European Journal of Dental Education ISSN 1396-5883

Dental students’ knowledge of ergonomic postural

requirements and their application during clinical care
A. J. Í. Garbin1, C. A. S. Garbin1, D. G. Diniz2 and S. D. Yarid2
1
Department of Children and Social Dentistry at Araçatuba Dental School – Univ Estadual Paulista – UNESP, SP, Brazil,
2
Preventive and Social Dentistry at the Dental School of Araçatuba – Univ Estadual Paulista – UNESP, SP, Brazil

Keywords Abstract
dentistry; human engineer; dental students.
Aim: To examine how much final-year undergraduate dental students know about
Correspondence postural dental ergonomic requirements, and how well they apply these requirements
Diego Garcia Diniz clinically.
Programa de Pós-Graduação em Odontologia
Preventiva e Social. Núcleo de Pesquisa em
Saúde Coletiva – NEPESCO. Background: Dentists are vulnerable to diverse mechanical (e.g. postural) and non-
Rua, José Bonifácio mechanical occupational risks.
1193. Vila Mendonça
CEP: 16015-050
Materials and Methods: Eight postural requirements found in normalising docu-
Araçatuba/SP, Brazil
ments were identified, reproduced, photographed, and analysed to develop a test of
Tel: +18 3636-3249; +18 3636-3250
visual perception (TVP). Photographs of the 69 participating students were taken dur-
Fax: +18 3636-3332
ing their clinical care to ascertain ergonomics compliance, after which the students
e-mail: diegogdiniz@hotmail.com
were administered the TVP. Pearson’s test was used to correlate the level of knowledge
Accepted: 9 December 2009
(TVP) and its clinical application (photographic analysis) among the 552 observations
made for each test (total of 1104 observations).
doi:10.1111/j.1600-0579.2010.00629.x
Results: 65.7% of the TVP questions were answered correctly and 35% of the photo-
graphic cases were in compliance with ergonomic requirements (+ 0.67, P < 0.0001).

Conclusion: The knowledge of ergonomics postural requirements and their clinical

application among the dental students surveyed were not satisfactory. The reasons for
the learning difficulties encountered by the students should be identified to improve
the learning process. The didactic use of digital images in this study may help in this
endeavour.

the highest risk in elderly subjects and women. Spine, shoul-

Introduction
Dentistry is a profession in that its clinical performance is
restricted to an area covering only a few tens of millimetres
(the mouth), and that it requires repeated, precise force
applications. These situations demand a fixed posture that can
create occupational hazards in both dentists and dental
students (1–3).
In addition, technological advances in dentistry have led to
an increased workload amongst dentists, which also impacts
occupational risks. Although such technologies can simplify
dental work and improve dental care, they frequently ignore
the role of posture in daily work. This negligence is reflected in
the growing number of complaints specifically related to work-
related musculoskeletal disorders (WMSDs) (4, 5).
For example, 55.4–93% of dental professionals (dentists, den-
tal hygienists and dental auxiliaries) experience WMSDs, with
ders, elbows and hands are the most likely areas of the body to
be involved (6).
Ratzon et al. reported a high prevalence of non-specific lower
back and cervical (55% and 38.3%, respectively) WMSDs
amongst dentists, which were well correlated with the time
spent sitting (3). Another study reported a 58% rate of upper
segment (neck, shoulder, backbone and upper limb) musculo-
skeletal pain amongst dentists, with 26% of respondents report-
ing daily pain and 40% moderate/strong pain (7). Moimaz
et al. found that 50.5% of female dentist respondents reported
some problem related to professional performance, most com-
monly columnar pain (8). Because the development of WMSD
symptoms affects productivity, adaptation strategies for occupa-
tionally dangerous tasks must be adopted (9).
Ergonomics is defined as a set of multidisciplinary know-
ledge applied to the organisation of labour activities and

