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Dynamic sitting in dentistry: get on the ball!

Dentistry has come a long way over the last 150 years. The evolution of anesthesia, dental techniques, materials, equipment and approaches has come a long way from standing up with a pair of pliers and a can of ether. While professional football players and ultimate fighters expect pain to be part of their daily routine, pain appears to be an accepted part of the dental profession as well. The patients are pain-free, but how about the dental staff?

While our ultimate career goals are to be efficient, effective and healthy, surviving the maladies of the profession is part of the equation. Our goals can be negatively impacted by the presence of mechanical neck and low back pain. Daily discomfort continues to be tolerated day in and day out. Evidence from Scandinavian literature as early as the 1950s reports complaints of neck, shoulder and low back pain within the dental profession.' Eccles and Powell reported in 1967 that the practice of dentistry leads to excessive fatigue and to certain occupational illnesses and disabilities.2 Although dental practice transitioned from standing postures to sitting postures for most patient care tasks in the mid-1960s, a decrease in the prevalence of reported discomfort has not been reported.'

Kilpatrick observed, "Whether in ancient times or today, one observes a common physical profile, an unnatural body form reflecting degrees of contortion and distortion which range from moderate to extreme ... a great deal has changed and improved in the art and science of dentistry over the centuries, but little has changed in the manner of work." (4) Orthopedic research has shown that 70 percent to 80 percent of the population will experience transient neck or low back pain during the course of their lives. (5), (6) Studies have found that 23 percent to 79 percent have symptoms that persist or recur. (7), (10) The incidence in dentistry appears to be worsening. A majority of dentists and hygienists have musculoskeletal complaints related to the back and neck. (11), (12) The prevalence of neck pain and lower back pain was reported at 52 percent and 58 percent, respectively, in the ADA News in June 2010, with similar findings reported in the ADA member survey in 2007. (13), (14)



The work of dentistry in the operatory relies a great deal on the upper body, particularly the musculature of the shoulder. Shoulder muscles are largely responsible for the dynamic stability and joint motion of the glenohumeral joint. When the shoulder muscles fatigue, joint mechanics become altered, thus possibly leading to pathologies such as tendonitis, impingement, and even subluxations or dislocations (McQuade et al)." According to Escamilla, et al., if normal scapular movements are disrupted by abnormal scapular muscle firing patterns, weakness, fatigue or injury, the shoulder complex functions less efficiently and injury risk increases. (16) Prolonged sitting in a slouched seated position also increases the intra-discal pressure of the lumbar spine significantly. (17)

Pain in dental practice can result from prolonged atypical posturing and can be further complicated by deconditioning. The cumulative effects of abnormal stresses and strains on the clinician have been well documented in the literature, so what can clinicians do? Is it possible for dental professionals to counteract the ill effects of their profession on their bodies by participating in a regular exercise routine? Research has shown that participation in a regular exercise program has a multitude of beneficial effects: improved blood flow; increased level of endorphins and encephalins in the bloodstream, which are known to relax the body; better muscle and joint function with improved relaxation; more restful sleep patterns; and improved level of alertness during waking hours to name a few. (18), (19) More specifically, there are several exercises in the literature that exhibit high to very high activity from the rotator cuff, deltoids and scapular muscles of the shoulder. These include prone horizontal abduction and abduction with external rotation; prone flexion; lifts and chops (DI. and D2 diagonal patterns) as well as a variety of weight-bearing upper extremity exercises, according to Escamilla. (16) These are exercises that can strengthen those areas most relied on by dental professionals. The challenge then becomes integrating such an exercise routine into an extremely busy clinic schedule. Where do they fit into your life?

For years, dental professionals have been constrained by the limitations of their own work environment and the negative effect on their bodies while paying a high price physically. The concept of caring for our most important instrument, our body, is invaluable yet often ignored. Regular exercise has been shown to improve postural endurance and decrease the cumulative trauma that ultimately results in pain. However, given a busy clinical schedule, how can the clinician incorporate regular exercise into his/her routine? By adding some exercise as a regular part of your life, can you counteract the ill-effects of the profession on your body? If you are going to invest the time in a regular exercise routine, where should you start?



One solution is an exercise ball program designed for the busy dental professional to strengthen those muscular areas that are most stressed and fatigued by the practice of dentistry. The author has worked with Posture Perfect Solutions to develop such a program. Additionally, dentistry for the most part is a "seated profession"; if one must sit to work, why not work to sit? Dynamic sitting on a therapy ball has been shown to improve one's working posture and spinal alignment, facilitate improved balance and continuous body movement and muscle function while working, and increase surface contact of weight bearing structures as well as improving weight distribution while sitting. (18-22) The rationale for use of the ball for sitting is based on the potential for increasing the neuromuscular demand required to maintain sufficient control of the spine and whole body motion. (23)

As human beings, we spend a significant amount of time sitting. A 2009 issue of Women's Health reported the results of a poll conducted by the Institute for Medicine and Public Health. The authors identified that the average American spends a little over 56 hours of the week sitting. (24) Several other studies have shown that prolonged sitting throughout the day may even increase your risk of morbidity and mortality. (25) Movement is life and can be a beneficial part of the working day (Yancey). (26) A colleague of mine often says, "motion is lotion."

With sitting as a chosen work position, we often sit in a fixed, frequently slouched posture for any number of hours tithing the working day. Not sure if you do? Take out the digital camera at work and take pictures of you and your colleagues working with patients in the operatory. It is often an eye-opening experience.

