentists
Self-administered
questionnaire
which based on
Nordic
questionnaire
India
The prevalence wasneck
(75.74%), followed by wrist/hand
(73.13%), lower back (72.01%),
shoulder (69.4%), hip (29.85%),
upper back (18.65%), ankle
(12.31%), and elbow (7.46%).
Vijaya
K K et
al.2013
8
3
Frequency of
Musculo-Skeletal
Pain in Dentists
Working in Public
and Private Sector
Dental Hospitals
of Peshawar,
Pakistan
Cross-sectional
s tudy
104 dentists
Semi s tructured
questionnaire
Pakistan
56% of the dentists experienced
backache, followed by 41% pain
in neck and 32% had pain in
hand
Arfidi S
et
al.2012
9
4
Musculoskeletal
Disorders among
Dental
Practitioners: Does
It Affect Practice?
Cross-sectional
s tudy
80 dentists
Standardized
Nordic
Questionnaire
India
The overall prevalence was
78%, the most common areas
affected with MSD in order of
magnitude were the neck (52%),
low back (41%), shoulders
(29%), and wrists (26%)
Dhanya
M et
al.2013
1
0
5
Muskuloskeletal
disorders among
dental surgeons at
selected private
dental hospitals in
dhaka city
Des criptive
cross -
sectional
96 dental
surgeons
Semi s tructured
Questionnaire
Bangladesh
The current s tudy revealed
that among the respondents 90 %
are
suffering from pain during work
in last 3
months.
Jahan
KMR et
al.2015
1
1
6
Musculoskeletal
pain and
ergonomic aspects
of dentistry
sect
90
self-applicable
questionnaire
Bra
This s tudy found there has been
job-related pain in at least
65.67% of dentists
Garbin
AJI et
al.2015
1
2
7
Prevalence of
musculoskeletal
disorders among
dentists in the
Ha’il Region of
Saudi Arabia
A cross-s ectional,
s tudy
80 licensed
dentists
A self-
administered
questionnaire,
based on the
Nordic
Musculoskeletal
Questionnaire
(NMQ)
Saudi Arabia
The prevalence of MSDs among
respondents was 77.9% (n=53)
with the most commonly
affected areas the lower back
(73.5%) (39/53) followed by the
neck (66%) (35/53) and the
shoulders (43.3%) (23/53).
Aljanak
h M et
al.2015
1
3

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Vol. 7 No. 2 | October 2017
49
Table 2 : Risk factors of musculoskeletal disorders
among dental practitioners
Study
title
Study
design
Sa mple
size
Co untry
Key
findings
Autho r
&
yea r
Ref erenc
1
Musculoskeletal
pain and
ergonomic aspects
of dentistry
Cross-
sectional
study
90
dentists
Brazil
Risk factor: This study showed high
prevalence of musculoskeletal pain
related to inadequate postures adopted
during clin ical assistance and to long
working hours withoutpause.
Garbin
AJI et
al.2015
12
2
Musculoskeletal
Disorders in
Dentists
Cross-
sectio
nal
sur vey
92
dentist
s
Iran
Risk factor: Direct inspection was a risk
factor for neck pain (OR: 35 .34 ,
p <0 .001 )
Maryam
R et
al.2012
14
3
Prevalence of
musculosk eletal
disorders in
dentists
Cross-sectional
study
430
dentist
Gr eece
Risk factor :Self-reported factors of
physicalload were associated with the
occurrence of back pain (OR = 1 .59 ),
shoulder pain (OR = 2 .57 ) and,
hand/wristpain (OR = 3 .46 ). Physical
load showed a trend w ith the number of
musculoskeletal complaints with ORs of
2 .50 , 3 .07 and 4 .40 for two, three and
four musculoskeletal complaints,
respectively.
Evangelo
s C A et
al 2014
15
4
Prevalence of
Upper Extremity
Musculoskeletal
Disorders in
Dentists:
Symptoms and
Risk Factors
Cros s-sectional
study
130
dentists
India
Risk factor : Significant relationships
were observed between musculoskeletal
pain and daily work hours (P = 0 .07 ) and
number of patients (P = 0 .02 ), butthe
pain was notsignificantly associated
with BMI and experience.
Forouzan
Ret
al.2011
16
5
Frequency of
Musculo- Skeletal
Pain in Dentists
Working in Public
and Private Sector
Dental Hospitals of
Peshawar,
Pakistan
Cross-sectional
study
104
den tists
Pak istan
Risk factor : Backache was found to be
significantly associated with working
position, years in practice; number of
patients treated per day and breaks taken
between patients, neck pain was related
to years in practice.
Arfidi S
et al.2012
9
6
A risk assessment
study on work-
related
musculoskeletal
disorders among
dentists in Bhopal,
India
Cross- sectional
study
93
den tists
India
Risk factor : This study found that
younger participants, male (OR = 4 .1 ),
involved physicalactivity (OR = 1 .04 ),
dentists not taughtaboutergonomics in
their dental school (OR = 1 .69 ) or never
attended any workshops (OR = 1 .38 ),
who reported task involving sustained
muscle contraction (OR = 1 .12 ) or task
with repetitive movements (OR = 1 .11 )
are the major risk factors for the
developmentof MSDs among the
dentists.
