Active Research Musculoskeletal Disorder Risk Assessment in Dental Hygienists
Nearly 70% of dental hygienists report experiencing discomfort in their forearms/wrists/hands, primarily due to the use of dental scaling instruments. Dental scaling requires sustained pinching and repetitive movements that place high load on the forearm and hand muscles. This high muscle load, combined with pinching and non-neutral wrist positions, approximately doubles the risk of developing hand and median nerve pathology due to strain on the tendons and compression of the median nerve. Scaling of more than four hours per day has been directly associated with pathology.
Dental hygiene students have an elevated risk of musculoskeletal injury due to intensive exposure to scaling during their educational training. We have documented a significant increase in subjective reports of discomfort in the hand, wrist, and fingers of these students, with the prevalence of students with discomfort doubling to tripling across their two-year training program. Up to 60% of individuals report having discomfort at the end of their training. To enhance education, develop preventive training, and address work-related musculoskeletal disorders in dental hygienists, it is necessary to better understand the link between exposure and pathology development.
Overall, the problem of musculoskeletal injury within the practice of Dental Hygiene is a multifaceted issue. In addition to adopting awkward trunk and neck postures for long hours due to patient positioning, dental hygienists are also required to apply significant hand forces during removal of plaque and calculus from patient’s teeth. In an effort to mitigate these issues, we are utilizing a synchronized three-view video capture system to monitor dental hygienists during clinical practice.
These videos are being used in the following assessment projects:
Task Analysis of Dental Hygiene Students: We are investigating the duration, frequency, and sequencing of various dental hygiene activities and instrumentation tasks conducted by dental hygiene students within a clinical setting. We aim to not only describe the activity of dental hygiene students, but to provide nuances of the various positions and relative organization of the workspace, which could help to identify targeted evaluations of postures and other health risks. These data will provide insight into key areas for evaluation and training as a foundational step in reducing injury potential in dental hygienists.
Postural Assessment in Dental Hygiene Students: The prevalence of low back pain has been reported to be as high as 68% in dental hygienists and neck/shoulder pain as high as 34%. Our team is applying the Rapid Upper Limb Assessment (RULA) tool as a means of investigating musculoskeletal injury potential for dental hygienists during various instrumentation tasks they perform throughout a single patient visit. We are specifically interested in the relationship of postures to various tasks and relative positioning of the hygienist student to the patient. We aim to not only describe postures and identify key areas of highest risk, but also to compare the postures adopted among students with and without complaints of musculoskeletal discomfort.
Hand Strain in Dental Hygiene Students: In a recent study, 75% of dental hygienists surveyed reported having hand problems while 56% exhibited direct symptoms of carpal tunnel syndrome (CTS). We are investigating the amount of incident and overall strain within the hand that dental hygiene students are exposed to using the Revised Strain Index (RSI). We aim to evaluate individual and cumulative strain, and will utilize these data to examine the relationship of strain exposure to the development of symptoms and other disorders.
Ergonomic Training and Self-Monitoring in Dental Hygiene Students: Given the prevalence of musculoskeletal injuries in dental hygienists, the development of a standardized ergonomic assessment tool that is directly related to dental hygiene practice is needed. Our team is evaluating the validity and reliability of a new assessment, the Movement Strategies and Alignment Tool (MSAT), that would be useful as an adjunct to ergonomics education.
Funding
Dental hygienist behaviors as precursors for the development of work-related musculoskeletal disorders
USC Office of Provost
Undergraduate Provost’s Fellow: Trisha Willie
Total Funding: $5,000
Funding Period: 6/1/21 – 5/30/22
Sonographic tissue morphology in early stage work-related pathology
National Institute for Occupational Safety and Health / Centers for Disease Control
R01-OH010665 (PI: Roll)
Total Funding: $2,324,186
Funding Period: 9/30/15 – 9/29/20
Observational assessment of injury risk in dental hygiene practice
USC Office of Undergraduate Programs – Undergraduate Research Associates Program
Total Funding: $4,600
Funding Period: 8/15/19 – 5/15/20
Validity and reliability of ergonomic assessment tools used in dental hygiene practice
USC Office of Provost
Undergraduate Provost’s Fellow: Samanatha Randolph
Total Funding: $1,000
Funding Period: 10/1/18 – 11/30/18
Identifying risk of musculoskeletal injury in dental hygiene practice
USC Office of Undergraduate Programs – Undergraduate Research Associates Program
Total Funding: $4,500
Funding Period: 8/15/17 – 5/15/18
Publications
Yao, B., Takata, S. C., Mack, W. J., & Roll, S. C. (2023). Modeling extracurricular activity participation with physical and mental health in college students over time. Journal of American College Health, 71(4), 1232-1240. https://doi.org/10.1080/07448481.2021.1926263Show abstract
Objective. To describe extracurricular activity participation and explore its relationship with college students’ health.
