By Dr. Bethany Valachi, Clinical Instructor of Ergonomics, OHSU School of Dentistry, and author of Practice Dentistry Pain-free: Evidence-based Strategies to Prevent Pain & Extend your Career
As any practitioner in the field can attest, dentistry is a very physically demanding career. Even at a young age, dental practitioners can experience debilitating back pain. Studies show that dentists are nearly three times more prone to low back pain than the general population. Often, dental assistants struggle with lower back pain due to positioning challenges chairside, while hygienists and dentists also prone to neck and shoulder pain.
Fortunately, there are prevention strategies you can use to avoid these problems. Don’t wait for a painful episode to start implementing these. Just like you advocate to your patients for management of oral healthcare, your own management of your musculoskeletal health can prevent an acute problem from occurring.
The Persistence of Pain
Despite the emergence of new equipment – from dental stools to delivery systems for managing work-related pain – these problems persist. The reason is that we need to understand the mechanisms that lead to these problems, and then apply evidence-based interventions, not hand-me-down solutions that have been taught in dental schools for decades.
Research shows that there are five steps to preventing work-related pain in dentistry:
- Dental ergonomics
- Stress management
- Myofascial treatment
- Chairside stretching
- Muscular endurance training
Step 1: Dental Ergonomics
Risk factors in the operatory include prolonged static postures, mental stress, non-neutral postures, visual challenges, repetitive motions, and force. To understand how these risk factors progress and end up in an injury, we need to understand how this progression happens in the operatory. These stressors cause physiological changes to start happening in the body. This can include muscle ischemia, inflammation, muscle imbalances, or disc degeneration.
Your first line of defense is to resolve ergonomics in the operatory. One important step is choosing the right dental stool and making sure it’s adjusted appropriately. Factor that go into choosing the stool include:
- Body type: Find out if you are ectomorph, mesomorph, endomorph, or full bodied. Knowing this will dramatically impact which stool you choose because different seat sizes and backrest shapes are better suited for each of these body types.
- Lumbar curve: Some people have an excessive lumbar curve while others have a flattened one. One issue that has caused a lot of problems in the past is non-tilting operator stools, because sitting on a flat seat, combined with leaning forward, flattens your lumbar spine. This causes the disc to protrude posteriorly, which is a big risk for disc herniation.
- Height: Some stools are not appropriate for different heights of operator.
- Gender: Some stools are better suited for women than men.
Some dentists use a traditional stool with a tilting seat in the operatory. However, recent research shows that even with the seat tilted 15 degrees down, it's still not enough to maintain a low back curve unless you're in continual contact with the back rest.
This is one reason saddle stools are becoming popular. They open up the hip angle much larger, so the position is halfway between standing and sitting. This makes it easier to move around the patient, and to get into a tight 12:00 position. However, these stools are not ideal for those who have an altered lumbar curve or excessive curvature of the low back. Hybrid saddle stools are better options in that case.
Once you select the stool, it’s equally important to know how to adjust it based on your hyperlordosis or hypolordosis. For example, there are certain populations, such as endodontists, people with short forearms, and pregnant women, who will benefit from using armrests. Also, if you have a disc problem, this will impact how your stool is adjusted.
Next, consider how you’re positioned on the stool. Many dentists were taught in school to sit with their thighs parallel to the floor. However, research into seated biomechanics does not indicate that this is effective. If you are perched on the edge of your seat, you have a low back curve, but your muscles are constantly having to contract to hold you in that position. An easier way to maintain that lumbar curve without force is with a seat pan.
Step #2: Stress Management
More than 50 percent of dentists report high job stress. There is a real correlation between stress and pain. Low back pain in particular is correlated with interpersonal conflict. Studies show that stress causes the formation of tight muscles. That’s why when we are stressed, it is more challenging for things like massage therapy to work. It’s very important to down regulate the sympathetic nervous system before moving to the next step of treating trigger points or performing chairside stretches.
As an employer, encourage team members to communicate openly. Asking them what their needs are in terms of stress relief is a good first step.
Step #3: Myofascial Treatment
Myofascial tissue is the connective tissue that provides support for our muscles and bones. With muscle overuse, which happens a lot in dentistry, combined with dehydration, the fascia in the muscle get trapped together. This results in a trigger point. That is, a hyperirritable knot in the skeletal muscle. A trigger point hurts when you press on it, and when you do so, it can refer pain to distant areas of the body.
These areas can feel tight, because of the adhering of the fascia and the muscle together. This can be very painful, and exercising muscles that have these active trigger points can actually make it worse.
Trigger points are characterized by:
- Sore spots in muscles
- Pain that is primarily dull, aching, and nagging
- Weakness or heaviness in the affected area
- Lack of relief from stretching or anti-inflammatory medications
- Some relief from hot showers or baths
Pain medications don’t work on these trigger points. They require physical intervention. For example, piriformis is a trigger point near the buttocks that is caused by prolonged sitting or driving. The treatment protocol is the application of heat or ice, compressing and then vibrating the area for no more than a minute, followed by specific stretches.
#4: Chairside Stretching
Muscles need to have full range of motion before we can begin to strengthen them. Chairside stretching is essential for addressing all of the microtraumas resulting from prolonged static postures. A frequent series of short stretches has been shown to be more beneficial than a less frequent series of longer stretch breaks.
Most dental professionals find that they are tighter on one side than the other. If that is the case, stretch toward the tightest side.
Step #5: Muscular Endurance Training
Muscular endurance training that is designed specifically for dental professionals is critical for preventing neck and back pain. Dental professionals are prone to a unique muscle imbalance that's caused by forward head and rounded shoulder posture unlike any other occupation. For this reason, the middle and lower trapezius muscles need to be properly trained for endurance. This will help you to sit with good posture all day without pain or fatigue. If these muscles aren't properly targeted, other muscles take over and have to compensate and do their job.
A word of caution: Generic exercise programs that include strengthening ischemic muscles can actually cause an imbalance that can throw you into a vicious pain cycle. Instead, focus on strengthening your postural muscles. This includes three scapular muscles and three rotator cuff muscles.
Although dentistry is a physically intense profession, there are proactive steps you can take to keep your musculoskeletal system working smoothly. The right ergonomic, stretching, and strengthening practices, coupled with preventative steps toward minimizing stress, can set you on a journey to being pain free.