43 2

Ergonomics Principles Applied

to the Dental Clinic
Karen Cristina Kazue Yui, Cristiani Siqueira Barbosa Lencioni,
Eliel Soares Orenha, and Carlos Rocha Gomes Torres

2.1 Introduction – 44

2.2 Ergonomics in Dentistry – 44

2.2.1  orking Posture – 45
W
2.2.2 Positioning of the Delivery Unit and Dental Chair – 50
2.2.3 Positioning of the Patients on the Chair – 53
2.2.4 Positioning of the Patient’s Head – 54
2.2.5 Positioning the Operating Field in Relation to the Dentist – 55
2.2.6 Positioning of the Operating Field in Relation to the Assistant – 56
2.2.7 The Use of Overhead Chair Light – 57
2.2.8 Vision of the Teeth to Be Treated – 58
2.2.9 Types of Movements During the Dental Treatment – 58
2.2.10 Ways to Grasp the Hand Instruments – 59
2.2.11 Rest Places – 61
2.2.12 Work Environmental Conditions – 63

2.3 Work-Related Musculoskeletal Disorders – 65

2.3.1  ccupational Diseases Epidemiology – 67
O
2.3.2 WMSD Prevention – 68

2.4 Exercises to Prevent Osteomuscular Problems – 69

2.5  urrent Panorama of Dental Ergonomic: Challenges,

C
Proposals, and Goals – 74

References – 75

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_2
 44 K. C. K. Yui et al.

Learning Objectives machine (equipment, tools, furniture, and spatial arrange-

The learning objectives of this chapter are related to the fol- ment), and characteristics of the worker’s environment (tem-
lowing topics: perature, noise, vibrations, light, colors, gases, etc.), besides
2 55 The principals of ergonomics in dentistry the consequences of the job, among other things.
55 How to ergonomically seat during the dental treatment In dentistry, as in any other health professions, this inter-
55 How to properly position the patient in the chair in order action between the worker, the environment, and the tool has
to have the operating field facing the operator and very special characteristic. The goal of the activity is not to
assistant produce or manufacture a product or an object but to offer a
55 How to grasp the instruments and rest the fingers in the service. This service is very special, because it is performed
oral environment, in order to have the full control of the for and to a human and not for nor to an object; this fact,
hand during treatment obviously, leads to very specific aspects, where the emotional
55 How to deal with the work environmental condition in aspects relative to the environment, the clinician, and the
order to protect the dental team health patient play a very fundamental role. That is why a satisfac-
55 How to prevent the most common work-related tory adaptation between the dentist and his job requires an
musculoskeletal disorders in dentistry environment that is emotionally positive and pleasant; where
the feelings to go further than comfort and productivity
flourish such as desire, pleasant surprises, interest, delight,
2.1 Introduction admiration, satisfaction, fascination, kindness, acceptance,
tolerance, proactivity, motivation, and confidence [29]. A
We, human beings, are provided of a force that drives us to a good adaptation does not occur where there is negativity
continuous search of the knowledge of ourselves and to bet- and is not pleasant and where feelings such as indignation,
ter adapt to the environment in which we live, aiming to disdain, grief, unpleasant surprise, excessive competition,
improve and ease the development of our activities, so we can dissatisfaction, frustration, intolerance, suspicion, subor-
reach superior levels of interaction, satisfaction, and internal dination, monotony, and fear flourish. Giving emphasis to
and external well-being, socially and individually. This the emotional aspects and using the knowledge on human
power, which at the same time drives and is driven by this sciences as psychology and sociology, the contemporary
search, enhances our capacity to transcend and develop; and ergonomics aims to turn the dental service more pleasant
nowadays, it has come to proportions never imagined before and enjoyable, and that way demystify the image people
[29]. Throughout the last few years, we have noticed a rapid have about the dentist, untying it from unpleasant feelings
transformation in our society due to the huge quantity, avail- and experiences. For that, it needed a more humanized den-
ability, and transference of information. This has allowed a tistry, where more empathy, affection, love, and satisfaction
significant improvement at work and life conditions. Multi- are noticed. Positive sensations and good feelings must be
and transdisciplinary strategies have each day been more instilled on the dentistry character and on the development
used to break barriers that once before hindered the acquisi- of the dental attention to reach those sublime goals [29].
tion, transference, and availability of knowledge.
The ergonomics, by its own nature, has benefited on this
context, enclosing and interconnecting the knowledge of
Ergonomics is the study of the adaptation of the job to
physiology, psychology, sociology, architecture, semiotics,
human being. What has been seen on most of the
industrial design, anthropometry, engineering, physical ther-
professions is an adaptation of human being to the job
apy, anthropology, medicine, communications, and many
and not the inverse. However, the human being is not
other neighboring sciences, applied to the work and on
always capable to adapt to the job.
human being activities, with the purpose to improve the
adaptation of the methods, means, and environment work to
men [20]. Ergonomics is the study of the adaptation of the
job to men, and it has been defined as “the group of scientific
knowledge about men that are needed to conceive an instru- 2.2 Ergonomics in Dentistry
ment, a machine and tools that can be used with maximum
comfort, safety and efficiency” [30, 36, 64]. What has been The knowledge on dental ergonomics has advanced much on
seen on most of the professions is an adaptation of men to the the last decades, revealing its importance for the dentist.
job and not the inverse. However, the human being is not However, we observe the non-implementation and practice
always capable to adapt to the job. Therefore, it can be seen of this knowledge. Some studies show that it is high the
that men should be the center of the attentions to elaborate occurrence of joint, muscles and lumbar problems, and many
projects for each job, adapting it to the human being capacity clinicians’ diseases related to the bad posture, lack of ergo-
and limitations [60]. Therefore, for the ergonomic studies, it nomic planning of the dental treatment unit, work
is important for us to know human being’s characteristics ­environment, work systems, among others [27]. This has
(physical, physiological, psychological, social aspects and caused many of the dentists to work on a low productivity
age, gender, training, and motivation), characteristics of the rate, without comfort and especially without the quality of
Ergonomics Principles Applied to the Dental Clinic
45 2
life and, in many cases, it has even drive them to abandon the >> The rationalization of the job can be obtained by
career prematurely. means of organizing the clinical procedures, applying
There is no doubt the dentistry is a weary and stressful the corporate management concepts and ergonomic
profession, which causes damage to the health, both physical principles, space arrangement, and four-handed
and psychic [10, 37, 39, 41, 46]. Studies about the musculo- dentistry.
skeletal disorders among dentists have been performed since
International standards on the ergonomic field were elabo-
the 1950s, and they are responsible for the first proposes to
rated aiming to promote significant improvement and to
change their working process, including the changes on the
assure that the standard procedures, for a healthy and safe
orthostatic position to the sitting position [61]. The actual
job, are established. The ISO 11226:2000/Cor 1:206 estab-
postural awkwardness at the dental work has been subject to
lishes the health limits for a static sitting job [31]. The ISO
many discussions [12]. Non-ergonomic dental workspace
6385:2004 presents a glossary of the main ergonomic terms,
and awkward postures cause musculoskeletal disorders,
requirements and necessary procedures for the development
which are common among dentists. This context is the theme
of working systems and places [33]. In 2009, the ISO 4073
for studies, especially in the ergonomics area. The posture
was revised and updated, and even though its first edition has
adopted by the dentist on their tasks has changed throughout
been published about 40 years ago, not all clinicians apply its
the world over the last 30 years [40]. However, the require-
principles on the spatial arrangement of their work environ-
ments of the dental practice, as the restrict visual field and
ment [15, 32]. In . Fig. 2.1, a correctly spatial arrangement of
adoption of awkward postures, increase the predisposition
the dental office according to the ISO 4073, in which we can
for the dentist to get musculoskeletal diseases [40, 51, 58].
notice a correct division of working zones on the floor, will
Therefore, more research is needed, which can define the
be described further in this chapter.
impacts of the muscular and nervous diseases on those clini-
cians, with the aim to prevent their development. With that,
there will be a better quality of life and a better service [52].
2.2.1 Working Posture
There is a consensus among authors in relation to the
causes of repetitive strain injuries (RSI) and work-related
The posture is defined by the American Academy of
musculoskeletal disorders (WMSD) among the dentists and
Orthopedics as a reactive arrangement of the body parts;
it can be highlighted:
the good posture is related to the balance between the sup-
55 Factors with organizational nature: Movement concen-
port structures, the muscles, and bones, protecting them-
tration on the same person, extra work hours, double
selves from aggression (direct trauma) or progressive
shifts, accelerated work rhythm, lack of necessary
deformity (structural changes) [1]. It is called postural
pauses, pressure from the boss, and others
work, the invisible effort that the back, shoulders, and arms
55 Factors with biomechanical nature: Excessive strength,
muscles do in silence against gravity. When we are sitting,
intense repetitiveness of the same movement pattern, the
there is a continuous effort of the back muscles to maintain
wrong posture of the upper limbs, compression on the
the torso erect, any other way, the body would collapse. This
lower limb structures, static posture, and others
muscular effort generated is in disadvantage because it
55 Factors with psychosocial nature: Excessive pressure for
blocks the blood flow. To have postural comfort, uncom-
results, excessively tense work environment, interper-
fortable positions for the torso, head, and arms should be
sonal relation problems, excessive rigidity at the work
avoided [5]. During the dental procedure, it should be
system, and others
­permitted to alternate between the sitting and standing
55 Factors of work conditions: Temperature, vibration,
furniture, noise, illumination, space, tools, and others

For the described factors to be considered a risk to cause RSI/

WMSD, it is important to observe their intensity, duration,
and frequency [44, 45]. Among those predisposed elements,
it can be pointed out the factors with organizational nature.
The way in which the work is organized can cause a greater
impact on the well-being of the individuals when compared
to the other factors.
The ergonomics applied to dentistry has the primary goal
to find mechanisms to reduce the physical and mental stress
on the dentist, to prevent diseases related to the dental prac-
tice, increasing the productivity but also the quality of life
[52]. The rationalization of the job can be obtained by means
of organizing the clinical procedures, applying the corporate
management concepts and ergonomic principles, space ..      Fig. 2.1 Dental clinical room built observing the criteria of the ISO
arrangement, and four-handed dentistry. 4073:2009 standard
 46 K. C. K. Yui et al.

