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The dentist’s operating posture – ergonomic aspects

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Journal of Medicine and Life Editor-in-Chief: Florian pooa
Volume 7. lssue 2.April-June 2014 "Carol Davila" Universitv of Medicihe
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Journal of Medicine and Life
Volume 7. lssue 2.April-June 2014

Table of contents
Informatics and Health 119
Purcarea VL

Rev i ews
Perineural invasion in head and neck cancers. a review.
Frunza A, Slavescu D, Lascar I

Clinimetric measurement in traumatic brain injuries 124

Opara JA, Malecka E, Szczygiel J
lntraoperative Radiation Therapy in Gastric Cancer 12E
Bacalbaga N, Balescu l, Calin M, Balalau C
Secondary peritonitis .evaluation of 204 cases and literature review 132
Doklestic SK, Bajec DD, Djuki6 RV, Bumbaiirevic V, Detanac AD, Detanac SD, Bracanovic l,,l (araa-a.rl,'i R.1
Clinical and therapeutic considerations of GIST 139
Gheorghe M, Predescu D, losif C, Ardeleanu C, Bacanu F, Constantinoiu S
Growth assessment in diagnosis of Fetal Grovuth Restriction. Review 150
Albu AR, Horhoianu lA, Dumitrascu MC, Horhoianu V

Original Artictes
NBI - plasma vaporization hybrid approach in bladder cancer endoscopic management $5
stdnescu F, Geavlete B, Georgescu D, Jecu M, Moldoveanu c, Adou L, Bulai c, Ene c, Geavlete p

General Articles
Apoptosis in Colorectal Cancer 160
Stoian M, State N, Stoica V, Radulian G
Predictive factors for intrauterine growth restriction 165
Albu AR, Anca AF, Horhoianu VV, Horhoianu lA
Types of radical hysterectomies From Thoma lonescu and wertheim to present day 172
Marin F, Plesca M, Bordea Cl, Moga MA, Blidaru A
The dentist's operating posture - ergonomic aspects 177
Pirvu C, Pdtragcu l, Pirvu D, lonescu C
Concepts in local treatment of extensive paediatric burns 163
Ungureanu M
Pneumorias - a dynamic relationship between the human organism and the etiologic agent 192
Chiotan R, Chiotan M
Massive upper gastrointestinal bleeding - complication of pancreatic pseudocyst 202
Mavrodin Cl
The benefits of using Sentinel WebDashboard in medicine: lT solution for monitoring and treatment of patient with liver 205
cirrhosis
Dumitrescu SR, Pooescu D, Purcarea VL. Albu LC

Case Presentations
Comparative study of conventional urothelial carcinoma, squamous ditferentiation carcinoma and pure squamous 211
carcinoma in patients with invasive bladder tumors
Gluck G, Hortopan M, Stanculeanu D, Chiritd M, Stoica R, Sinescu I

Expression of interleukine-8 as an independent prognostic factor for sporadic colon cancer dissemination zl5
Nastase A, Paslaru L, Herlea V, lonescu M, Dima S, Popescu I
Primary omental torsion in a 9 year old girl: a case report 220
Anyfantakis D, Kastanakis M, Karona V, symvoulakis EK, Fragiadakis G, Katsougris N, Bobolakis E
Finger enchondroma treated with bone substituents - a case presentation 223
Raducu L, Anghel A, Vermesan S, Sinescu RD
Efectrical injuries. Biologicalvalues measurements as a prediction factor of local evolution in electrocutions lesions 226
Teodoreanu R, Popescu SA, Lascar I

Cytomegalovi rus reti n itis in H IV/AIDS patients 237

Chiotan C, Radu L, Serban R, Cornicel C, Cioboata M, Anghel A
Gingival overgrowth as secondary effect of calcium channel blockers administration, A case report 241
Mironiuc-Cureu M, Dumiiriu AS, Gheorghiu lM, Stoian lM
Self harm through foreign bodies ingestion - rare cause of digestive perforation
Petrea S, Brezean I
Replacement of clarithromycin with azithromycin in triple therapy regimens for the eradication of helicobac{er pylori: A 254
randomized clinical trial
Khoshnood A, Hakimi P, Salman-Roghani H, Reza Mirjalili M
Effect of physical activity on the life quality of coronary artery bypass graft patients 260
Firouzabadi MG, Sherafat A, Vafaeenasab M
Current therapy in children and adolescents with von Willebrand disease
Buga-Corbu l, Arion C
 pp -r7 -r-

