Pain Relief in the Practice of Dentistry

By Shirley B. Gutkowski, RDH, BSDH

Keywords: Loupes, ergonomics, dentist pain, musculoskeletal pain, dental practitioner pain, magnification loupes, auxiliary lighting, ergonomic seating.

Reports of pain relief from magnification in the dental literature is scarce although musculoskeletal pain in oral healthcare providers is a real phenomenon.¹ Often attributed to repetitive movements, musculoskeletal pain can also be the result of musculoskeletal and psychosocial aspects of the job as well.^1-4 Estimates for lost productivity as a result of pain is over $60 billion per year in the United States.⁵

From medicinal herbs and pharmaceuticals to physical manipulations or surgery, pain relief is very much sought after. The consequences of unrelenting pain are numerous. They include depression, anxiety, sleep disturbances, decision-making difficulties, and significantly diminished quality of life.^6-9 Clinician pain prevention is important for the worker, the patients treated, and the rest of the dental team, because magnification for dentistry is intuitively and practically focused on visualization for tasks with little mention of pain benefits.⁹ This study shows pain relief in dentists wearing loupes, proper seating, and auxiliary lighting, which may be work related.

E-mail invitations were sent out to a database of 10,341 oral healthcare providers, inviting them to fill out an online questionnaire. One Apollo headlightwas given away for each 100 responses; five headlights were given away. Thenon-respondents were not pursued because of the give-away.This article will focus on the answer given by the 344 dentists of the total 466 clinicians who responded by filling out surveys. The costs incurred for this study and the costs for the Apollo headlights were incurred by Kerr Orascoptic, a subsidiary of Danaher.

Dentists and dental hygienists responded to the survey invitation. Ninety-seven percent of the 344 dental respondentswere dentists, 2%were instructors, and less than 1% were dentalstudents. The majority of dentists, 61.6%,practiced general dentistry (Table 1). Orthodontic dentistrywas a distant second place at 10.2%. Sixty-one percent practiced between 31 to 40 hours per week, and the majorityof dentists reported seeing 13 or more patientsper day. Thirty-six percent of dentists saw between 7 and 10 patients a day.

The unrestricted e-mail address lists found 90% of the total respondents currently wearing loupes. Of the total respondents wearing magnification, 54% wore loupes with 2.5x magnification, which broke down to 61% of the dental hygienists and 52% of the dentists. A majority, 76%, wore through the lens (TTL) configuration.

Ergonomic seating or auxiliary lighting was not as popular as the loupes. Just over one third of dentists, 38%, used ergonomic seating and 45% used auxiliary lighting.

In the survey there was no distinction made for the difference betweenpain and ergonomics.For the purposes of distinguishing between themfor this discussion, ergonomic purchases were considered pain prevention.

Pain in dentistry is often found in three key areas on the body: neck, shoulder, and lower back. Hand/wrist pain presents in fewer instances. Table 2 addresses the location of pain in clinicians. Neck and shoulder pain is more common in dental hygienists than dentists; however, approximately half of the dentist respondents said they had pain there.

Only 7% of the total number of dentists responding to the survey purchased loupes with the stated purpose of relievingpain. While a majority of the dentists said theypurchased loupes for better vision, nearly one third were looking for better ergonomics. A small number of dentists, 4%, said that loupeswere an educational requirement, ascompared to 18% of the dental hygienists who responded. Table 3 shows the breakdown ofreasons clinicians gave for wearing loupes.

Nearly half of the dentists responding wear some kind of auxiliary lighting. The reasons for not wearing auxiliarylighting were equally split between thinking thelighting was unnecessary for providing qualitycare, the cost of the lights, and being unsureof the benefits of the extra light.

Nearly all purchased lighting because they were looking for better vision. Although many respondents skipped this question (61.5%), this study found that the extra lighting did help those with pain. Of the dentists who answered the question, 24.7% found pain relief by using auxiliary light (Table 4).

The definition of the term ergonomic chair was left up to the one taking the survey. Ergonomic seating can be described as having a contoured seat pan, a chair with a back, one with arms, or one with floating arms. The question asked in the survey, “Do you use ergonomic seating?” did not lead in any particular direction. All chairs deemed to be ergonomic by the respondent hadan adjustable seat and most had an adjustable back.

Many clinicians mentioned that they attribute their back, leg, and neck pain to their chair. Seventy-seven percent said they thought their back pain was attributed to their chair. More than two thirds of the 344 respondents said they did not own an ergonomic chair. When the remaining one third was asked why they used an ergonomic chair, 84% said that they wanted better ergonomics and 29% said they wanted to relieve pain. Those with lower back and shoulder pain found relief by using the chair (Table 4).

