By Mary Govoni, CDA, RDA, RDH, MBA
Whenever I go to dental practices for consulting or training, I watch the team members grimacing and gesturing to work out the “kinks” in their backs, necks, and shoulders that result from the postures they assume while they are working. Many times the team will pass around a bottle of aspirin or ibuprofen at the morning meeting. More often than not, the team members have come to accept that soreness and stiffness are a natural part of being a dental professional - it goes with the territory. The dangerous part of that belief is that the soreness and stiffness can lead to debilitating injuries that can ultimately limit or prevent one from performing job tasks and can begin to interfere with activities of daily living.
I challenge all of you to make this the year that you become proactive about ergonomics in your work setting. Look around your treatment rooms and your business offices with a critical eye for the type and placement of equipment and workflow. Ask yourself if every member of the team can perform his or her job tasks without having to assume awkward postures most of the time. Take photographs of team members as they are performing their jobs. Better yet, videotape them! The photos and videos will tell the story of why so many of you are stiff and sore. If you’re not sure what to look for, let’s look at some of the basics of ergonomics.
Ergonomics is a discipline that studies human performance and the interface between the human body and technology to perform tasks. One of the basic tenets of ergonomics is to enhance performance through efficiency and to prevent injury to the body that can result from repetitive movements and awkward postures and other workplace risk factors. In order to benefit dental professionals, equipment and instruments must be designed to meet these principles. Work settings, such as the business office and treatment rooms, must also be designed for the team members who perform their jobs there. In many cases, however, the design is developed and produced, and the team members must adapt themselves to that workplace or equipment.
Optimally designed work settings and equipment allow for team members to work in a “neutral” posture the majority of the time, meaning awkward postures are assumed infrequently and for short periods of time. Neutral posture means that the back and neck are straight and upright, shoulders are not raised or hunched over, and elbows are at your sides (not raised up). When seated, your knees are slightly lower than your buttocks. In this position, your muscles are balanced and not stressed or stretched in one direction more than another. This allows you to have greater range of motion, ease of movement, and no pain while you are working. Some of you are probably thinking that this just isn’t possible. How can you see what you’re doing if you sit up straight and don’t lean? In some situations you just have to work in an awkward posture to be able to see, but if you carefully analyze your work environment and your habits, you can make changes that will improve your posture. Here are some very practical tips to help you improve your work environment.
Whenever you analyze your work environment, begin by identifying where you work most frequently and what equipment you use the most. Take the business office, for example. One can reasonably assume that the telephone and computer are the two pieces of equipment that team members utilize in this area. I call this the “center of your universe.” In order to achieve neutral posture, the computer keyboard and monitor should be positioned directly in front of where you sit most frequently. In many instances, the computer monitor is placed off to the side, perhaps in a corner, and the upper body must be rotated to one side or the other to look at the screen. Older style CRT monitors take up a great deal of space on the counter or desktop and sometimes the only place they fit is in the corner. Consider replacing them with flat screen monitors, which take up much less space, and provide better resolution and less eye strain. The keyboard and mouse should be at a height below the counter height to allow you to type with your shoulders and elbows down and wrists straight. Wireless or cordless keyboards and mice are desirable because the tug of the cords, which can cause hand and wrist strain, is eliminated.
If you are right-handed, the telephone should be positioned to the left side of the computer monitor, to the right if you are left-handed. This allows you to pick up the phone in your non-dominant hand and still be able to write with your dominant hand. Speaking of the telephone, do you frequently hold the handset between your ear and shoulder? As many of you know, this can cause neck pain and injury. Using a telephone headset can eliminate this problem. Two excellent resources for headsets for multiple line telephones are www.headsets.com and www.hellodirect.com. I recommend that you consider wireless headsets and handset lifters, which allow you to get up from the desk without having to disconnect the headset cord and to answer the phone when you are not at the desk.
