|Year : 2021 | Volume
| Issue : 5 | Page : 441-448
Ergonomic risks and prevalence of musculoskeletal disorders among dental surgeons in Nigeria: A descriptive survey
Lillian Lami Enone1, Afolabi Oyapero2, Olabode Ijarogbe3, Tope Emmanuel Adeyemi4, Rasheedat Oluwakemi Ojikutu5
1 Department of Restorative Dentistry, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
2 Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
3 Department of Restorative Dentistry, Faculty of Dental Sciences, College of Medicine University of Lagos, Ikeja, Lagos, Nigeria
4 Department of Child Dental Health, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
5 Department of Oral and Maxillofacial Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
|Date of Submission||15-Feb-2021|
|Date of Decision||04-Aug-2021|
|Date of Acceptance||23-Jun-2021|
|Date of Web Publication||11-Oct-2021|
Dr. Afolabi Oyapero
Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Ikeja, Lagos.
Source of Support: None, Conflict of Interest: None
Aim: To determine the prevalence of musculoskeletal disorders (MSDs) among dentists in Nigeria, where it is underreported, and to correlate these MSDs with occupational and stress-related ergonomic challenges. Materials and Methods: This descriptive study was conducted among randomly selected dentists in Nigeria. A modification of the validated Nordic questionnaire was utilized to determine the prevalence of MSDs. Paired t-tests and analysis of variance tests were used to determine statistical differences between numerical variables. The logistic regression analysis was used to confirm significant effect of predictor variables on work-related MSDs (WMSDs). Difference at the 5% level was accepted as significant. Results: Most of the participants were males (58.8%), aged between 26 and 30 years (37.2%), had <5 years of experience (38.2%), and worked an average of 31–40 min for each patient. Eighty-eight participants (44.2%) had WMSDs within 7 days, whereas 126 (63.3%) had in the preceding year. Within a 12-month period, however, neck pain was the commonest complaint (22.2%), followed by lower back (20.6%) and upper back pain (18.3%). The linear regression analysis showed that age of participants: >40 years [Exp β: 1.003; confidence interval (CI): 0.848–1.187; P = 0.020], body mass index: obese (Exp β: 1.079; CI: 0.733–1.589; P = 0.027), average time spent on each patient: >50 min (Exp β: 0.903; CI: 0.313–2.609; P = 0.049), having dental nurses in the clinic: >10 (Exp β: 0.959; CI: 0.410–2.243; P = 0.000), and a high level of environmental stress (Exp β: 1.092; CI: 0.862–1.384; P = 0.029) were significantly associated with MSDs. Conclusion: Our study showed that dentists who were older than 40 years, those who were obese, those who spent an average of 50 min on each patient, and those who had few dental nurses in the clinic and had a high level of environmental stress had a significantly higher prevalence of MSDs. Modifiable chairs, correct sitting postures by the dental surgeon and the patient, adequate lighting, use of indirect vision, use of magnification loupes, and sufficient rest and breaks at work could help to ameliorate these conditions.
Keywords: Dentists, Ergonomics, Musculoskeletal Disorders (MSDs)
|How to cite this article:|
Enone LL, Oyapero A, Ijarogbe O, Adeyemi TE, Ojikutu RO. Ergonomic risks and prevalence of musculoskeletal disorders among dental surgeons in Nigeria: A descriptive survey. J Int Oral Health 2021;13:441-8
|How to cite this URL:|
Enone LL, Oyapero A, Ijarogbe O, Adeyemi TE, Ojikutu RO. Ergonomic risks and prevalence of musculoskeletal disorders among dental surgeons in Nigeria: A descriptive survey. J Int Oral Health [serial online] 2021 [cited 2021 Dec 6];13:441-8. Available from: https://www.jioh.org/text.asp?2021/13/5/441/327867
| Introduction|| |
In spite of contemporary technological advancements, dentists still remain susceptible to many work-related risks. These hazards encompass cross infections, ocular trauma, harmful irradiation, allergies and reactions to dental materials, psychological distress, and musculoskeletal disorders (MSDs). MSDs are complaints, symptoms, or pain that include a number of conditions such as neck pain, back pain, shoulder pain, pain of limbs, carpal tunnel syndrome, myofacial dysfunction syndrome, atypical facial pain, etc. In 2015, musculoskeletal pain (MSP) affected over 94 million people globally, resulting in a form of disability. In several professions, work-related MSDs (WMSDs) are common and are major reasons for reduced productivity, human injuries, delay in the work time, and absence from work.
