MSDs

 

Musculoskeletal Disorders among Dentists in Saudi Arabia

MUSCULOSKELETAL DISORDERS AMONG DENTISTS IN SAUDI ARABIA *TARIQ ABDULLAH ABDULJABBAR, BDS, MSC, DMSc.  ABSTRAC  ABS TRACT T The objective of the study was to find out the prevalence and distribution of musculoskeletal symptoms among dentists in Saudi Arabia. Furthermore, to find possible correlations between these symptoms and working positions and actions. A questionnaire about musculoskeletal symptoms in different parts of the body was completed complet ed by 140 dentists (63 male, 77 7 7 female) from the public dental service clinics in Dammam and Riyadh cities. Also, A lso, a physical ergonomic examination was carried out o ut during visiting the work places of 60 freshly graduated dentists in King Saud University College of   Dentistry, Dammam Dammam Central Hospital and the Military Hospital in Al-Khobar. The following aspects were investigated: the sitting work posture, the clock-related working position, the use of dental mirror, active neck mobility and support of the left arm. The descriptive data were analyzed and chi-square test was used for statistical significance (P<.05). Eighty-three of the responding dentists had pain or discomfort from the neck, shoulders, lower back or head. Younger Youn ger dentists had more symptoms than the older dentists. The female dentists had a significantly higher frequency of pain, headache and weakness than their male counterparts. Pain and headache were the most commonly reported symptoms. The dentists who use the mirror more often had less pain or discomfort in the upper locomotor system than those who do not. The analysis of the ergonomic examination showed that the most frequently used postures were posture 1 (the whole back bent, the seat straight) and posture 3 (straight lower and upper back, the neck bent, the seat straight) (46.7% and 40.0% respectively). Dentists who used posture 1 have more neck ache (25%) and lower back pain (57.1%) than those who used posture  3. No significant difference was found between male and female dentists in regard to the presence of   pain (P>.05). The 10 o’clock position was the most frequently used working position by the dentists.  Most of dentists supported their left arm over the left side of the head of the patient. It can be concluded that the prevalence of musculoskeletal symptoms among dentists in Saudi Arabia is high. A correlation between back pain and different work actions was observed in this investigation. Key words: Musculoskeletal words:  Musculoskeletal disorders, Occupational health, Dentists in Saudi Arabia, Working  positions.

INTRODUCTION Occupational health hazards are common in many sectors and are on the increase. Musculoskeletal disordis orders (MSDs), which are problems of musculoskeletal system, are significant and costly workplace problems affecting occupational health, productivity and the careers of the working population. Musculoskeletal diseases, including pain, weakness and parasesthesia, are reported to be associated with wide range of 

occupations 1-6 . Nearly 2 million workers suffer from musculoskeletal disorders each year. These problems are caused by repetitive, awkward, or stressful motions 7.  Dental personnel had an increased risk of  developing such disorders 8, 9. Physically unfavorable load is probably an essential factor in the emergence of symptoms in the upper locomotor system. However, it should be indicated that other factors can contribute to the development and

* Assistant Professor, Professor, Departmen Departmentt of Prosthetic Dental Dental Sciences, College College of Dentistry, Dentistry, King Saud University, University, Riyadh Correspondence: Dr. Correspondence:  Dr. Tariq Abdullah Abduljabbar, P. O. Box 60169, Riyadh 11545, Saudi Arabia. Cell: (966) 504413113, Phone: (966) 1- 467 7325, Fax: (966) 1- 465 6663, Email: [email protected] Pakistan Oral & Dental Journal Vol 28, No. 1

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the experience of pain and discomfort. Later investigations indicated that causes in the psychic working environment such as work satisfaction, the level of  appreciation, self-confidence, anxiety and worry about the future can also influence the experience of pain and discomfort. Rundcrantz et Rundcrantz et al al.. 10 emphasized that dissatisfaction with work, demand of performance, anxiety,

tendinitis or tendo-vaginitis, probably due to friction. The three possible routes to neck-shoulder muscular pain are mechanical failure, local ischemia and energy metabolism disturbance. The high frequency frequ ency of symptoms from the neck, shoulders, and upper extremities extremitie s of the dentists was probably related to their difficult work positions with cervical flexion and rotation, ab-

psychosomatic sickness (headache, insomnia, stomach trouble) and concern about the future, can be strong contributing factors in pain and discomfort perception. He concluded that these factors together may give rise unsatisfactory personal harmonity, which probably increases the risk of pain and discomfort.

ducted arms, and repetitive precision-demanding handgrips18 .

