CLINICAL RESEARCH

Brandon S. Astin, DMD,

Risk Factors and Prevalence of F. Micah Nuzum, DDS, MS,
Alexander J. DiMassa, DMD,
Occupational Musculoskeletal MSD, and Andre K. Mickel, DDS,
MSD, MDiv
Pain among Endodontists in
the United States

ABSTRACT
SIGNIFICANCE
Introduction: A musculoskeletal disorder (MSD) of pain, weakness, numbness, or
paresthesia is a common issue for dental health care providers. The aims of this study were to The findings of this study apply
(1) identify the prevalence of MSDs among endodontists in the United States, (2) to identify risk to the well-being and career
factors of MSDs among United States endodontists, and (3) to compare these findings with longevity of all providers in our
other published findings for dental providers. Methods: A 24-question survey regarding the profession, which trickles
demographics, potential risk factors, and prevalence of MSDs was formulated and distributed down into enhanced patient
to 5394 members of the American Association of Endodontists. Data were then analyzed care; there was high interest
using descriptive statistics and chi-square analysis to find significance at a 5 0.05. during data collection, with
Results: Six hundred twenty participants responded to the survey for an overall response over 600 respondents from the
rate of 12%. Of the submitted surveys, 527 of them confirmed to be endodontists practicing in AAE membership.
the United States, and all results were derived from those 527 surveys. Seventy-four percent
of respondents reported having experienced MSDs in the last 12 months, and 88% reported
having experienced at least 1 MSD thus far during their career. Eighty-five percent of female
participants reported an MSD within the past 12 months compared with 70% of males.
Conclusions: MSDs have a high prevalence among endodontists in the United States. The
neck and lower back were the areas of highest MSD prevalence. Female sex and the frequent
adoption of awkward postures were factors associated with significantly higher rates of
reported MSDs in the last 12 months. (J Endod 2024;50:17–21.)

KEY WORDS
Endodontists; musculoskeletal disorders; occupational injury; pain

A musculoskeletal disorder (MSD) is defined as a condition or ailment of 1 or more areas of the body,
which causes symptoms such as pain, weakness, excessive fatigue, burning, tingling, numbness, or
paresthesia1. MSDs often arise from injuries resulting in damage or inflammation directly to the
musculoskeletal, nervous, or circulatory systems or their associated supporting structures.
Occupational MSDs have 2 primary origins: acute and chronic injuries. Acute injuries result from
singular incidents in the workplace such as slips, falls, collisions, cuts, or crushes. Chronic injuries, also
known as overuse injuries, are the result of repetitive actions that result in microtraumas, which are
cumulative in nature until ultimately producing the aforementioned symptoms associated with MSDs2. From the Department of Endodontics,
Case Western Reserve University School
Approximately 70% of dental health care providers have experienced MSDs3. The prevalence of
of Dental Medicine, Cleveland, Ohio
MSDs among dentists, especially in the neck, shoulder, and back area, was significantly higher than in the
Address requests for reprints to Dr
general population4.
Brandon S. Astin, Department of
Ergonomics is the scientific application of designing and arranging things people use to maximize Endodontics, Case Western Reserve
efficiency and safety in movement. When poor ergonomics are used in the dental workplace, chronic University School of Dental Medicine,
injury can present as the frequency, intensity, and duration of repetitive stresses and microtraumas 9601 Chester Avenue, Cleveland, OH
exceed a tissue’s capacity to maintain itself; thus, the affected tissues begin to yield the symptoms of 44106.
E-mail address: [email protected]
MSDs5. 0099-2399/$ - see front matter
Studying magnification and ergonomics, it was determined that a dental operating microscope
Copyright © 2023 American Association
(DOM) provided the most ergonomic viewing position for a dental operator. It significantly reduces of Endodontists.
forward head tilt more than loupes, which more significantly reduce forward head tilt compared with no https://doi.org/10.1016/
magnification6. Prolonged excessive forward tilt of the head is associated with increased shoulder and j.joen.2023.10.004