Batham
C et
al.2016
17
Discussion:
Musculoskeletal disorders account for the most
common reason (29.3%) for early retirement in
dentists worldwide. The key to preventing musculo-
skeletal disorders is to understand potential risk
factors. The findings from this literature review were
sourced from 13 original articles which has been
conducted in different countries among dental practi-
tioners. In several studies musculoskeletal symp-
toms were assessed by Standardized Nordic Ques-
tionnaire (REF) which is a valid and accepted screen-
ing tool for assessing MSDs, other method included
pilot tested surveys, self administered questionnaire.
The highest overall prevalence of MSDs among
dental practitioners were observed 92% in this
review. [7] The overall prevalence of musculoskeletal
disorders in dentistry differs from 63 to 93 % world-
wide.[18] MSDS in different body area it was found in
the study conducted by Anna K et al.2011 [7] especial-
ly in the neck (47%) and lower back (35%). More than
29% of the dentists experienced trouble with fingers,
23% with hip, whereas 20% demonstrated problems
in the midback, and also in the shoulders (20%). The
body area wise prevalence in an Indian study
conducted by Vijaya K K et al.2013[8] was neck
(75.74%), followed by wrist/hand (73.13%), lower
back (72.01%), shoulder (69.4%), hip (29.85%),
upper back (18.65%), ankle (12.31%), and elbow
(7.46%). Another study of Pakistan[9] showed that
56% of the dentists experienced backache, followed
by 41% pain in neck and 32% had pain in hand,
where in an Indian study according to Dhanya M et
al.2013[10] the overall prevalence of MSDs was 78%,
the most common areas affected with MSDs in order
of magnitude were the neck (52%), low back (41%),
shoulders (29%), and wrists (26%). In our country
there are severe scarcity of data regarding this issue.
One Bangladeshi study conducted by Jahan KMR et
al.2015[11] showed that 90% surveyed dentists were
suffering from musculoskeletal pain during work in
last 3months. In Brazil a study conducted by Garbin
AJI et al.2015 [12] showed that 65.67% dentist had job
related pain, where as in Saudi Arabia the preva-
lence of MSDs among respondents was 77.9%
(n=53) with the most commonly affected areas the
lower back (73.5%) (39/53) followed by the neck
(66%) (35/53) and the shoulders (43.3%) (23/53).[13]
According to these studies the most prevalent
regions that dentists experienced musculoskeletal
symptoms were back, neck and shoulder region,
[7,8,9,10,13] however the reported prevalence for these
regions varied to some extent between studies. About
identification of risk factors of MSDs the review result
uncovered different risk factors according to different
studies in different countries in which inadequate
posture during dental work is an important risk factor.
In the study Garbin AJI et al.2015[12] showed high
prevalence of musculoskeletal pain related to inade-
quate postures adopted during clinical assistance
and to long working hours without pause. With this, it
was also observed that many professionals would
rotate their heads during consultations (73.13%),
their spine (47.76%) and that the position of their legs
was less than 90º with regard to the floor during work
(91.04%). That study also mentioned when relating
pain to gender, no statistically significant association
has been found, but the prevalence of pain was
higher among female dentists (67.86%).Direct
inspection was a risk factor for neck pain (OR: 35.34,
p<0.001) [14],where as in the study Evangelos C A et al
2014[15] showed that physical load were associated
with the occurrence of back pain (OR = 1.59), shoul-
der pain (OR = 2.57) and, hand/wrist pain (OR =

Update Dental College Journal
Vol. 7 No. 2 | October 2017
41
3.46). Physical load showed a trend with the number
of musculoskeletal complaints with ORs of 2.50, 3.07
and 4.40 for two, three and four musculoskeletal
complaints, respectively. In India the study conduct-
ed by Forouzan R al.2011[16] found significant
relationships between musculoskeletal pain and daily
work hours (P = 0.07) and number of patients (P =
0.02), but the pain was not significantly associated
with BMI and experience. Another study conducted
by Batham C et al.2016 [17] found that younger partici-
pants, male (OR = 4.1), involved physical activity (OR
= 1.04), dentists not taught about ergonomics in their
dental school (OR = 1.69) or never attended any
workshops (OR = 1.38), who reported task involving
sustained muscle contraction (OR = 1.12) or task with
repetitive movements (OR = 1.11) are the major risk
factors for the development of MSDs among the
dentists. An interesting fact of this study is that this
study showed those dentists who were unaware of
ergonomics either through taught in school (OR =
1.69) or through any workshops (OR = 1.38) are at
more risk of developing MSDs in their professional
life. Backache was found to be significantly associat-
ed with working position, years in practice; number of
patients treated per day and breaks taken between
patients, neck pain was related to years in practice
according to the study conducted by Arfidi S et
al.2012 [9] which also supports the study[17] findings.
This review work did not include the papers that were
unpublished, only published original articles were
included according to the inclusion criteria of the
study, which may be considered as a limitation of this
review work. Moreover in study selection there may
some selection bias to include different countries
study in the review work.
Conclusion : From this review work it can be conclud-
ed that MSDs represent a significant burden for the
dental professionals. A number of possible risk
factors for the development of musculoskeletal disor-
ders uncovered with this review work. Further studies
are required including large sample size to be able to
reach valid conclusion and be able to generalize
results.
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