The physical load among dentists seems to put them at risk for the occurrence of musculoskeletal disorders. Muscular imbalance, neuromuscular inhibition, and pain and dysfunction may frequently be observed among oral health care providers. Repeated unnatural, deviated or inadequate working postures, forceful hand movements, inadequate equipment or workplace designs and inappropriate work patterns are likely to be the particular particula r risk factors. However, MSDs are not an avoidable part of the oral health care providers’ professional lives 11-13. The high frequency of musculoskeletal disorders probably reflects the specific work load in dentistry, with high demands on vision and precision and fine manipulative hand movements and work with unsupported, elevated arms. The symptoms might impair work capacity and the future possibility to stay in the profession. Studies have shown that active leisure and several psychosocial work factors strongly influence good general health and well-being. Physical tasks influence musculoskeletal musculoskeleta l disorders more than active leisure and psychosocial work factors 14-17. The possible pathophysiological mechanism mechan ism of occupational stress on the neck and shoulders has been reviewed by Hagberg 18. A mechanical origin for cervical disc degeneration and osteoarthrosis is reported for a few occupational groups. However, a mechanical origin for osteoarthrosis is debatable. deb atable. A work posture involving elevated arms may accelerate degeneration of shoulder tendons through impairment of circulation due to static tension and humeral compression against the coracoacromial arch. Furthermore, work tasks with repetitive arm movements may evoke shoulder Pakistan Oral & Dental Journal Vol 28, No. 1

 A high proportion of dental practitioners suffer from backache 19, 20. A dentist would have approximately 50% chance for partial or complete premature retirement due to ill health. Data collected in the 1940’s revealed that more than 65 percent of dentists suffered backache 21.  Ever since, many major changes have occurred in dentistry such as: a change to “sit-down” technique; improved design of most dental equipments and increased utilization of motion- economy principles, e.g., four-handed dentistry. Chronic musculoskeletal pain appears early in dental careers, careers , with more than 70 percent of dental students of both sexes reportr eport22, 23 ing pain by their third year . MSD was shown to interfere with daily activities in some cases, while a considerable proportion of dentists had also sought medical attention for their symptoms24, 25. The dentists in the Public Dental Service were found to have a high prevalence of pain and discomfort in the locomotor system. Female dentists had a higher prevalence of  pain and discomfort. Younger dentists had pain and discomfort in the neck, shoulders and headaches than older dentists. Male dentists, who positioned their patient carefully to gain a direct view, suffered less from headache. Furthermore, dentists who used the mirror reported less headache and pain and an d discomfort in the shoulders. The ergonomic examination showed that dentists without symptoms applied a wedge cushion under the upper part of the patient’s back to obtain ob tain an optimum view. Specialists, both with and without cervico-brachial symptoms, were more satisfied with their personal control over their work and the stimulation from their work than were general practitioners. Physiotherapy with a psychosomatic approach and individual ergonomic instruction gave better relief  from pain and discomfort and an increased feeling of  mental well-being than did ergonomic instruction only. Personal harmony and age had the highest value for explaining the number of painful sites in the muscu136

 

Musculoskeletal Disorders among Dentists in Saudi Arabia

loskeletal system 26. The frequency of lower extremity complaints was low, and only a few of these complaints complai nts 27 were considered work-related .

