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Work 48 (2014) 37–45 37
DOI 10.3233/WOR-131712
IOS Press

Work-related musculoskeletal disorders in

dentists and orthodontists: A review of the
literature
Lisa Sakzewski∗ and Shazia Naser-ud-Din
Discipline of Orthodontics, School of Dentistry, The University of Queensland, Brisbane, QLD, Australia

Received 25 June 2012

Accepted 20 December 2012

Abstract.
BACKGROUND: Work-related musculoskeletal disorders (WMSD’s) are on the rise worldwide. These disorders have numerous
repercussions, from serious ill-health effects at the individual level to decreased workplace efficiency and productivity affecting
not only quality of life but the economy.
OBJECTIVE: This review aims to provide an overview of WMSD’s in the dental profession, more specifically, among general
dental practitioners and specialist orthodontists.
METHODS: Literature was hand searched from Pubmed with greater emphasis on contemporary literature as the professionals
demands have evolved over the years.
RESULTS: While there have been numerous papers published relating to the prevalence of ergonomic problems among general
dentists, orthodontists have received little investigation.
CONCLUSION: This review highlights the need for research into the risk factors of WMSD’s in the dental profession (both
general dentistry and orthodontics), as this would provide a more direct approach for prevention which is essential as professionals
work for longer years in practice.

Keywords: Occupation, pain, ergonomics, dentistry, orthodontics

Abbreviations ing epidemiologic methods began during the 1970’s

MSD’s Musculoskeletal disorders
WMSD’s Work-related musculoskeletal
disorders
1. Introduction
Over the last 20 years, MSD’s have become con-
siderably more common in the workplace [1]. Inves-
tigation into the occupational aetiology of MSD’s us-
∗ Corresponding author: Lisa Sakzewski, Clinic 1 – Orthodon-
tics; School of Dentistry, The University of Queensland, 200 Turbot
Street, Brisbane 4000 QLD, Australia. Tel.: +61 7 33658084; Fax:
+61 7 33658199; E-mail: lsakzewski@yahoo.com.
and has since appeared regularly in the scientific lit-
erature with countless articles published to address er-
gonomics in the workplace [2]. Despite the increased
awareness, MSD’s remain a major cause of work-
related illness in many countries [3]. The relation-
ship between the workplace environment and the pro-
gression of disorders involving muscles, tendons and
nerves is one of growing interest and substantial de-
bate [2,4]. Research is being conducted in many coun-
tries including Japan, Europe (particularly Scandi-
navia), the United States, Australia and New Zealand
to analyse these relationships in an effort to reduce the
burden of illness associated with these disorders [4].
The rise in the number of WMSD’s reflects the
implementation of new technology in the workplace
which has assisted in making jobs quicker and easier.

1051-9815/14/$27.50 
c 2014 – IOS Press and the authors. All rights reserved
38 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
High physical workloads and tasks such as heavy lift-
ing are reduced but the repetitive “light” tasks are fo-
cussed on fewer and smaller muscle groups [4]. The
contributing factors to the disorder are vast, however a
positive correlation with fixed postures has been found
in various fields [1,5].
2. Extent of the problem
In Australia, WMSD’s are the most common con-
dition for which worker’s compensation claims are
made [6]. They contribute significantly to lost work
time and long term disability [4,6] as well as com-
prising a significant social and economic problem for
the country [6]. Although the exact cost of WMSD’s
are not known, the United States estimates it costs
the country between $13 and $20 billion annually [2].
Even the most conservative estimates indicate a large
problem in terms of both health and economy [2].
Compensation may be limited initially to medical and
indemnity costs however, the full range of expenses
will subsequently include lost wages and production as
well as the cost of recruiting and training new staff [2].
3. Definitions
MSD’s comprise a diverse range of inflammatory
and degenerative conditions which affect various com-
ponents of the body [6]. A MSD is defined by the
World Health Organisation (WHO) as: “a disorder of
muscles, tendons, peripheral nerves or vascular system
not directly resulting from an acute or instantaneous
event (e.g., slips or falls). These disorders are consid-
ered to be work-related when the work environment
contributes significantly to the causation [9].