positions. When only one of the positions needs to be cho- 55 Erectus: It is reached when we intentionally position
sen, the sitting position must be preferred. the forward and upward, with the vertebral column in a
Another important aspect is the interchange of the body neutral position, and the closest as possible to the shape
2 posture to avoid prolonged muscular static tension, that will that it has when it is in the orthostatic position (stand-
lead to fatigue. On the same way, a good balance between the ing). This avoids overload of the intervertebral discs,
body movements should be established, and the movement herniated disc, hyperlordosis, hyperkyphosis, and sco-
must be preferred against the prolonged immobility. The liosis of the vertebral column. This way, when passively
high precision movements, common in dentistry, should not seated, the correct support on the upper and lateral parts
involve a significant muscular force. of the pelvis, which must be proportioned by the support
The healthy posture for the dental job is sitting, also called of the dental stool, is fundamental to increase stability
“finger control posture” or “pianist posture.” The working and reduce the muscular overload.
position should be similar to the positions that we adopt
when we are reading a book, in a way that the visual field is
>> The healthy posture for the dental job is sitting, but
perpendicular to our visual axis [26]. To reach this healthy
this working position has also to be erectus, active,
posture, three basic work positions can be used [26, 28].
and symmetric.
55 Active (dynamic): Static positions are only possible
when the object to be seen by the dentist can face his The ISO 11226:2000/Cor 1:2006: standard “Ergonomics –
visual axis. For example, when the dentist is adjusting a Evaluating the posture of static work” establishes the healthy
temporary crown outside the mouth, all the surfaces can limits for a job performed sitting and static and determines
be easily seen by rotating the tooth completely without the ideal position considering the head, the torso, the arms,
having to change the visual axis. On the other hand, and the legs angles [31]. To reach an ideal posture, according
when the dentist makes a preparation on the buccal and to this standard, the column must be erect, the legs must
lingual surfaces of the tooth 46, it is necessary to change remain perpendicular to the ground, and the tights must be
his position and the position of the patient’s head in a parallel to the ground or slightly leaned, forming a 90° to a
way that it is possible to look in a perpendicular manner 125° angle on the knees and hip angle (. Fig. 2.2a). The head
to the working field. This frequently happens during the can lean up to 20° forward in relation to the column, while
intraoral procedures. Therefore, it is frequent the the torso can lean up to 10° forward (. Fig. 2.2a). The upper
necessity to visualize different sites, which cannot be arms must present a maximum angulation of 20° on the for-
completely positioned in the direction of the visual axis ward inclination (. Fig. 2.2a).
of the dentist, being necessary to move to get adequate
vision without excessive inclination. For that, it is Tip
necessary to have enough space under the back of the
patient’s dental chair that will allow the dentist to freely The dentist must pay attention to his body. The head
move, without obstructions and where the legs will not should not lean more than up to 20° forward in
be “hindered and restrained” under the back of the relation to the column, while the torso can lean up to
chair. 10° forward. The upper arms must present a maximum
55 Symmetric (stable and balanced): The working field angulation of 20° on the forward inclination.
must be positioned in front of and centralized in relation
to the chest of the dentist. Every time that the working The patient must be positioned in a way that the forearms of
field is not centralized in relation to the chest of the the operator are leaned, at least, 10° and the most to 15°
dentist, an asymmetric work posture will occur. It upward, when the hands are in a position of operating
requires more muscular effort to maintain the balance (. Fig. 2.2a). This inclination of the forearms avoids the
and it will generate more fatigue and tiredness. The excessive frontal inclination of the torso, so it is possible to
inclination and effort will lead to scoliosis. Other have a good vision of the operating field [26]. The elbows
important disadvantage will be the difference in distance must be close to the body with a maximum lateral distance
among the objects focused by the left and right ocular of 20° (. Fig. 2.2b) [26, 28]. It is very common to observe
globe [62]. This difference in distance leads to more that the dentist and the dental students usually work with
effort on the ocular muscles to correct the distortion of an excessive distance between the elbows, and always that
the image that will be generated, which will predispose the patient’s mouth is positioned above the recommended
prematurely the dentist to a presbyopia condition [24]. A distance from the ground, which is 5–10 cm below the
symmetrical position is reached when there is a parallel elbows when the dentist is well positioned in the stool. This
relation to the imaginary lines that go through the patient’s position can avoid that the dentist leans the torso
pupils, shoulders, hips, knees, and feet completely laying beyond the 10° forward, in the anteroposterior direction.
on the ground. This also requires that the foot control of To lean the body forward produces a reduction of body’s
the chair is closely positioned to the foot of the dentist, agility and increase the static load. The back and neck of the
so it is not necessary to stretch the leg to reach it. dentist should not lean or rotate laterally, and the top of the
Ergonomics Principles Applied to the Dental Clinic
47 2

a b

..      Fig. 2.2 Healthy work posture for the dentist according to the ISO 11226:2000 standard. a Side view; b back view

shoulders should stay parallel to the ground, which charac- mobility and freedom of movements are necessary when we
terizes a symmetric and equilibrated posture, without mus- do a cavity preparation that comprehends two or more sur-
cular overload (. Fig. 2.2b) [26, 28]. faces, or even the preparation for a full crown that compre-
On the other hand, the effective application of the rules to hends all surfaces of the tooth. On those cases, only asking
the postural needs of the dentist demonstrates a great chal- for the patient to move the head left or right, backward or
lenge, because the working field (surface, tooth, quadrant, or forward, may not be enough and requires that the dentist
region) cannot always be directed perpendicularly to the move himself more to the right or behind the patient.
visual axis. In many cases, the use of the clinical mirror is Consequently, there is a need for a work posture that is at the
essential because it facilitates the visualization without the same time symmetrical, erect, balanced, and stable, but
need to lean laterally or forward, especially in procedures prone to the movement [26, 28].
performed on the upper jaw, and even that, it is not always Other benefit in using an angle greater or equal to 110°
enough [28]. between the thigh and lower part of the leg is that this leads
One difficulty is related to the angles formed by the thigh to a neutral positioning of the pelvis, slightly leaning forward
and the leg. When a 90° knee angle is adopted (. Fig. 2.3a), and downward. When this angle is lower, close to 90°, there
the space under the back of the chair is limited, especially is an upper and backward leaning of the pelvis. Therefore,
when the patient is sitting down, forcing the dentist to back when the pelvis is raised and forced back, there is more ten-
up from the patient and to lean forward to approach the sion on the lumbar region of the vertebral column, reducing
working field, causing a compression on the abdominal its normal curvature and causing a compression on the inter-
region that will lead to a diminishing of the venous circula- vertebral discs [31].
tion [26]. This space becomes greater when we increase the Kinematic chain balance and neutral working posture is
angle to 110°, and it can go up to 125° (. Fig. 2.3b, c). most easily achieved by working in a higher sitting posture,
Another additional benefit is that this increase, to at least with a 125° knee/hip angle, because it allows the patient’s
110°, propitiates less compression on the abdominal region, chair to be raised, creating the necessary space for proper
facilitating the blood circulation on this region. It also per- movement of the legs of the dentist under the back of the
mits that the work posture of the dentist become more chair. However, currently, most of the dental stools offered
dynamic, prone to the movement, permitting the alternation on the global market have a flat seat; hence working in a
of the position on a simple way, naturally and without obsta- higher sitting posture leads to a greater compression on the
cles, which is an essential condition, for example, when a returning venous circulation, and, consequentially, there are
procedure is performed on the first quadrant, comprehend- more chances to have varicose veins because there is a
ing the buccal, lingual, mesial, and distal surfaces. This greater support on the legs and less support on the coccygeal
 48 K. C. K. Yui et al.

a b c

..      Fig. 2.3 Angle between the leg and the thigh. a 90° angle. Distance between 5 and 10 cm between the height of the elbows and the mouth
of the patient; b 110° angle. The inadequate stool leads to a compression of the thigh (arrow). c Use of the saddle shaped stool (Salli System)

a b c d

..      Fig. 2.4 Dental stool with design of two-inclination seat, which allows the dentist to adopt a healthy work posture. a, c Stools with straight
seats; b, d stool with double inclination. (Courtesy from Professor Paul A. Engels)

region (. Fig. 2.3b – arrow) [2]. So that does not happen, it simulation as if the individual was standing up, and because
is necessary that the dentist’s stool comprises a seat pan, con- of that, there is no back in the stool. The angle on the knee
sisting of a horizontal rear part for the pelvis, and an inclin- region is found to be more adequate, which lowers the pres-
able sloping down front part for the upper legs, with a sure on the knees, improves the joint metabolism (knee and
vertically and horizontally adjustable back rest [13, 28]. hips), and lowers the risks of future problems, also contribut-
. Figure 2.4 shows the Ghopec dental stool with an appro- ing to improve the circulation on the legs. Because it is com-
priate design, that allows the dentist to assume a passive as posed of two separate pars, it ventilates the genital region of
well as a dynamic posture [28]. the woman, which reduces the occurrence of infections and
Other option would be to use stools shaped like a horse’s reduces the pressure on the masculine genital organ. This
saddle (Salli System), as it can be shown in . Fig. 2.5. On this system also reduces pressure on the chest, on the ribs, and on
type of seat, the support happened at the ischium bones in a the upper part of the column, increasing the inhaled oxygen
Ergonomics Principles Applied to the Dental Clinic
49 2
Vianna and Arita [63] described a working position that
is based on the logic performance concept, which is a scien-
tific model of improved performance by means of emphasis
on a more natural position, to do a finite task on a balanced
posture. Studying the space relation between the operator
and his work plane, it can be concluded that the dental work
is much better performed on the midsagittal plane, with the
hands, on the chest or heart level, in myocentric harmony
(. Fig. 2.2).
The dentist must sit with his feet completely supported on
the ground, providing a position of equilibrium and a posi-
tive physiologic condition. The greater the area in which a
force acts on, the smaller the pressure and better distribution,
so more favorable to the health of the feet. The feet must be
parallel to the ground, in a way where the right foot is slightly
ahead of the left foot, and this position can be alternated. The
right foot must be free on a plane area to reach the command
of the dental chair, without diverting the attention from
the operating field. Furthermore, the shoes must be comfort-
able and loose [19]. The dentist should not sit on his legs and
should always sit on the gluteus region, with the support on
the ischium bones, which is part of the hip bones [2]. The
whole seat surface must be used to support the operator’s
weight. The compression of the tissues varies with the type of
seat, been greater on the stools with a flat surface and lower
on a saddle-shaped stool, as it can be seen on the . Fig. 2.6a,
b. In relation to the angle formed by the gap between the legs,
it can be between 25° and 45° (. Fig. 2.14).

