ADHA Access July 2012 : Page 4

Sitting May Be Hazardous to Your Health! By Jane L. Forrest, RDH, EdD and Jacquelyn M. Dylla, DPT, PT D { ental hygienists are exposed to several occupational risk factors that can lead to musculoskeletal disorders (MSDs). These are often chronic, painful and/or disfiguring. Although rarely fatal, they affect the quality of life by preventing indi-viduals from enjoying a healthy and active lifestyle. Biomechanical and physiological changes due to prolonged static postures, such as sitting, can lead to MSDs resulting in reduced work time or a career-ending disability. Although literature of 60 years continues to cite this occupational prob-lem, the scientific knowledge in biomechanics, kinesiology and occupational health has not been adequately translated into dental hygiene education or practice. Suggestions to “find a neutral sitting position,” “keep the back straight” or “keeping the head fairly up,” may be ambiguous, and attempts to as-sume such positions may result in further discomfort or injury. Low back pain (LBP) is one of the most prevalent condi-tions reported by dental professionals, and is currently the most prevalent and costly orthopedic problem in society. In fact, it’s predicted that 80 percent of adults will experience LBP in their lives 1 and 34 percent who experience LBP will have recurrent episodes. 2 While the financial cost of treat -ing LBP looms in the billions, the cost of declining attendance on productivity in the workplace should not be overlooked either. For example, Americans spend at least $50 billion each year on LBP. Likewise, LBP is the most common cause of job-related disability and the leading contributor to missed work. 3,4 Considering these astounding statistics, we must ask if this topic garners interest from any prominent organization positioned to assist with investigating this wide-reaching and costly problem. The answer is yes. There is limited knowledge on the full scope of the problem since current national data are not available on the majority of the dental workforce. The National Institute on Occupational Safety and Health (NIOSH) is part of the Centers for Disease Control and Pre-vention (CDC) and is the federal agency established to help assure safe and healthful working conditions. The NIOSH research agenda (NORA) recognizes the extent of MSDs as a societal problem and identifies the need for research on fac -tors such as posture, movement and force within the context of temporal factors (duration and frequency). 5-7 Furthermore, prevention of back and other musculoskeletal injuries in the health care sector is recognized as an important priority area. Specific strategic goals are targeted at reducing back and shoulder disorders due to patient handling and/or working in awkward postures, 6 which are very common in dental hygiene practice. Capturing data unique to any of the dental professions poses a challenge. First, NORA does not specifically reflect data on the majority of the dental workforce, since national statistics on the self-employed, which includes most dentists, are not gathered by the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor. 7 However, injuries or illness reported for private and service-providing industries include worker motion or position, injuries involving the shoulder, and injuries from repetitive motion. 8 These injuries or illnesses parallel findings from the dental literature. Second, the professional organizations are equally remiss in not collecting data. Neither the American Dental Associa -tion (ADA) nor the American Dental Hygienists’ Association (ADHA) collects specific data on MSDs experienced by dentists or dental hygienists. Consequently, there is limited knowledge on the full scope of the problem since current national data are not available on the majority of the dental workforce. What is known has been gathered from multiple small studies conducted among different populations, involving a focus on different body sites and using a variety of survey instruments. Yet, given these limitations, there is consistency in identifying several occupational risk factors that can lead to MSDs in den-tal professionals. These include the prevalence of MSDs and their distribution among the different body areas, and by the type of practitioner who sustains the injury. 9 For example, ap-proximately 60 percent of both dentists and dental hygienists report LBP; 10,11 whereas there is a greater difference reported by these two groups related to hand/wrist pain, with a preva-lence as great as 69 percent for dental hygienists and only 54 percent for dentists. 11-13 To turn the focus on dental hygienists only, in 2009 a sys-tematic review by Hayes et al 9 identified 14 studies ranging from 1993 to 2006 that examined MSDs that reported on the prevalence of musculoskeletal symptoms in dentists, dental hygienists and dental students. Of those 14 studies, only four specifically investigated MSDs in dental hygienists, two stud -ied both dentists and hygienists reporting separate prevalence rates for each profession, and one surveyed MSDs in dental hygiene students only. The results from the six studies involv-ing dental hygienists established ranges of prevalence rates by body region: Site Back: Wrist/Hand: Neck/Shoulder Neck only Shoulder only Percent 21-57 64-69 64 (only one study combined both regions) 28-68 26-81 guest editorial continued on page 28 4 JUL 2012 access