WMSD’s may be defined differently by various au-
thors and as such, some controversy surrounds the rel-
ative importance of numerous risk factors in their aeti-
ology [2]. Definitions used by some investigators have
included presence of clinical pathology, symptoms, ob-
jectively demonstrated pathological processes and the
inability to work (lost work-time status). However, by
far the most commonly used health outcome is the ex-
perience of pain, which is presumed to be the initiator
of more serious disease [2].
4. Risk factors
Risk factors for WMSD’s exist across the spectrum
of work environments. Research continues to be di-
rected toward identifying the risk factors as it is quite a
complex and multi-faceted problem. Only after estab-
lishing the risk factors can a clear approach be made
toward prevention.
In 1997, the United States National Institute of Oc-
cupational Safety and Health (NIOSH) published a
comprehensive review of over 600 epidemiological
studies of occupational MSD’s [2,10]. While the ae-
tiological mechanisms are still poorly understood, it
has highlighted three particular categories of risk fac-
tors which may contribute to the onset of work-related
MSD’s: 1) Individual factors, 2) Physical work factors
and 3) Psychosocial factors [2].
4.1. Individual factors
The is some evidence to suggest that certain individ-
ual factors such as increased Body Mass Index (BMI),
carpel tunnel syndrome (CTS), a history of back pain
and current issues with lower back pain can contribute
to the incidence of MSD’s [2]. However, there is min-
imal evidence to suggest that these individual factors
have an additive effect when combined with physi-
cal work-related factors in the contribution to MSD’s.
Thus, these disorders may occur in the absence of any
workplace exposures or events [2].
Other individual factors that have been studied in-
clude age, gender, smoking, fitness level, marital sta-
tus and education [2,11]. One individual variable most
frequently reviewed is age and an increase in age has
been found to be an important predictor of back dis-
orders in many studies. In contrast, other studies have
found no association with age and one actually con-
tradicts this with back disorders more common in the
younger population [11].
4.2. Physical factors
The contribution of physical work factors to MSD’s
has been well documented [2]. Reviews have found
that there is strong evidence to suggest a causal re-
lationship between workplace exposures to repetition,
forceful exertions, awkward and prolonged static pos-
ture and vibration with MSD’s of the neck, upper ex-
tremity and lower back [2,10,12].
Evidence has been found to support a causal rela-
tionship between repetitive work and development of
MSD’s of the neck and shoulder [2]. Repetitive work
for the neck has previously been described by epi-
demiological studies as work activities that “involve
continuous arm or hand movements which affect the
 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
neck/shoulder musculature and generate loads on the
neck/shoulder area” [2]. Those that studied repetitive
movements of the neck by measuring the position of
the head found a statistically significant correlation
with neck MSD’s [2].
There is evidence within the epidemiology literature
to link the occurrence of MSD’s of the neck with force-
ful exertion. This has been described in previous litera-
ture as forceful hand/arm movements generating loads
in the neck and shoulder region [2].
Moreover, there is strong evidence to associate
working groups who have high levels of static con-
traction or prolonged static posture and extreme or
awkward working postures of the head/neck region
with increased risk of MSD’s in the neck/shoulder re-
gion [2]. Studies have consistently found a link be-
tween tension-neck syndrome with static postures or
static loads [2].
A causal relationship between lower back pain and
whole body vibration, hand-arm vibration syndrome
and segmental vibration has been documented [10].
However, in contrast the epidemiological data may be
equivocal when it comes to a causal relationship be-
tween neck MSD’s and vibration. Further studies must
be conducted to determine any relationship with neck
MSD’s [2].
A small number of prospective studies have placed
interventions within the workplace to address some of
these risk factors by decreasing repetitive work and
providing less extreme working postures [2]. These
studies were able to illustrate a decrease in the inci-
dence of neck MSD’s and improvement of symptoms
of those workers previously afflicted with pain [2].