There is no sufficient information about the spread of  such disorders in Saudi Arabia 36. The purpose of this research was to study the prevalence and distribution of symptoms of MSDs among dentists in Saudi Arabia. Basic operating posture is considered an important  Also, the relationship between these symptoms and occupational health issue for oral health care clini- work sitting postures of newly-graduated dentists was cians. It is generally agreed that the physical posture to be identified. of the operator, while providing care, should be such that all muscles are in a relaxed, well-balanced, and MATERIALS & METHODS neutral position. Postures outside of this neutral posiQue est stio ion nna nair ire e tion are likely to cause musculoskeletal discomfort 28. I. Qu Ergonomics is the application of a body of knowledge In the first part of the investigation, 300 questionquestio naddressing the interactions between man and the total naires concerning analysis of musculoskeletal sympworking environment, such as atmosphere, heat, light toms in different parts of the body were randomly and sound, as well as all tools and equipment of the distributed in the Public Dental Service Clinic in workplace. Work related musculoskeletal injuries, Dammam and Riyadh cities. The questionnaire, as caused by poor posture, have been discussed discuss ed in human shown in table 1, was adopted and modified modifie d from forms dentistry for several years. Neglect of ergonomic prin10, 19 in previous studies . Only 46.7% of dentists (140: 63 ciples brings inefficiency and pain to the workplace. An male, 77 female) responded by answering the questionergonomically deficient workplace may not cause imnaire. mediate pain, because the human body has a great capacity for adapting to a poorly designed workplace or II. Ergo Ergonomi nomic c Exam Examinat ination ion structured job. However, in time, the compounding In the second part of the study, physical examinaexa minaeffect of job and/or workplace deficiencies will surpass tion was carried out during visiting the work places pla ces of  the body’s coping mechanisms, causing the inevitable: 60 freshly graduated dentists in KSU Dental College, physical symptoms, emotional stress, low productivity, Dammam Central Hospital and the Military Hospital in in and poor quality of work 29, 30. Khobar. After the physical examination was carried Since 1992 the Occupational Safety and Health out, the dentists were asked if they have any of   Administration (OSHA) has been preparing Federal musculoskeletal symptoms. All dentists were asked to legislation concerned with ergonomic hazards in at- examine the distal surface of the left maxillary first risk workplaces 31 . Ergonomics is the study of people at molar. The following aspects were investigated: work to understand the complex relationships among people, machines, job demands, and work methods. metho ds. As  A. The sitting work wor k postures long as stress is kept within reasonable limits, work The sitting position of the dentist dentis t while working on performance will be satisfactory and the worker’s a simulated case was registered according to Fig 1. health and well-being will be maintained. However, if  clock lock-re -relat lated ed workin working g position position stress is excessive, undesirable outcomes outco mes may result in B. The c the form of accidents and injuries. injuri es. A variety of muscuWith the mouth of the patient as the center of a loskeletal injuries and disorders can be caused by circle, the dentist’s working positions are described physical stress in the work environment. Because of  according to the figures on a clock dial (Fig 2). the high medical and compensation costs associated Consequently, twelve o’clock corresponds to the with these problems, it becomes essential in many dentist sitting behind the head of the patient. manufacturing situations to implement programs for controlling physical stress. An important part of any C. Th The e use use of d den enta tall mirror mirror control program is job evaluation 32, 33. D. Act Active ive ne neck ck mob mobili ility ty (The  (The mobility was graded The epidemiologic data regarding MSDs have been as normal, moderately restricted and very re14, 16, 34, 35 obtained from many countries and societies . stricted). Pakistan Oral & Dental Journal Vol 28, No. 1

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Musculoskeletal Disorders among Dentists in Saudi Arabia

F. Su Supp pport ort of the the lef leftt arm arm The chi-square test was used for statistical analysis. A probability level of P<.05 was accepted as statistically significant. RESULTS Results of the questionnaire The results showed that dentists without symptoms are somewhat older than those with symptoms. They have also been in the profession for a longer time. It was found that dentists who have increased the working-hours per week showed more symptoms. No significant difference was found between male and female dentists (Table 2).

 A. The whole back bent the seat straight B. Straight lower and upper back , the neck bent, the seat straight str aight C. The whole back bent, the seat forward tilted D.

Of the 140 dentists who answered the questionnaire, 82.9% dentists (63 male and 77 female) had one or more symptoms in the musculoskeletal system, which include pain (59.3%) as the most severe symptom

Straight lower and upper back, the neck bent, b ent, the seat forward tilted.

in the neck and shoulders region followed by headache (28.6%), then weakness (15.7%). The female dentists had a significantly higher frequency of pain, headache Fig 1: The four sitting work positions and weakness than their male counterparts (Table (Tab le 3). Eighty-three dentists (59%) had pain and discomfort in E. Abil Ability ity to perfo perform rm active active mobilit mobility y of the shoulshoul- different parts of the locomotor system during the ders was registered using the following tests; previous 12 months. The highest percentage of dentists had pain and discomfort in the neck (67.9%) followed by • The ar arm m behin behind d the the back back with with the fin finger gerti tips ps the lower back (52.1%). The symptoms were most touching the opposite inferior angulus of  pronounced among female dentists (Table 4). The scapula. dentists who reported symptoms during the previous • The arm ove overr the the head head wit with h the the hand hand tou touchi ching ng seven days had the highest frequency of pain and discomfort in the neck, shoulders, lower back region the opposite ear. and/or headache. When the operating position of the dentist in relation to the patient was described as clock face with the patient’s mouth as the centre of the dial, 67.9% of the dentists reported using a position between 10 and 12 o’clock. Dentists who used 9 o’clock position reported more symptoms (76.5%), while dentists who used 10 o’clock position reported the lowest symptoms (48.3%). Only 17 dentists with symptoms from neck and lower back used position 12 o’clock.