Participants. 159 college students majoring in dental hygiene or occupational therapy.
Methods. Data were collected prospectively at baseline, one- and two-year follow-ups. Self-reported participation in extracurricular activities over the past six months was grouped into eight categories: Fitness, Sports, Creative arts, Leisure, Social, Work, Caregiving, and Animal care. Physical and mental health were measured using SF-36, a valid tool measuring general health.
Results. Participation in fitness, sports, creative arts, and work significantly decreased at one-year and two-year follow-ups (p < 0.01). Work/volunteer activity participation was associated with poorer physical health (β = –1.4, 95% CI: (–2.2, −0.5), p < 0.01), but a change from nonparticipation to some participation in work/volunteer activity was associated with better mental health (β = 2.6, 95% CI (0.3, 4.9), p = 0.04).
Conclusions. Educators should consider the potential impact of maintaining extracurricular activities on college students’ health when designing academic courses.
Keywords. College student; extracurricular activity; health; SF-36; well-being
Pozzi, F., Sousa, C. O., Plummer, H. A., Andrade, B., Awokuse, D., Kono, N., Mack, W. J., Roll, S. C., & Michener, L. A. (2022). Development of shoulder pain with job-related repetitive load: mechanisms of tendon pathology and anxiety. Journal of Shoulder and Elbow Surgery, 31(2), 225-234. https://doi.org/10.1016/j.jse.2021.09.007Show abstract
Background. The paucity of longitudinal clinical studies limits our understanding of the development of shoulder pain with repetitive shoulder tasks, and its association with underlying mind and body mechanisms. Tendon thickening characterizes painful shoulder supraspinatus tendinopathy, and the perception of pain can be affected by the presence of psychological factors such as anxiety and depression. This study determined the incidence of shoulder pain in novice individuals exposed to repetitive shoulder tasks, and the associated change in outcomes of supraspinatus tendon morphology and measures of anxiety and depression.
Methods. We recruited dental hygiene (DH) students (N = 45, novice and exposed to shoulder repetitive tasks) and occupational therapy (OT) students (N = 52, novice, but not exposed to shoulder repetitive tasks), following them over their first year of training. We measured shoulder pain, supraspinatus morphology via ultrasound, psychosocial distress via the Hospital Anxiety and Depression Scale. We compared the incidence of shoulder pain (defined as a change of visual analog pain scale greater than minimal clinically important difference) between DH and OT students using Fisher’s exact test. We used mixed-effects models to longitudinally compare the change in outcomes between three groups: DH students that develop and did not develop shoulder pain, and OT students.
Results. The incidence of shoulder pain is higher in DH students [relative risk = 4.0, 95% confidence interval (CI): 1.4, 11.4]. After one year, DH students with pain had the greatest thickening of the supraspinatus (0.7mm, 95%CI: 0.4, 0.9). The change in supraspinatus thickness of DH students with pain was greater than both DH students with no pain (0.4mm, 95%CI: 0.1, 0.8) and OT students (0.9mm, 95%CI: 0.5, 1.2). Anxiety score increased 3.8 points (95%CI: 1.6, 5.1) in DH students with pain, and 43% of DH students with pain had abnormal anxiety score at one-year (relative risk = 2.9, 95%CI: 1.0; 8.6).
Conclusion. Our results provide support for the theoretical model of repetitive load as a mechanism of tendinopathy. The supraspinatus tendon thickens in the presence of repetitive tasks, and thickens the most in those who develop shoulder pain. Concurrently, anxiety develops with shoulder pain, indicating a potential maladaptive central mechanism that may impact the perception of pain.
Yao, B., Takata, S., & Roll, S. C. (2021). Relationship between extracurricular occupations and health in college students: A longitudinal study. American Journal of Occupational Therapy, 75(Supplement_2), 7512505178. https://doi.org/10.5014/ajot.2021.75S2-RP178Show abstract
Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.