4.3. Psychosocial factors
There is increasing evidence to suggest a relation-
ship between psychosocial factors within the occu-
pational environment and the onset of work-related
MSD’s such as those of the upper extremity and
back [2]. Many psychosocial factors can be associated
with MSD’s [13,14].
The substantiation for the role of psychosocial fac-
tors in the onset of work-related MSD’s may be con-
fusing as the term includes a wide variety of condi-
tions. These psychosocial factors fall into three dif-
ferent categories; those associated with the internal
work environment, those associated with the external
work environment and the individual characteristics of
the worker [2]. The combination of these psychosocial
factors and the interaction between them is termed a
39
“stress process”, the outcome of which may affect in-
dividual health status and work performance [2].
Firstly, the internal work environment involves an
array of factors also referred to as work organisation
factors [2]. This relates to certain aspects of the job
content such as workload (amount of work), repetitive-
ness, amount of job control (ability to make decisions
and use a variety of skills), mental demands of the job
(difficulty as well as enjoyment of work), and job clar-
ity [2]. It also encompasses organisational character-
istics (tall or short structures, communication issues),
interpersonal relationships (relationship with employer
and fellow employees, social support network), tim-
ing aspects (length of working day, shift work, breaks),
financial/economic aspects (wages, benefits awarded
and equity issues) and community support (job rep-
utation and status) [2]. The aforementioned job and
work environment factors are commonly regarded as
“job demands” [13,15]. These demands are all consid-
ered risk factors for WMSD’s and are thought to en-
danger the health of the individual [2,13,15]. External
work demands reflect the role of the individual outside
of work and their duties relating to parents, children,
spouses and/or friends [2].
Lastly, there are individual worker factors which
comprise three different aspects [2]. These may be cat-
egorised as genetic (gender, intelligence), acquired (so-
cial class, culture, educational status) and dispositional
aspects (personality traits, character, life/work attitude,
job satisfaction) [2]. Personality and attitude will in-
fluence a person’s ability to handle potential stressors
in the work environment. This may reflect in whether
or not that stressor will have an unfavourable out-
come [16].
There are several issues in establishing the relative
influence of physical and psychosocial factors. One
concern is that psychosocial factors are usually mea-
sured at the individual level, whereas the physical fac-
tors are often measured at the group level (for exam-
ple measuring a job or task) and the methods used of-
ten lack accuracy and precision [2]. Secondly, it is hard
to find objective measures for various aspects of the
psychosocial work environment while those to mea-
sure the physical environment are more easily accessi-
ble [2].
5. Physiological effects
Rapid, repetitive and/or forceful movements (espe-
cially if in conjunction with high static load or un-
40 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
natural postures) can progress to muscle fatigue with
ischemia and metabolic changes that inhibit enzyme
function [4,17]. The affected muscles and tendons are
at risk of micro-tears and inflammation resulting in
pain and decreased mobility [4]. Tendons may become
thickened and inflamed, thus compression of adjacent
nerves is possible [4]. An increase in the severity of
symptoms has been described in conjunction with the
above physiological changes. Generally it begins with
aching of the affected region of the body (at work)
which disappears if the task is not repeated. However,
symptoms may worsen if the task continues and pain
that does not abate even during resting periods. Most
importantly it can be disabling to the point where day
to day life is a struggle due to its chronic nature the
problem can persist indefinitely [4].
6. Mechanisms leading to MSD’s in the dental
profession
It is well documented that those practising dentistry
are particularly susceptible to MSD’s and are more
prone to occupational pain than the general public [17,
18]. Dentistry is an occupation that requires perfect fo-
cus and accuracy, and in an effort to visualise proce-
dures, unnatural positions are often adopted [19,20].
