Survey About Hand Pain: New York University College of Dentistry Students

ABSTRACT

Background

The objective of this study was to determine the prevalence and associated risk factors for current hand musculoskeletal pain in dental students at a dental school.

Methods

1,889 dental students and postgraduate residents were recruited from the clinics at New York University College of Dentistry to participate in a closed-ended survey on hand pain.

Results

The close-ended survey was completed by 373 dental students (20% response rate) of which 30.6% were D2, 30.6% D3, 27.2% D4, and 11.6% postgraduate. 235 (63.0%) reported musculoskeletal pain of the hand/wrist/fingers while a student at the school. The majority who reported pain responded that it lasted seconds (21.7%) or minutes (42.5%) in duration. However, 35.3% of those with pain described it as moderate or severe, of whom 26.0% reported visiting a physician for their symptoms. There was no overall statistically significant difference in hand/wrist/finger pain by year in dental school training.

Conclusions

Hand musculoskeletal pain may be common among dental students and residents and can be severe for some individuals. Future research should consider the contributions of dental school training on hand pain among students (potentially combined with other factors like mobile phone, tablet, and computer use), as well as implementation of preventive ergonomic training.

KEYWORDS:

• Ergonomics
• dental education
• musculoskeletal pain
• dental students

Introduction

The purpose of this study was to assess the prevalence and identify characteristics and behaviors associated with musculoskeletal pain among dental students and to make recommendations to reduce those risks. Musculoskeletal pain is one of the most reported pain experienced by health care clinicians. Pain, which is an indicator of potential tissue damage, is categorized as acute or chronic, while chronic pain lasts a minimum of 3 months.¹ There is an emotional and physical aspect of pain. Pain can have a negative effect on emotions, whereas a negative emotional state (i.e., fear and anxiety) can lead to increased pain.² Physical pain, as experienced in dentistry, is caused by something that is done to the body that causes tissue damage and is not associated with triggers that reactivate the pain if the body encounters them again, as is emotional pain.³ Musculoskeletal disorders (MSDs) in dentistry are a rising problem that is starting to become more prevalent as a cause of disability in the United States.⁴ With more dental clinicians being affected with MSDs, the cost of treatment increases as well as lost work time and income. Musculoskeletal disorders are a group of injuries or disorders of the soft tissues (e.g., muscles, tendons, ligaments and cartilage) and nervous system.⁵ The term work related musculoskeletal disorder refers to MSDs that are made worse or longer lasting by repetitive work.⁶ Some examples involving the hand include carpal tunnel syndrome, tendonitis, muscle/ligament/tendon strain, trigger finger/thumb, and DeQuervain’s Syndrome.⁷ Symptoms of MSDs usually develop over time. Parts of the body that can be affected by poor ergonomics during dental procedures include the neck, back, legs, arms, shoulders, wrists, fingers and hands.^8–11 Proper ergonomic design is necessary to prevent work-related injuries.¹² Poor instrument design, poor workplace design or the use of improper instruments can cause physical stress on the clinicians’ body which can lead to injury.¹³ This study specifically studied work-related hand/fingers/wrist pain in a group of dental students.

Hypotheses associated with this survey were that hand pain would be less likely among more advanced students and older students because of more dental experience. For those who experience hand pain, it was hypothesized that most would experience the pain in their dominant hand/wrist. The other questions about the type of pain and its impact were collected to learn more details about pain experienced among dental students and no pre-study hypotheses were established.

Materials and Methods

Students in the 2^nd through 4^th years of dental school plus post-graduate dental students at the New York University College of Dentistry were asked to participate in a survey about hand pain. The survey ran from August 2018 until January 2019 (IRB exempt determination; i16–00687). The survey was completed anonymously in an electronic format using Qualtrics (web-based) software, and there was no incentive offered to participate. All participants were asked if they had experienced finger, hand, or wrist pain while a student in the school, and those who answered affirmatively were asked an additional series of questions about the pain.

A total of 373 students, who were recruited from the clinics of the dental school, completed a set of demographic questions plus the primary question about pain experienced while a student at the school, out of 1,889 invited (20% response rate). Response rates were similar for each grade level.