The dentist's operating posture - ergonomic aspects

C**
Plrvu C' Pdtraqcu I--, Pirvu D**' lonescu
.Department of Oro-Dental Diagnosis.' Research Methodology'
'" ";6rior !1qonomi9131d Bucharest
otuila" Universiiy of Medicine and Pharmacy' pharmacy, Bucharest
of Medicine and
**Department of Denrures r...'noiogy ;ndDentar Mrir;;i;, rc;;or ouuir" Univeisity

and Research rvethodorosv

pirvu,
conespondence to: cristina
s:iilJl:r,$ff:llilJfir:.il?f:t:::irJi:i:Hi
Ap 15' District4' Bucharest
+Z tiitu VasiteStreet, Bl 2, St l' 3dfloor'
-
trloOite phone: 0721 27 B028' E-mail:
crstnprv@yahoo com

Received: July 18th' 2013 - Accepted: November 18th' 2013

*:ili:: or dentistrv invorves raborious

particuiar attention, ,on.*ntirtion and
hls!.li:Y::,':1^ofli::li'i-;.li:i:':i,:$','il'}jffi-i.:l:,x:i'?'ri.3iffi:
patience-of il",e centist and'finally
physical and mental resistance The optimal
ti. oeltiiis
for the dentist and hrs ieam tn an ergonomlc
of practice invorve special working conditrons
therapeutic appr'acn ,no ir..,.'.rr.uss
environment. ,- ...1i^L ri$nran* ^rrrc of
nf the
ihp body located and thus lhe repons are
hndv are locate
of the posture in ergonomics is the manner rn which different parts wnen
The meaning discusses the posture adopted by dentists
between them in orddr to aliow a speciai task execution This article
established Theidealpostureof adentistgivesnim'on
Posture
lheywork,beginningwrtntileurtanc.opostureanogoingto,oijprent,vllanh,of and on the other hand physical and
(acciss.-visibirity and controlln'the mouth)
the one hand the optrmar working condiiions
continuing
in ihe undersraduate coursss and the
r',,1,'Xlr:*ixyl[:x$:i::::::J*::.Jlli:Jii'9,:'::1:H::::::'ted
mani Jentrsts ngt,,kno-w tne iuolect wet enough nor
the theo'etical issues and
education courses on ergonomics
in cientistry !o p.stures
disorders related to unbalanced
nor the praciicar appricability The risk anl perspective of the musculoskeietal effects of
therefore measures in order io limit the negative
the deniisis take posturai correclive aciions and compensation
should determine
working in a bad Posture
posture working positions
Keywords. baianced postufe unbalanced

lntroduction
to understand
high distinguished. This differentiation is useful
The practice of dentistry involves laborious
control the working conditions'
finesse dental preparattons, precision and
in
a flre rdeal posture of a dentist gives him on the
executions thatrequire attention'
particular
. one hand, optimal workrng condrtions
(access' visibility
and finally the
.on..nitution and patience of the dentist
The optimal andcontrolinthemouth)andontheotherhand'physical
O.ttiti;t pftysical and mental resistance' anO psycfrongical comfort throughout
the execution of the
therapeutic approach and the success of practice involve 'u.tt. A "good"
in .ii*.tf posture provides the dentist more
rp.tili*otfing conditions folthe dentist a1-d his team in working energy, a reduced stress level'
increased
.l-.tgono*ic environment' The ergonomics applied .on'tto'i, lack oi pain and muscular tension
and a lower
;;.ti;itto.ut.t on the practitioner and his team as the posture
practice' iiir, toi therapeutical errors' A "bad" induces
most important resource of the
one pi.*t1ur. fatigue, pain, stress and a neg.ative attttude to
ln the field of ergonomics applied in dentistry a poor
work, high-risli for musculoskeletal disorders and
ofthemostdiscussedthemeistheworkingpostureofthe
l.ntut. The special attention on this topic is explained
by r-'-
quality of work [1].
This jrticle discusses the posture adopted
by
posture is
tn. *iO.fV recognized and accepted fact -that dentists when they work, beginning with
the balanced
disorders'
ine fey oipteuenting the musculoskeletal
' fire meaning of the posture in ergonomics is the p.itr" and going to different variants of posture' The
be a reference
are located balanced posture is a posture that should
manner in which different parts of the body are daily adopted by dentists'
them in order to puint tut the postures that
and thus the reports established between provides numerous data on this topic' many
Litetature
iffo* speciai task execution' In dentistry' the
working
. of the authors being concerned about it' The
instances in which
ootition represented by the spatial anangement working
tfre Oentists ieverely deviate from an ergonomic
l.ntitit Jntit. body around the patient must be
 jorirnal ::! lVtr.litt,'.: j .) :.i. .':t, I i::ut 2, Aprti iut:e 20J.1

