SPECIAL ARTICLE

What’s ailing us? Prevalence and type of long-

term disabilities among an insured cohort of
orthodontists
Paul N. Brown, DDS, MS
Detroit, Mich

Occupational health risks are present in every profession. This article reviews 4 commonly mentioned
conditions that might be health risks in orthodontics and dentistry—musculoskeletal problems, carpal tunnel
syndrome, dermatoses and allergies, and psychosocial problems—and compares the reported prevalence
rates with data from the American Association of Orthodontists Long-Term Disability Insurance Plan. There
is an estimated 3.56% prevalence of long-term disability among orthodontists. The expected and actual
specific conditions affecting orthodontists could differ from those of the general public or of general dentists
and do not appear to equate with self-reported surveys. Suggestions for improved reporting are made.
Orthodontists appear to be quite healthy compared with other insured populations and the general public.
Most long-term disabilities among orthodontists appear to be chronic illnesses and not repetitive injuries or
specific occupational hazards. (Am J Orthod Dentofacial Orthop 2004;125:3-7)

T
he practitioner today is well aware of the
external forces that impact many facets of
orthodontic practice, including the ergonomic
regulations of the Occupational Safety and Health
Administration (OSHA) that, although recently re-
pealed, might come back in an altered form.1 What
occupational hazards are present in the practice of
orthodontics?
A good understanding of the nature and prevalence
of disabling conditions in the orthodontic specialty is
necessary before one can begin to form and test a
hypothesis regarding the attributable risk of any occu-
pational risk or workplace hazard. It would also seem
reasonable that a specific, documented need for a
workplace injury-prevention program should exist be-
fore the federal government’s intervention or imple-
mentation.
In addition to orthodontic practice itself, one must
consider the individual practitioner, his or her genetic
makeup, amount of physical activity, and lifestyle in
general. The American Dental Association (ADA)
points out that the cumulative nature of occupational
injuries is the result of all of the person’s activities and
not just work-related activities.2
Assistant professor of orthodontics, University of Detroit/Mercy, Birmingham,
Mich.
Reprint requests to: Dr Paul N. Brown, University of Detroit/Mercy, School of
Dentistry, Department of Orthodontics, 8200 W Outer Dr, PO Box 19900,
Detroit, MI 48219-0900.
Submitted, June 2003; revised and accepted, August 2003.
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2003.08.021
The purpose of this article is to review studies
involving both orthodontists and dentists and the prev-
alence of 4 often-mentioned disabling conditions: mus-
culoskeletal problems, carpal tunnel syndrome (CTS),
hand dermatosis and allergies, and psychosocial prob-
lems. Another purpose is to compare and contrast these
rates with a cross-sectional survey of long-term dis-
abling conditions among orthodontists insured by New
York Life through the disability-insurance program
sponsored by the American Association of Orthodon-
tists (AAO).
A computer search and a follow-up hand search of
the literature for studies that included both dentists and
orthodontists or “specialists” with the results reported
in subgroups were performed for the 4 conditions. Few
studies that compare these conditions among general
dentists and orthodontists or any specialists were found.
MUSCULOSKELETAL PROBLEMS
Lalumandier et al3 surveyed more than 5000 active
dental personnel, including orthodontists, in the United
States Army. There were 8 categories of dentists and
specialists and 3 categories of auxiliaries. The self-
reported survey asked the respondents to indicate which
body parts frequently gave them pain or soreness.
These areas were the neck, arms, shoulders, back, and
legs. It was emphasized that occasional pain or soreness
would not constitute a positive response. Most general
dentists (n ⫽ 647) and orthodontists (n ⫽ 59) worked
about 40 hours per week, and both groups treated
similar numbers of patients each week (41-50). The
3
4 Brown
Table I. Percentages of Army general dentists and
orthodontists reporting musculoskeletal pain by
location (modified from Lalumandier3)
Back Neck Shoulders Legs Arms
General dentist 35.1 28.1 21.3 9.2 6.3
Orthodontist 42.6 19.1 14.7 14.7 8.8
proportion of men to women was 10:1 in both groups.