Dentists’ work can contribute to musculoskeletal pain and microtraumas as a result of repetitive and improper movement.^3,4,10 Equipment necessary to safely care for patients, or make work life easier or better, can impact more than just the clinicians’ level of comfort.^6,9Pain can limit the scope of physical and mental movements and distract the clinician from early detection of problems and potentially compromise the outcome of treatment.

This study shows that pain can be alleviated by wearing properly fitted loupes, which can help result in diminished musculoskeletal pain. Auxiliary lighting and ergonomic seating can and do provide a level of pain relief to those using them as well.

Pain issues were not a motivating factor for purchasing loupes, as compared to purchasing a chair. The major goal for purchasing loupes was better vision followed by better ergonomics. The results of this study showed that only 7% of the dentists purchased loupes to relieve pain, and 28% of those who purchased chairs did so for pain reasons. It is not possible to discern whether those who chose better vision also chose ergonomic benefits for their impetus to purchase.

New and challenging ways of practicing dentistry with an emphasis on a purposeful verbalized diagnosis is difficult enough. If the brain is occupied or distracted by pain, some conditions may be missed or the diagnosis delayed until the problem becomes more obvious. With the push toward early diagnosis and treatment, the clinician in pain may not be able to persevere.

Some practitioners did choose to purchase loupes to accommodate smaller preparations, supporting the trend of earlier intervention. Early detection is not limited to enamel infections; it may also refer to detecting dysplastic growths on the soft tissue, occlusal discrepancies, or many other maladies in the scope of dental practice.

The users of loupes had very strong emotions about them and it was found that there were many reasons for investing in loupes beyond the options given in the survey. The primary reason in the “other” category was from dentists who practice orthodontics. They responded that they expected and got better accuracy when placing brackets and wires.

Working faster was another benefit mentioned by the respondents. One dentist responded that he had been using loupes for more than 10 years and would not practice without them. This may sound like hyperbole to some; however, sales team members often hear this exaltation from their clients.

This study showed that more dental hygiene students are required to wear loupes than dental students. The best time for implementing loupes into dental practice is during the educational experience.^11-13 Learned skills could be most effectively taught in the most ergonomic conditions.

Table 4 reveals the most important information in this study. Of the dentists reporting neck pain, 87% said that the pain was diminished or relieved by wearing loupes. Although some respondents choose not to wear loupes because of the loupes’ weight, a large majority of dentists responded that their neck pain was relieved by their use. Even 24% of the dentists revealed that neck pain was reduced by using a headlight. It may be a safe assumption that those wearing lights also wore loupes because of the attachment mechanism of the light. If that is true, then the amount of pain reduction in those wearing both is substantial, making an investment in loupes and a light together particularly wise.

Eye fatigue was relieved by loupes in 25% and by the light in 22% of the respondents. It was not possible to determine whether respondents were using one, two, or three of the ergonomic adjuncts.

The most common reason for not purchasing loupes is the feeling that they are not necessary to provide adequate care. Understanding the preventive and, now, curative benefits of loupes should help clinicians understand that early intervention is the standard of care. Avoiding pain associated with dental practice is much easier with magnification and proper posture.

Of interest would be a future study on the relief of pain as a function of loupes’ fit measurements. It is quite possible that ill-fitting loupes could cause or exacerbate pain in the clinician who has not already suffered any pain.

Ergonomics played a larger role in chair purchasing than for loupes in this cohort. Nearly double the percentage of dentists purchased a chair for ergonomic benefit over loupes, and even fewer purchased a headlight with ergonomic benefit in mind. Smaller preparations played a large role in the purchasing decision for loupes than for the light. None of the participants in the study purchased a chair with the goal of smaller preparations in mind.

Of 132 respondents to the question about ergonomic seating and hand pain, 6% found relief by using an ergonomic chair. Because all nerves exit to the extremities from the spinal column, it would be easy to see how these relate, and studies precisely at these correlations would be of interest. The next questions beg answers: How much is the body really connected? Can proper back posture alleviate pain throughout the body?

The secondary reason for not purchasing a lighting system was the cord. The word cumbersome appeared again and again in the “other” column when asked why clinicians chose not to use a headlight. The newer styles alleviate some of that. While the cord in any treatment room can be a problem, the newer lighting systems are light enough, small enough, and cool enough to wear on the person. The trend is to wear the housing either by an arm band or the pocket of the laboratory coat. The cord is not draped into the operator’s space.