We examined the relationships between participation in different extracurricular activities and the overall physical and mental health in college students across a 2-year period. Participation in certain occupations was associated with positive mental health, whereas other occupations were linked to poorer physical health. Exploration and promotion of participation in extracurricular occupations should be considered to support student health.
Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.
Although multiple robust ergonomics tools are available to assess postural risk, these tools are often too general and do not consider nuances of specific jobs. This study examined the concurrent validity of a postural assessment tool tailored to dental professionals. Findings provide support for use of this tool to assess risk and identify areas for intervention by OT practitioners.
Roll, S. C., Hardison, M. E., Forrest, J. L., Colclazier, N. L., Sumi, J. Y., & Baker, N. A. (2021). A standardized protocol for the comprehensive assessment of dental hygiene work. Work, 69(3), 1041-1052. https://doi.org/10.3233/WOR-213534Show abstract
Background. Work-related musculoskeletal disorders are prevalent in dental hygienists. Although engineering controls and ergonomic training is available, it is unclear why this intransigent problem continues. One possible barrier is that a comprehensive, standardized protocol for evaluating dental hygiene work does not exist.
Objective. This study aimed to generate a valid and reliable observational protocol for the assessment of dental hygiene work.
Methods. An iterative process was used to establish and refine an ecologically valid video acquisition and observation protocol to assess key activities, tasks, and performance components of dental hygiene work.
Results. Good inter-rater reliability was achieved across all variables when the final coding scheme was completed by three independent raters.
Conclusions. This work provides an exemplar of the process required to generate a comprehensive protocol for evaluating the work components of a particular job, and provides standardized nomenclature for use by scientists and practitioners interested in understanding and addressing the pervasive issue of work-related disorders in dental hygienists.
Keywords. Dental hygienists; clinical; ergonomics; research protocol.
Fang, Y., Tung, K. D., Beleno-Sanchez, J., Forrest, J. L., & Roll, S. C. (2020). Characterization of tasks and time efficiency of dental hygiene students during clinical training. Journal of Dental Hygiene, 94(5), 30-37. Full textShow abstract
Purpose. Dental hygiene graduates often experience significant psychological stress while transitioning from the educational setting to clinical practice environments. The purpose of this study was to characterize the duration of dental hygiene activities and tasks and explore efficiency within appointments, by students in educational programs.
Methods. Right-handed female dental hygiene students were recruited from two dental hygiene education programs. Each participant was video recorded while providing patient care during 3 sessions, once per term, over 3 consecutive terms. Activities, tasks, and student postures and positions were coded across the patient visit. Descriptive analyses were conducted to characterize overall durations and distributions across each category. Time spent on non-dental hygiene related activities was compared to other durations, as well as across the education/training time points and by patient type.
Results. Fifty-three videos were analyzed from nineteen participants. The average patient visit length was 155.06 ± 35.63 minutes; approximately half the visit was dedicated to instrumentation activities. Nearly 20% of the visit was categorized as activities or tasks unrelated to education or patient care. Although most participants completed the patient visit more quickly by the third time point, the percentage of non-dental hygiene activities did not decrease, and there were no associations between patient category type and the duration of the patient visit.
Conclusion. Patient visits were roughly three times the length of the typical dental hygiene care appointment, indicating a disconnect between training and practice. In addition to spending more time on hand scaling tasks, participants spent a lot of time on equipment setup and interacting with or waiting for faculty members. These findings have implications for improving efficiency in educational settings, particularly to facilitate a successful transition to clinical practice.
Introduction. The Rapid Upper Limb Assessment (RULA) is an ergonomic assessment tool used to screen for risk of musculoskeletal injury due to working posture. The RULA is traditionally applied once during a work task to approximate overall risk. No method exists for estimating a RULA score for work requiring frequent shifts in posture across an extended period of time.
Purpose. The goal of this study was to identify an optimal sampling method for applying the RULA across a long time-period that accurately represents overall risk.
Methods. Four right-handed female dental hygiene students were video recorded from three angles while performing hand scaling during patient clinic visits (88.97 minutes on average). RULA was continuously scored across the entire session, updating the score when a significant postural shift lasting for more than 15 seconds occurred. A time-weighted average (TWA) RULA score was calculated. Three sampling methods were evaluated: equivalent interval samples, random samples, and random samples selection weighted within “clock positions.” Each method was compared to the TWA using a paired samples t-test and percent difference.