The most frequent age range was 35-44 years.
Both general dentists and orthodontists ranked the
prevalence of pain in the same order of location, but
there were differences in magnitude (Table I).
The 42.6% of orthodontists who reported back pain
was the largest positive response of any group for any
location. General dentists reported the second highest
positive response (35.1%) of any group for any loca-
tion. This prevalence difference of back pain was also
the largest difference in the highest and second highest
responses among all groups for any location.
In a self-reported survey of Finnish dentists (n ⫽
147) and orthodontists (n ⫽ 81), Kerosuo et al4 found
that 70% and 72%, respectively, reported “life-time
prevalence” of musculoskeletal complaints. Among
orthodontists, the most frequent age range was 40-50
years, with 40% older than 50 years. The proportion of
men to women was 1:3.76. In order of frequency, the
sites most involved were the shoulders (56%), the neck
(53%), and the back (28%).
Neither study asked whether the musculoskeletal
pain or soreness was directly or indirectly related to the
practice of the specialty or whether there were other
precipitating risk factors for the symptoms such as a
previous or simultaneous injury or a genetic disposi-
tion.
Overall, orthodontists and general dentists reported
a high prevalence of musculoskeletal problems. The
higher rates in the Finnish cohort might be because the
participants were likely to be older and female. Both
factors carry a higher risk for musculoskeletal symp-
toms compared with being younger and male.5
Although musculoskeletal pain is prevalent among
Army and private practice orthodontists, the external
validity of both studies to a North American population
of orthodontists in private practice could be difficult to
show. There could be confounding demographic fac-
tors, such as those reported in the Journal of Clinical
Orthodontics Orthodontic Practice Study.6 It reports
that those in private practice work only about 42 weeks
per year (assumes a 40-hour week) and see about 50
patients per day as compared with the army orthodon-
American Journal of Orthodontics and Dentofacial Orthopedics
January 2004
tists who see about the same number per week. It is
very likely that private practice orthodontists also have
higher incomes than Army orthodontists. Unlike the
Finnish group in which most were women, only about
9% of orthodontists overall were women in the Journal
of Clinical Orthodontics study.
CARPAL TUNNEL SYNDROME
No specific study of carpal tunnel syndrome (CTS)
among orthodontists was found in the literature. Kero-
suo et al4 reported on neurologic symptoms similar to
CTS among dentists and orthodontists, including
numbness, pricking of the fingers, and “white fingers,”
and concluded that there were no substantial differ-
ences.
A survey in 1997 by the ADA reported that 9.2% of
dentists had been diagnosed by a physician as having
some type of repetitive motion disorder, with a higher
prevalence among female and older dentists.7
A cross-sectional study of dentists for CTS by
Hamann et al8 reported a prevalence both by self-
reported screening and as evidenced by positive electro-
diagnostic testing for symptoms. A total of 2197
dentists participated in health screening programs dur-
ing the ADA’s annual conventions in 1997 and 1998.
Of this number, 1079 dentists participated in CTS
screening. The aggregate group (n ⫽ 2197) reported a
higher prevalence of CTS symptoms (36%) than the
group that volunteered (n ⫽ 1079) to be screened for
CTS, who reported a 28% prevalence. The cohort was
84% male with a mean age of 49.8 years. The average
doctor had practiced for 22.2 years, worked 35.5 hours
a week, and practiced 47.3 weeks per year. Although
28% of the dentists participating in the CTS screening
reported hand or finger numbness, and tingling or pain
at the end of the day, only 13% tested positive electro-
diagnostically, with a 0.5 ms prolongation as the
criterion. Of the 13% who tested positive, only 32%, or
4.8% overall, had symptoms of CTS. The prevalence of
CTS increased with age. Female doctors in this study
were on average 8 years younger and less likely to test
positive.
With a criterion of 0.8 ms prolongation, an overall
prevalence of 2.9% was obtained. By using the 0.8 ms
criterion, a recent cross-sectional study of a comparable
Swedish general population produced a similar preva-
lence rate of 2.7%.9 According to this criterion, there
appears to be little attributable occupational risk of CTS
when comparing these 2 groups.