The overwhelming finding in this study about the benefits of pain relief should make investing in this aid easier. The second most common reason for not purchasing a light was a lack of understanding about the benefits of wearing lighting. Decreasing lower back pain in more than one third of the respondents may make this an investment worth a second look. This study shows clearly that vision is not the only reason to be using loupes and a headlight.

The question of career enhancement (Table 5) shows the value clinicians put on ergonomic seating, lighting, and loupes. A vast majority report that using any of the three would prolong their career or would recommend them to colleagues. Of the 344 total dentist respondents to the survey, 33% reported that they used an ergonomic chair; however, 61% said they would recommend an ergonomic chair to colleagues. The discrepancy between loupes users was evident though not as large: 87% said they use loupes and 96% would recommend them to a colleague. One may be tempted to surmise that word of the usefulness of ergonomic products has made an impact on the psyche of the dental world even if the practice does not fully reflect it.

There was no question on the survey looking for the expense the respondents pay in pain relief from medications, traditional or nontraditional medicine, massage, chiropractic therapy, or surgery. This is also a worthwhile future avenue to pursue. Lack of productivity in time off due to pain, and the costs of massages, chiropractor visits, physical therapy, and prescriptions may be alleviated by shifting costs to proper ergonomic conditions in the treatment room.

Further research on the cognitive and psychosocial affects of chronic pain would also be of interest. Using ergonomic systems in the dental treatment rooms and for the front office personnel may make the working environment more pleasant.

The current study finds that dentists who wear loupes can have their pain associated with dental practice alleviate to at least some extent. Study participants who suffered from musculoskeletal pain found reliefnot only from wearing loupes, they found relieffrom wearing headlights and sitting inergonomic clinician’s chairs.

The author would like to thank Orascoptic for supporting thisresearch and Anne Guignon, RDH, MPH, forbeing a valuable resource.

References

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3. Leggat PA, Kedjarune U, Smith DR. Occupational health problems in modern dentistry: a review. Ind Health. 2007;45(5): 611-621.

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5. Griffin M. “The Cost of Pain.” WebMD. Available at: www.medicinenet.com/script/main/art.asp?articlekey=50430. Accessed May 16, 2009.

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Commentary

By Howard E. Strassler, DMD

There is no doubt that the practice of dentistry involves visualizing and evaluating small details of teeth, soft tissues, restorations, casts, radiographs, and instruments. For dentistry, “seeing is believing” is only half the story; the other half is “seeing is knowing” so that a reliable diagnosis, evaluation, and precise critical treatment can be accomplished. Also, using magnification improves posture and ergonomics for dental treatment which provides for musculoskeletal health. The primary decision to use loupes is typically to improve visualization. In many cases, normal vision can be adequate to make treatment decisions and complete treatment, but is it adequate enough? During treatment we use both our instruments and our own vision to make decisions to accomplish our treatment goal, whether it is removing caries, scaling and root planning, restorative treatment, endodontic treatment, or surgical interventions. To make these detailed decisions, magnification with both conventional loupes and a dental operating microscope play a critical role. Fortunately, an important side benefit of visualization with loupes is that they help us to sit and work more ergonomically, minimizing stress on our shoulders, back, and hips.

This retrospective survey of dentists relating to the use of magnifying loupes, ergonomic seating, and head-mounted illumination provides important insight for a topic that, while it has been addressed in the past, is not the primary reason why clinicians buy loupes. Most clinicians purchase loupes to see better. When purchasing dental stools for a treatment operatory, most dentists make the purchase because they are comfortable to sit on, not that they are comfortable to work while sitting for extended periods of time. These two decisions can overlap, but may not always be case. A soft padded stool is comfortable to sit in but may not provide the support for good working posture. This study used an Internet survey to gather data concerning the use of loupes, ergonomic seating, and headlamp illumination while practicing; 344 dentists responded to the survey. Of note, dentists who had pain reported health improvements through the use of loupes, an ergonomic chair, and/or headlights. For those with the initial symptoms of back pain or more pronounced back pain and for those not yet experiencing any problems, it is worthwhile to investigate the use of loupes and headlights not only to see better, but to improve career longevity with comfortable posture. As part of your evaluation, revisit the operatory stool you are using to evaluate its adequacy for those long periods you are performing dental treatment. Also, loupes and ergonomic posture is not just for dentists; consider an evaluation for your dental hygienists, as they will benefit as well.—Howard E. Strassler, DMD

Disclosure

Dr. Strassler has received grant/research support from Kerr Corporation.

About the Author

Howard E. Strassler, DMD
Professor and Director of Operative Dentistry
Department of Endodontics, Prosthodontics and Operative Dentistry
University of Maryland Dental School
Baltimore, Maryland