Dental professionals assume these type of positions on
a daily basis and this certainly has detrimental health
effects [5,20]. Szymanska [20] found nearly all respon-
dents worked in an unnatural position for about 7 hours
each day. Furthermore, one-third did not take a break
during the day thus causing overload of the muscu-
loskeletal system for a lengthy period [20].
Numerous related mechanisms or risk factors have
been found with WMSD’s in the dental profession.
Prolonged static postures, repetitive movements, poor
lighting and positioning, genetic predisposition, men-
tal stress, physical conditioning and age are thought to
be related to the onset of such disorders [9]. The most
common factor appears to be prolonged static posture
which induces high static muscle load in the neck and
shoulder areas and indicates risk for the development
of MSD’s [9,19]. Static postures require the contrac-
tion of over 50% of the body’s muscles to keep it still
whilst resisting the forces of gravity [9] These static
muscle forces have been found to be far more wearing
than those forces which are dynamic [9].
It is widely acknowledged that risk factors for
MSD’s in the dental profession are multi-factorial.
Neck and shoulder problems are often related to static
and awkward postures, while hand and arm problems
are more frequently a result of repetition and force. Ad-
ditional individual factors include height, weight, gen-
der and general health particularly where stress is a
compounding factor [8,9,21].
7. Occupational differences between dentists and
orthodontists
It could be suggested that the musculoskeletal com-
plaints of dentists and orthodontists may vary slightly
due to the differing nature of the work [30]. Sev-
eral authors have drawn general conclusions and made
recommendations to dental professionals as a single
group, without acknowledging differences between the
distinct sub-groups [22,26,28]. This analysis fails to
recognise the variation of musculoskeletal demands
between different specialty areas of the dental profes-
sion [30]. To date, the vast majority of literature on
musculoskeletal disorders in the dental profession is
focused on the general dentist. Newell and Kumar [30]
conducted a study to specifically investigate muscu-
loskeletal disorders in orthodontists, in which the dif-
ferences in job demands between orthodontists and
general dentists were recognised [30]. General dentists
are often required to carry out work in the posterior re-
gions of the oral cavity and as a result tend to bend fur-
ther over the patient [30]. This results in a more awk-
ward head, neck and torso posture in order to improve
access and vision of procedures [30]. In contrast, it has
been postulated that orthodontists tend to work more
superficially, positioning themselves at the head of the
patient, with a more neutral position in comparison to
general dentists [30]. The reasoning put forward for
a more neutral position was that orthodontists do not
need to see the other side of the teeth [30], although
this may be contended. This study was able to provide
the initial step toward a comprehensive review of the
work environment of orthodontists [30].
Kerosuo et al. [22] reported that the occurrence of
WMSD’s in dentists and orthodontists are not only
simply related to the presence of physical work fac-
tors and that similar to office employees, other organ-
isational and psychosocial working conditions such as
work pace, job security, job constraints, work planning
and the psychological work climate all play a part [22].
Other psychosocial risk factors that have been con-
sidered in the dental population include job organi-
sation, job demands (patients treated, hours worked),
job control, type of supervision and support from co-
workers [8].
 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
Dentistry is a profession linked to increased personal
stress, which is by no means a direct association, but
an important factor to be accounted for when assessing
WMSD’s [23]. The effects of job strain are not only
physical but also largely mental, as strong connections
continue to be made between job strain and exhaus-
tion/depression, mortality, poor perceived health, poor
mental health and physical function [23]. To simplify
the issue, job strain increases the risk of chronic dis-
ease which is a feature of disability [23].
7.1. Prevalence of MSD’s in dentists
The prevalence of MSD’s in dentistry is relatively
high and it has been reported as ranging from 36 to 72
per cent, although more recent studies suggest it could
be even higher [5,24]. On average, about two thirds of
dentists may experience pain in a 12 month period and
up to 30% of dentists may be required to retire early
due to these disorders [17]. During the earliest studies
it was found by Biller (1946) that 65% of dentists re-
ported back pain [9]. Today, even with the progression
to four-handed dentistry and more ergonomically sup-
portive equipment, some studies are reporting symp-
toms such as back, neck, shoulder and arm pain in up
to around 80% of dentists [5,9,25]. This increase in re-
ported pain is thought to be due to the fact that those
practising four-handed dentistry have reduced move-
ment as a result of having a dental assistant or working
for extended periods without having a break [5,9].