Fig 2: The workin working g positio positions ns accord according ing to a clock clock figure. Pakistan Oral & Dental Journal Vol 28, No. 1

Participants were asked to indicate how ho w long they worked without taking a 10- minute break. Respondents were categorized according to the length of time 138

 

Musculoskeletal Disorders among Dentists in Saudi Arabia

Please answer by putting a cross in the appropriate box - one cross for each question (To be answered only by those who have had symptoms). Have you, at any time during the last 12 months, had symptoms (ache, pain, discomfort)? Neck

1. No

At any time during the last 12 months that interferes with normal work? 2. Yes

At any time during the last 7 days?

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

Shoulders 1. No. 2. Yes, in the right 3. Yes, in the left 4. Yes, in both shoulders Elbows 1. No 2. Yes, in the right 3. Yes, in the left 4. Yes, in both elbows Wrists/hands 1. No 2. Yes, in the right 3. Yes, in the left 4. Yes, in both Upper back 1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

One or both knees 1. No

2. Yes

1. No

2. Yes

1. No

2. Yes

2. Yes

1. No

2. Yes

1. No

2. Ye

Lower back One or both hips/ thighs

One or both ankles/feet 1. No

TABLE 1. THE QUESTIONNAIRE USED IN THE T HE STUDY  With symptoms (mean±SD)

Without symptoms (mean±SD)

Male (n=45)

Female (n=71)

Male (n=18)

Female (n=6)

 Age  Ag e

42.31±7.61

38.7±5.87

47.44±12.21

39.17±7.88

 Years inprofession

15.56±8.14

7.38±4.48

21±10.59

13.17±7.39

Working hours per week

42.30±7.0

34.69±9.23

32.27±15.74

39.5±5.05

TABLE 2. DEMOGRAPHIC DATA OF THE DENTISTS INVOLVED IN THE STUDY. Pakistan Oral & Dental Journal Vol 28, No. 1

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Symptoms

Total (n=140)

Male (n=63)

Female (n=77)

No

%

No

%

No

%

Pain

83

59.3

36

57.1

47

61

Headache

40

28.6

8

12.7

32

41.6

Numbness

11

7.9

5

7.9

6

7.8

Weakness Pins & Needles

22 5

15.7 3.6

4 1

6.3 1.6

18 4

23.4 5.2

TABLE 3. FREQUENTLY REPORTED SYMPTOMS Total (%)

Male (%)

Female (%)

Pain

59

57.1

61

Ne c k

67.9

66.7

68.8

Right

25

30.2

20.8

Left

5

7.9

2.6

Both

16.4

3.2

27.3

52.1

52.4

51.9

Right

2.9

3.2

2.6

Left

0

0

0

Both

0

0

0

Right

14.3

11.1

16.9

Left

1.4

3.2

0

Both

3.6

0

6.5

One or both hips/thighs

3.6

4.8

2.6

One or both knees

7.1

1.5

11.6

One or both feet/ankles

0.7

0

1.3

Shoulder

Lower back Elbow

Wrist/Hand

TABLE 4. MUSCULOSKELETAL PAIN AND DISCOMFORT IN DIFFERENT PARTS OF THE BODY  DURING THE PAST 12 MONTHS AMONG MALE AND FEMALE DENTISTS Symptoms

Number of dentists with pain Number Percentage

Pain

19

86.4

Ne c k

17

77.3

Shoulder

10

45.5

Lower back

18

81.8

TABLE 5. CORRELATION OF SYMPTOMS WITH WORKING WITHOUT A  10-MINUTE BREAK (n=22) Pakistan Oral & Dental Journal Vol 28, No. 1