There are many seating alternatives available for the dental professional. One of them is dynamic sitting, which provides a unique alternative to typical seated posture. Posture Perfect Solutions' Evolution chair is a dynamic seating product that provides an opportunity to actively "participate" in the act of sitting, and while this may not be a good fit for all practitioners, it is a viable option to consider. Dynamic sitting allows us to avoid the habitual slouched sitting posture that our mothers always warned us about. We are continuously moving, adjusting and repositioning ourselves against the forces of gravity throughout the day, thus counteracting our typical "holding patterns" of poor posture. This certainly allows us to work in a more upright position while exercising our postural and core muscles. It is nearly impossible to sit poorly on such a chair more than once, which may delay the muscle fatigue that normally accompanies our working day. It may delay some of the usual daily discomforts and perhaps save our career from debilitating injury! Efficiency, effectiveness and career longevity may be positively impacted by the fitness of the operator and their choice of seating. So when considering career longevity with the hope of making it to the end of your career in great shape, get on the ball! Note, if pain persists beyond several weeks' time, seek out professional help.


(1.) Seyffarth H, Steen Johnson S. The dentist's working posture and musculoskeletal disorders. Tandlaegebladet. 1954; 4:139-59.

(2.) Eccles JD, Powell M. The health of dentists: A survey in South Wales 1965/1966. Br Dent 3. 1967; 379-87.

(3.) Rundcrantz BL. Pain and discomfort in the musculoskeletal system among dentists. Lund Sweden: Department of Physical Therapy, University of Lund, 1991; 3-59.

(4.) Kilpatrick H. Work simplification in dental practice: applied time and motion studies. 3rd ed. Philadelphia: W.B. Saunders, 1974.

(5.) Spratt KF, Lehmann TR, et al. A new approach to the low back physical examination: behavioral assessment of mechanical signs. Spine. 1990; 15: 96-102.

(6.) Kelsey JL, White AA. Epidemiology and impact of low back pain. Spine. 1980; 5:133-42.

(7.) Toroptsova N, Benevolenskaya L, et al. "Cross-sectional" study of low back pain among workers at an industrial enterprise in Russia. Spine. 1995; 20:328-32.

(8.) Croft PR, Macfarlane GJ, et al. Outcome of low back pain in general practice: a prospective study. Br Med J. 1998; 316: 1356-9.

(9.) Carey TS, Garrett JM, et al. Recurrence and care seeking after acute back pain. results of a long term follow-up study. Medical Care 1999; 37:157-64.

(10.) van den Hoogen, Koes BW, et al. On the course of low back pain in general practice. a one-year follow up study. Ann Rheumatological Disability.1998; 57:13-19.

(11.) Oberg T. et al. Musculoskeletal complaints in dental hygiene: a survey from a Swedish country. 3 Dent Hyg. 1993; 67(5): 257-61.

(12.) Murphy D (ed.): Ergonomics and the dental care worker. American Public Association, 1998.

(13.) American Dental Association. ADA News. June 21,2010.

(14.) American Dental Association. ADA member survey, 2007.

(15.) McQuade KJ, Dawson J, Smidt GL. Scaputothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. JOSPT. 1998; 28(2):74-80.

(16.) Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder muscle activity and function in common shoulder rehabilitation exercises. .1 Sports Med. 2009; 39(8): 663-85.

(17.) Andersson B3, Ortengren R, Nachemson AL, et al. The sitting posture: an electromyographic and discometric study. Orthopedic Clin North Am. 1975; 6(1):1 05-20.

(18.) Mayo Clinic.

(19.) Centers for Disease Control and Prevention.

(20.) Sochaniwskyj AR, Koheil K, Bablich M et al. Dynamic monitoring of sitting posture for children with spastic cerebral palsy. Clin Biomechanics. 1991; 6(3).

(21.) Dieter Breithecker P. "Ergodynamic" work station design and its effect on physiologically correct body behavior, attention span and concentration at school. Federal working group on the development of posture and exercise V. Matthias-Claudius-Strabe, 14 D-65185 Wiesbaden, Germany, 2007

(22.) Bauman A. Updating the evidence that physical activity is good for health: an epidemiological review 2000-2003.3 Sci Med Sport. 2004; 7(1) Supplement 1.

(23.) Marshall PWM, Desai I. Electromyographic analysis of upper body, lower body and abdominal muscles during advanced swiss ball exercises. J Strength Conditioning Res. 2010.

(24.) Women's Health Magazine. Survey, November 2009.

(25.) Patel AV, Bernstein L, Deka A et al. Leisure time spent sitting in relation to total mortality in a prospective cohort of US adults. Am J Epidemiol. 2010.

(26.) Yancey T. Instant recess: building a fit nation 10 minutes at a time. University of California Press, 2010.

By Timothy J. Caruso PT, MBA, MS, CEAS, Cert. MDT

Timothy J. Caruso PT, MBA, MS, Cert. MDT, CEAS is a physical therapist focused on manual therapy and orthopedics. He provides direct patient care at Shriner's Hospital for Children in Chicago and Community Physical Therapy, a private physical therapy practice. He has worked extensively with pediatric and adult populations with orthopedic conditions and is involved in seating and positioning for children and adults with special needs. Cofounder and president of the Kids Equipment Network Childrens Charity, he has many publication credits and is a nationally known professional speaker, having worked extensively with dental professions since 1988 in ergonomics, injury prevention, productivity, exercise and wellness. He has an ongoing interest in assessing musculoskeletal pain in dental professionals and creative prevention strategies.

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Title Annotation:clinical feature
Author:Caruso, Timothy J.
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2012
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