Shugars et al. [7] found that 59.5% of U.S. dentists
had experienced some form of musculoskeletal pain
during a 12 month period [26]. The difference in pain
was significant between those who practised with a
pre-existing condition and those who had no previous
problems [7].
A 1997 study of dentists in New South Wales (Aus-
tralia) asked respondents to report symptoms based on
the month preceding the survey [5] 82% reported ex-
periencing one or more symptoms including headache,
pain, numbness, pins and needles and finger weak-
ness. More specifically, 64% indicated they experi-
enced pain in the month prior to the survey [5].
Finsen et al. [19] observed that dentists had a
greater frequency of complaints when compared with
the Scandinavian working populations [19]. The fre-
quency of neck, shoulder and lower back complaints
were similar to that reported from dentists in other
countries [19]. Within a 12 month period approxi-
mately two-thirds of dentists reported trouble in the
neck and/or shoulder as well as a similar number with
lower back trouble [19].
41
In a prospective five year study of dental person-
nel, Akesson et al. [27] found dental personnel had a
higher risk of developing MSD’s (verified using symp-
toms and diagnoses) as well as more painful condi-
tions [27]. In the fifth year, 68% of subjects had expe-
rienced pain in the last seven days, while 92% had ex-
perienced symptoms in the previous 12 months [27]. A
relatively large number of dental personnel left the pro-
fession during the study period. Those who did so had a
higher prevalence of MSD’s, both from the start of the
study period and after five years. This was confirmed
via clinical examination of these participants [27].
Kerosuo et al. [22] found life time reported preva-
lence of musculoskeletal complaints in general den-
tists were 70% as compared with 60% for office work-
ers [22]. The office workers had significantly less
symptoms than the dental professionals (when the
general dentists and orthodontists were grouped to-
gether) [22].
Lalumandier et al. [28] asked dental professionals
to rate which body parts frequently gave them pain or
soreness [28]. Approximately 33–35% of general den-
tists rated back pain as the most frequent source of pain
followed in decreasing order by neck, shoulders, leg
and arm pain [28].
In 2004 Alexopoulos et al. investigated a popu-
lation of Greek dentists. In relation to the previous
12 months; 62% reported at least one musculoskele-
tal symptom, 35% reported two symptoms, 15% re-
ported at least three symptoms and 6% reported all
four symptoms in the neck, shoulders, lower back
and hand/wrist [1]. It was found that those who suf-
fered from back pain were more likely to suffer neck
pain (41%) and hand/wrist pain (38%) compared to
those without back pain (neck pain 13% and hand/wrist
16%) [1].
A study of New Zealand dentists in 2005 found 53%
had experienced symptoms in as many as four areas of
the body and 53% had also experienced symptoms in
the previous week in four body areas [29]. Approxi-
mately one-third of New Zealand dentists had experi-
enced symptoms in the last 12 months that prevented
normal activities [29].
Leggat and Smith [25] studied Queensland dentists
and found 87.2% had experienced at least one muscu-
loskeletal symptom in the last 12 months [25]. It was
also seen that hand pain was more frequently reported
by female practitioners [25]. In this study neck, up-
per back and shoulder pain was more often reported
by younger dentists and those with fewer years experi-
ence [25].
42 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
A recent study by Kierklo et al. [24] studied the
symptoms of musculoskeletal pain among dentists
from northeast Poland [24]. It was found that limited
ergonomics in the dental environment resulted in den-
tists developing MSD’s at a very high prevalence [24].