Eur J Dent Educ 15 (2011) 31–35 ª 2011 John Wiley & Sons A/S 31
Ergonomic postural requirements
elements that make up a job. The goal of ergonomics is to
establish a safe, healthy and comfortable working environment,
thereby preventing health problems and improving productivity
(10). When applied to dentistry, ergonomics seeks to reduce
cognitive and physical stress, prevent occupational diseases
related to the practise of dentistry and improve productivity,
with better quality and greater comfort for both the profes-
sional and patient (11).
The identification of postural inadequacies may help prevent
or minimise the consequences of labour practises (12, 13).
Therefore, here we examined students in their final year at Ara-
çatuba Dental School, Unesp (FOA-UNESP) to ascertain their
knowledge of dental ergonomics postural requirements and
their clinical application.
TABLE 1. Dental ergonomic postural requirements
1. The angle between the lower and upper leg, with the legs slightly
spread, must be  110 or slightly more.
2. The dentist should sit symmetrically upright and as far back as
possible in the seat, tilting the upper body forward to a maximum
of 10—20º, avoiding rotation and lateral slopes.
3. The head of the surgeon-dentist can be tilted forward to up to 25.
4. The pedal drive must be positioned close to one of the feet, so that it
does not have to be directed laterally during its operation.
5. The upper limbs are next to the upper body in front of the trunk,
with the forearm raised from  10º to a maximum of 25º.
6. The working field (patient’s mouth) must remain aligned with the
front of the upper body, with a distance between the working area
in the mouth and the eyes (or glasses) of  35—40 cm.
7. The hand tools should be positioned within the visual field of the
dentist at a distance of 20—25 cm.
8. A dental operating light must be able to be positioned around the
head of the dentist, before and sideward so that the light beam is
running parallel to the viewing direction.
= 18º
32
Garbin et al.
Materials and methods
This descriptive, analytical and observational study approved by
the Committee of Ethics of the School of Dentistry of Araça-
tuba (protocol 2008/3203) was based on the document, ‘Adopt-
ing a healthy sitting working posture during patient
treatment.’(14) This document was part of an ISO (15) project
describing the ergonomic guidelines for proper posture, treat-
ments, instrument manipulation and adequacy of dental offices
in patient treatment. Eight postural items from the above docu-
ment were chosen (Table 1), reproduced and photographed
with a digital camera (CASIO Exilim Z1000 10.1 MP; Casio
Latin America, Inc. Miami, FL, USA) at the ergonomic tests
laboratory of the Center for Research in Public Health - NEPE-
SCO of the FOA-UNESP. Two pictures for each posture were
taken, one representing compliance with the postural require-
ment and one representing non-compliance. Adobe Profes-
sional 6.0 (Adobe Systems Incorporated. San Jose, CA, USA)
was used to analyze the images. An angle of 90 with predeter-
mined edge lengths was previously printed on a sheet of A4
paper and used as a reference and help-scale when the photo-
graphs were taken (Fig. 1).
We next developed an evaluation didactic material, the test
of visual perception (TVP), which consisted of slides prepared
with Microsoft Power Point 2007 (Microsoft Corporation. Red-
mound, WA, USA). These slides contained photos representing
compliance and non-compliance with each postural require-
ment, and were used to verify the level of knowledge about
ergonomic requirements.
A pilot study was developed to analyze the quality of images
exposure of the TVP. Twenty dental students of the FOA-
UNESP, not involved in the final study with the condition that,
such individuals should have already taught the principles of
ergonomics during their vocational guidance coursework, were
asked to mark the appropriate image requested on each slide
(Fig. 2).
A sample population of 69 (86.2%) of the 80 fourth-year
students of FOA-UNESP were chosen, selected amongst
= 41º
Fig. 1. Representative photographic analysis
item, demonstrating the ergonomic requirement
related to operator head inclination. Left and
right photos show appropriate and inappropri-
ate positioning, respectively.
Eur J Dent Educ 15 (2011) 31–35 ª 2011 John Wiley & Sons A/S
Garbin et al. Ergonomic postural requirements

Arms position

Fig. 2. Representative slide made to test the

visual perception of postural requirements for
the operator arms. Right and left photos show
appropriate and inappropriate positioning,
respectively. Numerical values were not shown
in the test images.