Selection bias is likely in the previous studies,
resulting in an underestimation of the true prevalence.
Dentists who are suffering from severe CTS and not
practicing or are retired might not attend annual meet-
American Journal of Orthodontics and Dentofacial Orthopedics Brown 5
Volume 125, Number 1

ings or be included in a survey. An unpleasant screen- Table II. Category, type, and number of AAO
ing test (electrodiagnostic) is likely to bias those who disability insurance claims, and category of claims as
volunteer for screening. Finally, the “healthy worker percentage of total
bias” is well documented and contributes to an under- Claims Total claims
estimation of the actual prevalence. Disability (n) (%)

DERMATOSES AND ALLERGIES Nervous system & sense organs (total) 14 19.7
Eye problems 2
Hand dermatoses were reported by 42% of the Multiple sclerosis 1
Finnish dentists and orthodontists who responded to a Parkinson’s disease 2
mailed questionnaire; the complaints were similar in Polymyositis 2
Nervous system & sense organs 3
both groups.3 These dentists and orthodontists thought
Neurasthenia 3
that 21.5%, or 9% overall, of the dermatoses were Unspecified neuropathy 1
related to the materials used in the profession, with Accident (total) 10 14.1
methacrylates and natural rubber latex gloves as the 2 Unspecified accidents 8
most common materials giving rise to complaints. Accidental poisoning 2
Another survey of Norwegian orthodontists showed Musculoskeletal (total) 9 12.7
Degenerative discs of thoracic or lumbar 3
that 40% had hand or finger dermatoses.10 The mean Osteoarthrosis 2
age was 46 years, and 18% were female. It was found Lateral epicondylitis 1
that these complaints were often mild and were related Nonunion of fracture 1
to seasonal variations and temperatures. Unspecified disorders 2
The OSHA believes that 8% to12% of health care Cancer (total) 6 8.5
Colon 2
workers are sensitive to latex and states that, between Liver 1
1988 and 1992, there were more than 1000 reported Other malignancies 3
adverse health effects from exposure, including 15 Circulatory (total) 5 7.0
deaths.11 There appears to be good evidence for the Cerebrovascular disease 2
increasing prevalence of latex allergy caused by more Heart disease 3
Organ problems (total) 2 2.8
occupational exposure to latex products.12 Diabetes mellitus 1
Pneumonitis 1
PSYCHOSOCIAL PROBLEMS Complications of labor 1 1.4
Twenty percent of the dentists on long-term disabil- Unspecified allergy 1 1.4
Unspecified illness 23 32.4
ity through the Canadian Dentists’ Insurance Plan were
Total 71 100
diagnosed with mental or nervous problems.13
Based on a mailed questionnaire to a group of
Swedish dentists and specialists, Rundcrantz et al14 use of these data and provided them through the plan
reported that specialists were more satisfied with their administrator. All information was anonymous.
work environment, were more stimulated by their work,
had more self-confidence, and experienced less anxiety RESULTS
than general dentists. Table II shows a breakdown of 71 disability claim-
The reasons for these findings have not been ex- ants from among 1992 insured orthodontists. The data
plored but might be related to extra years of training or have been loosely grouped according to category and
income differences. subcategory headings or diagnosis codes as provided by
New York Life. The overall prevalence rate is 3.56 per
AAO DISABILITY INSURANCE DATA 100 insured orthodontists.
The reported AAO cases represent claimants (those The prevalence rate of 3.56% is probably an over-
receiving disability benefits, either total, residual, office estimation. From the data, it is likely that some claim-
overhead, or some combination thereof) as of October ants were insured under more than 1 policy and were
1, 2001. At the time of disability, these claimants were counted 2 or more times (5 claimants were probably
insured through the AAO insurance program and rep- counted 11 times; 65 ⫼1992 ⫽ 3.26% prevalence). For
resent people with objective findings as evidenced by example, a new claimant could be insured for both
self-report, both initial and ongoing independent med- long-term disability and office overhead, and would
ical evaluation, and laboratory or clinical testing. There have been counted twice. Because it was not possible to
is a minimum 30-day waiting period before receiving verify this accurately from the data, each claim was
benefits. The AAO Council on Insurance approved the counted as separate and unique.