Over 92% of surveyed dentists were found to have
experienced pain and disability of the musculoskele-
tal system with responders generally having more than
one part of the body affected [24]. Symptoms were
reported most commonly in the neck (47%) and the
lower back (35.1%) [24]. Females were statistically
significantly more likely to have experienced pain in
the fingers, while males has significantly more pain in
the lower back [24].
Back pain would appear to be the most common
symptom among dentists, with the majority report-
ing pain in the cervical, sacral or lumbar regions [20,
28]. Marshall et al. [5] found 58% of dentist also re-
ported headaches [5]. Up to 12% of dentists have re-
ported pain in the forearm with symptoms including
numbness and paresthesia [20]. Pain in the back, neck,
shoulders and uppers limbs has been associated with
awkward postures as these typically result in cervical
flexion, unsupported elevation of the arms and specific,
strength-demanding hand movements [20].
Generally a high prevalence of musculoskeletal dis-
orders has been found in dental professionals. For dif-
ferent body parts the presence of pain may range from
67% for the lower back, 40–67% for neck and shoulder
and 15–20% for the wrist and hands [1,19,29].
7.2. Prevalence of MSD’s in orthodontists
One of the earliest studies [26] found that 41% of or-
thodontists had general back pain, 22% had upper back
pain and 38% had lower back pain, however the num-
ber of orthodontists in the sample was fairly small [26].
Kerosuo et al. [22] aimed to determine whether self-
reported occupation-related health problems of general
dentists and orthodontists differed from office employ-
ees in Finland [22]. It was found that musculoskele-
tal complaints were the most frequent problem in all
groups although prevalence was significantly higher
for dental professionals (orthodontists −72%, n = 81;
general dentist’s −70%, n = 147) than for office work-
ers (60%) [22].
Lalumandier et al. [28] asked dental personnel to in-
dicate which areas of the body frequently gave them
pain or soreness [28]. Respondents were given the op-
tions (neck, arms, shoulders, back and legs) with spe-
cific instruction that occasional soreness should not
constitute a positive response [28]. Their study con-
cluded that general dentists and orthodontists had the
same ranking of pain – back followed by neck, shoul-
ders, legs then arms. Approximately 43% of orthodon-
tists reported back pain compared with 35% of gen-
eral dentists, however the sample sizes were vastly dif-
ferent (59 orthodontists and 647 general dentists) [28].
With regard to other areas of the body, orthodontist’s
responses found pain prevalence’s were; neck (19.1%),
shoulder (14.7%), legs (14.7%) and arms (8.8%) [28].
On the other hand, Alexopoulos et al. [1] found den-
tal specialists differed from general dentists in physical
and psychosocial risk factors, subjective health com-
plaints and prevalence of complaints [1]. Significant
differences were found in that orthodontists worked
less hours per week and reported lower perceived ex-
ertion and need for recovery. Hand/wrist complaints
were more frequent in orthodontists than general den-
tists (42.1% vs. 25.5%), but shoulder complaints were
more frequent in general dentists (21.2% vs. 0%) [1].
More than half of the total number of work absences
in orthodontists were found to be a result of hand/wrist
problems [1].
Newell and Kumar [30] reported that their find-
ings on the number and type of WMDS’s in orthodon-
tists were consistent with other studies on surveyed
dental professionals [30]. It was found that the lower
back was the most prevalent MSD affecting 59% of
those surveyed, followed by neck (56%) and shoul-
der (47%) problems [30]. A limitation of this study of
this study was that not all variables (such as psychoso-
cial stressors, leisure activities, fitness and health, time
and work stressors) were investigated [30]. It has also
been reported that instantaneous loads cannot be con-
sidered alone as these are not indicative of the cumu-
lative stress [31]. A large amount of the orthodontist’s
day is spent in a static, reasonably symmetrical seated
position with neck, shoulders and elbows bent. There
is minimal variation in load between tasks and as such
the work position is somewhat tedious [31].