>> The dentist must sit with his feet completely supported
..      Fig. 2.5 Saddle-shaped stool (Salli System)
on the ground, providing a position of equilibrium.

quantity. Furthermore, lowers the pressure on internal In relation to the leaning of the body on the anteroposterior
organs, especially on intestine and stomach (. Fig. 2.3c). position, the ideal is to maintain the sitting positioning on a
Limitations are attributed to saddle stool which are related to medium posture (. Fig. 2.7a). On this position, it is reco-
increased angle in the lumbar spine when sitting with a 135° mended a support on the upper pelvic region or lumbar [28],
hip angle and muscle fatigue in the same region by the which alleviates the abdominal cavity, an important region
absence of the backrest [13]. A recent systematic review [50] for blood flow and digestion [2]. A slight leaning forward
has revealed that there is a limited number of studies and <10°, on a relaxed position, decreases the electrical activity of
insufficient scientific evidence that using saddle stool leads to the muscles, and so it is favorable. However, if the forward
improved dentist’s sitting posture, and there are no studies on leaning of the chest is too high, there will be a compression
its effect to reduce neck pain and musculoskeletal pain. on the abdominal cavity (. Fig. 2.7b). On the anterior posi-
Therefore, prospective longitudinal studies that are necessary tion, the large saphenous vein can be compressed, causing an
to strengthen the scientific evidence about its contribution obstruction of the veins of the leg and undesirable effects on
and effect. the internal organs, which can reflect on the chest or on the
However, the recommendation to use an angle >90° con- groin [2]. In addition, this leaning pushes the organ upward,
tinues to be a problem for most of the dentist around the which impairs the well-functioning of the lungs and heart
world, who may not have a stool with a proper design avail- due to a less volume on the thoracic cavity. If the dentist is
able on the market. In the case the stool does not have one of leaning backward, in a posterior position, there will have a
the mentioned designs and an angle >90° is used, the result- displacement of the equilibrium point with its tragic conse-
ing forces on the tripod legs stool can push the stool back- quences (. Fig. 2.7c).
ward and also result in the compression and venous According to Ferreira [17], there is a consensus among
obstruction on the thigh region. Therefore, in the abscence of researchers that working on a seated position allows a more
an adequate stool, a 90° angle should be used. The incorrect comfortable condition for the clinician. On the other hand, it
drawing of the stool can seriously affect the health of the cli- is fundamental to point out that the bad posture at a seated
nician, leading to an irreversible deformation of the vertebral job, can be potentially more harmful to the individual than to
column [2]. work in the standing up position. In other words, the dentist
 50 K. C. K. Yui et al.

a b

..      Fig. 2.6 Relation between the kind of seat and the compression on the soft tissues. a Straight surface stool; b Saddle-shaped stool. The red
areas represent greater compression regions. (Images kindly supplied by the Salli System Company)

a b c

..      Fig. 2.7 Leaning of the body on the anterior-posterior direction. a Medium sitting posture; b Anterior sitting position with excessive leaning; c
Posterior sitting position

who works standing up has less harmful consequences than 2.2.2  ositioning of the Delivery Unit
P
the one who works sitting down in a wrong position. In sum- and Dental Chair
mary, to work on a healthy way, the dentist needs to work
symmetrically erect on active and stable position, avoiding There are four basic concepts to build dental treatment unit.
lifting and curving the shoulders and only making small On concept 1, the most commonly used dental delivery unit
movements with the arms. To make this possible, the operat- (treatment cart or instrument bridge) is positioned to the
ing field must be positioned on the correct height, in sym- right of the dental chair and to the right of the dentist
metrical position in relation to the dentist, facing his visual (. Fig. 2.8).
field in a way that he/she is capable to see the field in a most To analyze the dental treatment unit according to its posi-
perpendicular way as possible. The instruments must be tion in the dental office, the ISO/FDI is established to divide
positioned on the correct working height, inside the vision the room into areas, like a clock face. The center, correspond-
field, at 30° angle to the left and right. As a result of all that, ing to the axis of rotation of the clock, is located in the
the dentist will be able to reach the instruments without patient’s mouth (the most important point in the dental
extreme movements. Finally, the dynamic working method office). Around the center, three concentric circles are drawn,
must be applied instead of a static method. named A, B, and C, with a radius of 0.5, 1, and 1.5 m, respec-
Ergonomics Principles Applied to the Dental Clinic
51 2

..      Fig. 2.8 Basic concept 1 for delivery unit and chair. (Scheme kindly supplied by the Dabi-Atlante company)
 52 K. C. K. Yui et al.

12
11 1
2 C

10 B 2
A - Transference zone (instruments, handpieces, stool)
A 50cm
50cm B - Work zone (auxiliary table and delivery unit)
50cm
9 3 C - Useful office area (sinks and furniture)

4 Operator area
8
Assistant area

7 5

..      Fig. 2.9 Functional work circles at the dental office. (Scheme kindly supplied by the Dabi-Atlante company)

tively (. Fig. 2.9) [2]. The A circle is called the transference above 20°. On those positions, the working field will not be
zone, where the instruments, handpieces, and stools must be located in front of the dentist’s body, forcing him to execute
placed. The B circle is the working zone, where the cart and lateral flexion movements of the body to the side of the
the body of the dental delivery unit are placed. The C circle is patient. That will generate an overload of the intervertebral
the rest of the useful area of the dental office, where the sink discs on the lumbar region and on the cervical column, and
and stable furniture are placed. The position 12 o’clock is may cause scoliosis and herniated disc. This may also pro-
always marked by the head of the patient, in other words, the duce, further than tiredness, a lot of muscle fatigue on the
back of the chair. right shoulder.
The use of the zone of activity concept is the best way to The 12 o’clock position may permit the operator to work
identify the work position for the working dental team. The on a labial surface of the anterior maxillary teeth and to use a
6–12 h line divides the room into two areas (. Fig. 2.9). The direct vision. However, it presents disadvantage that the
operator’s zone is where the dentist will be positioned, to the movement of the instruments will occur above the patient’s
right of the patient, going from 7 to 12 o’clock for cases of face, exposing him to the risk of an accident, being not used
right-handed clinicians and from 5 to 12 on the left-handed more than 10% of the dentist’s time. The dentists work mainly
cases. The ideal work position is reached when the clinician on a 9–11 o’clock position. As an advantage of those posi-
is positioned in front of the patient’s mouth and is able to tions, the direct vision of almost all surfaces of all teeth is
place the working field the closest as possible and facing his possible, with a minimum leaning of the column forward
visual axis. and never laterally, being more natural and better to the ver-
The 9 o’clock position is considered by most authors as tebral column. The operators can also use direct vision mov-
the basic for the dentist’s job (. Fig. 2.10a). At this position, ing to the 8 o’clock position, when working on an occlusal
one of the best places for the dental delivery unit is to the surface of the posterior mandibular teeth on the right side.
right. This way, the dentist can reach the high and low-speed The assistant’s zone is the area of auxiliary activities, situ-
handpieces and the 3-way syringe with only one movement ated to the left of the patients for the right-handed clinician. In
of the forearm, with the elbows in a comfortable position that area the furniture, auxiliary equipment, and all equip-
near the body, without rotating the head. The 7 and 8 o’clock ment used by the assistant are placed, such as the vacuum suc-
positions are not appropriate for the intraoral procedures, tion tip and the 3-way syringe. The assistant position varies
only for the external procedures or when the clinician is talk- from 2 to 4 o’clock for the right-handed (generally is 3 o’clock),
ing to the patient, for example, during the anamnesis and from 8 to 10 o’clock for the left-handed. Nothing in this
(. Fig. 2.10b) [34]. The attempt to work on the mouth being zone can interfere on the access of the assistant to the instru-
in one of those positions will lead to an asymmetrical pos- ments and handpieces (. Fig. 2.10a–c). The static zone is the
ture, leaning laterally and with the dentist’s right elbow lifted limit between the operator and auxiliary areas on the region
Ergonomics Principles Applied to the Dental Clinic
53 2

a b c
12 12 12
11 1 11 1 11 1

10 2 10 2 10 2

9 3 9 3 9 3

8 4 8 4 8 4

7 5 7 5 7 5
6 6 6

Dentist: 9 o´clock Operator area Dentist: 7 o´clock Operator area STATIC AREA
Assistant: 3 o´clock Assistant area Assistant: 3 o´clock Assistant area TRANSFERENCE AREA

..      Fig. 2.10 Working zones for the dentist and assistant. a Dentist at 9 o’clock and assistant at 3 o’clock; b dentist at 7 o’clock and assistant at
3 o’clock; c static areas and transference areas. (Scheme kindly supplied by the Dabi Atlante company)

behind the chair, being from 12 to 2 o’clock for the right-­ 2.2.3 Positioning of the Patients
handed and from 10 to 12 o’clock for the left-handed [2]. It is on the Chair
a zone of less activity, and, in general, it is used to place emer-
gency materials for the dentist and auxiliary equipment, as The patient must be, always as possible, positioned in a
amalgamator, ultrasonic scaler, and curing light, among oth- supine position (lying on his back), so that the dentist and
ers. The transference zone is located from 4 to 7 o’clock for the the assistant can have a direct vision on the operating
right-handed and from 5 to 8 o’clock for the left-handed clini- fields. One of the advantages of the supine position is that
cian (. Fig. 2.10c). the patient’s tongue falls behind, blocking the pharynx,
During the procedure, the operator must be capable to this way, even when the patient’s mouth is full of water he
keep hands and eyes on the working field, without being wor- does not have the need to swallow. In addition, if any mate-
ried about from where the next instrument will come. Care rial or tool escapes the hands of the dentist, the chances of
should be taken so that members of dental team do not inter- being swallowed are minimum, since the deglutition is
fere on the activity of each other inside the designated zones, harder on this position (. Fig. 2.11a, b) [2]. The working
avoiding unnecessary movements that could interfere on the field on the mouth of the patient can be turned to the visual
procedure. Both team members sitting correctly must have axis of the dentist in an easier way if the patient is in a
all the material and instruments in a minimum reaching dis- supine position.
tance, inside the working areas, and in the radius of circle A On the supine position, the knees and the legs of the
which is the size of the forearm (. Fig. 2.9) [2]. patients must be at the same level as the head (. Fig. 2.12).
>> During the procedure, the operator must be capable to This replicates the position that most people adopt when they
keep hands and eyes on the working field without are sleeping for many hours without blocking the blood flow.
being worried about from where the next instrument The position of the patient when the legs are higher than the
will come. head for a prolonged time is not recommended [7].
Once the patient is in a supine position, the operator can
The concept that the less movement done, the less use of lower the chair up to the point where the patient’s head is at
energy and the greater the productivity should be adopted his lap, so he will not have to raise the forearm above 15° or
[2]. The working surfaces to place the instruments must be in lean himself more than 10° to work at the patient’s mouth [7].
front of the patient, more or less 20 cm from his chin, on the The dentist will have to lean excessively forward when the
frontal transference zone, next to the working area. The oral patient is at the same height or lower than his elbows. On the
cavity of the patient, the dentist’s delivery unit, the assistant’s other side, when the mouth is positioned much higher than
delivery unit, the top of the furniture with the equipment, the level of the dentist’s elbow, the dentist will have to raise
and the trays with the instruments, must be placed on a the shoulders, arching them and moving the elbows far away.
hypothetical horizontal plane, from 5 to 10 cm above the As it has already been mentioned, the mouth of the patient
elbow of the dentist (. Fig. 2.3a). must be 5–10 cm above the elbows of the dentist.
 54 K. C. K. Yui et al.

a b

..      Fig. 2.11 Relation between the leaning of the head and the opening of the digestive and respiratory way. a Patient sitting with the orophar-
ynx opened; b patient laying down with the oropharynx closed by the backing up of the tongue

tributing to the infection control. The operator will also not

invade the breathing space of the patient, and this way will
show consideration about his comfort throughout the treat-
ment.
For the working position currently recommended, the
leaning of the chair’s back depends on where the dentist will
be working in the oral cavity of the patient. The leaning of the
articulated headrest of the chair must change according to
the arch that is being treated. On the upper jaw, the patient
must be on the supine position, and the headrest must be
leaning backward. For procedures on the lower jaw, the head-
rest must be leaning forward (. Fig. 2.13a, b).
>> One of the advantages of the supine position is that
the patient’s tongue falls behind, blocking the
..      Fig. 2.12 Adequate positioning of the patient on the supine pharynx.
position