All results are based on self-report of participants regarding their experiences. The responses were recorded as a closed-ended survey allowing only one answer. For age, weight, and height, students were given categories to choose from rather than reporting their exact measurement. For some of the questions about pain, students were given many options; in some cases, similar options were combined to achieve conciseness and to improve interpretability. Questions asking the students to describe how frequent their pain is felt (Everyday, at least once in last week, last month, last year) and describing their pain (Numbing, tingling, throbbing, burning, stabbing, cramping, weakness). Also, whether their hand hurt only when performing certain movements (Moving their wrist up, down, left right, opening and closing their fingers, moving their fingers left or right, or other reasons). These questions, along with the length of the pain (Seconds, minutes, hours, days, weeks, months) and their current reported pain scale (from 0 to 10) was used to gather data on their experiences.

Statistical analysis was applied using Chi-square test or Fisher exact test where appropriate to measure the association of categorical variables. A p value of less than or equal to .05 was deemed to be statistically significant. In the analysis below, percentages are based on the number of students who answered each question.

Results

The students who responded were most often female, aged 20–25. Participants were almost as likely to be Asian as Caucasian, with about one-fifth of the participants identifying with another race/ethnicity. Fewer than 10% of the participants reported having practiced dentistry or dental hygiene prior to enrolling at NYUCD, and only 5 (1.3%) reported having previous dentistry-related hand pain.

Of the 373 subjects, 235 (63.0%) reported musculoskeletal pain of the hand/wrist/fingers while a student at the school. The data on hand pain among dental students in terms of pain were presented in Table 1. Second year dental students (D2) reported having the most hand pain (70.2%), but the prevalence of hand pain did not differ statistically significantly by year in dental school.

Table 1. Description of hand pain among dental students currently have felt finger/wrist pain at NYUCD.

	No n (%)	Yes n (%)	Total n (%)	p-value*
Year in Dental School
D2	34 (24.6)	80 (34.0)	114 (30.6)	.0999
D3	49 (35.5)	65 (27.7)	114 (30.6)
D4	35 (25.4)	67 (28.5)	102 (27.3)
Post Graduate	20 (14.5)	23 (9.8)	43 (11.5)
Total	138 (100.0)	235 (100.0)	373 (100.0)

(*) Chi-square test.

If the pain lasted only seconds, then the student had statistically significant less pain (p = .0290, data not shown). But if the pain lasted more than hours then the pain was greater (Table 2). Students in the clinic use ambidextrous gloves. 76.3% (data not shown) of students reported that the gloves fit them properly; however, this did not have any effect on whether they experienced pain or not. Of those who did activities (e.g., hand splint, seeking medical treatment) to reduce the impact of the hand/wrist pain, significantly higher percent of students (46.4%) had moderate to severe pain compared to 27.6% who expressed no impact on their lives with mild to severe pain, p = .0055 (Table 3). Among those who went to a physician, 51.4% with moderate to severe pain verses 31.8% who had same level of pain but did not go, p = .0238 (Table 4).

Table 2. Length of time hand pain last

	No/Mild n (%)	Moderate/Severe n (%)	Total n (%)	p-value
How long does the pain last				.1143*
Seconds	36 (26.9)	9 (12.3)	45 (21.7)
Minutes	56 (41.8)	32 (43.8)	88 (42.5)
Hours	25 (18.7)	22 (30.1)	47 (22.7)
Days	11 (8.2)	8 (11.0)	19 (9.2)
Weeks	5 (3.7)	1 (1.4)	6 (2.9)
Months	1 (0.7)	1 (1.4)	2 (1.0)
Total	134 (100.0)	73 (100.0)	207 (100.0)

(*) Chi-square test; however, the result may not be valid due to low expected frequency count.

Table 3. Has the pain impacted your life.

	No interference n (%)	Activities reduced/Treatment Sought n (%)	Total n (%)	p-value
Pain Scale				.0055*
No/Mild pain	89 (72.4)	45 (53.6)	134 (64.7)
Moderate/Severe	34 (27.6)	39 (46.4)	73 (35.3)
Total	123 (100.0)	84 (100.0)	207 (100.0)

(*) Chi-square test.

Table 4. Examine of the relationship of pain scale and going to physician regarding the pain symptoms: going to physician.

