Dental Tribune UK & Ireland
Besides causing discomfort, back pain caused by incorrect posture and positioning may also undermine clinicians’ confidence and affect treatment outcomes. (Image: Ali Nankali)

Back pain—a clinician’s nightmare

By Dr Ali Nankali
May 25, 2021

Back pain is one of the most common complications of an incorrect sitting or standing posture. It may appear gradually or suddenly. Many dental practitioners only realise how much of an impact back pain can have on their practice once they experience it. Luckily, although some people suffer from long-term shoulder or back pain, this pain can be reduced within a few weeks or months of treatment.

Back pain is one of the main disadvantages of a dentist’s profession. Some studies show that over 70% of dental practitioners suffer from chronic back pain. In one study on back pain prevalence and intensity in French dentists, female clinicians reported more frequent and intense pain than men, especially in the neck and upper back areas. In the same study, age and years of practice had a direct relationship to the intensity of pain and discomfort.

Dental students are starting to experience musculoskeletal pain as well—an alarming observation that should be taken seriously. I am a clinician myself and have taught both postgraduate and undergraduate dental students for many years. I have also been involved in various research projects and studies. In my experience, it is clear that incorrect posture and positioning is what causes back pain among clinicians.

The problem usually begins when a dental student starts to work with a phantom head at an early stage of his or her studies. A student who is just starting practical exercises is often too eager to absorb all the information and to complete the programmed tasks. Tutors might talk in-depth about the required posture and positioning, yet young practitioners often think that by minimising the working distance and getting closer to the treatment area, they will be able to get a better look at what they are doing and, consequently, achieve a better outcome. This is a false assumption.

Dr Ali Nankali is a clinical senior lecturer at Barts and the London School of Medicine and Dentistry at Queen Mary University of London in the UK and the president of UKDentalCourses. (Image: Ali Nankali)

After a while, many tutors, myself included, get tired of repeatedly talking about the importance of correct posture. Unfortunately, the students in question do not realise that the problem is only getting worse, and they become aware of it only when they start treating their first patients. Since they have a gap in their learning, they do not have enough confidence to correct their posture and positioning, and therefore the incorrect posture and positioning will remain.

For the last seven years, I have paid special attention to the topic and discovered some interesting facts. For example, I now know that the wearing of glasses is one of the main factors affecting posture. Regular reading glasses, provided by an ophthalmologist, have a 22−25 cm focus point. Therefore, the student or practitioner maintains the recommended distance in order to see clearly. Asking for new glasses with a focus point of about 40−45 cm is an easy solution that could help tremendously.

Another interesting fact is that practitioners know better than anyone that they have incorrect posture and positioning, yet they do not know how to correct it. The lack of confidence does not allow them to challenge their habits on their own, and so they often seek help.

Choosing the right dental care unit

Being a member of the dental community, I realised that the first step for many professionals who suffer from back pain is getting a new patient chair. I contacted Planmeca, a well-known dental unit manufacturer based in Helsinki in Finland, to explore its opinion on the topic. Planmeca offers a selection of dental care units with many different configurations. Discussing the issue, Planmeca Senior Vice President Jukka Kanerva explained that the company’s product philosophy has always been that its equipment needs to adapt to the user’s ways of working, not the other way around.

Planmeca is a global company, and its products are distributed in over 120 countries. In order to successfully function in all these markets, the company’s dental units have to adapt to different market requirements. “For example, the preferences of Japanese dentists differ greatly from those of their French colleagues. People come in different shapes and sizes, and dentists like different types of instrument delivery systems,” Kanerva explained.

“Also, some like to treat their patients while sitting down, some while standing. This means that the design of the dental unit needs to adapt to several different variables. For this reason alone, our Planmeca Compact i5 dental unit has an almost unlimited number of different customer configurations available. All our units can also be customised for left-handed users,” he continued.

As we can see from Planmeca’s response, manufacturers are happy to provide practitioners with what is needed. Kanerva assured me that Planmeca follows ergonomic guidelines and studies closely since these are the backbone of its product development process. He commented: “We (Planmeca) also gather feedback from our customers by using many different methods, such as clinic visits by our usability specialists and trade show visits by our sales staff.”

“Of course, anyone can submit their ideas through our website, and these submissions are saved in our database and analysed. The most common requests are those pertaining to a particular way of working, and these vary from country to country. Ease of use and ergonomics are the key attributes that dentists around the world are looking for. We are constantly following trends and developments in the industry.” He also added that Planmeca has several qualified in-house dental professionals who help improve the daily dental workflow from a clinician’s point of view. Additionally, the company says that it tests its products in cooperation with dental clinics. So what, then, are the main factors that a dental unit manufacturer has to consider?