In the treatment rooms, again consider what equipment or items you use the most and position them as close to where you sit as possible. The “center of the universe” in the operatory is around the head of the patient chair. Does your patient chair allow both the operator (doctor, hygienist, and sometimes assistant) and the clinical assistant to sit close enough to the patient to avoid leaning over to see? Can the operator work with his or her legs together under the back of the patient chair to avoid straddling the back of the chair? Straddling has become a common method of adapting to some of the wide, thick backs on patient chairs. This sitting position strains the hip-flexor muscles that join the pelvis and the femur. Stretching these muscles can cause hip and low back pain. Is the back of the patient chair so wide that the assistant can’t get close enough to the patient? Continually leaning to one side in order to see in the patient’s mouth can cause hip and back pain for the assistant. Some patient chairs have flexible wings on the backs of the chairs. The rationale for these wings is to provide support for the patient’s arms. If the assistant needs to lean against them, they will flex to allow the assistant to get closer. If the assistant must flex the wing with his or her hip continually, pain and injury to the hip and low back can result. To avoid this pressure, the assistant must sit farther away from the patient and lean in. To make a short story long, an ideal patient chair would be one with a thin and narrow back. This allows the operator to sit with his or her legs under the back of the chair and for the assistant to sit close. The patient chairs I recommend most frequently are from DentalEZ and Pelton & Crane. The DentalEZ Classic J and J/V Generation (pictured at left) chairs fit these criteria, as do the Pelton & Crane Spirit 3000 chairs.
In addition to the patient chair, the operator and assistant’s stools are equally important. This is where the clinical team spends the majority of their time. In order to be at your best, you need to be able to sit comfortably all day. There are many stools to choose from and I always encourage teams to try many of them before making a choice. As body types and sizes vary widely, so do the team members’ needs in a stool. What may feel comfortable to one assistant, for example, may not work well for another. Many stool manufacturers will allow in-office trials of their stools, so take advantage of this opportunity. For operator stools, always look for broad, contoured seats, adjustable back rests, and possibly arm rests. Assistant stools (in my opinion) should have a body support and a back rest. Be careful, however, that the body support can be easily adjusted in height and position. Stools that I frequently recommend are again from DentalEZ, and Pelton & Crane; as well as RGP, Orascoptics, and Hager Worldwide’s Bambach Saddle Stool with the back rest.
For the doctor and the hygienist, another important equipment item is the delivery system. Many manufacturers and designers are proponents of rear delivery systems. The premise is that the less the patient sees in front of him or her, the more esthetic and less threatening the environment will be. While this is a valid argument, I believe that since the patient spends the least amount of time in the treatment room (as opposed to the team), efficiency should win out over esthetics. When doctors, hygienists, or assistants in the operator’s position must retrieve handpieces from the rear delivery position, they must rotate their upper body and reach across their upper body to grasp the handpiece. I recommend over-the-patient or trans-thorax delivery, in which the operator simply reaches forward to pick up a handpiece or air/water syringe. Side delivery is another option, but in most cases, ambidexterity is sacrificed. If selecting over-the-patient delivery, consider those that are commonly called “euro-style” or “continental style,” with the hoses above the bracket tray, rather than ones with the hoses that hang down over the patient.
In addition to comfortable seating at chairside, evaluate the ease of with which you can access instruments and equipment while you are treating patients. Items that are used most frequently, such as hand instruments, curing lights, ultrasonic scalers, and other items, should be placed within arm’s length of your seated position. This minimizes the amount of movement and energy that must be expended when reaching for these items. Less movement - bending, twisting, and/or reaching - results in less muscle strain and fatigue.
When selecting hand instruments, look for those with lightweight, large-diameter handles. These types of handles have been more common for hygiene instruments, but are not readily available for restorative instruments and mirrors. These handles help to decrease hand fatigue by requiring less grip strength during use.
The most difficult thing to modify at times is behavior, which is a large part of the ergonomic problem that we have in dentistry. It boils down to this - we develop bad habits. If patients give us the least bit of resistance to being positioned lower in the chair, we sit them up and compromise our posture. Many times we forget that we could improve visibility in the mouth by simply adjusting the patient’s head position, rather than leaning over the patient more. Using the mirror and indirect vision when working on the maxillary arch can do wonders for head and neck posture. But alas, old habits die hard.
The bottom line is that as we age, we have more of a tendency to develop physical problems. These physical problems can be exacerbated or caused by our work environment and habits. Making changes can preserve our bodies and careers and help us to be more comfortable and productive. That sounds like a winning strategy to me.
Mary Govoni is a Certified and Registered Dental Assistant and a Registered Dental Hygienist with more than 28 years of experience in the dental profession as a chairside assistant, office administrator, clinical hygienist, educator, consultant, and speaker. She is the owner of Clinical Dynamics, a consulting company dedicated to the enhancement of the clinical and communication skills of dental teams. She can be reached at [email protected].