	No n (%)	Yes n (%)	Total n (%)	p-value
Pain Scale				.0238*
No/Mild pain	116 (68.2)	18 (48.6)	134 (64.7)
Moderate/Severe	54 (31.8)	19 (51.4)	73 (35.3)
Total	170 (100.0)	37 (100.0)	207 (100.0)

(*) Chi-square test.

Approximately 80% of the respondents who experienced hand or wrist pain reported the pain to be only in their dominant hand (statistically more than half the population, p < .0001). Left-handed students did experience less pain than that of right-handed, but it was not statistically significant between the classes (p = .0623) indicating that there was no difference in proportion of left- or right-handed regarding the severity of pain.

About three-quarters of those impacted reported that pain occurred weekly or monthly, and about two-thirds stated that it lasted from seconds to minutes when it happened. The majority of the group experienced the pain during the daytime (i.e., while at school) and the most common type of pain was cramping. The most common type of movements that resulted in pain were moving the wrist up or down, or opening or closing the fingers, although about two out of five in the group could not identify a specific movement that hurt. About three out of five reported that the pain did not interfere with activities they participated in, while the rest were evenly split across deciding to reduce participation in leisure, school, or work activities.

More than 4 out of 5 of the group attributed their pain directly to dental practice activities, and fewer than 10% believed that the pain was the result of a sports injury. Almost three-quarters of the pain group reported pain in another part of the body system as well, but fewer than 10% reported bumps, swelling or anatomic changes to their hands or wrists.

Discussion

Work related MSDs occur when the physical capabilities of the worker do not match the physical requirements of the job. Prolonged exposure to ergonomic risk factors can cause injury to a worker’s body and lead to MSDs. Numerous conditions have been linked to cause hand related MSD problems which can be related to dentistry.¹⁴ To contribute to hand pain, however; these associated factors must be present for a sufficient duration, frequency, or magnitude.

It was hypothesized that the greatest prevalence of hand/wrist pain in dental students at NYUCD would be among those students with the least experience performing dental procedures. Indeed, hand pain was numerically highest among D2 students (70.2%) versus D3 (57.0%), D4 (65.7%) or postgraduate (53.5%), but these differences by class year were not statistically significant overall. At NYUCD, D2 students are in simulation lab and are introduced to the clinic at the end of the second year where they primarily shadow a D3 or D4. It is plausible that D2 students are starting to see patients and have not yet learned proper hand ergonomics. D3 and D4 students have more clinic experience than D2 students and it is possible that proper hand ergonomics are well practiced. Postgraduate residents are even more aware at this stage of learning about musculoskeletal disorder and dental ergonomics. Despite such experience, hand pain was common among students at all levels of training and this survey did not detect statistically significant differences.

Santucci et al., reported that dental students (D1), after a 9 month simulation lab restorative course experienced 42.4% hand pain and 55.4% reported pain after 1 month of starting the simulation lab.¹⁵ Hayes reported that the prevalence of general musculoskeletal pain has been reported in literature to be between 64% and 93% with approximately 60–69% affecting the hands and wrists of dental hygienists in the United States and 34–54% in dentists in Sweden, Poland and Australia.¹⁶ Rambabu and Suneetha reported that dentists (61%) had the highest, followed by medical surgeons (37%) and physicians (20%). Additionally, the majority of dentists had MSD problems in more than one site including the hand/fingers (22%), neck (30%), and lower back (24%).¹⁷ Dharsan and Arivarasu reported 70% of the dentists reported wrist and hand pain at some point in their career.¹⁸ Haas et al., reported that 30.8% of dentists in Germany had MSDs in the hand at any time in their lives, 20.3% in the last twelve months and 9.5% in the last seven days.¹⁹ In this survey, 72.8% of the students also reported to have other pains in the back, shoulders, neck and legs. Although the 9 sites of the hand were categorized, the majority of the students reported area C (19.3%) and area H (24.1%) (Figure 1) eliciting pain during hand movements, 20% of the students reported associated bumps, swellings or anatomic changes to their finger/hand or wrist in the same areas, none of these areas were significantly higher in reported pain between the dental classes.

Figure 1. Hand diagram.