6 Brown
DISCUSSION
Relative to the population in the United States and
a national population of insured people, it appears that
orthodontists are quite healthy in terms of long-term
disability.
The US Department of Health and Human Services
reported that 6% of working-age people have disabili-
ties that prevent them from working at all, and another
13% have some work limitations.15
UNUM Provident, the largest US disability insurer,
insures more than 10 million people including 285,000
physicians individually and furnishes group protection
for 1.4 million other health care professionals (includ-
ing physicians and other health care workers). It has
reported an estimated incidence rate of new disability
claims per year of 3.8% (380,000 new claims per year
per 10,000,000 insured).16 This compares with an
overall prevalence rate of 3.56% for orthodontists.
One can only speculate about what constitutes the
almost one third of all claims classified as “unspecified
illness.” Alcohol and drug abuse might be a substantial
part of it. In a national population, heart disease and
back problems are the 2 leading causes of long-term
disability.4 Among insured Canadian dentists, the lead-
ing cause of long-term disability is back problems
followed by mental and nervous problems (includes
alcohol and drug abuse); these combined constitute
over 40% of all claims.13
It might be that orthodontists are different from
both cohorts. With reported annual median incomes of
$350,000,17 and a maximum annual disability benefit of
less than one half that amount ($12,500/month),18 there
is certainly no financial incentive among orthodontists
to make a disability claim.
The large percentage of self-reported musculoskel-
etal pain among orthodontists in various practice set-
tings does not appear to equate to long-term disability
(⬎30 days). Perhaps most episodes of this kind of pain
are of short duration, are self-limiting, or involve only
mild-to-moderate symptoms. Ergonomic technology
could also help people to cope with these levels of
episodic symptoms.
No one was specifically diagnosed with CTS or
latex allergy among the AAO cohort; some of both
could have been expected. It would also seem likely
that some long-term disability cases would be psycho-
social. The “unspecified illness” category in the AAO
reporting leaves open the possibility for many such
cases. The reporting in this area should be improved. It
could be that alcohol and drug abuse is the leading
cause of disabilities among orthodontists.
There is a need for ongoing and sustained surveil-
American Journal of Orthodontics and Dentofacial Orthopedics
January 2004
lance and improved reporting at the individual level.
Guay19 has noted that research related to ergonomics in
the dental profession, particularly self-reported survey
research, is not clear and varies considerably. Ongoing
surveillance will allow for studies on the effects of
ergonomic interventions, problems related to the aging
of the orthodontic work force, demographic changes
among orthodontists as women make up an ever larger
proportion, and the impact of any OSHA-mandated
changes in the office.
It has been said that “[d]evelopment of effective
intervention strategies requires an adequate national
surveillance system for monitoring injuries, their
causes, and their short and long-term consequences.”20
Among orthodontists, AAO disability insurance claims,
while not perfect, would probably be an acceptable
database to understand injury causation and specific
occupational risk factors along with the distribution and
magnitude of long-term occupational injuries over
time. Such data could also justify the need, if any, for
government-mandated injury-prevention programs.
The AAO should consider reporting disabilities
using the International Classification of Functioning,
Disability and Health codes or the International Clas-
sification of Diseases codes. This would provide a
standardized and useful format to study disabilities.21
These codes, along with a short description of the
condition, would greatly improve the information that
New York Life reports to the AAO. For example, in the
category “unspecified accidents,” it is reasonable to
assume that some of those might be motor vehicle
accidents, which are not related to the specialty of
orthodontics but are certainly disabling. The disabling
condition resulting from a motor vehicle accident,
however, might be categorized as an “eye problem.” An
occupational accident causing disability from a broken
bur could also be classified as an “eye problem” or
“unspecified accident.” Of obvious interest to the pro-
fession is the number of injuries associated directly
with the occupation.
