Did you know that as many as one-third of dentists retire prematurely due to physical ailments? Poor ergonomics in dentistry isn’t just a pain—it’s a career-ender. Through extensive research and analysis, Dr. Bethany Valachi, PT, DPT, MS, CEAS, author of 5 Steps to Practicing Dentistry Pain-free (free e-book download here), and a clinical instructor of ergonomics at Oregon Health & Science University’s School of Dentistry, saved not only her husband’s back, but also his career. Here, she discusses the underrecognized importance of ergonomic dentistry practices and technologies for protecting the health, effectiveness, and clinical longevity of dentists and hygienists.
Q. You’ve developed a reputation as a “dental ergonomics maven.” How did ergonomics become a personal quest for you?
A. At age 35, my husband was forced to consider selling his dental practice due to severe lower back pain. My desire to help him prompted me to delve into the correlation between ergonomics and dentistry.
As a physical therapist, I earned an ergonomics certification but realized there really wasn’t any formal education for dental ergonomics. So, I had to take the existing information and apply them to dentistry. This meant hundreds of hours taping and analyzing the posture of dental professionals, and correlating their working positions to their reported pain. The patterns were so convincingly tied together—the correlations between ergonomics and pain were so evident—that I knew this was an area worth exploring much more deeply.
Not surprisingly, my husband became my first “client.” Based on my research, I suggested changes to his operatory, posture, and positioning. His pain soon dissipated, and I’m happy to report that he’s still practicing today.
Q. Has practitioner pain become more or less widely reported in recent years? What about historically?
A. Work-related pain in dentistry has always been a major problem. Back in 1946, it was reported that 65% of dentists experienced pain. Incredibly, the pain problem today is actually greater, about 70%. So with all our technological advances, education, and resources, the question becomes why? Why has the pain gotten worse?
In my opinion, it’s because the education and products used to mitigate these issues haven’t been based on research. Also, the etiologies of work-related pain in dentistry haven’t been properly identified and targeted. Many products exemplify a wishful-thinking, “spaghetti at a wall” approach. People hoped they would work, but of course hope isn’t a strategy.
Real progress can’t come until products including chairs, loupes, and other tools are ergonomically developed based on data-driven proof and experience-based evidence. Until that happens, we’ll continue to see dentists’ careers cut short due to avoidable pain and injury.
Q. There’s a significant difference between mild aches and pains and more serious, potentially chronic musculoskeletal issues. Can you define the difference, and discuss the prevalence of the latter among dentists?
A. Relating this to dentistry itself, there’s always a certain amount of damage to teeth that can happen on a daily basis. If you don’t brush and floss, you’ll get cavities and need crowns and root canals. Dental practitioners teach their patients about preventive care to avoid more severe problems further down the road, but no one is teaching practitioners to care for themselves now to avoid serious problems later. Dentists and hygienists strain in physically unnatural ways for extended periods of time. This creates microtraumas that can accumulate into larger defects—a musculoskeletal pain syndrome known as a cumulative trauma disorder. This refers to damage that is occurring incrementally yet steadily, and at a rate faster than the body can heal itself.
The parallels between ergonomics and dentistry itself are clear. Oral health requires preventive action, as does pain alleviation for dentists. And often, some of the early symptoms of this cumulative trauma can be difficult to recognize as distinctly related to posture and the way the body is positioned in relation to the environment, which adds confusion and complexity to an already underrecognized, underserviced problem.
Q. You’ve cited a five-step process toward alleviating pain, a method that includes stress reduction, pain point management, and targeted muscle strengthening. But ergonomics is the first step. Why?
A. I’ve seen many dental professionals attempt to resolve their work-related pain by massages, exercise, personal trainers, chiropractors . . . and then go right back to their poor operatory ergonomics. Until you address the source of the problem, you’re really just spinning your wheels. Ergonomics is the foundation upon which all other preventive tools must stand for dental professionals to achieve long-term, pain-free success.
Notably, the reason exercise is the last step is that dental professionals are prone to developing trigger points, knots in the muscles that cause pain. But if those points are stressed via exercise before they are addressed, the pain will usually worsen.