Ambidextrous gloves seem to stretch more and cause more force than fitted surgical gloves which in the long term could contribute to hand problems.²⁰ However, in this study it was not statistically significant whether the gloves were too tight or too loose resulting in more pain and discomfort.

The majority experienced the pain during the daytime and the most common type of pain reported was cramping. Although cramping (57%) and throbbing (13.6%) and weakness (9.5%) were the top three description of pain among all classes, however in comparing classes, there was no association between type of pain and severity of pain.

Repetitive strain injuries such as forceful pinching of dental instruments and stressful and “uncomfortable” repetitive wrist positioning, whereby the wrist is not in line with the forearm, may put the dental student as well as practicing dentists at risk for developing MSDs of the hand, fingers and wrist.²¹ Musculoskeletal disorders of the hand/wrist include a number of conditions, such as carpal tunnel syndrome, which is a peripheral neuropathy caused by compression of the median nerve as it passes through the carpal tunnel.²² Relieving pain through improving physical function is the primary goal of treatment. Proper ergonomic practices have been shown to reduce the risk of developing MSDs. This includes using sharp instruments, using instruments with at least 10 mm diameter handle, performing warming up exercises, scheduling patients so that you don’t have back-to-back difficult procedures and taking breaks when needed.^17,23

Most of the population including dental students use their mobile phones, tablets and computers either in school, during leisure time or in private practice daily. Speculatively, these students could be experiencing pain, but it may be attributed to these associated factors. The students may not have been taught proper hand positioning to prevent pain. Studies have shown that wrist pain and thumb tendonitis was common in mobile cell users.^24,25 Additionally, dental students and students in other professions are part of the general population having hand pain as a result of too much writing (note taking) or prolonged typing during their education programs, which may have increased the prevalence of MSDs.²⁶ We did not include these two associated factors in our survey, but a study in the future would be indicated.

Conclusion

Hand musculoskeletal pain may be common among dental students and residents. While the majority of students with pain reported only mild or short-duration pain, for some individuals, pain experience may be severe and prolonged. While dental school programs typically provide students lectures on body ergonomics, specific training on hand ergonomics appears warranted. Learning proper technique and other prevention strategies to reduce musculoskeletal pain in dental school may help the next generation of dental professionals enjoy lengthy, pain-free careers.

Disclosure Statement

Mea Weinberg, Stuart Segelnick, Peter Loomer and Enas Bsoul do not have any conflict-of-interest relationships

Additional information

Notes on contributors

Mea A. Weinberg

Mea A. Weinberg is Clinical Professor in the Ashman Department of Periodontology & Implant Dentistry at New York University College of Dentistry. She is a Diplomate of the American Board of Periodontology. She also has lectured on pharmacology and periodontics and is the author of many articles and books.

Stuart L. Segelnick

Stuart L. Segelnick Is an Adjunct Clinical Professor in the Ashman Department of Periodontology & Implant Dentistry at NYU Dentistry. He is a Diplomate of the American Board of Periodontology and the International Congress of Oral Implantologists. Dr. Segelnick is editor of the Northeastern Society of Periodontists NESP Bulletin and the Second District Dental Society of New York SDDS Bulletin. He also is the immediate past president of the American Association of Dental Editors & Journalists. Dr. Segelnick has co-edited five books on dentistry.

Enas Bsoul

Enas Bsoul is an Assistant Professor/Clinical in the Department of Comprehensive Dentistry at the University of Texas Health San Antonio, School of Dentistry. She is Director of Predoctoral Oral and Maxillofacial Radiology, and teaches and practices in the Advanced Oral and Maxillofacial Radiology Program. She has many publications with interests in 3D Advanced Imaging.

Peter M. Loomer

Peter M. Loomer is Dean of UT Health San Antonio School of Dentistry and previously served as chair of the Ashman Department of Periodontology & Implant Dentistry and Director of the Center for Global Oral Health Sciences at New York University College of Dentistry. He is a Diplomate of the American Board of Periodontology and the Royal College of Dentists of Canada. Dr. Loomer is an expert in health professions curriculum, which has been a major focus of his international research program. His work in global oral health is focused on interprofessional education, student international education and global research experience, faculty development and curriculum reform in developing nations with an emphasis on East Africa and the Middle East. He also has several projects in Africa and Brazil focused on improving oral health in children of poverty.