Results. TWA RULA across the four students ranged from 3.4 to 4.3. Preliminary sampling averages using 10 samples were all within 0.2 of the TWA. Further iterations evaluating various sample sizes is ongoing.
Discussion. Preliminary results suggest that all three sampling methods provide a reasonably accurate approximation of the TWA score at the sampling rate tested. Future iterations of this analysis will be continued to identify the minimum required sampling rate to meet our TWA criterion.
Roll, S. C., Tung, K. D., Chang, H., Sehremelis, T. A., Fukumura, Y. E., Randolph, S., & Forrest, J. L. (2019). Prevention and rehabilitation of musculoskeletal disorders in oral health care professionals: A systematic review. The Journal of the American Dental Association, 150(6), 489-502. https://doi.org/10.1016/j.adaj.2019.01.031Show abstract
Background. The authors’ objective in this systematic review was to describe the evidence for preventive and rehabilitative interventions for musculoskeletal disorders in oral health care.
Types of Studies Reviewed. The authors conducted systematic search, screening, and eligibility processes to identify experimental, quasiexperimental, observational, and survey research studies in which the investigators either directly evaluated or predicted the effects of preventive or rehabilitative interventions on the reduction of musculoskeletal symptoms in oral health care professionals.
Results. The authors identified and screened 3,571 unique abstracts, assessed 256 full-text articles for eligibility, and included 34 articles in the review. Investigators in 17 experimental studies described the results of preventive or rehabilitation interventions and in 17 survey research studies predicted or correlated preventive or protective techniques to a reduction in musculoskeletal symptoms. The primary techniques evaluated in the studies included equipment modification, ergonomic training, and physical exercise.
Conclusions and Practical Implications. The evidence suggests that magnification loupes and indirect-vision techniques have a positive effect on the reduction of musculoskeletal symptoms. In terms of evaluating intervention efficacy, other techniques have mixed evidence or are limited by low-level study design.
Tung K, Baker NA, Fukumura Y, Forrest JL, Roll SC. Identifying an optimal sampling method to estimate postural risk. Paper presentation at: Human Factors and Ergonomics Society Annual Meeting, 2019; Seattle, WA
Tung K, Baker NA, Fukumura Y, Forrest JL, Roll SC. Identifying an optimal sampling method to estimate postural risk. Poster presentation at: USC Ostrow School of Dentistry Research Day, 2019; Los Angeles, CA.
Forrest JL, Mack WJ, Roll SC. Factors associated with the development of hand discomfort in dental hygiene students. Poster presentation at: International Symposium on Dental Hygiene, 2019; Brisbane, Australia
Roll SC, Forrest JL. Implementation of ergonomic, observational techniques that empower dental hygiene educators, practitioners, and students to reduce the risk of work-related injuries. Workshop presentation at: International Symposium on Dental Hygiene, 2019; Brisbane, Australia
Roll SC, Forrest JL, Mack WJ. Differential effects of work-related task training on upper extremity health in occupational therapy and dental hygiene students. Poster presentation at: 97th Annual Conference of the American Occupational Therapy Association, 2019; New Orleans, LA
Colclazier, N. L., Sumi, J. Y., Forrest, J. L., & Roll, S. C. (2017). Developing an observational method for assessing dental hygienists’ injury risk. Poster presentation at USC Ostrow School of Dentistry Research Day, Los Angeles, CA.
Melrose, D., Wilkins, M. A., Forrest, J. L., & Roll, S. C. (2017). Identifying risk of upper extremity injuries in dental hygiene professionals. Poster presentation at USC Ostrow School of Dentistry Research Day, Los Angeles, CA.
Colclazier, N. L., Sumi, J. Y., Forrest, J. L., & Roll, S. C. (2017). An observational method for injury risk assessment of dental hygienists. Poster presentation at 94th Annual Conference of the American Dental Hygienists’ Association, Jacksonville, FL.
Hardison, M. E., Colclazier, N., & Roll, S. C. (2017). Risk for musculoskeletal strain among dental hygiene students: Video analysis protocol and pilot testing. Poster presentation at 6th Annual Occupational Therapy Summit of Scholars, Boston, MA.
Melrose, M. D., Wilkins, K., Forrest, J. L., & Roll, S. C. (2017). Identifying risk of hand injuries in dental hygienists: A longitudinal cohort study. Poster presentation at American Dental Educators Association Allied Program Directors’ Conference, Baltimore, MD.
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