It is important that both legs are positioned under the back 2.2.4 Positioning of the Patient’s Head
of the chair, without being “restrained” or “blocked,” with the
head of the patient, who is on the supine position, being able to The patient’s head must be placed in a way that the working
alternate the position from 9 to 12 o’clock and keeping his pos- field is facing the dentist’s visual axis, considering that he is
ture. As it has already been mentioned, this is attained by correctly positioned on the stool. To reach this position, the
adjusting the angle between the leg and the thigh above 90° patient’s head can be moved in three axis and three directions
using an appropriated stool. Therefore, the correct working (. Fig. 2.13a–f):
height depends on the dentist’s height and when he is posi- 55 Forward, by flexion, for a horizontal position of the
tioned correctly on the stool. This way, the dentist and the assis- lower jaw. Backward, by extension, so that the occlusal
tant must be at compatible heights, so that the adjustment of plane of the upper jaw can be switched in some cases on
the chair for the dentist is not uncomfortable for the assistant. a 20–25° angle in relation to the vertical plane. The
The final visual adjustments and the access to all quarters further the head is positioned backward, the more
of the mouth can be reached by rotating the head of the favorable is to work with a direct vision in a correct
patient. The torso of the dentist must be the closest as possi- posture on the upper jaw (. Fig. 2.13a, b).
ble to the back of the chair; this way, the head of the patient 55 To the left or right by the side flexion, positioning the
will be leaning on his lap at a distance of 30–40 cm below the head of the patient on a 30–40° angle sideways in
eyes/safety glasses, providing comfort for the vision and con- relation to the body’s long axis. This movement is
Ergonomics Principles Applied to the Dental Clinic
55 2

a b

c d

e f

..      Fig. 2.13 Movement of the patient’s head in three ways to place the working field perpendicularly to the visual axis of the dentist. a Forward;
b backward; c leaning to the left; d leaning to the right; e right rotation; f left rotation

necessary to put the operating field on the patient’s 2.2.5  ositioning the Operating Field
P
mouth on a symmetrical plane of the dentist in Relation to the Dentist
(. Fig. 2.13c, d).
55 To the left or right, rotating along the longitudinal axis It is frequent for us to see that the operating field on a patient’s
of the head (. Fig. 2.13e, f). mouth is not directed toward the dentist, and it is placed asym-
metrically in front of him, resulting in an asymmetric and
stressful operating posture. This must be avoided in a way that
Tip
the symmetrical posture can be kept. The principles for the
It is easier to move the patient’s head than try only to correct positioning of the operating field are described next:
adjust the dentist’s position to see the operating field. 55 The operating field must be placed symmetrically,
straight in front of the chest of the dentist, at a distance
 56 K. C. K. Yui et al.

of 20–25 cm from the sternum bone. In addition, it must Tip

be placed in a height that allows a correct working
posture. The more the dentist wants to work on the upper jaw
2 55 The clinician must look perpendicularly to the operating with direct vision, the more the patient’s head needs to
field or to the mirror. If this is not possible, as it happens be turned backward.
on the posterior region of the mouth or when using a
handpiece, the field or the mirror must be as perpen-
dicular as possible. The rotation of the patient’s head
allows the good positioning on the visual field. It can be 2.2.6  ositioning of the Operating Field
P
turned in three directions, according to the previous in Relation to the Assistant
description, to promote this vision.
The assistant plays an important role on the productivity and
If the head of a bur or instrument is positioned on the sight- on the improvement of the work quality inside a dental office.
line, interfering with the good visualization, the patient’s Therefore, the dentist divides with her some of his secondary
head is rotated and the dentist position is adjusted instead of attributions, such as some complementary tasks, saving the
the dentist moving his torso and head laterally to reach more time of the clinician and leaving to him the work that only he
visibility. can do [21]. As advantages of the assisted work, there is the
After defining those general rules, taking in consider- reduction on the movement quantity, that the dentist would
ation the position of the operating field in the patient’s have to perform if he was working alone, reducing the physi-
mouth, the question is how it can be reached and how the cal and mental fatigue. In addition, the work at four hands
arches of the patient must be placed. This position depends allows a higher performance, reducing the duration of the
completely on the procedure to be performed: treatment [21]. It will be the assistant’s duty to accommodate
55 When a procedure is done on the mandibular occlusal the patient’s head and to open his mouth, putting away his
plane, the dentist must sit on the side of the patient on a tongue and cheeks, suctioning the blood and saliva, always
position between 9 and 10 o’clock, for the right-handed placing the operating field to the direct vision field of the
people, and the occlusal plane will be placed more or less dentist [2].
horizontally. The patient’s head will be turned to the
>> The assistant plays an important role on the
dentist in a way that he looks perpendicularly to the
productivity and on the improvement of the work
occlusal plane. If the lower jaw is not placed like that, but
quality inside a dental office. Therefore, the dentist
in an oblique way, the dentist will have to raise the right
divides with her some of his secondary attributions,
arm to reach the operating field.
saving the time and leaving to him the work that only
55 When a procedure is done on the mandibular occlusal
he can do.
plane, from behind the patient (on the position from
10:30 to 12 o’clock for the right-handed people), the The dentist’s assistants must be capable to work sitting down at
occlusal plane on the lower jaw is placed approximately a healthy position, similar to the posture described for the
40° in relation to the horizontal plane, in a way that the dentist. However, she should occupy the position that goes
operating field is viewed perpendicularly, with the help from 2 to 4 o’clock [2]. When the dentist sits at the 12 o’clock
to the head’s rotation. position, this is almost impossible. The assistant will have to sit
55 When treating the maxillary occlusal plane, with an with the legs slightly separated, and so it does not interfere
indirect vision from behind the patient, the occlusal with the movement. The assistant’s legs must be synchronized
plane of the upper jaw is turned around 25° backward in with the dentist’s legs (. Fig. 2.14) [2]. At this position, she will
relation to the vertical plane. Followed by a rotation of avoid the torsion of the column to the left and the raising of the
the head, it is placed on the correct position in relation arms during the operative procedures, being better located in
to the mirror. Those 25° of rotation promote a great relation to the delivery unit, to reach with the left hand her
adjustment for the necessary position of the mirror. The elements and to help the dentist. Her back should rest on the
problem with most headrests is that it is impossible to back of the stool and slightly leaning forward. Her head must
position the upper jaw occlusal plane at 25° backward. be leaned downward, visualizing the working field [2].
Hence, the dentist is forced to lean the torso forward to Both the dentist and the assistant must have all the mate-
obtain a better visibility of the operating field. rial to the reach of their hands. The assistant should not move
55 When procedures are done on the buccal and lingual the whole arm, and for that, it is suggested that a third assis-
surfaces of the teeth, the dentist must place himself on tant to prepare and bring the materials that are more distant
the side of the patient, on a position between 9 and 11 [2]. Another way to reach this goal is to do an effective previ-
o’clock, with a direct vision, except for the anterior teeth. ous planning of the tray, and placing it on the ideal distance,
55 The more the dentist wants to work on the upper jaw to reach all the material and instruments that will be neces-
with direct vision, the more the patient’s head needs to sary during treatment.
be turned backward. However, the possibility to do that The adjustments on the patient’s position must be per-
must be evaluated. formed with the aid of the assistant, up to the point where
Ergonomics Principles Applied to the Dental Clinic
57 2

..      Fig. 2.14 Synchronization of the dentist’s and assistant’s legs ..      Fig. 2.15 Adequate vertical relation between the assistant and the
dentist for better visualization

those relations are established. When a deviation on the pos-

ture is noticed, she can communicate politely with the clini- directed nearly parallel to the dentist’s line of sight, without
cian asking: “Are you comfortable?” This is a sign that maybe shadows, with a maximum deviation of 15°. Proper position-
a rearrangement on the position is needed. The assistant ing of the dental operating light will avoid shadows behind
needs to be capable to see and have favorable access to the the lips, teeth, and face, under the hand and on the operating
oral cavity, at least of the teeth or the area that is being treated. field or around it (. Fig. 2.16a, b).
To increase visibility, the height of the assistant’s stool could Visual sharpness does not indefinitely get better with
be at least 10–15 cm above the dentist’s head (. Fig. 2.15). To crescent light levels; there is a peak when the luminance is
make it possible, it is necessary that the assistant’s stool has around 1000 cd/m2 (candela per square meter). Therefore,
footrest. However, when this special stool is not available, it the illumination above this value does not bring any benefit
must be adjusted so that the head of the assistant is at the in terms of vision sharpness. A best level of illumination also
same height of the dentist’s head. does not exist, because it depends from each observer and
on the reflexivity of the working area. The illumination from
the dental light must go from 8000 to 24,000 lx, which cor-
2.2.7 The Use of Overhead Chair Light responds to 200 to 2000 cd/m2 of the light inside the mouth.
The illuminance of 8000 lx is enough to visually discrimi-
The visual performance influences directly the efficiency of nate a white tooth, and 24,000 lx is more appropriate for the
the dentist’s work. The better the clinician can see, the faster visualization during procedures done in darker areas inside
and more reliable the work will be. The main components of the patient’s mouth, for example, during the procedures on
the visual performance are the ability to see small details the molars. The light level from the dental chair light must
(visual sharpness) and the ability to see small contrast (con- be easy to adjust. In combination with other sources, the
trast sensitivity). The light at the work environment must be illuminance of the mouth must not exceed 30,000 lx. Greater
well planned to allow a good dentistry to be performed, a light levels cause visual discomfort and reduction of visual
professional activity that requires accuracy and details. The sharpness.
perfect light at the dental office will reduce the fatigue and The correct distance of the overhead light to the operat-
the incidence of visual fatigue. The environment next to the ing field (patient’s mouth) must be around 70–80 cm, and the
mouth of the patient must be lighted with at least 1/10 of the environment’s light must be compatible with the illumina-
light over the mouth. For example, if the light over the tion inside the oral cavity, allowing the gradual accommoda-
mouth has a illuminance of 20,000 LUX (lx), then the sur- tion of the eyes [17]. When the dental light is positioned at
roundings must be lighted with at least 2000 lx and the room 70 cm apart from the patient’s mouth, it must form a rectan-
with 1000 lx. gle of light with the concentrated area and limited by 10 cm
height and 20 cm width, in a way that there is no direct light
>> The better the clinician can see, the faster and more
beam to the patient’s eyes, which causes dazzle and discom-
reliable the work will be.
fort. Therefore, when the patient leans laterally together with
One of the most frequent mistakes done by the dentists is in the rotation of the head, it is important that the light beam
relation to the incorrect positioning of the dental overhead may follow this position of the mouth without causing dis-
light, putting it in front of the patient and perpendicularly to comfort for the patient.
the visual axis. This causes the formation of shadows by the Near the mouth, instrument that have a reflectivity simi-
interposition of the hands and instruments between the light lar to mouth should be choosen. Instruments with dull sur-
and the object to be seen [62]. The light beam must be faces are preferable to avoid strong reflection, that will cause
 58 K. C. K. Yui et al.