Guest Editorial

Jane L. Forrest

Dental hygienists are exposed to several occupational risk factors that can lead to musculoskeletal disorders (MSDs). These are often chronic, painful and/or disfiguring. Although rarely fatal, they affect the quality of life by preventing individuals from enjoying a healthy and active lifestyle. Biomechanical and physiological changes due to prolonged static postures, such as sitting, can lead to MSDs resulting in reduced work time or a career-ending disability. Although literature of 60 years continues to cite this occupational problem, the scientific knowledge in biomechanics, kinesiology and occupational health has not been adequately translated into dental hygiene education or practice. Suggestions to “find a neutral sitting position,” “keep the back straight” or “keeping the head fairly up,” may be ambiguous, and attempts to assume such positions may result in further discomfort or injury. Low back pain (LBP) is one of the most prevalent conditions reported by dental professionals, and is currently the most prevalent and costly orthopedic problem in society. In fact, it’s predicted that 80 percent of adults will experience LBP in their lives1 and 34 percent who experience LBP will have recurrent episodes.2 While the financial cost of treating LBP looms in the billions, the cost of declining attendance on productivity in the workplace should not be overlooked either. For example, Americans spend at least $50 billion each year on LBP. Likewise, LBP is the most common cause of job-related disability and the leading contributor to missed work.3,4 Considering these astounding statistics, we must ask if this topic garners interest from any prominent organization positioned to assist with investigating this wide-reaching and costly problem. The answer is yes. The National Institute on Occupational Safety and Health (NIOSH) is part of the Centers for Disease Control and Prevention (CDC) and is the federal agency established to help assure safe and healthful working conditions. The NIOSH research agenda (NORA) recognizes the extent of MSDs as a societal problem and identifies the need for research on factors such as posture, movement and force within the context of temporal factors (duration and frequency).5-7 Furthermore, prevention of back and other musculoskeletal injuries in the health care sector is recognized as an important priority area. Specific strategic goals are targeted at reducing back and shoulder disorders due to patient handling and/or working in awkward postures,6 which are very common in dental hygiene practice. Capturing data unique to any of the dental professions poses a challenge. First, NORA does not specifically reflect data on the majority of the dental workforce, since national statistics on the self-employed, which includes most dentists, are not gathered by the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor.7 However, injuries or illness reported for private and service-providing industries include worker motion or position, injuries involving the shoulder, and injuries from repetitive motion.8 These injuries or illnesses parallel findings from the dental literature. Second, the professional organizations are equally remiss in not collecting data. Neither the American Dental Association (ADA) nor the American Dental Hygienists’ Association (ADHA) collects specific data on MSDs experienced by dentists or dental hygienists. Consequently, there is limited knowledge on the full scope of the problem since current national data are not available on the majority of the dental workforce. What is known has been gathered from multiple small studies conducted among different populations, involving a focus on different body sites and using a variety of survey instruments. Yet, given these limitations, there is consistency in identifying several occupational risk factors that can lead to MSDs in dental professionals. These include the prevalence of MSDs and their distribution among the different body areas, and by the type of practitioner who sustains the injury.9 For example, approximately 60 percent of both dentists and dental hygienists report LBP;10,11 whereas there is a greater difference reported by these two groups related to hand/wrist pain, with a prevalence as great as 69 percent for dental hygienists and only 54 percent for dentists.11-13 To turn the focus on dental hygienists only, in 2009 a systematic review by Hayes et al9 identified 14 studies ranging from 1993 to 2006 that examined MSDs that reported on the prevalence of musculoskeletal symptoms in dentists, dental hygienists and dental students. Of those 14 studies, only four specifically investigated MSDs in dental hygienists, two studied both dentists and hygienists reporting separate prevalence rates for each profession, and one surveyed MSDs in dental hygiene students only. The results from the six studies involving dental hygienists established ranges of prevalence rates by body region: They also reported the prevalence rate of general musculoskeletal pain in dentists and hygienists to be between 64 percent and 93 percent, with the occurrence of MSDs more prevalent in hygienists than dentists. While some data for dental hygiene