Posture

Pain (%) Neck

Shoulder

Lower back

Posture A

25

16.7

57.1

Posture B

21

14.3

8.3

TABLE 6. THE PRESENCE OF SYMPTOMS IN RELATION TO THE MOST FREQUENTLY  USED SITTING POSTURES AS SHOWN IN THE FIGURE #1

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they worked before taking a 10-minute break into toms and not to the frequency and intensity intensi ty of pain and periods of one hour duration. The most commonly discomfort. Furthermore, the results are based on a selected time period was of 1-2 hours duration (Table  visit to the workplace of 60 newly-graduated dentists 5). It was found that increasing increasin g the length of working and on a structural interview. time without 10-minute break for more than tha n 3 hours is The investigation showed that the frequency of  usually associated with increased increas ed pain and discomfort headache and also pain and discomfort in the neck, (86.4%), lower back pain (81.8%), and neck pain (77.3%). shoulders and lower back, was relatively high. This Eighty-nine percent of the sample reported that corresponds with earlier investigations from different they practice four-handed dentistry, with 57% parts of the world 22, 24, 26, 27. Only 24 dentists, out of the complaining of one or more of the musculoskeletal 140 who answered the questionnaire, were completely symptoms. The symptoms had been decreased with without pain and discomfort in the locomotor system. dentists who used the dental mirror all the time. The female dentists had a significantly higher fre According to the patient position, about 72.1% dentists quency of pain, headache and weakness than their use the supine position as the preferred patient posimale counterparts. This could be explained because tion. Sixty-eight percent of them had pain in the neck female usually has lower threshold of tolerance than and shoulders. male. Furthermore, the results showed that the freResults of the Ergonomic Examination quency of pain and discomfort had tendency to decrease with age and with the number of year in practice. The During the examination of the left maxillary first low occurrence of pain and discomfort among older molar by 60 recently graduated dentists (30 female, 30 male), the results showed that the most frequently dentists may be due to the “healthy workers effect” and due to the ignorance of ergonomics in the new dental used postures were posture 1 (46.7%) and posture 3 curriculum. In addition, older dentists have been taught (40.0%) in both groups (Fig 2). Dentists who used to more frequently use the dental mirror for directly posture 1 have more neck ache (25%) and lower back inaccessible areas in the patient’s mouth. mouth . While older pain (57.1%) than those who used posture 3 (Table 6). dentists are more specialized with less load of patients, No significant difference was found between male and younger dentists are mainly practicing general denfemale dentists in regard to the presence of pain tistry or enrolled in postgraduate training that put (P>.05). The 10 o’clock position was the most frethem under more pressure. Instead of using the dental quently used working position by the dentists. dentists . Most of  mirror, younger dentists work more often with a direct dentists used the dental mirror during the examination  view and with the use of wedge cushion to improve the of the left maxillary first molar. Most of dentists  view. However, there was no correlation between the supported their left arm over the left side of the head frequency of symptoms and the age. It appeared from of the patient. the results that the dentists who position their patients Moderate restricted mobility was found only in a in a appropriate position for direct view had a signififew dentists without significant differences between cantly lower frequency of pain. In agreement with groups and restriction was most common during flex- previous study the results showed that dentists who ion of the neck. However, no significant difference was usually use the dental mirror in positions where a found between dentists with and without pain and direct view is difficult had significantly less pain and 37 discomfort concerning the neck mobility. All dentists discomfort . were able to perform the active mobility tests of the shoulders without difficulty.

In regard to the ergonomic examination, the left maxillary first molar was chosen because it is difficult to obtain a direct view in such area from the mouth DISCUSSION without bending the neck into an unfavorable way. The The dentists were asked to note the occurrence occu rrence of  direct view may be improved by putting the wedge pain and discomfort over the past twelve months month s and cushion under the upper part of the back of the th e patient. the previous seven days. The questionnaire gives  Also, it is important to support the arms to reduce the answers only with respect to the occurrence of symp- static work of the muscles of the neck ne ck and shoulders. If  Pakistan Oral & Dental Journal Vol 28, No. 1