Various researchers have documented WMSDs as a prevalent source of occupational health disorders. In the field of dentistry, WMSDs frequently affect professionals; recognizing the ergonomic risk factors and its potential harms are of utmost importance. Some of the documented common risk factors include use of certain work tools (vibrating instruments), pattern of work or body position such as concentrated force or movement of specific body parts, reduced resting period, and repetitive movements., Although WMSDs may differ between dental professionals due to the variations in physical activity, the frequently associated symptoms of WMSDs include discomfort, tiredness or fatigue, restricted movement, and pain of muscles, tendons, and joints.
Over the past decade, WMSDs have gradually increased in prevalence across the world and there are extensive, well-documented literature on occurrence of WMSD and its associated risk factors among dentists.,, A secondary publication in 2009 documented a prevalence range of 64–93% for WMSDs in the dental profession, which is a high percentage of workers. Rambabu and Suneetha in 2014, in a descriptive study comparing the WMSDs among physicians, surgeons, and dentists observed that the highest occurrence of WMSDs was among dentists (61%) when compared with surgeons (37%) and physicians (20%). Another study by Kierklo et al. on WMSDs among 220 dentists found that over 92% of the dentists had WMSDs, especially in the neck (47%) and lower back (35%). More than 29% experienced issues with their fingers and 23% had issues with their hip.
Several studies have concluded that the high prevalence of WMSDs among dental surgeons could be due to poor ergonomics maintained by them while working with poor illumination, insufficient magnification, and a limited operating field and in some cases the inability to perform “6-handed dentistry.”,,,, Dental surgeons operate within the mouth which is a small field of operation and they often assume unsuitable postures while providing treatment. These harmful postures create strain and stress in the muscles and joints, with the greatest impact felt in the neck, back, shoulder, and waist. This ultimately leads to limited work productivity and disability.
However, most dentists are not adequately knowledgeable about ergonomics and its impact on musculoskeletal well-being. Providentially, good ergonomics can significantly decrease the risk and severity of WMSDs. An outline of the prevalence of WMSD complaints among healthcare providers including dentists may help to significantly prevent WMSDs and therefore provide a healthier and safer environment for them. Therefore, the aim of this study is to determine the prevalence of MSDs among dentists in Nigeria, where it is underreported, and to correlate these MSDs with occupational and stress-related ergonomic challenges.
| Materials and Methods|| |
This descriptive, cross-sectional study was reviewed by the Institutional Ethics Committee of the Lagos State University Teaching Hospital, and ethical approval was obtained before commencement of the study. The study was conducted in full accordance with ethical principles including the World Medical Association Declaration of Helsinki.
The inclusion criteria for the participants included being a dental house officer, dental officer/general dental practitioner who performs composite restoration procedure on a routine basis, junior registrar, senior registrar, and Specialist Dental Surgeons. Dentists who had spinal deformities, osteoporosis, cancer, or multiple sclerosis and those who had any injuries or disabling conditions in the head or neck were also excluded from the study. Dental students and dentists who did not consent to participate in the study were also excluded from the study. A simple random sampling procedure was used in the selection of government hospitals and private dental clinics, representing the different regions of Nigeria.
Measurement and devices
A modification of the standardized Nordic questionnaire, validated by Kuorinka et al., was used to determine the occurrence of MSDs. The self-administered survey instrument, with many multiple options and with every question indicated as mandatory, was randomly distributed to willing participants (interns, dental officers, resident doctors, and dental specialists in the selected Nigerian dental clinics). The questionnaire encompassed socio-demographic variables such as sex, age, height, weight, hand dominance, smoking and alcohol habits, duration of work, duration spent in treating each patient, work hours per week, and percentage of the day spent sitting. Body mass index (BMI) was determined from height and weight recorded. The incidence of ache, pain, and discomfort within the preceding 12 months and within 7 days was also obtained.
Subsequent to data collation, statistical analysis was performed using IBM SPSS Statistics 22.0 (IBM Corp., Armonk, NY, USA). Frequency distribution tables and cross-tabulations were generated for all inputs provided by participants. Descriptive statistics were generated, whereas means and standard deviations (SDs) were used to describe the demographic details such as age, height, weight, number of years practice, number of hours work per week, and percentage of day spent sitting. χ2 and Fisher’s exact tests were done on all categorical variables to determine whether any significant associations existed. Paired t-tests and analysis of variance tests were done to determine association between numerical variables. The logistic regression analysis was used to confirm significant effect of predictor variables on WMSD. Difference at the 5% level was accepted as significant.
| Results|| |
A total of 240 questionnaires were administered, of which 199 were satisfactorily completed and returned, giving a response rate of 82.9%. Most of the participants were males (58.8%), aged between 26 and 30 years (37.2%), and had <5 years of experience (38.2%). Most of them were general practitioners (44.1%), had normal BMI (60.8%), and were non-smokers (99.5%) [Table 1].