CONCLUSIONS
From the AAO data, it appears that most long-term
disabilities among orthodontists are chronic illnesses
and not repetitive injuries or specific occupational
hazards. In terms of long-term disability, orthodontists
appear to be quite healthy. Orthodontists, however, are
not exempt from the day-to-day risks and health factors
that affect the general population. Work-related acci-
dents and occupational hazards lasting longer than 30
days appear to be rare or of short-term consequence. As
the orthodontic workforce ages and the proportion of
women practitioners increases, it is likely that the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 125, Number 1
prevalence of long-term disabilities among orthodon-
tists will increase accordingly.
I thank the AAO Council on Insurance for making
these data available and Bob Bartee for reviewing the
manuscript.
REFERENCES
1. Furlong A. Ergonomics back in the spotlight. ADA News 2001
Aug 6.
2. Furlong A. Ergonomically correct. ADA News 2001 Aug.6.
3. Lalumandier JA, McPhee SD, Parrott CB, Vendemia M. Mus-
culoskeletal pain: prevalence, prevention, and differences among
dental office personnel. Gen Dent 2001;49:160-6.
4. Kerosuo E, Kerosuo H, Kanerva L. Self-reported health com-
plaints among general dental practitioners, orthodontists, and
office employees. Acta Odontol Scand 2000;59:207-12.
5. www.unumprovident.com/consumers/tools. Accessed December
15, 2002.
6. Gottlieb EL, Nelson AH, Vogels DS. 2001 JCO orthodontic
practice study. Part 3. Practice growth and other comparisons.
J Clin Orthod 2001;35:733-40.
7. American Dental Association Survey Center. 1997 survey of
current issues in dentistry: repetitive motion injuries. Chicago:
American Dental Association; 1997.
8. Hamann C, Werner RA, Franzblau A, Rodgers PA, Siew C,
Gruninger S. Prevalence of carpal tunnel syndrome and median
mononeuropathy among dentists. J Am Dent Assoc 2001;132:
163-70.
9. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J,
Brown 7
Rosen I. Prevalence of carpal tunnel syndrome in a general
population. JAMA 1999;282:153-8.
10. Jacobsen N, Pettersen AH. Occupational health problems and
adverse patient reactions in orthodontics. Eur J Orthod 1989;11:
254-64.
11. www.osha-slc.gov/SLTC/latexallergy. Accessed April, 8, 2003.
12. Charous BL, Blanco C, Tarlo SM, Hamilton RG, Baur X,
Beezhold D, et al. Natural rubber latex allergy after 12 years:
recommendations and perspectives. J Allergy Clin Immunol
2002;109:31-4.
13. CDSPI (Canadian Dental Service Plans Inc) Report. High stress-
related claims hurt everyone. J Can Dent Assoc 1994;60:387-8.
14. Rundcrantz BL, Johnsson B, Moritz U, Roxendal G. Occupa-
tional cervico-brachial disorders among dentists. Psychosocial
work environment, personal harmony and life satisfaction. Scand
J Soc Med 1991;19:174-80.
15. www.aspe.hhs.gov/daltcp/reports/task1es.htm. Accessed April 8,
2003.
16. UnumProvident. An open letter from UnumProvident Corpora-
tion. Medical Economics 2001;78:105.
17. Gottlieb EL, Nelson AH, Vogels DS. 2001 JCO orthodontic
practice study. Part 1. Trends. J Clin Orthod 2001;35:623-31.
18. www.aaortho.org (AAO Endorsed Insurance Carriers). Accessed
April 22, 2003.
19. Guay AH. Commentary: ergonomically related disorders in
dental practice. J Am Dent Assoc 1998;129:184-6.
20. Committee on Trauma Research Commission on Life Sciences
and the National Research Council and the Institute of Medicine,
Injury in America, 1985.
21. www.cdc.gov/nchs/about/otheract/icd9/icfhome.htm. Accessed
April 8, 2003.