BASIC STEP FOR WORK EFFICIENCY
As we go about our dental practice we tend to often forget certain nuances that looks insignificant but very important to our work efficiency as well as health- our proper posture when we do our dental treatments.
Did you know that an average of 2 out of 3 dental professionals experience occupational pain and nearly one third of dentists who retire early are forced to do so because of Musculoskeletal disorders? Musculoskeletal disorders (MSDs) are described as disorders of the muscles, nerves, tendons, ligaments, joints, cartilage, or spinal discs. The term “work-related musculoskeletal disorders” (WMSDs) refers to MSDs that are made worse by work condition. Majority of dental healthcare personnel cannot avoid prolonged static postures, thus, we are often susceptible to this kind of diseases. Even in optimal seated postures, more than one-half of the muscles of the body are contracted statically and there is little movement of the vertebral joints. This may result to physiological changes that can lead to damaging our back, neck, or shoulder pain that ends to be MSDs. If regular chronic pain or discomfort is ignored, the cumulative physiological damage can lead to an injury or worse, a career-ending disability.
There is a lot of factors causing MSDs in dentistry, ranging from non-ergonomic operator's chair to improper visualization procedure of the oral cavity up to lack of exercises that may worsen muscle imbalances. However, proper patient-positioning techniques can go a long way in preventing the progression toward chronic pain or potential injury for the operator. It has been shown that dentists who take the time to carefully position their patients to promote a direct view have significantly fewer shoulder and back pains. Patient-positioning techniques will vary slightly depending upon the actual tooth surface being treated, the patient’s tolerance to reclining, and patient chair shape and width
Guidelines for Operator’s Posture During Treatment
- The dentist is seated properly and the height of the stool is adjusted correctly.
- The assistant may be either standing or seated; alternating between these during the day can be very beneficial for the assistant’s musculoskeletal health.
- If seated, the assistant’s eye level must be 4 to 6 inches above the dentist’s for optimal viewing of the oral cavity.
- Back should be straight and respect for the body symmetry; avoiding rounding the back into "C" shape.
- Forward inclination of the trunk of a maximum of 20°; a greater forward inclination, the tilting to a side and the trunk rotation are contraindicated.
- Forward inclination of the head up to 20-25° from the trunk
- Arms should be placed along the body, forward oriented within 10°; the forearms raised up to 25° from the horizontal line.
- The angle between the thighs and shanks of 105-110°.
- The thighs apart up to 45°, avoiding a rigid fixation of the hip joint.
- The shanks oriented perpendicular to the floor or slightly posterior.
- The recommended distance between the working field and the dentist’s eyes is of 35-40 cm or slightly higher for very tall dentists.
- The use magnification systems (glasses and corrective lenses, loupes and telescopes, the operating microscope) deserves a special attention because it could help avoid serious implications for bad posture.
Patient's Positioning on Upper Arch
ON UPPER ARCH:
After the operator and assistant stools are properly adjusted, the patient must be positioned properly depending upon the quadrant and tooth surface being treated. For the upper arch, follow these general guidelines:
1. The patient should be recline fully supine position.
(Some patients resist reclining due to postural hypotension, inner ear issues, vertigo, difficulty in breathing and other conditions. However, this is oftentimes of a psychological origin.)
- Try positioning the chair already partly reclined before the patient arrives. In this way, when the chair is fully reclined, it will not feel as dramatic to the patient.
- Placing distractions such as TV, mobiles, or other on the ceiling can help get the patient more comfortable while supine.
2. Ask the patient to move to the end of the headrest. This is especially important if using a flat headrest. Avoid reaching or leaning over the headrest space as it leads to straining the trapezius and shoulder muscles.
3. Adjust the head tilt appropriately for the upper arch, angling the double articulating headrest up into the patient’s occiput. This will not only enable better viewing of the oral cavity, but also help relax the patient’s cervical muscles. The occlusal plane of the upper jaw should be tilted backward up to 25° in relation to the vertical plane.
4. Rotation and bending of the neck from side to side to achieve a better view of the working area. Rotation can be done with verbal cues, while side-bending can be performed manually to the patient’s head.
For example, when treating the occlusal of tooth No. 3, the patient’s head may be rotated slightly toward the operator. The operator must then be positioned correctly depending upon the tooth surface being treated.
5. Moving into different clock position that establishes a line of view that is perpendicular to the tooth surface being treated.
6. Mouth mirrors should be used whenever direct viewing of the oral cavity requires leaving neutral posture. A study reveals that more dentists who use a mirror appropriately are pain-free than those who do not utilize a mirror.
For example, when treating the occlusal of tooth No. 16 the dentist should be in the 11 o’clock to 12 o’clock position to enable an indirect line of sight perpendicular to the tooth surface. The 11 o’clock to 1 o’clock positions enable some of the most neutral operator postures, especially of the arms, and should be made easily accessible in the operatory Frequent positioning at the 10 o’clock position without a mirror tends to encourage more arm abduction and neck/ shoulder problems.
7. Position the tray and delivery system within easy reach. Handpieces and instruments should be at about elbow level. The use of rotoquick is also suggested to avoid carpal tunnel.
8. Direct the overhead light to prevent shadowing. The light should parallel the operator’s line of sight to within 15°. The light will be placed slightly behind and to one side of the operator’s head. A head-mounted light will parallel even more closely with the operator’s line of sight to prevent shadowing. For the upper arch, a mirror may be used to reflect light onto the surface.
ON LOWER ARCH:
1. Recline the patient to a semi-supine position. This will be only 20° elevated from the horizontal supine position. A common mistake is to position the patient halfway between supine and a full-upright posture for lower arch, which can make visualizing the oral cavity a postural challenge.
2. Adjust the headrest forward, so the patient’s chin tilts downward and the occlusal plane of the lower jaw is close to horizontal when the dentist is working in the 9 o’clock to 10 o’clock position.
- The head will need to be tilted further back when treating anterior teeth of the lower jaw and further still when treating the lower molars and premolars.
3. Adjust the height of the patient chair so forearms are parallel to the floor or sloping 10° upward. The height of the patient chair when treating the mandibular arch will need to be lower than when treating the maxillary arch.
4. Adjust the patient’s head position: Rotate the patient’s head to view the treatment area. For example, when treating the lingual of tooth No. 31, the patient’s head may be rotated away from the operator.<
5. Move into a clock position that establishes a line of view that is perpendicular to the lingual surface being treated. This may be direct or indirect, depending upon the tooth surface being treated. For the lingual of No. 19, the dentist should be in the 9 o’clock position to enable a direct line of sight perpendicular to the tooth surface.
6. When treating the anterior teeth, molars or premolars of the lower jaw, an 11 o’clock to 12 o’clock position may be used. For anterior lower teeth, the lower jaw should be angled backward about 30°. Tilt the headrest slightly backward or use the large end of the dental cushion to slightly elevate the chin. For molars and premolars, the lower jaw should be angled backward even further.
7. With tight patient schedules, emergencies, and production goals to consider, it is easy to overlook proper patient positioning. However, taking the time to position the patient, dentist, assistant, and equipment properly can not only have positive effect for the operator’s posture, comfort, and career longevity—it can also make the treatment efficient.
In conclusion, this is something, we, as dental practitioners should not ignore as it can truly be detrimental to us in practicing our profession. Making sure that we protect our health as we go about our business is crucial, so, we can continue providing our services to our patients and enjoy as much as we can our passion in going about our dental practice.
Dr. Bryan Anduiza - Writer
Dr. Jean Galindez - Editor