[Table 2] displays the work-related characteristics of the study population. The highest proportion (39.2%) worked between 30 and 40 h per week and worked for an average of 21–30 min for each patient (32.2%). Majority of them had right-hand dominance (85.4%), used direct vision (82.4%), took break in-between patients’ work (54.3), and were exposed to moderate stress (65.8%). There was a significant association among the age group, years of experience, average working time with patients, working hours per week, and hand dominance with the occurrence of MSDs. Those aged >40 years, with 15–19 years of experience, who worked an average of >50 min per patient and an average of >50 h per week and who had a dominant left hand had a higher prevalence of MDS [Table 3].
|Table 3: Socio-demographic and work-related characteristics and its association with MSD|
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[Table 4] presents the 7-day and 12-month prevalence of complaints of back, neck, shoulder, knees, ankle, and hand/wrist among the respondents. Eighty-eight participants (44.2%) had MSD within 7 days, whereas 126 (63.3%) had in the preceding year. Low-back pain was the most prevalent musculoskeletal complaint, reported by 26.1% of the respondents within the last 7 days; this was closely followed by upper back pain. Within a 12-month period, however, neck pain was the most prevalent complaint (22.2%), followed by lower back (20.6%) and upper back pain (18.3%).
|Table 4: Total prevalence of MSDs shown in 12-month and 7-day prevalence (in %)|
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The correlation between environmental stress and age showed a moderate positive correlation (P = 0.027, r = 0.35), whereas a weak, positive correlation was observed between environmental stress and BMI (P = 0.016, r = 0.187). The 12-month prevalence of MSDs correlated significantly with age (P = 0.041, r = 0.10), BMI (P = 0.000, r = 0.191), body weight (P = 0.007, r = 0.173), and body height (P = 0.038, r = 0.128). The 7-day prevalence of MSD showed a significant positive (weak) correlation with age (P = 0.002, r = 0.123) and BMI (P = 0.001, r = 0.178) [Table 5].
|Table 5: Correlation between age/BMI/body height/body weight, level of stress, number of complaint regions in 12-month and 7-day prevalence of MSD|
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The linear regression analysis showed that age of participants: >40 years [vs. other age categories, Exp β: 1.003; confidence interval (CI): 0.848–1.187; P = 0.020], BMI: obese (vs. normal weight, Exp β: 1.079; CI: 0.733–1.589; P = 0.027), average time spent on each patient: >50 min (vs. 1–10 min, Exp β: 0.903; CI: 0.313–2.609; P = 0.049), having dental nurses in the clinic: >10 (vs. none, β: 0.959; CI: 0.410–2.243; P = 0.000), and a high level of environmental stress (vs. low level, β: 1.092; CI: 0.862–1.384; P = 0.029) were significantly associated with MSDs [Table 6].
|Table 6: Logistic regression analysis showing the predictors of MSDs among the study participants|
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| Discussion|| |
Ergonomics is the systematic assessment of human work environments, particularly the interface between humans and equipment. An increase has been observed in WMSDs due to prolonged work hours, poorly designed seats, improper postures, and wrong instrumentation. Prolonged standing and sitting position was the most common form of improper posture identified by the participants in our study, followed by monotonous repetitive movement. Eighty-four respondents (42.2%) rated their work environment as highly stressful, whereas the highest proportion of participants rated their work as moderately demanding. Dental surgeons are particularly vulnerable to musculoskeletal symptoms because the nature of their work exposes them to risk factors for conditions such as tendinitis, synovitis, tenosynovitis, and bursitis. Indeed, a review of about 1000 professions regarding these risk factors concluded that the dental professional is the most vulnerable to them. Dental procedures often involve precise manipulation of the wrists and digits, awkward posturing, use of drills and ultrasonic scalers which transmit vibrations vibrating dental instruments, and monotonous repetitive duties over a prolonged period. This often leads to strain and long-lasting muscular weakness, discomfort, and chronic pain.
The prevalence of MSD among our study participants within the preceding year was 63.3%. This was similar to findings from a study among New Zealand dentists, who had a high yearly prevalence of MSD; 63% of them had lower back or neck discomfort, 49% experienced shoulder discomfort, whereas 42% had symptoms in wrists and hands. In our study, low-back pain was the most commonest MSD and it was reported by 26.1% of the respondents within the last 7 days; this was closely followed by upper back pain. Within a 12-month period, however, neck pain was the most prevalent complaint (22.2%), followed by lower back (20.6%) and upper back pain (18.3%). In a systematic review, WMSDs were most frequently experienced in the neck (58.5%), lower back (56.4%), shoulder (43.1%), and upper back (41.1%) among dentists. The review also documented a prevalence of 57% in Australia, 56% in Poland, 51% in the Netherlands, and 20% in Saudi Arabia, respectively. Among German dentists, 86.7% had complaints from the spine in the preceding year, primarily in the neck and upper back. Likewise, Chinese dentists had neck (83.8%), shoulders (40.1%), hand (18.4%), and elbow (15.1%) symptoms in the preceding year. Extended periods of sitting while treating patients in addition to bending movements as well as lateral flexions of the torso are obvious predisposing factors for these observations.