= 69º

Fig. 3. Representative photographic analysis

item of clinical care performed by final-year
students at UNESP-FOA. The left photo shows
the tilt of the operator head and the right
photo indicates the foot position on the pedal
drive. The black line represents the ideal
position.

students of graduate faculty who had agreed to participate in
the research. This study was not of a probabilistic design. The
sample population had been taught the principles of ergonom-
ics during their vocational guidance coursework in the second
year of graduation. Photographs were taken of the participants
casually and not necessarily on the same day, during the course
of their dental clinical rotations, by a researcher and an assis-
tant. The researcher had been trained to take-off as many pho-
tos were necessary of the eight items selected of the each
student in a manner that they would not associate them with
ergonomics training. The assistance used the angle of 90
printed on a sheet of A4 paper serve as a reference and help
scale when the photographs were taken. This methodology
allowed us to reliably analyze student postures with respect to
TABLE 2. Classification system for the test of visual perception and the
photographic analysis
Score (correct items) Classification
1—2 Inadequate
3—4 Regular
5—7 Satisfactory
8 Excellent
compliance with ergonomic requirements. Image analysis was
the same as used in the pilot study (Fig. 3). To prevent any
associations between the images shown in the slides and clinical
practise, students were administered the TVP in a classroom.
The data included 552 observations made for each test (TVP
and photographic analysis – 8 for each student), for a total of
1104 observations. Test data were evaluated and classified as
inadequate, regular, satisfactory and excellent, based on the
number of compliant images correctly identified on the TVP or
on the clinical compliance of the student, based on photographic
analysis (Table 2). In all cases, the optimal condition was a per-
fect interaction between the operator/equipment/treatment.
Data were analyzed by descriptive statistics. Pearson’s test
was used to correlate the level of knowledge about postural
requirements and their clinical application, using the software
BioEstat 5.0 (WCS. Belém, Pará, Brazil).
Results
In the TVP, 363 (65.7%) of the observations correctly identified
the compliant photo. In the photographic analysis, 193 (35%)
of the observed cases were clinically compliant with ergonomics
requirements (Tables 3 and 4). The TVP data were strongly
correlated (+0.67 for P < 0.0001) with the clinical application
of ergonomic requirements.

Eur J Dent Educ 15 (2011) 31–35 ª 2011 John Wiley & Sons A/S 33
Ergonomic postural requirements Garbin et al.

TABLE 3. Identification of each ergonomic requirement in the test of visual perception (TVP) and proper clinical application of dental ergonomics by the
students (Clinical)

TVP Clinical

Requirements C % C %

1. The angle between the lower and upper leg, with the legs slightly 31 44.9 24 34.7
spread, must be  110 or slightly more.
2. The dentist should sit symmetrically upright and as far back as possible 47 68.1 14 20.2
in the seat, tilting the upper body forward to a maximum of 10—0º,
avoiding rotation and lateral slopes.
3. The head of the dentist can be tilted forward at up to 25. 47 68.1 19 27.5
4. The pedal drive must be positioned close to one of the feet, so that it 52 75.5 41 59.4
does not have to be directed laterally during its operation.
5. The upper limbs are next to the upper body in front of the trunk, with 62 89.8 29 42.0
the forearm raised from  10º to a maximum of 25º.
6. The working field (patient¢s mouth) must remain aligned with the front 43 62.3 26 37.6
of the upper body, such that the distance between the working area
in the mouth and the eyes (or glasses) must be 35)40 cm.
7. The hand tools are positioned within the visual field of the dentist at a 64 92.7 31 44.9
distance of 20—25 cm.
8. The beam of light should be kept parallel to the observational 17 24.6 09 13.0
direction.
Total of correct observations 363 65.7 193 35.0
Total of incorrect observations 189 34.3 359 65.0
Universe of postural observations 552 100.0 552 100.0

C, correct observations;
N, 69.