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the dentist works with direct vision, it is probably appropriate for him to sit in the 9 o’clock position when working in the upper jaw to reduce the stress on the neck. In the working position 11 or 10 o’clock, the dental mirror should be used to reduce the load on the neck. The appearance of musculoskeletal symptoms among dental students, even after a relatively short clinical training period, suggests that ergonomics should be covered in the educational system to reduce risks risk s to 38 39 dental practitioners . Valachi et al  showed that there are deficiencies in operator position, posture, flexibility, strength and ergonomics. Education and additional research are needed to promote an understanding of  the complexity of the problem and to address the problem’s multifactorial nature. A comprehensive approach to address the problem of MSDs in dentistry represents a paradigm shift in how operators work. New educational models that incorporate a multifacto-

source of economic drain to these organizations. Sources of this drain include economic losses incurred from lost or decreased productivity as well as medical treatment and indemnity costs. Therefore, it is within the best interest of these organizations to prevent work-related musculoskeletal disorders from occurring, before they manifest into serious issues of medical, social, and economic concern. The dental teams need functionally designed dental equipment and proper training in ergonomic methods 40-42. Therefore it is useful to take again a closer look at the preventive measures that can contribute to less physical and psychological strain in the daily practice 43. The use of ergonomic design and appropriate selection of hand tools can reduce exposure to cumulative trauma. Remember, tissues of each individual have a threshold of resistance, and if that threshold is crossed too many times by a defective or illfitting tool, pathologic changes can occur. The proper tool design, rotating work schedules, work pacing, scheduling, and exercise programs can, in combina-

rial approach can be developed to help dental operators manage and prevent MSDs effectively. Physiological changes that accompany these disorders can be related to practices used by today’s operators-primarily being seated for prolonged periods. Studies associated such postures with increased disk pressures and spinal hypomobility, which are factors that may lead to degenerative changes within the lumbar spine and low back pain or injury. There is a relationship shown between prolonged, static (motionless) muscle contractions and muscle ischemia or necrosis. Weak postural muscles of  the trunk and shoulder may lead to poor operator posture. As muscles adapt by lengthening or shortening to accommodate these postures, a muscle imbalance may result, leading to structural damage and pain. A significant number of today’s dental operators experience musculoskeletal pain and are at risk of  developing serious MSDs. A thorough understanding of  the underlying physiological mechanisms leading to these problems is necessary to develop and implement a comprehensive approach to minimize the risks of a work-related injury.

tion, improve productivity and promote human wellness14, 44-47. Although there have been considerable advances in dental equipment, the introduction of  such technology has often been piecemeal and “rushed to market.” As a result there has been insufficient attention paid to ergonomic considerations and a systematic approach to dental ergonomics have not yet emerged 48.

Work-related musculoskeletal disorders diso rders are of serious concern to many organizations, including industry, insurance, and health care. They are also of  immediate concern to the workers and their families who are adversely affected by these disorders. Workrelated musculoskeletal disorders are a substantial

Within the limitations of the present research, research , the following conclusions can be drawn down:

Dentists can recognize and identify their own postures, practicing positions, and the equipment usage patterns that are associated with increased risks ris ks of  experiencing musculoskeletal pain and discomfort. Such recognition is the first critical step to avoiding or neutralizing ergonomic habits and work environment layouts that might otherwise unnecessarily shorten professional clinical careers 49. Further studies are required to identify the factors, which will reduce the prevalence of the musculoskeletal symptoms among Saudi dentists. CONCLUSIONS

1

The resu results lts sugg suggest ested ed that that the the pre preval valenc ence e of  musculoskeletal symptoms among dentists in Saudi Arabia is high.

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Musculoskeletal Disorders among Dentists in Saudi Arabia

2

Pain and Pain and head headach ache e were were the the mos mostt comm commonl only y reported symptoms.

3

Youngerr dent Younge dentists ists had mor more e symp symptom tomss than than the older dentists. The female dentists had a significantly higher frequency of pain, headache and weakness than their male counterparts.

4

Modific Modi ficat ation ion of of the the workp workplac lace e does does not not have have an effect on the prevalence of symptoms.

14

Akesson I, Schutz A, Horstma Akesson Horstmann nn V, Skerfv Skerfving ing S, Morit Moritz z U: Musculoskeletal symptoms among dental personnel; - lack of  association with mercury and selenium status, overweight and smoking.  Swed Dent J 2000;24(1-2):23-38.

15

Milerad E, Ekenv Milerad Ekenvall all L: L: Symptom Symptomss of the the ne neck ck and upper extremities in dentists.  Scan d J Work Envir on Heal th 1990;16(2):129-34.

16

Murtomaa H, Haav Murtomaa Haavio-M io-Mannil annila a E, Kandoli Kandolin n I: Burnout Burnout and and its causes in Finnish dentists. Community Dent Oral Epidemiol

17

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