style (which implies a correct posture) are extremely segments, each of them with its neutral limits for a risk-
numerous from many reasons. The working posture of the free use [3].
dentist is strongly influenced by the relationship between The balanced posture features can be

his body and the different elements of his workstation, so
that an incorrectly designed workstation and/or incorrectly
used workstation affect the posture. By workstation, we
understand all the spatial and environmental elements
with which the dentist interacts while working [2].
Among the spatial elements of the dentist's
workstation the following can be identified. the dentist's
stool, the patient lying in the anatomical chair, the
components of the dental unit (the dentist's cart, the lamp,
the vacuum system and the control pedal), the fixed
elements surrounding the working area (the fixed
furniture, the mobile case and all the tools and equipment
placed on it), the equipment used and the presence of the
dental assistant and the working relationship established
with her. The multitude of these items reflect the extent to
which the dentist can be conditioned and limited at his
workstation, which may lead to an increased physical and
mental stress, often manifested by a feeling of
"frustration" experienced during all the working stages.
The dentist's posture evolved from the
summarized as it follows [4]:
-a straight back and respect for the body symmetry;
avoiding rounding the back into "C" shape;
-fonruard inclination of the trunk of a maximum of 20'; a
greater forward inclination, the tilting to a side and the
trunk rotation are contraindicated;
-fonvard inclination of the head up to 20-25' from the
trunk;
-the arms placed along the body, fonrvard oriented within
10"; the forearms raised up to 25" from the horizontal
line;
-the angle between the thighs and shanks of 105-110" or
more;
{he thighs apart up to 45', avoiding a rigid fixation of the
hip joint;
-the shanks oriented perpendrcular to the floor or slightly
oosterior:
-the feet on the floor oriented fonrvards in the same plane
with the shanks; when the feet are symmetrically
positioned below the operator hands, the posture ts

orthostatic posture to a seated posture especially on the balanced.

account of adopting the four hands working style [1]. The postural symmetry implies all the body
Today, we meet the two posture possibilities (the horizontal lines (the eyes, shoulders, elbows, hips and
o(hostatic posture and the seated posture) used in knees horizontals) being parallel and perpendicular to the
varying degrees. In practice, we often observe that many median line of the body [4].
dentists work in incorrect postures because of their
habitude, working routine and poorly designed
workstations. All these conditions act on the lack of the
dentist's information in the field of ergonomics and on
ignoring the fact that the human body has its adaptive
limits. Beyond these limits, the dentists are exposed to
the risk of professional illness.
The oosture described in "lSO Standard 1'1226
Ergonomics - Evaluations of static operating postures" is
recommended for the dentists and is called balanced or
neutral posture. The balanced or neutral posture is a
reference point for the correct working posture and it is
recommended to be maintained within the limits imposed
by the practice conditions, throughout all the stages of the
clinical acts. This is a seated posture - natural, unforced,
stress free and symmetrical - that takes into account the
loco-motor physiology of the human body. The neutral
posture is the result of the general ergonomic studies
adaoted to the needs of the dental practice. This posture
is comfortable (assuming minimal contractions and
muscular tensions), stable (stabilizing all body segments
and joints) and symmetrical -the defining element for
postural balance. The notion of "neutral" derives from the
fact that each joint of the body has a neutral zone to
which the movements are reported and which recurrent
exceeding eould generate the joint and muscles
overstrain [1]. The balanced or neutral posture is the
Fig. 1 a,b,c The balanced Posture
result of a complex positioning of the different body