Planmeca dental chair production in Helsinki in Finland. (Image: Ali Nankali)

“There are several key requirements regarding the design and manufacturing of dental units. First of all, wide and smooth movements of instrument delivery are crucial because the unit needs to adapt to different working positions. Wide movement range of the patient chair as well as the shape of the chair’s backrest are also important since they help to ensure that the clinician can get as close to the patient as possible and find and maintain the best working position,” Kanerva explained.

“In order to maintain an ergonomic way of working while treating a patient, all necessary equipment and instruments need to be close by, with the instruments always in the peripheral vision of the practitioner. In this way, hand and arm movements can be limited to the fingers, wrist and elbow, and larger shoulder and torso movements can be avoided. We have also designed special mid-bending instrument arms that further contribute to an ergonomic workflow since they make instruments especially light to use.”

As we can see from the manufacturer’s explanations, it is in its interest to listen to practitioners’ requirements. However, statistics demonstrate that many clinicians are still suffering from back pain. Many dentists who do not know how to manage back pain try to work in a standing or a different sitting position, which, unfortunately, is reported to lead to more intense pain, especially in the upper and lower back areas. Having said that, there are some situations where practitioners should stand to perform the required tasks. These include when extracting a tooth and when taking impressions.

Maintaining the correct posture

Maintaining a good posture helps practitioners achieve superior outcomes and protects them from future problems such as back pain. It allows the practitioner to see the working area properly, which optimises performance and minimises the risk of iatrogenic damage. Contrary to popular belief, keeping the eyes closer to the working area does not help the clinician to have better control of a handpiece. In fact, being too close to the target area, less than 25 cm away, will not only decrease the level of accuracy but will also create discomfort for the patient.

When talking to practitioners, I realised that many of them are turning to self-help sources. I found out that these sources are relatively expensive and written in a very general manner. To help clinicians, I spent nearly three years with both right- and left-handed students and practitioners to create and publish a textbook named Posturedontics. This textbook aims to show the best position and posture for treating each tooth surface area. The book was published a few years ago and has received excellent feedback. Some practitioners mentioned that it is difficult to use the book at first, but as soon as you understand it, you benefit from it.

Being too close to the target area [...] will not only decrease the level of accuracy but will also create discomfort for the patient

In most cases, if a practitioner needs to move his or her head or change posture, he or she has not been able to see the working surface area correctly during the procedure. Not maintaining the most suitable posture for each task will most likely affect the treatment outcome too. To give practitioners guidance on the topic, I started to run courses on posture and positioning on UKDentalCourses.

Studies demonstrate that about 85.5% of clinicians have a forward head posture, whereas 68.8% have a round shoulder posture. For this reason, 36.1% of practitioners suffer from scoliosis and hyperlordosis. Most studies on working posture demonstrate a high risk to the lower back and neck. However, appropriate posture muscle strengthening exercises for the neck area can play an important role in minimising this risk.

Although it is clear that a dentist’s back pain is mainly caused by an incorrect posture, alternative diagnoses should be ruled out by examining or reviewing the signs and symptoms. If a serious underlying pathology is suspected, the dentist should be referred to the right specialist for relevant guidance. Medication, exercises, surgery and cold or warm therapies are the most common methods of treatment depending on the definitive diagnosis. However, the pain will return if the practitioner does not improve his or her posture and positioning.

To remain active in their daily activities, practitioners are advised to take over-the-counter painkillers such as paracetamol or ibuprofen. In my opinion, this depends on the severity of the pathology, as taking medicine might temporarily make you feel better, but it will not solve the problem permanently. Exercises such as lower back pain exercises, bottom to heels stretches, knee rolls and pelvic tilts could be of help.

In conclusion, a young learner needs to understand the importance of his or her posture and positioning from day one and follow the instructor’s recommendations. Incorrect posture and positioning not only cause discomfort such as back pain but also undermine a clinician’s confidence and affect treatment outcomes. Existing self-help sources are highly limited, and practitioners need more help on the topic. Dealing with back pain is crucial, and postponing the treatment may result in more complications.

1 Comment

  • Bernhard Frey says:

    Dear Dr. Nakali,
    thank you for your interesting article. May I suggest you include information about loupes and operating microscopes? Both can help dentists to get a correct working distance.
    Could you let me know the exact name of the studies, please? Thank you! Appreciated.

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