professionals point to risk factors and associations with MSDs, there is clearly a paucity of literature establishing MSDs in dental hygiene students, where career preparation and formation of habits begin. Only two studies were identified that examined MSDs in dental hygiene students.14,15 They found risk factors (working with a bent neck, static posture, precise motions and repetition) to have a stepwise progression from the students with no prior clinical experience, to student/assistant, to the experienced dental hygienist. Results also demonstrated significant associations between shoulder pain and working above shoulder height, and neck symptoms when working with a bent neck. While both studies identified the neck and shoulder regions to be vulnerable to MSDs in students, only one study identified the low back as an area of complaint. Overall, risk factors and symptoms all increased in frequency with professional progression. Solutions to these problems must be linked to our understanding of anatomy, the movement-related sciences, and risk factors that contribute to MSDs. To assist in educating the profession and those who may be experiencing work-related pain, we highly recommend Practice in Motion,16 a multimedia, free four-credit hour online continuing education course in physical preservation and fitness for dental professionals. It can be found on the Procter & Gamble website, www.dentalcare.com/en-US/home.aspx (course #366 under Self Improvement). In addition to content material, it ends with video demonstrations of associated exercises that can help prepare us to become fit to sit. Many of these can be incorporated into daily practice to minimize postural stress, and for those in education, this course can be integrated into the curriculum to prepare students for a long and healthy career. References 1. Melloh M, Elfering A. Egli Presland C. et al. Identification of prognostic factors for chronicity in patients with low back pain: a review of screening instruments. Int Orthopaedics. Apr 2009; 33(2): 301-13. 2. MacDonald D, Moseley GL, Hodges PW. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain. Apr 2009 ;142(3): 183-8. 3. National Institute of Neurological Disorders and Stroke. Low back pain Fact sheet. Available at: www.ninds.nih.gov/disorders/backpain/ detail_backpain.htm. Accessed May 30, 2012. 4. U.S. Department of Labor Bureau of Labor Statistics. Lost work time injuries and illnesses: characteristics and resulting days away from work, 2003.Washington D.C.: United States Department of Labor, 2004. 5. National Occupational Research Agenda for Musculoskeletal Disorders: Research topics for the next decade, a report by the NORA Musculoskeletal Disorders Team. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Jan. 2001, p.7. 6. Centers for Disease Control and Prevention. NIOSH Program Portfolio, Draft HCSA Goals. Available at: www.cdc.gov/niosh/programs/hcsa/ goals.html. Accessed May 29, 2010. 7. Centers for Disease Control and Prevention, NIOSH. NIOSH Publication No. 97-141: Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. CDC: July 1997. Available at: www. Cdc.gov/niosh/docs/97-141/ergotxt1.html. Accessed May 29, 2012. 8. Bureau of Labor Statistics (BLS), U.S. Department of Labor. Nonfatal occupational injuries and illnesses requiring days away from work, 2010. Economic News Release November 9, 2011. Available at: www.bls.gov/news.release/ osh2.nr0.htm. Accessed May 29, 2012. 9. Hayes MJ, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg. 2009; 7: 159–65. 10. Finsen L, Christensen H, Bakke M. Musculoskeletal disorders among dentists and variation in dental work. Appl Ergon. 1998; 29: 119–25. 11. Anton D, Rosecrance J, Merlino L, Cook T. Prevalence of musculoskeletal symptoms and carpal tunnel syndrome among dental hygienists. Am J Industrial Med. Sep 2002; 42(3): 248–57. 12. Akesson I, Johnsson B, Rylander L, et al. Musculoskeletal disorders among female dental personnel – clinical examination and a 5-year follow-up study of symptoms. Int Arch Occup Environ Health. Sep 1999; 72(6): 395–403. 13. Booyens SJ, van Wyk PJ, Postma TC. Musculoskeletal disorders amongst practicing South African oral hygienists. SADJ. Oct. 2009; 64(9): 400-3. 14. Morse T, Bruneau H, Michalak-Turcotte C, et al. Musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students. J Dent Hyg. 2007; 81(1): 10. 15. Hayes MD, Smith DR, Cockrell D. Prevalence and correlates of musculoskeletal disorders among Australian dental hygiene students. Int J Dent Hyg. Aug. 2009; 7(3): 176-81. 16. Dylla J, Forrest JL. Practice in motion, course #366 under Self-Improvement. February 3, 2011. Available at, www.dentalcare.com. (Procter & Gamble website). Accessed May 30, 2012. Jane L. Forrest, RDH, EdD is professor of Clinical Dentistry; section chair, Behavioral Science, Ostrow School of Dentistry, University of Southern California; and director, National Center for Dental Hygiene Research & Practice. Jacquelyn M. Dylla, DPT, PT is director, USC PT Associates – UPC; assistant professor of Clinical Physical Therapy, Division of Biokinesiology & Physical Therapy, Ostrow School of Dentistry, University of Southern California.

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