178

Preserving the balanced posture and its
symmetry throughout the clinical act is largely conditioned
by the relationship established between the dentist and
the intraoral working field. In an ideal situation, the
sudace of the treated teeth should be parallel to the front
of the dentist and his view oriented perpendicular to the
working field. lt
is recommended that the distance
between the working field and the dentist's eyes is of 35-
40 cm or slightly higher for very tall dentists. When this
relationship is not established or it is lost during the
clinical act, the dentist's eyes will look for it and the dentist
will depart instinctively from the balanced posture. To
establish such a relationship it is important to pay
attention to the dentist's position around the patient and
the patient's head position on the headrest. To position
the patient's head it is important to use all his possibilities
of motion: extension and flexion, rotation right or left and
side flexion right or left in varying degrees and
tombinations [5].
The balanced posture does not require a rigid
body attitude. The dentist has the freedom to move within
some limits so that no harmful positions result. Gentle
rebalancing movements are often made. The specialty
literature uses the concept of active and passive balanced
posture. The active balanced posture involves the dentist
supporting the back straight (the physiological spine
curvatures and the "S" spine form) only by means of
paraveftebral muscles tonicity. The passive balanced
posture is characterized by the use of lumbar suppott
provided by the seat back [4].
To maintain an ideal posture for as long as
possible, the working equipment and the working space
(the workstation) must be "tailored" to the dentist and it
must fit him like a glove. This ideal situation corresponds
to the most favorable positioning of the dentist's head,
body segments, dominant hand and fingers, elements that
can be tested by proprioceptive control according to the
proprioceptive derivation concept. Numerous tests have
been done on the dentists who were left to look for blindly
and to feel the most convenient working body position
(posture) that allowed them a high working finesse and a
good manual control, asking them to try to ignore their
equipment around and their old habits. The results
showed a number of preferences: placing the dominant
hand index around the armpit level on the midline of the
body and the dentist sitting with the back straight without
using support from the backrest [6]. In order to take and
use the medical tools, the dentist extends his arm
horizontally and vertically so that allowing this service
without compromising the balanced posture, the tools
must properly positioned [6].
179
)ournal of Medicine and trfe Vol. 7, Issue 2, April-June 2014
Using the magnification systems (glasses and
corrective lenses, loupes and telescopes, the operating
microscope) deserves a special attention because it could
have serious implications for posture. Properly chosen
and adjusted, the magnification systems can prevent the
bending of the dentist's head and the development of the
musculoskeletal disorders. On the other hand, their
misuse could have adverse effects, increasing the risk of
musculoskeletal injuries or aggravating them [7]
The prolonged static postures are strongly
incriminated in the etiology of musculoskeletal disorders
and therefore they deserve a special attention. Sitting on
the chair for a long time involves the activation of
paravertebral muscles and a substantial "charging" of the
lumbar curvature of spine higher than standing (2'7)' To
maintain a posture for a long time, including a balanced
posture, predominantly involves a static muscular effort.
The static work is more tiring than the dynamic work
though it requires lower oxygen consumption. In a static
work to the nerve centers of the cerebral cortex, a large
number of impulses from proprioceptors of muscles and
tendons reach the same place, this meaning a continuous
long time excitation of these cerebral cortex nerve
centers. This mechanism explains why the static work is
more tiring than the dynamic work [8]. On the other hand,
in a static posture (especially if it is incorrect) the oxygen
supply to the muscles may be affected, which translates
quickly through muscle inefficiency and even pain. In the
dynamic work functions, the muscle pump (the altemative
contraction and relaxation of muscles) promotes blood
circulation [4,9-11]. Studies have been made which
showed that maintaining the posture requires more fran
50% of the body muscles to be isometrically contrmted
which means an intense muscular effort' This efu4 :an
lead to muscular overworking, poor blood inigacn rd an
increased pressure on joints and muscles ['l2r
When a prolonged static posture s oao; :t"er
oostures constraints its effects. 0n the crer -ffrlt'10
discomfort caused by a prolonged slat'c ffi-r-= a-'J ihe
required recovery times are direcily- nmrTtrra :3 the
time spent in this manner [13],
ln order to comPensab re *hx :' a static
work and postural demands. rTtrr aJtrtrE "*-'mmend a
dynamic way of working. This inar nes
- employing the active balaraec ffiturc tn: re passlve
balanced posture altematiwl'
-using the short breaks bgren ltmr rme^s in order to
leave the stool and walk
-a working program nriF mfiq @ra'*jlng treatment
sessions alternating b trllr ffIm ffiEr:r€s;