Brown [32] investigated the various types of long-
term disability among orthodontists insured with New
York Life and compared prevalence rates with those
of published studies [32]. At October 1, 2001 there
were 71 disability claimants from 1992 orthodontists
insured, a prevalence rate of 3.56% [32]. This was ac-
tually considered an overestimation due to some indi-
viduals being insured under multiple policies. Of the
71 claims, nine were in relation to musculoskeletal dis-
abilities, this being only 12.7% of the total claims [32].
The numbers of long term disability claims (more
 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
than 30 days) were found to be incomparable with
the large percentage of self-reported musculoskeletal
problems [32]. It has been suggested that periods of
musculoskeletal pain are of shorter duration, with more
often mild or moderate symptoms and the tendency to
be self-limiting [32]. The aforementioned as well as a
lack of financial incentive is likely to account for the
reduced number of claims made by orthodontists for
musculoskeletal conditions [32].
8. Prevention of MSD’s in the dental profession
Fewer studies have focussed on the prevention of
work related MSD’s with most aimed at identifying the
risks and providing subsequent recommendations [18].
Valachi and Valachi [9] described detailed prevention
strategies and ergonomic techniques to diminish the ef-
fects of prolonged static posture and positioning dif-
ficulty as well as addressing symptoms due to muscle
imbalance, stiff joints, muscle necrosis and spinal disc
degeneration [33]. Postural awareness techniques are
aimed at maintaining the lower back curvature by using
appropriate magnification and properly adjusting both
the operator and dental chairs [33]. Static postures may
be avoided by alternating between standing and sitting,
repositioning the feet, putting patients at the correct
height and avoiding twisting movements [33]. Dentists
are advised to incorporate frequent breaks and stretch-
ing both between appointments but also during proce-
dures (for example, while local anaesthetic is taking
effect). Strengthening exercises should become part of
the regime as well as aerobic exercise as this increases
blood flow to all tissue of the body and improves mus-
cle use of oxygen [33].
Stress-management is also an important factor as
it is known to increase muscle tension and elicit
pain [24]. Dentistry is generally acknowledged as be-
ing an occupation prone to stress and operators are
encouraged to adopt management techniques, for ex-
ample relaxation, meditation, aerobic exercise and
yoga [33]. Improved organisation and planning of-
ten means less stress and may directly impact on
the posture of the dentist by lowering the shoulder
height [18]. For increased effect, the most reliable pre-
ventive behaviours should be introduced earlier rather
than later [34].
Studies concentrating on the implementation of pre-
vention strategies are rare [18]. It has been found that
partial application of recommendations may be con-
nected with certain barriers or facilitators [18]. Barri-
43
ers reported in the literature have included; changing
old routines, financial difficulty, work pressure, patient
numbers and if it was thought that the change was too
profound [18]. In contrast, facilitators may come from
a positive influence in the home environment, changes
specifically designed for the practice, surgery redesign
and unfortunately often pain is also a major incentive.
Given that barriers and facilitators are numerous, any-
thing more than partial implementation cannot be ex-
pected as changing behaviours is quite a difficult pro-
cess [18].
Prevention is a considerable challenge, as people are
fairly resistant to change unless the change is perceived
to be beneficial. A number of issues thwarting preven-
tion are reported in the literature including unfamiliar-
ity with the benefits, a belief that risk assessment is
ineffective and perceived costs [34]. The issues raised
impeding intervention should not be taken lightly as
preventive measures have the potential to substantially
reduce MSD’s in the workplace [34]. When recom-
mendations are implemented, especially in regard to
posture, a strong correlation may be found with the re-
duction of complaints [18].
Across all fields there is a requirement for more in-
tervention studies to increase understanding of the ef-
fectiveness of various prevention strategies. Implemen-
tation of any prevention strategy is in need of a long-
term approach, with comprehensive training followed
by observation and mentoring in practice to sustain
new systems [3].
A study by HaverDroeze and Jonsson [18] imple-
mented an intervention program in the Netherlands to
reduce musculoskeletal disorders in dental clinics [18].