a b

..      Fig. 2.16 Correct positioning of the dental light to avoid the appearance of shadows and to improve the illumination

tension on the eyes and reduction of the eye sharpness. In Even if the dentist is in an adequate posture, the patient and
addition, white and black objects should also be avoided. operating field are on a correct position, and it is hard not to
Other important factor for the correct positioning of the lean the head more than 20° as recomended. Due to that, spe-
light beam of the dental chair light is the need to have three cial glasses were developed for the dentist, so it can allow an
rotating axis. This is important so the beam of light can fol- adequate position of the head and neck (. Fig. 2.17a–f).
low the movement of the patient’s head and, consequentially, Those glasses have a piece of a prism on the lower part of the
his mouth. It is common that the mouth is placed on an lens, and they are tilted. This way, when the dentist directs his
oblique manner in relation to the headrest, on the vertical, vision to this area of the glasses, there is no need to lean the
horizontal, and depth ways. The length of the chair light’s head and the neck. Others also present magnifying lens to
arm must be enough to place the light on the side and above enlarge the image.
the head of the dentist, even if he is in any position between
9 and 12 o’clock. Especially, when he places himself at 12
o’clock, the light must be placed according to the clinician’s 2.2.9  ypes of Movements During
T
visual axis, being at most 15° laterally or above the den-
the Dental Treatment
tist’s head, being this information little known and applied by
most clinicians.
The movements executed by the dentist and the assistant
can be divided into five classes, with increasing complexity
order [6]:
2.2.8 Vision of the Teeth to Be Treated 55 Class 1 – Finger movement. For example, the root canal
preparation
The operator can use two forms to see the operating field in
55 Class 2 – Finger and wrist movement. For example,
the oral cavity, the direct and indirect vision. The direct
cavity preparation
vision occurs when the operator looks directly to the cavity
55 Class 3 – Finger, wrist, and elbows (forearm). It is
preparation or the place to be treated; the indirect vision
important that this occurs inside the ideal space in the
requires the operator to look through a mirror to see the area
transference zone. For example, to reach the high-speed
to be treated. The indirect vision eliminates the need for the
handpiece at the delivery unit
operator to lean to see the operating field. To treat the occlu-
55 Class 4 – Movement of the whole arm. It is the maxi-
sal surface of the second upper molar on the right side, even
mum reaching area. For example, open an auxiliary
with the patient on the supine position, maybe the clinician
drawer when it is slightly farther than the transference
will need to lean a little to have a direct vision. The use of a
zone and inside the functional working circle
mirror will allow the operator to be seated in a healthy pos-
(. Fig. 2.18)
ture and observe the operating field satisfactorily using an
55 Class 5 – Torsions of the body and displacement. For
indirect vision.
example, to reach the suction across the patient, at the
>> The direct vision occurs when the operator looks assistant’s side
directly to the cavity preparation or the place to be
treated; the indirect vision requires the operator to From all those movements, the ones in Classes 4 and 5 are the
look through a mirror to see the area to be treated. The ones more difficult and time-consuming, because they need
indirect vision eliminates the need for the operator to more muscle activity, new visual accommodation, and new
lean to see the operating field. focus on the operating field. Movement 5 is eliminated by the
Ergonomics Principles Applied to the Dental Clinic
59 2

a b

c d

e f

..      Fig. 2.17 a Special glasses with a prism segment to correct the leaning of the head; b glasses with image magnification and correction the
head position; c posture without the glasses; d posture with the prismatic glasses; e–f posture with the image magnification glasses

work with an assistant, and in case she is efficient, it can even focus on the operating field. Therefore, they should
eliminate the movements Class 4, leaving for the dentist only always be avoided, and this rule is applied to the
movements Class 1, 2 and 3. Therefore, movements 4 and 5 dentist and the assistant.
must be always avoided, and this rule is applied to the dentist
and the assistant [2]. The correct posture can be easily main-
2.2.10 Ways to Grasp the Hand Instruments
tained if the operator remembers that the operating field
must be positioned in his direction.
During the dental procedure, the hand instruments can be
>> The movements of the whole arm, torsions of the body, grasped by the hands in different ways, depending on the
and displacements produce more tiredness and are dental arch to be treated and the work to be performed. To
most time-consuming, because they need more guarantee the correct positioning and the precision of the
muscle activity, new visual accommodation, and new job, the hands must be rested, which also avoids accidents.
 60 K. C. K. Yui et al.

2
12

11 1

10 2

9 3

4
8

7 5

..      Fig. 2.18 Class 4 movement. (Scheme kindly supplied by the Dabi-Atlante company)
Ergonomics Principles Applied to the Dental Clinic
61 2
On the lower teeth, a modified pen grasp is used handles are placed on the palm of the hand and held tightly
(. Fig. 2.19a). It is a grasp that allows more gentle move- by all fingers except the thumb, which will rest on a tooth
ments. The name means that it is similar to the one when we right next to it, on the same arch, for firmness. For an ade-
hold a pen, but not identical. The pads of thumb, index, and quate control, this grasp form requires careful use [56].
middle fingers contact the instrument, while the tip of the
>> During the dental procedure, the hand instruments
ring and little finger is slightly placed on a dental sur-
can be grasped by the hands in different ways,
face nearby, at the same arch, as a rest point. The palm of the
depending on the dental arch to be treated and the
hand is not facing the operator. The pad of the middle finger
work to be performed.
is placed on the topside of the instrument, and its work,
together with the wrist and the arm, produces the pressure
on the blade of the instrument. The instrument must not rest
on the first articulation of the middle finger, as a conven- 2.2.11 Rest Places
tional pen, which restrings the pressure applied [56]. On the
upper teeth, a modified and inverted pen grasp must be To obtain a correct rest place for the instrument is funda-
applied (. Fig. 2.19b). The position of the fingers is the same mental for a precision dental procedure. Extra oral rest and
position of the modified pen grasp. However, the hand is the rest at the opposing arch should be avoided due to the
turned, and the palm of the hand faces the operator [56]. For possibility of the patient to move. Whenever possible, the
the upper teeth, when more force is needed, a palm-and- dentist should opt for a rest point on the teeth nearby the
thumb grasp can be adopted (. Fig. 2.19c). It is similar to the place where the treatment is being performed. The closest
position used to hold a knife when peeling an orange. The the rest to the area of working, the more thrust worthy it is.

a b

..      Fig. 2.19 Ways to grasp the hand instruments. a Modified pen grasp; b inverted and modified pen grasp; c palm-and-thumb grasp
 62 K. C. K. Yui et al.

However, in some situations, it is not possible to establish a 2.2.11.1 Lower Arch

rest place on a tooth structure and the soft tissues must be At this arch, the modified pen grasp is recommended,
used. Neither the soft tissue nor the hard tissues farther with rest place on the teeth of the same arch, next to the
2 from the operating area allow a reliable control. Occasionally, cavity preparation, using the ring and little finger
it is also not possible to establish a regular rest using the (. Fig. 2.20a). When working on the buccal surface, the
fingers of the same hand that is grasping the instruments. mirror is used to displace the check musculature to
On those cases, the control can be reached using an index improve the visualization (. Fig. 2.20b). When working
finger of the other hand, touching the instrument on the on the lingual surface, the mirror is used to displace the
handle, or using an indirect rest. That means that the operat- tongue (. Fig. 2.20c).
ing hand will rest on the other hand, which will rest on a
stable oral structure [56]. 2.2.11.2 Upper Arch
On the anterior teeth, there is the possibility to directly On this arch, the modified and inverted pen grasp is recom-
visualize the surfaces to be treated. However, in some regions mended. On the right side of the patient, the use of the clini-
of the mouth, this can become very difficult, if not impossi- cal mirror improves the illumination of the operating field
ble, that is the reason we opt for an indirect vision, through when using the direct vision or allows the indirect vision. The
the reflected image on an oral mirror. rest place is on the neighboring teeth on the same arch
(. Fig. 2.21a). On the left side, the use of the clinical mirror
Tip improves the illumination at the operating field and allows
the indirect vision, besides helping to displace the check
To properly grasp the instrument and rest the hand is musculature. The rest place is at the same arch, on the oppos-
essential for stability and precision while working. Rest ing side (. Fig. 2.21b). When the palm-and-thumb grasp is
your finger on teeth nearby the place where you are used, the tip of the thumb is placed on the tooth that is being
doing out intervention. treated in a neighboring tooth or on a convenient area at the
same arch.

a b

..      Fig. 2.20 Rest areas using modified pen grasp of dental instruments at the lower arch. a Rest on the teeth from the same arch; b check
musculature displacement; c tongue displacement
Ergonomics Principles Applied to the Dental Clinic
63 2

a b

..      Fig. 2.21 Rest areas for the use of instruments on the upper dental arch. a Rest on the neighboring teeth on the same arch at the right side;
b work on the left side of the patient and rest on the right side

2.2.12 Work Environmental Conditions the hearing threshold. For prevention, there are protective
hearing devices, such as earplugs and earmuffs, but on
High stress sources at work are the unfavorable environmen- the other hand, they can cause deficiency on the
tal conditions, such as the excessive heat, noise, and vibra- ­communication.
tions. Those factors raise the risk of accidents and produce When the noise happens on a nonconstant way or even in
discomfort and damage to the health [30]. The environmen- an unexpected way, it can interfere with the concentration,
tal comfort is an extremely important point for the dentist, reducing the intellectual performance and making it harder
who spends his whole day inside a closed room and concen- to do more complex tasks. The noises that are not so loud can
trated on the treatment of his patients. only cause a slight bothering, but the greater the intensity,
Studies developed by Heimstra and McFarling [23] have frequency/duration and the age of the individual, the more
already mentioned the complexity involved on the creation damage the noise will cause [36].
of a satisfactory environmental condition, for a group of According to Fernandes et al. [16], the dentist is subjected
people who work at the same place, because each worker to two types of noises:
presents a different level of physical and psychological sensi- 55 Outside the working environment: Traffic, voices,
tivity. The authors report that the noise, temperature, humid- compressor (when outside the work environment),
ity, and illumination can produce comfort or annoyance, telephone, bell, and sounds coming from the waiting
affecting the performance of the individual. room
55 Inside the working environment: Dental handpieces, air
2.2.12.1 Noise compressor (when inside the work environment),
When looking for noise definition, the literature is ambigu- suction, amalgamator, air conditioner, among others
ous, but in a general way, the noise can be defined as an unde-
sirable sound. There is a subjective and a physic definition for According to the standards from the Occupational Safety and
noise, described as followed: Health Act (OSHA), 80 decibels (dBA) is at the maximum
55 Subjective definition: Noise is all the annoying or tolerable limits of sound for the dentist [9]. The manufactur-
unhealthy audible sensation. ers in general claim that the noise level of their dental treat-
55 Physic definition: Noise is all not periodical acoustic ment unit (especially of the handpieces) is below 80 dBA. The
phenomenon without harmonic components defined. longer the dentist is exposed to the noise during his profes-
sional life, the greater will be the chances of a reduction of the
On the last decades, more people have been affected by the hearing capacity [49]. The noise-damaging effects can also
noise, but since 1989, the World Health Organization produce many physical, mental, and social problems on the
started to treat noise as a public health problem. The dentist.
human ear can notice a great range of sound frequencies
from 20 to 20,000 Hz, and the intensity (volume) of the Tip
sound is defined by the level of sound pressure, varying
approximately from 0 to 130 decibels. The noise can cause The use of handpieces with low noise emission is a very
damage on the hearing organ, as deafness, that is charac- important point when deciding the purchasing of a new
terized by a deficit in the range of 3000–6000 Hz, or one.
fatigue, which manifests by a temporary increase of
 64 K. C. K. Yui et al.