-performing simple exercises between patients at the end
of the program [1].
Although the importance of the balanced posture
to avoid prolonged static posture is widely recognized,
some authors recommend the use of several alternative
postures in order to employ more muscular groups [14-
161. A specific study shows that the dentists who work
exclusively seated, suffer more pronounced pain in the
lumbar curvature of spine compared with the dentists who
alternate seated posture with the orthostatic posture [17].
There are authors who recommend changing the posture
and position after maximum one hour of working. On the
other hand, during the long clinical acts, a pause of five
minutes after one hour of activity would be welcomed in
terms of postural challenge to both the dentist and the
patient. The position of the patient (especially head
positions) may also become tiring when the clinical act is
extended [18].
The mental and psycho-emotional stress caused
by the difficulty of working can induce an increased
muscular tension, a reduced attention to posture and
finally a wider body response to a bad posture [7,10].
Using an ergonomic stool and adjusting it
correctly and in an easy way has a major contribution in
the adoption and maintenance of a balanced posture.
Through its features, the dentist's stool has to encourage
a good posture [2].
The stool's height adjustment is necessary for
the correct orientation of the thighs to the floor and a
minimum angle of 105-110' between the thighs and the
shanks. A too high position of the stool requires sitting on
the edge, losing the weight distribution on the stool axis
and losing the contact of the dentist's back with the stool's
back. This way, the risk of slipping off the stool appears.
When the stool is too low, the lumbar curvature of the
spine is reduced through posterior rotation of the pelvis
I7l
The orientation of the dentist's stool base can be
horizontally or forwardly inclined. A horizontal stool base
may cause a posterior rotation of the pelvis and reduction
of the lumbar curvature of the spine while its fonivard
inclination prevents this phenomenon. In addition, a
horizontal stool base with a too large sudace and a hard
edge can generate a posterior compression of the thighs,
which affects the shanks and legs blood supply. By tilting
the stool base, this phenomenon is avoided. The tilting
degree must be reduced at 5 to 150 because a bigger
degree could determine sliding off the chair. A saddle-
shaped stool base does not pose such problems, being
favorable from this point of view. Both the fonrvard
inclination of the base and the saddle-shaped base
conformation allow a trunk-thigh angle greater than 90"
L80
Journal cJ Medictre i.-r - '. " :,i /, !ssue 2, April]une 201t\
and a closeness to the patient which facilitates a better
access and visibility in the patient's mouth [1,7].
Supporting the back on the backrest of the stool
is necessary in order to avoid the muscular fatigue and
reduction of the lumbar curvature of spine during long
clinical acts. A properly support does not require a great
height of the backrest, 20 cm being sufficient [7].The
lumbar support is recommended to be set on the upper
half of the lower back, where switching to thoracic
convexity [1]. The relationship between the position and
the stool base and the position of the backrest is
especially important to reduce the lumbar curvature
tension [2]. Increasing the angle between the torso and
the thighs in order to position closer to the patient, has a
favorable effect reducing the lumbar kyphosis [13].
For the long lasting clinical acts is also important
to support the arms on the special supports of the stool.
This support addresses in the same time to the shoulders,
preventing the back pain and the shoulder and neck
tension that may occur due to the prolonged muscular
tension. The stool with supporls for arms is bigger and it
seems to limit the free movements (especially if we do not
have proper conditions to approach the patient). For this
reason, it is often avoided by practitioners, but after a
while of use and adaptation, the benefits become crear
[19]. In order to respect the symmetry of a balanced
posture it is recommended to use the supporls for both
arms simultaneously [5].
The deviations from the balanced posture
In practice, it is almost impossible for the dentists
to maintain a balanced posture throughout a long clinical
act even when this posture is very well known and initially
adopted. Fully aware of the effects of an incorrect
posture, the dentists should consider the deviations as
rare as possible, of small amplitude and short duration.
The wider and longer these deviations are, the more the
risk of MSDs increases [3].
The deviations from the balanced posture during
the clinical act may be caused by:
-an incorrect positioning of dentist around the patient
according the working area;
-an inadequate working level (often the mouth is too low);
-an incorrect positioning of the patient's head (not rotated,
tilted or extended enough);
-avoiding to work in an indirect vision (working in the
mirror is more difficult and requires extra effort fixing the
image);
As means of deviation from the balanced
position, the following can be seen most often [1,12]:
{he excessive bending of the dentist's head and the
extent of neck, the rotation and the tilting of the head;