TABLE 4. Classification of the results of the test of visual perception

that the light beam is parallel to the observational direction,
(TVP) and compliance with ergonomic requirements during clinical care
thus maintaining shadow-free lighting, with a good balance
(Clinical)
between the light and the mouth of the patient. To improve
TVP Clinical visualisation, the student frequently positioned the reflector
incorrectly. This malalignment contributed to the incorrect
Classification n % n % posture of the tilt of the head (65.3%), torso (80.8%) and
Inadequate 2 2.9 25 36.2 upper limbs (66%), as well as the distance between the opera-
Regular 26 37.7 34 49.3 tor and field work (62.4%).
Satisfactory 38 55.1 10 14.5 Similar results were observed in Project Sonde, a previous
Excellent 3 4.3 0 0 study that evaluated the posture adopted by 1250 dentists and
Total 69 100 69 100 found that 75% of professionals work with substandard lighting
or light distributions. In addition, 89% of the dentists showed
n, number of students (69). a forward bending of the head, exceeding the 20–25 healthy
postural limit; 63% had a spine flexion exceeding 20; and 35%
displayed forearm inclinations of >25 to the horizontal plane
Discussion
(18). In another study, 60% of students in their final year of
Posture reflects the position that an individual maintains in dental school had difficulty visualising the oral cavity during a
space via his bone–muscle–skeletal system, according to a static procedure, because of incorrect use of the dental stool backrest,
or dynamic balance (16). By maintaining a good posture, the which resulted in an inadequate working posture (19). Garcia
body lowers its energy expenditure, improves organ functioning et al. likewise found that 11.7% of dental students adopt a
and is protected against disturbances that could undermine malaligned right-tilted posterior column, probably to improve
occupational practise (17). The results of the present study viewing (2).
reflected a lack of adequate posture by the investigated We also found inadequacies in lower limb posturing in our
students, during the performance of dental care. This result sample population. Only 34.7% of students correctly positioned
was evidenced by the 65% incorrect analysis of ergonomic their legs, and about 30% of students incorrectly positioned
requirements, with only 14.5% of responses being classified as their feet on the pedal drive. Good positioning of the feet and
satisfactory. legs broadens the support base of the body, avoiding possible
During clinical practise, the reflector was the least accurately changes in the circulatory system such as varicose veins,
positioned item (13%). The reflector should be positioned so oedema, pain and inflammation because of muscle compression

34 Eur J Dent Educ 15 (2011) 31–35 ª 2011 John Wiley & Sons A/S
Garbin et al.
on the lower extremities impeding the venous return (20). Ben-
dezú et al. found that only 1.9% of dental students correctly
position their feet and legs during dental work (21). The lower
limbs are the second most likely body region to experience pain
because of poor positioning during sitting, with 48% of
reported pain occurring within the lower limbs and 81% within
the neck and back (17).
Students answered 65.7% of the TVP questions correctly,
and 55.1% of students demonstrated ‘satisfactory’ knowledge of
dental ergonomics in this test. However, a significant percent-
age of students ranked below satisfactory (40.6%).The TVP
data were strongly correlated (+0.67 for P < 0.0001) with the
clinical application of ergonomic requirements. Students who
have obtained a better rate on photographic analysis (clinical
application) repeated this fact in TPV. It was observed more
correct items in this test also.
This indicates the knowledge was not reflected entirely on
the correct posture during clinical procedures. Therefore,
the reasons of these deficiencies must be inquired. A poor
understanding of ergonomics theory; a gap between the
theoretical discipline and its clinical application; and a working
environment unsuitable for ergonomically correct dental work
may be interfering in learning ergonomic principles. In this
sense, it is an interesting improvement in the teaching and
learning as well as their form of assessment. The use of digital
images reproducing ergonomic dental positioning proved to be
a positive methodology in this aspect. The education system
must allow students to apply their theoretical ergonomics
knowledge to their clinical practise. The acquisition of ergo-
nomics knowledge can occur at any time; however, their early
installation results in improved assimilation and incorporation,
preventing deleterious habit formation (13, 22).
Conclusion
The ergonomic posturing of the dental students surveyed was
not appropriate. This indicates that they are subject to develop
WMSDs. It is necessary to investigate how to improve the stu-
dent learning process of proper dental posturing. The didactic
use of digital images in this study may contribute to this
understanding.
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