2.2.12.2 Temperature 2.2.12.4 Illumination

The stress caused by the heat or cold at work environment is In all working places, there must be adequate illumination,
motive of concern because it affects, besides productivity, the natural or artificial, but always accordingly to the nature of
2 physical and mental health of the worker. The literature the the activity. It should be uniformly distributed and diffuse,
ideal temperature to work is between 16 and 22 °C, but in avoiding obfuscation, reflection, shadows, and excessive con-
countries with a hot weather, it can be accepted up to 5 °C trasts. A well-illuminated environment with light colors on
more. Other standards state a temperature between 20° and the background, brings to the environment visual comfort
23°, emphasizing that the difference in temperature in the and rest, improving the quality of life and at work. The light
same environment cannot be >4 °C. According to Bauman level is measured in lux. A well-illuminated environment is
[3], technically comfortable environments favor the achieve- important to have visual comfort, avoiding, this way, the loss
ment of high quality services; the worker feels more attracted of sight sharpness, fatigue, misreading, and work accidents.
by the working post, by his activity and by the positive results Some studies has shown that bad light conditions can
of his tasks. It is noticed less complaints in relation to the cause psychosomatics problems, as stress, and greater sensi-
individual necessities and in relation to the diseases acquired bility to the microbial attack. The effects of the very lumi-
on those environments, which result in a drop on the opera- nous environments over the vision are significant in a
tional costs. long-­term. In cases of obfuscation there is always the risk of
According to Grandjean [20], “the excessive heat at work- accidents. The lack of adequate illumination can cause
ing places leads to tiredness and drowsiness, which reduces visual fatigue, characterized by the irritation and pain on
prompt responses and increase the chances of mistakes to the eyes, redness on the conjunctiva, modification on the
happen.” Therefore, the thermal factor produces a great influ- blinking pattern, tearing, photophobia (light intolerance),
ence in the comfort during the work. The temperature, air diplopy (double vision), feeling of blurred vision, percep-
speed, solar radiation, and relative humidity are fundamental tion of colored aura around objects, abnormal persistence
for a comfortable thermal sensation, which also depends on of after-images, and instability of the image on its optical
the type of work being performed and the kind of clothes definition and in space. It usually comes with other symp-
worn. The speed of air displacement should not be superior toms as headaches.
to 0.2 m/s. The following are some very important points in relation
Guiton [22] states in his studies that the human body to the illumination:
presents its own mechanism to produce heat. The heat gener- 55 Type of light bulb and luminaire: Depends especially on
ated by the metabolic activity exceeds the need to maintain the environment’s characteristics and on the activities to
the body temperature in its normal level, of approximately be developed.
37 °C. That means that we should not need any other external 55 Quantity of light bulbs/luminaire: An adequate number
heating source and that the most important thing would be should be installed with the goal to reach the needed
to eliminate this excess of heat, without affecting the func- illumination, with base on a technical project, which will
tioning of the organism. Our working environment should consider the variables from the environment.
allow the control of the temperature, avoiding an extremely 55 Distribution and placement of the luminaires: The
hot or cold sensation. luminaires must be placed on the environment in a way
to give a homogeneous and uniform illumination,
>> The thermal factor produces a great influence in the considering the physical arrangement of the place,
comfort during the work. The temperature and air avoiding contrasts and shadows at the working areas.
speed, solar radiation, and relative humidity are 55 Maintenance: The burnt out light bulbs or with inad-
fundamental for a comfortable thermal sensation, and equate illumination must be changed, and the good ones
it also depends on the type of work being performed frequently cleaned.
and the clothes worn. 55 Colors: The colors of the walls, dental treatment unit,
and furniture must be chosen in a way that they have a
2.2.12.3 Relative Humidity of the air good light reflection in the room. The working table and
The relative humidity must not be below 40 or higher the delivery unit, for example, cannot have a very
than 60% in the work environment. The exposition to envi- reflexive surface because the incidence of light could
ronments with levels of humidity far from the ideal may cause obfuscate the eyes.
diseases, but can aggravate some preexisting ones, such as 55 Variation of light: The accentuated difference between
osteomuscular diseases (generally called rheumatism), the the levels of illumination between one environment and
lung, and skin diseases. another can damage the eyes, bringing fatigue and loss
of sharpness; this occurs due to a sudden dilatation/
>> The exposition to environments with different contraction of the vision muscles, even in a small-time
relative humidity can aggravate some preexisting interval. When repeated many times during the years, it
osteomuscular, lung, and skin diseases. could cause an injury.
Ergonomics Principles Applied to the Dental Clinic
65 2
55 Age: The greater the age of the people at the working When there is not a good relation among the different
place, the greater should be the light intensity. parts of the body, a bad posture can happen, inducing to an
55 Direct incidence: Windows should be positioned so that increase of aggression to the supporting structures, resulting
there is no excess of natural light within the work in a less efficient balance of the body over the legs. During the
environment. In dental offices located in the southern dental work, many inadequate postures occur, which could
hemisphere, it is recommended that the window be lead to musculoskeletal overload over some body segments,
directed in a north-northeast direction, and in cases which could cause lumbar inflammation, cervical pain, and
where it faces south, it is recommended that there is a aches [1]. According to Rio [54], the following inadequate
clear wall for natural light to be reflected into the posture could occur:
interior of the environment. In dental offices located in 55 Flexion, extension, lateral leaning, and lateral rotation of
the northern hemisphere, it is recommended that the neck
they should be facing south or north, and that the design 55 Abducted arms
of the roof and windows be planned according to the 55 Elevated arms above the shoulder levels
path of the sun to prevent the direct incidence of solar 55 Flexion of the forearms higher than 90°
rays during the summer, and allow their entry during 55 Pronation and supination of the upper limbs
the winter. Regardless of which hemisphere the dental 55 Ulnar and radial deviation from the body
office is located, when the window is directed to the east, 55 Lateral leaning and torsion of the vertebral column
there is an excess of illumination in the morning and a
shortage in the afternoon, the opposite occurring when The problems caused by the incorrect work posture are a
the window is facing west. In these cases, it is mandatory lumbar and back pain, and affect the feet and lower limbs. It
to use barriers (internal or external) to avoid excess is called lumbar pain all and any pain located on the lumbar
light, forcing the use of artificial lighting. column. Many are the causes for the lumbar pain, and the
treatment can be conservative, which will include specific
medication, physiotherapy, back braces, and medical orienta-
>> A well-illuminated environment, with light colors on tion or surgical treatment, which involves different types of
the background, brings to the environment visual surgeries [1]. According to Knoplich [35], the work on a sit-
comfort and rest, improving the quality of life during ting position increases the intradiscal pressure, increasing
the working hours. the bad adjustment of the disc and column. In addition, the
dentist executes movements of lateral leaning, flexions, and
extensions, which lead to defects of postural origin, named
2.3 Work-Related Musculoskeletal scoliosis, kyphosis, and lordosis. The scoliosis is a lateral
Disorders deviation, permanent to the vertebral column. When the
inclination can be corrected voluntarily, it is a scoliotic atti-
The multitissue lesions of the upper limbs of the motor sys- tude. Kyphosis is sagittal curves on the normal vertebral col-
tem, attributed to be caused by repetitive strains at work, umn on the anterior concavity, located on the dorsal and
previously known as repetitive strain injuries (RSI), were sacrum and coccyx segment, while lordosis is the posterior
renamed to work-related musculoskeletal disorders concavity, specifically in the cervical and lumbar region [19].
(WMSD), because it is the most appropriate name. The When a dissolution or destruction of vertebrae occurs, it is
WMSD, according to Lopes [38], is characterized by the called spondylosis.
affections of the motor system, upper limbs, shoulder and
>> Incorrect work posture causes lumbar and back pain
neck, that have direct relation with the requirements for the
and affects the feet and lower limbs.
repetitive, fast and continuous movements of the tasks
executed. In addition, the stress generated during the den- The dentists can be affected by return venous circulation
tal practice is other factor that can contribute for the devel- problems, as varicose veins and thickening of the nails, and
opment of the WMSD [1]. The WMSD is defined as a also the formation of bunion, callus, and hallux valgus, which
phenomenon related to work, characterized by the inci- happens because of the use of badly dimensioned shoes that
dence of different symptoms at the same time or not, with are made from inadequate fabrics or materials. It is essential
pain, paralysis, heavy feeling, and recurrent fatigue, gener- that the dentist works with his feet completely rested on the
ally on the upper limbs [45]. Those disturbances, related to ground, keeping, this way, a balanced position and a positive
the work, initially cause pain and can evolve to the incapac- physiological factor on the physical condition, lowering the
ity to do some movements, temporarily or permanently. pressure on the feet [1].
Therefore, the early detection of the lesions can be essential If hand injuries happens to the dentist, this could force
to avoid the worsening of the disease, long treatment, and him to leave work for a short or long period many times
medical conditions that would take the professional away throughout his professional life. The improper use of dental
from his practice [1]. instruments can promode hands injuries and are related to
 66 K. C. K. Yui et al.

constant and repetitive force, with a pinching movement of Oh et al. [47], verified that ultra-structural changes occur
the fingers and thumbs, combined with extreme hand move- in the subsynovial connective tissue from patients with
ments. The carpal tunnel syndrome has the highest preva- carpal tunnel syndrome, as deformed collagen fibers, that
2 lence among the dentists. The carpal tunnel is limited by the appear to be in a spiral form, and phagocytosis of the elas-
concave arches formed by the carpal bones of the hands and tic fibers.
by the transverse carpal ligament, holding the carpal nerve, The tendons, when compressed, press the nerve, which,
nine flexor tendons and blood vessels, as can be observed on with chronicle repetition of the movement, become
. Fig. 2.22a–i. inflamed and suffer damages. This causes sensitive, motor,
and functional alterations, pain, swelling, and stiffness of
>> The improper use of the instruments can produce the
the hand. If this situation continues for a period of, for
carpal tunnel syndrome, resulting in motor and
example, 1 or 2 years, a paresthesia sensation on the wrist
functional alterations, pain, swelling, and stiffness of
level, pain, and swelling of the fingers will occur. Later, if the
the hand, requiring surgical treatment by surgery.
situation persists, from 2 to 8 years, a reduction of the
When the hand is flexed, it extends or deviates from the pinching force will appear and an atrophy of the hand’s mus-
central position; the volume of the tunnel is reduced and cles will eventually result in incapacity to hold an instru-
the internal pressure increases (. Fig. 2.23a, b). According ment. Once the damage is installed, the treatment consists
to Osamura et al. [48], the most characteristic tissue in the in immobilization of the hand, hydrocortisone injec-
carpal tunnel is the subsynovial connective tissue and its tions and finally surgical treatment, depending on the
small permeability can explain the predisposition of the degree of the nerve’s alterations. The presence of the carpal
region to increase the pressure, causing this neuropathy. tunnel syndrome can be confirmed by the positive result on