The aim was to improve methods of prevention by
evaluation of a secondary prevention program. It was
found that more than half of the dentists implemented
the ergonomic recommendations fully or nearly fully
and a further 40% partially implemented the recom-
mendations [18]. The main barriers accounting for
not implementing recommendations included chang-
ing old routine and financial aspects [18]. The impor-
tant facilitators included motivation, pain and individu-
alised recommendations [18]. The dentists involved re-
ported an obvious association between their implemen-
tation of ergonomic recommendations and a reduction
in MSD’s [18]. It highlights a need for more focus on
the barriers and facilitators to implement prevention
strategies, because even with such a highly motivated
group there was still only partial implementation of
recommendations [18].
44 L. Sakzewski and S. Naser-ud-Din / Work-related musculoskeletal disorders in dentists and orthodontists
9. Ergonomic design for dental practices
It is believed that the productivity and workflow of
dental practitioners may be affected by an increased
complexity of the dental surgery environment [35].
Modern technological developments have resulted in
the accumulation of range of new products and equip-
ment without an overall strategy or design for the
surgery [35]. This may result in a surgery with an op-
erative set up that is quite spread out and may increase
the likelihood of awkward postures while the clini-
cian is working [35]. The prevention of WMSD’s and
improved workflow and productivity are central to an
overall improvement in the practising work environ-
ment [35].
Ahearn et al. [35] made ergonomic recommenda-
tions to improve dental surgery design [35]. It was
suggested that patient chairs should have narrow and
adjustable head rests with a narrow back rest allow-
ing ease of access for the clinician. Patient positioning
should tend toward supine rather than semi-reclined for
the comfort of the operator thus reducing the need for
twisting around the mid-section to see into the oral cav-
ity [35]. The operator’s chair must support the lower
back and abdomen in order to reduce fatigue [35]. Tra-
ditionally, chairs have been equipped with lumbar sup-
port and allowed for height adjustments so that the feet
may be positioned flat on the ground with the body in
an upright neutral position [35]. One of the remain-
ing difficulties is the provision of support to the lower
back. Some of the newer designs comprise an ante-
rior support which is attached to the patient’s chair de-
signed to provide abdominal support and reduce fa-
tigue of the lower back muscles [35].
Working with correct lighting and magnification is
important in attaining an ergonomically correct pos-
ture. If direct vision is to be used the light must be
aligned with sight, or alternatively be reflected off the
mirror for optimal viewing. The angle of light nec-
essary for viewing should remain within 15 degrees
to the line of sight with the light handle within arm’s
reach of the clinician [35]. Following such recommen-
dations in relation to dental space workflow and equip-
ment selection may increase comfort, efficiency and
productivity of the clinician and practice [35].
10. Conclusion
The literature pertaining to WMSD’s in the special-
ist dental field of orthodontics is not extensive. To gain
insight into the problem, information was derived from
previous investigations of MSD’s mainly in dentists,
with only a small number of orthodontists having been
previously studied.
However, the type of work differs between gen-
eral dentists and orthodontists, therefore the postures
adopted whilst working must also exhibit variation.
Currently, there is not enough evidence to determine
whether the differences between the two groups are
enough to have a clinically significant effect. Dental
professional groups should be investigated and anal-
ysed separately in order to make valid comparisons be-
tween general dentists and orthodontists.
Further research should be directed toward risk fac-
tors (such as cumulative load and prolonged static pos-
tures) and prevention through ergonomic intervention
and redesign of surgery equipment and layout [30,31].
Other preventive measures to be investigated include
ergonomic education of dental students as it is essen-
tial that correct techniques are taught and enforced at
an early stage.
Ongoing research is needed to investigate the effects
of ergonomic interventions, problems associated with
an aging workforce and the changing demographics
as more females enter the orthodontic profession [32].
Work related musculoskeletal disorders are an increas-
ing problem and the associated costs, both personal
and economic are substantial. Armed with an improved
understanding of the risk factors and barriers impeding
prevention, a specific and more effective approach to
ergonomic intervention can be made.
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