There was a significant association among the age group, years of experience, average working time with patients, working hours per week, hand dominance, and the occurrence of MSDs. Those aged >40 years, with 15–19 years of experience, who worked an average of >50 min per patient and an average of >50 h per week and who had a dominant left hand, had a higher prevalence of MDS. Zarra and Lambrianidis correlated the number of treated patients with the risk of suffering from musculoskeletal diseases and obtained an odds ratio of 3.52 for dental professionals who treated six to eight patients per day compared with those who treated less than six patients. Hodacova et al. similarly confirmed this result among dentists who attended to 20 patients per day. The findings of our study also concur with a Tunisian study, which reported a strong relationship between long service employment and WMSD (P = 0.001). In addition, a study in Saudi Arabia found that the majority of participants employed in the public sector for 5 years or more had a high prevalence of WMSD. These findings demonstrate the cumulative effect of wrong posture on WMSD.
Among the participants, 20.1% were overweight, whereas 16.1% of them were obese. The 12-month prevalence of MSDs correlated significantly with body weight and body height, whereas the 7-day prevalence of MSD showed a significant positive (weak) correlation with BMI. Moreover, the linear regression analysis showed that obese participants had a higher prevalence of WMSD. A longitudinal population study in Norway identified that obese people had a 20% higher risk of experiencing chronic MSP when compared with those of normal weight. Similarly, for dentists in an Indian study, overweight and obesity were found to be associated with MSP.
Furthermore, the average time spent on each patient was significantly associated with WMSD. Pejčić et al. observed that dentists who did not take breaks in-between patient appointments had significantly higher odds of MSP. Thus a careful schedule of breaks in-between appointments will have an ameliorating effect on WMSD. Another research among Danish dental surgeons also revealed that the duration of each appointment has an influence on neck pain. This was further corroborated by another study that showed that patient treatment time is positively correlated with WMSD pain. Furthermore, having few dental nurses in the clinic and a high level of environmental stress were significantly associated with MSDs.
Established WMSDs cause discomfort, difficulty in task performance, absenteeism, reduced productivity and financial losses from lower working hours, medical expenditure for therapy, and early retirement by dentists. The main goal is to prevent progression of the said changes to the chronic phase of disability. Gupta et al. established that the incidence of MSDs (29.5%) was the primary reason for early retirement among dentists. Besides WMSDs, dental clinical personnel are increasingly developing arthritis and tendinitis in comparison to other occupational groups studied (e.g., doctors and lawyers).,
These identified risk factors for MSDs can be ameliorated with good ergonomics practices. In dentistry, the recommendations to achieve good ergonomics include the use of adjustable chairs with good support, correct positioning of the dentist and patient, proper lighting, indirect mirror viewing, magnification (using loupes), using ergonomic instruments, and taking regular rest breaks with exercise/stretching during breaks.
Due to the self-reported nature of the study, the data obtained are subject to recall bias. Similarly, it is possible that we did not capture all psychosocial stressors, fitness and health activities, job satisfaction, lack of social support by colleagues, and subjective perception of work load on perception about WMSD.
| Conclusion|| |
Our study showed that dentists who were older than 40 years, those who were obese, those who spent an average of 50 min on each patient, and those who had few dental nurses in the clinic and had a high level of environmental stress had a significantly higher prevalence of MSDs. Modifiable chairs, correct sitting postures by the dental surgeon and the patient, adequate lighting, use of indirect vision, use of magnification loupes, and sufficient rest and breaks at work could help ameliorate these conditions.
The authors acknowledge the assistance of the resident doctors who were involved in the dissemination of the study questionnaires.
Financial support and sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
There are no conflicts of interest with respect to the study.
E. L. L. conceived and designed the study, conducted research, provided research materials, collected and organized data, analyzed and interpreted data, and wrote the initial and final draft of the article. O. A. conceived and designed the study, conducted research, provided research materials, collected and organized data, analyzed and interpreted data, and wrote the initial and final draft of the article. I. O. designed the study, conducted research, provided research materials, collected and organized data, interpreted data, and wrote the initial and final draft of the article. A. T. E. and O. R. O. conducted research, provided research materials, collected and organized data, interpreted data, and wrote the initial and final draft of the article. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.
Ethical policy and Institutional Review board statement
Approval for the study was obtained from the Health Research and Ethics Committee of the Lagos State University Teaching Hospital. The purpose of the study was explained to the selected participants and participation was voluntary. Written informed consent was also obtained from all the participants.
Declaration of patient consent
Data availability statement
The datasets will be made available from the corresponding author on reasonable request.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]