A
F H

G
B C D E I

..      Fig. 2.22 Hand’s sections in different levels. a Carpal bone; b thenar muscle; c transverse carpal ligament; d median nerve; e concave arch of
the carpal bones; f flexor tendons; g cubital nerve; h–i flexor tendons

a b

..      Fig. 2.23 a Correct work positioning of the hand; b flexed hand, resulting in a diminishing of the carpal tunnel volume
Ergonomics Principles Applied to the Dental Clinic
67 2
the Phalen’s maneuver, which consists on the placement of 55 About 89% show forward flexion of the head, exceeding
the dorsum of the hands in contact to each other, with the in 20°, which is considered the limit for a healthy
individual with the shoulders and elbows in 90°. With this position.
maneuver, the mediated nerve is pressed against the ventral 55 About 61% show rotation of the neck combined with
retinaculum and reproduces the night symptoms, which is strong flexion forward.
“tingling” (hypoesthesia) [11]. 55 About 63% show flexion of the posterior part of the
body exceeding in 20°.
55 About 36% work with the neck turned combined with
2.3.1 Occupational Diseases Epidemiology the torsion of the back.
55 About 35% keep their forearms on an angle higher
The application of the ergonomic principles in the dental than 20°.
office allows rationalizing the work, allowing the elimination 55 About 32% keep their forearms on an angle higher
of nonproductive maneuvers. This way the clinician produces than 25°above the horizontal line.
more and faster, with less stress and more results, providing 55 About 25% rest their hands wrongly when working.
at the same time more comfort and safety to the patient [2]. 55 About 47% do not grasp correctly the instruments (on
Therefore, it is fundamental to avoid or to correct the wrong the modified pen position).
working habits, the ones that can bring serious damage to the 55 About 20% show strong flexion of the wrist.
clinician. Seventy-two percent of the dentists examined by 55 About 65% work with a stool with a wrong back
Rundcrantz et al. [59] reported complained about some dis- support.
comfort or pain on the head, neck, or shoulders. Similar 55 About 75% of the dentists work without the head of the
results were reports by Kerosuo et al. [14], who observed that patient being symmetrically in front of them.
70% of the general dental practitioners had musculoskeletal 55 About 32% work with their feet and legs farther than the
symptoms. They also observed that the symptoms were more necessary from the dental chair.
frequent on women. Some specific body areas are associated 55 About 55% work for more than 7 h sitting down every
with injuries related the dental practice as described as fol- day.
lowed: 55 About 75% work with inadequate light and differences
55 Carpal tunnel syndrome – Problem associated with the in light distribution that are not according to the
continuous flexion and extension of the wrist standards.
55 Shoulder and neck ache – Tension or flexion of the
shoulders for more than 1 h/day Santos Filho and Barreto [61] performed a study evaluating
55 Back and neck ache – Extension or elevation of the arms the prevalence and sysmtoms of osteomuscular pain on 358
for a long period dentists, using a self-reporting questionnaire, and they
55 Low back region ache – Torsion of the body for a long observed the prevalence of pain on the upper segment was
period 58%, being 22% on the arms, 21% on the column, 20% on
the neck, and 17% on the shoulder; 26% reported that the
According to Wagner [65], from all the occupational dis- pain was daily and 40% was moderate/strong. According to
eases affecting the dentists, the ones that are caused by the Méndez and Gómez-Conesa [43], the information about
posture are those with the most neglected prevention, the arrangement of the dental treatment unit and the ade-
because they will only feel its effects with the passing of the quate posture at work can reduce the musculoskeletal symp-
years. It is very hard to convince the young dental students toms risk. According to Melis et al. [42], there is a critical
in the universities to take prophylactic measurements in need to insert the topics of ergonomics on the educational
relation to the damages to the column. Even with the ergo- system to prevent the risks for the future clinicians. A study
nomic coming to help the profession, there are excessive performed with students of a university demonstrated that
working hours spent at the clinic. In addition, there are more than 70% of them report pain already on the third
idiopathic predispositions from each one to specific types year of school. It also demonstrated that this number
of skeletal degeneration, such as spondylosis and interver- increased gradually from the first to the last year of the
tebral disc flaccidity, that sooner or later compromise the course. The authors concluded that the teaching of ergo-
column of some individuals, while others never come to nomics needs to be better elaborated and worked through-
manifest any symptom, at least, during the productive prac- out undergraduate phase [55].
tice of his profession [18].
On the Netherlands, a study was done to evaluate the >> The application of the ergonomic principles on the
posture adopted by 1250 dentists throughout dental proce- dental office allows rationalizing the work, allowing
dures, which was named the Sonde Project [27]. The authors the clinician the elimination of nonproductive
concluded that high percentages of deviations in relation to maneuvers. This way the clinician produces more and
the correct working posture are practiced by the clinicians, as faster, with less stress and more results, providing at
they are shown here: the same time more comfort and safety to the patient.
 68 K. C. K. Yui et al.

2.3.2 WMSD Prevention It is known that the constant force during the pinching
movements of the fingers and the extreme movements of the
It is important to adapt the work environment to the operator hands, used simultaneously, can produce the carpal tunnel syn-
2 instead of the operator having to adapt to the environment drome. On the other hand, the damage can be completely
[2]. This concept requires that the dentists take a favorable avoided with the preventive elimination of the causal factors,
sited posture and then place the patient, assistant, and deliv- which must be recognized and identified early. Therefore, aim-
ery unit in relation to his position. This working condition is ing to prevent those lesions, some measurements can be taken.
called “balanced posture” [8]. It does not intend to have the The first would be to give preference to instruments with
operators sitting like a statue but to establish a series of rules thicker handles (. Fig. 4.5), which diminishes the need to a
that may help them to obtain comfort while working. The strong pinching to hold them tightly. The habit constantly to
specialists agree when they say that the frequent change in hold the instrument strongly should also be avoided, because it
position, for those who work sitting down, is the key to pre- results on unnecessary fatigue and incorrect control of the
vent problems on the column [25, 26, 28]. hands. The correct attitude is to hold the instruments gently,
only squeezing when necessary to perform an active move-
>> It is important to adapt the work environment of the ment, reducing the force right after to relax the muscles. The
operator instead of the operator having to adapt to the extreme movements of the hands should also be avoided,
environment. because the displacements of the tendons that are compressed
The adoption of a healthy posture at work is fundamental on during those movements compress the median nerve causing
the prevention of WMSD. Besides having dental treatment damages. The arm should turn around its fulcrum, using as rest
unit that permits to work correctly, it is important that the den- place the surface to be instrumented, avoiding the excess digital
tist effectively know and apply the necessary knowledge about work or the turning of the hand. Regis Filho et al. [53] confirm
the correct use of that unit. Only having a good dental treat- on their study that most dentists use instruments that do not
ment unit is not a guarantee that the dentist will work on a follow the ergonomic requirements and execute procedures
correct posture. Therefore, the learning/teaching process in inadequately, among other factors, being submitted to adverse
ergonomics is determinant to adopt a healthy work posture work conditions, where pain and discomfort are present.
[28]. A good ergonomic training during the university studies Hokwerda and Shaw [26] recommend that the dentist
on the preclinical phases and initial clinic is essential, so that should adopt a more dynamic posture of work. According to
the student learn to identify and adopt a healthy work posture. the authors, the problem with the dentist’s work posture is the
The use of the proprioception mechanism is fundamen- static nature, while the human body is supposed to be in con-
tal, so that the dentist can effectively develop and adopt a stant movement. During the dynamic movement, the muscles
correct work posture [4, 57]. The proprioception is the act as bomb for the blood supply, with high levels of oxygen,
capacity to recognize the position in space of each part of and removal of blood with residual products from the meta-
the body. It results from the interaction among the muscles bolic activity of the muscles. The movement is necessary to
to keep the body position, the tactile information and on recover the distended muscles by the static work. Therefore, the
the vestibular system, found on the internal ear, responsible dentists must keep a more dynamic work model, as, for exam-
for the equilibrium. ple, the incorporation of the most movements as possible in his
The proprioception mechanism works automatically as activities. The different activities can contribute to that [26, 28]:
part of the chain of reflexes to keep the body balanced and 55 Adopt a dynamic way to seat alternating between active
organizing the movements. It can be used to recognize and and passive seating.
locate the problems and adapt the posture [4, 57]. The healthy 55 Use various positions the maximum as possible.
work posture is not a condition preprogrammed by the pro- 55 Receive personally the patients at the waiting room.
prioception, and it does not occur without a conscious learn- 55 Always possible, to work standing up or sitting down
ing. Learning and training are necessary to get the adequate alternately. This requires an office with adjustable heights
posture, starting by determining the aim to a physiologically of the patient’s chair and delivery unit. In addition, it is
acceptable posture, understanding how to reach that and also possible to give instructions to the patient on a
then executing the necessary actions, followed by a training standing up position. The computer work can also be
at the mirror for feedback, or using a biofeedback equipment done on a standing up position, if it is organized for that.
[4]. To consciously use of the knowledge about propriocep- 55 The installation of a sink on an adequate distance from
tion is only possible during the preclinical training, where the head of the patient, so it is always necessary to stand
low complexity work is being performed, which allows the up and walk to the sink.
student to concentrate on the ergonomic training, without 55 The planning of the short procedures should be alter-
having to worry with the result of the procedure itself. On nated with the long ones.
this initial phase, the student has not established bad postural 55 Schedule short intervals during the treatment, when
habits, which will lead the body to find alternative postures to small exercises can be done, as flexion of the fingers,
keep balance. Because of that, it is important that the dental deep breathing, and stretching (more details later on).
schools prioritize the teaching of ergonomics at the preclini- 55 Take short intervals between treatments, also taking
cal phase or at the initial clinical phase. stretching exercises.
Ergonomics Principles Applied to the Dental Clinic
69 2
55 Take longer breaks, for coffee, tea, and lunch. Take at
least 10 min of break after each two hours of work. 9. Avoid forward flexion of the vertebral column.
55 To keep or maintain the muscles in good condi- 10. Keep the legs slightly separated (between 35° and not
more than 45°).
tions by doing exercises at least twice a week. 11. Do not keep the neck bent or pulled.
55 Plan short or long vacations, courses, etc. every 6 weeks. 12. Rest the back on the upper part of the pelvis.
The dental profession is very hard, so it is essential to 13. Oral cavity of the patient from 5 to 10 cm above the height
schedule regular breaks. It is proven that adequate of the dentist’s elbows.
leisure and sport activities reduce stress. 14. Distance from 30 to 40 cm from the operator’s nose and
the patient’s face.
55 Do not work more than 8 h/day. 15. Head leaned forward not more than 20°.
16. Operating field well-illuminated and on the medium line of
Other indispensable factor to allow a healthy work posture is the dentist.
the use of dental treatment unit that has the ergonomic 17. The back of the patient’s chair is positioned lying down to
requirements. Significant changes on the concepts changed allow the operator to freely move the legs under the back
of the chair.
the design of dental treatment units, which allow the work on 18. Avoid sudden movements and forces that cause heavy
a more ergonomic way. It is important to know how to adopt stress of short duration.
a healthier work posture and know how to recognize the 19. Change posture and perform movements.
ergonomic requirements when purchasing a new dental 20. Limit the duration of any continuous muscular strength,
treatment unit [25, 26, 28, 33]. The market for dental units is preventing muscular exhaustion.
21. Take short and frequent breaks.
regulated by the demand, and this means that the dentists 22. Take a well-accommodated position at the seat of the
need to claim for units that allow an adoption of a healthy stool, in a way that it supports the whole weight of the
posture. body.
The treatment of WMSD must be multidisciplinary, so 23. The head of the patient is rotated accordingly in three
the doctor identifies the alteration and coordinates the treat- directions (backward or forward, leaning to the right or
left, and turned on the longitudinal axis) in a way that the
ment, the physiotherapist uses exercises to rehabilitate the operating field is positioned symmetrically in front of the
compromised movements, the occupational therapist verifies dentist’s thorax. That allows to look into the mouth or to
if the work environment needs to be changed, and the psy- the mirror as perpendicularly as possible.
chologist or psychiatrist detects the causes or factors like 24. The dental light must be as parallel as possible to the line
anguish and anxiety at the work environment [1]. of sight, at a 15° angle, with the light being positioned to
the left or the right, very close to the side and above the
To avoid fatigue, tiredness, and stress, the dentist can fol- dentist’s head. When an intraoral mirror is necessary, the
low the checklist presented on 7 Box 2.1 [19, 26, 28]. light must be positioned slightly in front of the head.
25. Instruments need to be grasped with the tip of the first
>> The carpal tunnel syndrome can be avoided with the three fingers, which must be arched around the instru-
preventive elimination of the causal factors; such as ment, in a way to reach three contact points, and the
fourth and fifth fingers must be used to rest on the mouth.
giving preference to instruments with thicker handles;
If necessary, one finger of the inactive hand is used for help
eliminating the habit to strongly hold the instrument; the rest.
and avoiding extreme movements of the hands. 26. The instruments must be positioned at the same height to
the patient’s mouth, as much as possible inside the visual
field of the dentist (30° to the left and right). The hand
instruments must be positioned at a distance of 20–25 cm
and the handpieces at 30–40 cm.
Box 2.1 Ergonomic Check List for a Good Dental
Practice (According to ESDE Document) [28]
 rgonomic Check List
E
1. Legs perpendicular to the ground. 2.4  xercises to Prevent Osteomuscular
E
2. Feet soles on the ground, while the pedal is positioned in a
direction in which the feet does not need to be directed
Problems
sideways during the operation.
3. The angle between the thigh and the lower part of the leg The stretching exercises can be done at the office, during
is greater or equal to 110°, in a way that the knees are intervals between sessions, to obtain flexibility of the articu-
slightly below the hip level (just if there is an adequate lations, improving the circulation and loosening the tense
stool with double inclination or a saddle stool). For the
regular stool this angle must be 90°.
areas, preserving the health, and optimizing the quality of life
4. Forearms slightly elevated at least 10° to the maximum of 15°. of the practitioners. They are recommended for prevention of
5. Arms ahead at maximum of 20°. tenosynovitis, tendonitis, synovitis, myositis, fasciitis,
6. Elbows next to the body and not far more than 20° ­epicondylitis, paralysis of the upper limbs, and tingling of the
sideways. hands. During the stretching the dentist must be alert not to
7. Symmetrical sitting position with the shoulders lowered
and relaxed.
pass the expansion limit of his muscle, to hold the exercise
8. Avoid torsion of the torso and pressure the intervertebral for 10 s and to avoid postural compensations of bad position-
discs of the column. ing during the exercise. Each stretching must be repeated
three times, alternating the sides (. Figs. 2.24 and 2.25).
 70 K. C. K. Yui et al.