Q. For obvious reasons, dentistry is a field that makes maintaining proper, healthy posture quite difficult. Are there any dental subspecialties where ergonomics is particularly problematic? In your experience, what muscles/body areas do dentists tend to complain about most frequently?
A. Each dental specialty has unique pain patterns. For example, orthodontists report the most back pain, while endodontists experience the most shoulder pain.
I see the most overall pain complaints from endodontists, which might seem odd since they typically spend a lot of time sitting fairly upright while looking into microscopes. However, they actually tend to strain, “turtling” their head forward to look through microscopes. This prolonged static posturing can lead to muscle ischemia, stagnant blood flow, compressed cervical discs, and other “can’t-move” issues.
For dentists overall, the most prominent pain points I’ve seen are neck first and lower back second, followed by shoulder and hand or wrist pain.
Q. What are some ways dentists can work toward correcting their posture and improving their ergonomics?
A. Investing in truly ergonomics loupes, proper positioning of patients and their headrests, and the right “clock” position are all important first steps toward achieving correct posture, as is a chair or stool that ideally suits a dental professional.
Unfortunately, manufacturers of most products don’t teach dental professionals how to utilize or position their products for proper, healthy usage. A better approach would consider both the patient servicing aspect and the dental professionals’ comfort and health because ultimately, those two factors are intimately connected.
Q. Why are loupes such a key aspect to this?
A. Studies have shown that working with a neck flexion angle greater than 20 degrees is significantly associated with neck pain. Unfortunately, from what I’ve measured among hundreds of dental professionals, most loupes in the industry today do not keep dental professionals in a head posture of less than 20 degrees of neck flexion.
Regarding loupes, the key here is declination angle. Unfortunately, some manufacturers claim their products’ declination angles are greater than they actually are, often exaggerating by 10 or more degrees. That’s simply not sufficient, nor is it acceptable. It’s also widespread: misleading declination angles have been an issue far too often at the dental school where I teach.
Q. How can dental professionals avoid this pitfall?
A. They need to understand that, if they order basic, through-the-lens loupes, they really might not get the declination that’s promised. The problem then becomes compounded simply because most dental professionals (or students) don’t know how to measure a declination angle, meaning the issue goes unobserved and therefore unresolved.
The best bet to overcoming this is to choose truly ergonomic loupes right from the get-go, which is an uncomplicated choice because there are really only a handful on the market. For example, Admetec makes an ergonomic series available through Andau Medical here in North America.
The most beneficial ergonomic loupes are made using prismatic deflection technology that enables practitioners to see small details without having to bend over. Such loupes typically offer the highest-possible declination angle, both allowing and instructing practitioners to work in an ergonomically healthy posture that helps protect their career longevity.
Q. What other challenges or drawbacks have you experienced with loupes in the past?
A. One issue arises when dental practitioners fail to allow for an accommodation period with new loupes. They’ll work with the loupes for a full day from inception, and experience headaches and other discomfort as a result. It then becomes tempting to abandon the loupes entirely. The correct approach is a gradual ramp-up that allows the body to adjust to the loupes, and build up toward their optimal utilization.
Q. Loupes have evolved and segmented over the years, with a wide variety of types, options, etc. What are essential criteria for dental professionals to consider when selecting the most ergonomic (yet functional) loupes?
A. Again, the top concern must be the declination angle, which really needs to be as high as possible for most clinicians to work within a safe head posture range. Working distance—the distance from the eye to the tooth surface—also is vital. If the working distance is measured too short, the clinician is forced to lean forward too much.
Q. Posture is a learned habit, meaning the earlier it is taught the better. “Clinical Instructor of Ergonomics” is a fairly unique title. What’s the most valuable lesson you try to instill in your students?
A. The most valuable lesson is “prevention prevention.” Many students, because they’re young and strong and not in pain, have an attitude that they’re invincible, that pain or injury will never happen to them. What’s ironic is that many of the faculty at their schools are only teaching because they can’t physically service patients any longer.
So the best advice is to prevent the pain before it becomes a problem, which is an extension of the same advice they’ll be giving their patients about preventive maintenance. This preventive maintenance should include adopting ergonomic habits and technologies early and often.