-the tilting and the rotation of the trunk on one side,
-lifted arms (dominant, non-dominant or both) without
adequate support on the trunk or on the arm support of
the stool;
-lifting one shoulder or both;
-an increased thoracic curvature of the lumbar curvature
reduction;
-the angle between thighs and shanks below 90"
Avoiding the patient seat backrest and headrest
margins, in order to gain access and visibility in the
mouth, the patient's shoulder or some tools create
a poor unbalanced posture. The direct
conditions for
consequences of these "interferences" are twisting and
tilting the body segments (head, shoulders and trunk) on
one side and raising the elbows and shoulders. In the
absence of a specific attention to the postural changes,
these may become repetitive and of long standing. On the
other hand, due to interferences, the need for a repetitive
repositioning of the tools, the equipment or the patient,
reduce the dentist's chance of working in a balanced
posture. The act of repositioning could compromise the
posture favoring the occurrence of musculoskeletal
disorders, reducing the access to the mouth and creating
conditions for working incidents and poor lighting of the
surgical field. All these conditions lead to physical and
mental fatigue and tension. Avoiding interferences and
the repetitive repositioning cause fatigue, confusion and
conditions for musculoskeletal disorders [6],
The frequent unidirectional trunk twisting and
tilting is a consequence of a faulty positioning of the tools,
equipment and materials. Positioning these useful items
at a big distance outside the working area of the dentist
(the circular area around the dentist described by the
forearms length in his sight) forces him to deviate from the
balanced posture. The help of the dental assistant
regarding the tools also handing has a major influence on
postural deviations of the dentist [14].
Fig. 2 a,b The frequent deviations from the balanced
posture
L81
jtIititjl L:i i\iitrjilti,t: -|til Ltle ,.iDi 7 i;i,.,; . ,:\rt,! irtti: )ii.l:i
The unbalanced dentist's postures
In dentistry practice, only the ofthostatic posture
can be often seen despite its many disadvantages. The
dentist's orthostatic posture is an asymmetrical posture
with the body support mainly on the right foot and the
internal organ compression on the right side due to
bending towards the patient. Only certain short clinical
acts should be done in this posture (e.9.. the bite records,
the impressions, some extractions, the aesthetic
evaluations) [9,11].
The possible causes of maintaining this posture
are: the habitude, the changing resistance, the intensive
working rhythm, the feeling of losing some freedom of
movements once sitting on the stool and working
unassisted or assisted only in part by the dental assistant
(the dentist himself takes the tools, which requires moving
free in the office space for easy access).
*1; 't'
$*.
Fig. 3 The orthostatic unbalanced posture
Another dentist's unbalanced oosture is a
seating posture with the upper body tilted on the right side
caused by the vertical or only slightly oblique positioning
of the patients. Compared with the orthostatic posture, it
protects the shanks and legs but all the problems
associated with of the marked long maintained asymmetry
are still manifesting. Twisting the trunk in only one
direction leads to serious muscular and joint unbalances
and favors the low back pain [20].
,S6q r
 Jou!'nal of Medicine c.(l L,l? \.,a1 7 issue 2, April-June 2014

Fig.4 a.fThe seated unbalanced posture

Conclusions
Although the theme of the dentist's posture is
treated with great care and often presented in the
undergraduate courses and the continuing education
courses on ergonom\cs in dentstry, many dent\sts do not
know the subject well enough, nor theoretically, and
therefore nor its practical applicability. Unfortunately,
many dentists are in the situation of feeling the negative
effects of unbalanced postures in the first years of
practice. In case musculoskeletal disorders arise, they
should take correcting actions and compensatory
measures in order to compensate the negative effects of
the unbalanced posture. Each dentist who feels
responsible for his health should reassess his working
posture. A good posture is not a luxury and it does not
require major investments but a rethinking of the way of
working. The dentists should not live their professional life
in terms of discomfort and musculoskeletal disorders
perspective.

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