a b

c d

..      Fig. 2.24 Stretching for the back, shoulders, chest region, arms, Keep the stretching for 10 s and repeat the other side. i Stretching of
and neck. a Stretching of the arms. With the arms raised above the the chest. This stretching must be done with the fingers interlaced
head and palms of the hands together, stretch out the arms upward behind the back. First, slowly roll up the elbow inward while the arms
and a little to the back. Breathe in while stretching upward. b Stretch- extend. Second, elevate the arms behind the back until you feel the
ing of the arms and thorax. Interlace the fingers, turn the palms arms, shoulders and chest stretching. j Stretching the back. Stand up
outward, above the head, and extend the arms. Stretch, this way, the with the feet apart about the same distance of your shoulders and feet
arms and thorax. c Stretching of the arms. Interlace the fingers, extend pointing forward. Keep the knees slightly bent, put one of the hands
the arms in front of yourself with the palms facing outward. Feel the on the hip for support and the other arm extends over the head. Now
stretching of the arms and on the upper back. d, e Stretching of the lean to the side in the same direction as the hand on the hip. Come
arms. With the arms extended above the head, hold the elbow of one back slowly and keeping the control. k Stretching of the arms. Instead
of the arms with the hand of the other arm. Pull kindly the elbow of using the hand on the hip for support rise both arms above the
behind the head. Stretch both sides. f Stretching of the shoulders. With head. Hold the right hand with the left one and bend slowly to the
the fingers interlaced behind the head, keep the elbows facing right side, using the right arm to gently pull the left arm above the
outward, wide open, keep the torso erect. Push the elbows backward, head and later downward, toward the ground. Using one arm to pull
one toward the other. Keep the feeling to liberate the tensions for the other is possible to intensify the stretching. l–o Stretching of the
about 8–10 s, then relax. g, h Stretching of the arms. Hold the right arm neck. Turn the neck slowly and in case you feel a greater tension in any
right above the elbow with the left hand. Now pull slowly the elbow on position keep there for 10 s
the direction of the left shoulder while looking over the right shoulder.
Ergonomics Principles Applied to the Dental Clinic
71 2

e f

g h

i j k

..      Fig. 2.24 (continued)

 72 K. C. K. Yui et al.

l m

n o

..      Fig. 2.24 (continued)

a b

..      Fig. 2.25 Stretching for the hands and wrists. a Stretching of the and then to the right, repeating every series 3 times. d–f Stretching of
flexor muscle. Start the exercise with the palm of the hand facing the wrists. Open the hands and touch them in “praying” position. With
downward, extending the right arm. Put the left thumb over the dorsal the fingers together, compress one hand with the other in a way that
side of the fingers and the other four fingers over the palm side of the the forces are concentrated on the wrists. Lean the palm of the hand in
fingers for support. Stretch the flexor muscle group pulling the fingers the direction of the arms. Repeat to the other side. g–i Stretching of the
backward (dorsal flexion). Keep this position for 10 s and then let it go. fingers. Open the fingers the farther as possible. Close the fingers
b Stretching the external side of the forearm. Stretch the external side squeezing them with the hand extended. Squeeze the fingers against
of the forearm and keep the arm at this position, with the palm of the each other, stretching them one by one. It can be done with all the
hand facing downward. Put the four fingers of the left hand over the fingers at the same time. j Stretching of the fingers. Squeeze the thumb
dorsal surface of the right wrist. Bend the whole hand inward. Keep this against the other fingers of the hand, one at a time. k Stretching of the
flexed position for 10 s. c Stretching of the wrists. Interlace the fingers fingers. Cross the fingers and thumbs, one by one, each finger forming
of both hands and extend both arms in front of you. Turn the hands a hook. l Stretching of the fingers. Close the hands tightly as they are
interlaced to the left, having the wrists as the fulcrum of the movement. holding something strongly. After open them and stretch the fingers
After, turn to the right. Each rotation must take 5 s. Turn first to the left well. After, put the arms down and swing them, rotating to the sides
Ergonomics Principles Applied to the Dental Clinic
73 2

c d

e f

g h

i j

..      Fig. 2.25 (continued)

 74 K. C. K. Yui et al.

k l

..      Fig. 2.25 (continued)

>> The stretching exercises can be done at the office, The dental schools should promote the development
during intervals between sessions, to obtain flexibility pedagogical strategies that are more efficient to allow the
of the articulations, improving the blood circulation proper teaching of ergonomics. The student must be stimu-
and loosening the tense areas, preserving the health, lated to appreciate and to take a healthy work posture since
and optimizing the quality of life of the practitioners. the first work, performed in laboratory or preclinical and,
later on, the clinical activities. The current knowledge of
ergonomics must be spread out on the various specialties,
2.5  urrent Panorama of Dental Ergonomic:
C through manuals of ergonomics that serves as the base for
Challenges, Proposals, and Goals the students and for the professors of every area.
The clinicians must be stimulated to select and to buy
The international literature reveals that the practice of the dental treatment unit that satisfy the ergonomic principles,
dental profession needs more use of the existing ergonomic and to know the cost benefit relationship when taking their
knowledge. To change this picture, it is needed the imple- decision. Only with the effective and integrated participation
mentation of a vast program to stimulate the application of of all those sectors, of this complex dental system, will be
ergonomics in dentistry. This program must embrace actions possible to implement the necessary improvement of the
in every sector of the dental system, in a way that there is an dental work conditions.
effective participation on the dental schools and representa-
>> The dental schools should promote the development
tive associations of dentists, such as Federal and State Dental
of more efficient pedagogical strategies to allow the
Boards, Unions, and any other Dental Associations. It is
proper teaching of ergonomics. Students should be
necessary that parameters should be defined and strategies
strongly encouraged to understand and value the
should be created, to allow the adequate teaching of ergo-
importance of adopting a healthy work posture as
nomics on dental courses and that this information would
soon as possible, ie, from the first procedures
be applied when building clinics and preclinical laborato-
performed in mannikin and during the procedures
ries, which allow students and clinicians to work at a healthy
performed in patients at all clinics during the dental
posture.
course.
The manufacturers of dental treatment unit and their
­representative associations need to stimulate the constant
search and improvement of the unit, and their suitability to Conclusion
the ESDE document [28]. It is important that dental treat- The working position in dentistry is essential to protect the
ment unit manufactures promote ergonomic studies in dental team health. In this chapter, the correct way of ergo-
their ­laboratories and in conjunction with the egnonomic’s nomically seat during the dental treatment and properly
research associations. The companies should be stimulated to position the patient in the chair was explained, as well how to
commit part of their incomings to the development of ergo- grasp the instruments and rest the fingers in the oral environ-
nomic research, and to create manuals that promote the ment. The control of the environmental condition in order to
adequate use of the dental treatment unit, because only protect the health was explained. The exercises that can be
to manufacture a ergonomic unit does not guarantee that done inside the dental office were shown, helping to prevent
they will be used in an ergonomic way. the most common work-related musculoskeletal disorders.
Ergonomics Principles Applied to the Dental Clinic
75 2
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