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neck pain7. DOM usage among endodontists onto the next page where all survey questions “never” by 48% of endodontists, and .90%
in the American Association of Endodontists were located. practice 4-handed endodontics “always” or
(AAE) revealed increased use from 52% in Data were collected over a 1-month “usually.”
1999 to 90% in 20078. period with the survey link expiring on May 18,
One study was identified that 2023. One reminder e-mail was sent out on
investigated MSDs among endodontists. Zarra May 6, 2023, to all accounts that had not yet MSD-related Data
and Lambrianidis9 surveyed endodontists in completed the survey. Seventy-four percent of participants reported
Greece and reported that the prevalence of The inclusion criteria for participants experiencing an MSD within the last
MSDs for the previous 12-month period was were as follows: 12 months. This number was higher among
greater than 60% among their respondents, female respondents at 85% versus 70% for
1. age range from 18–79 years old and males. Eighty-eight percent of the participants
although DOMs were only used by less than
2. endodontist practicing in the United States. reported an MSD at some point in their career.
half of those surveyed. With such a vast
difference in reported usage of DOMs by the Eighty-three percent selected “pain” as the
The exclusion criteria for participants
endodontists in Greece compared with the primary symptom experienced.
were as follows:
reported DOM usage among endodontists in The neck (56%), lower back (49%), and
the AAE and no studies to date specifically 1. age ,18 years old or .79 years old, shoulders/arms (44%) were the most
2. nonendodontists, and commonly selected areas involved with MSDs.
addressing the prevalence of MSDs among
endodontists in the United States, we fulfilled 3. endodontists practicing outside of the The dominant-hand side of the body was
an important and applicable need in United States. affected 66% of the time, and 78% of
performing this study. providers attributed their MSD as work-related
No personal identifiers were collected nor
The purpose of this study was to ergonomics being the main contributor.
stored in conjunction with the survey
examine the prevalence of MSDs experienced Ten percent of endodontists have
responses. The sample size was calculated
by endodontists in the United States. Our missed work in the last 12 months because of
using a 95% confidence and 5% margin of error
hypothesis was that the increased an MSD, and 26% have missed work because
yielding a target recruitment of 359 participants.
implementation of DOMs by endodontists in of MSDs at some point in their career. The
From the original e-mail distribution, 61 e-mails
the United States over the past 15 years will most common prevention strategies were
failed to send, 59 e-mails bounced, and 14
result in less reported neck problems and “stretching” (70%), “strength training” (64%),
were marked as duplicates. These 134 surveys
lower prevalence rates of MSDs than are seen and massage therapy (47%).
were also excluded from the population
published in the literature for other dental Chi-square analysis comparing the
because of impossible contact. Completed and
health care providers. responses of everyone in the survey against
partially completed surveys were used in data
The aims of this study were the responses of those reporting an MSD in the
calculations.
past 12 months was completed (Table 1).
Data gathering, storage, and analysis
1. to identify the prevalence of MSDs among Significant associations of higher MSD
endodontists in the United States, were all completed inside the Qualtrics
prevalence in the past 12 months were found
software. Survey data were analyzed with chi-
2. to identify risk factors of MSDs among for “female” sex (P , .05) as well as for those
square analysis or Fisher exact tests
United States endodontists, and having marked the adoption of awkward
3. to compare these findings with other comparing each of the response percentages
postures “always,” “usually,” or “often”
published findings for dental providers. against the proportions reporting they had
(P , .05). Work-related ergonomics as the
experienced an MSD in the last 12 months. A
main contributor for MSDs was also found to
level of significance was set at a 5 0.05 for
be significant with those suffering an MSD in
these comparisons.
MATERIALS AND METHODS the past 12 months (P , .05).
The design for this research was given an
institutional review board (IRB) exemption RESULTS
granted by the Case Western Reserve
DISCUSSION
A total of 620 participants responded to the
University IRB (IRB number: STUDY20230278 Seventy-four percent of participants reported
survey for an overall response rate of 12%. Of
on 3/23/2023). experiencing an MSD within the past
the submitted surveys, 527 of them confirmed
A 24-question survey was formulated 12 months. When asked about experiencing
to be endodontists practicing in the United
that addressed demographic data and MSDs, an MSD at any point in their career, the number
States, and the following results, as well as
risk factors, prevalence, management, and of participants was predictably higher with a
those seen in Table 1, are derived from those
prevention. This survey was then formatted into confirming response of 88%. These results are
527 surveys.
an online survey software (Qualtrics, Provo, UT), higher than the 61% found in endodontists in
and a link to the survey was prepared into an e- Greece over the previous 12-month reporting
mail for distribution. A list of e-mail addresses for Demographic and Workplace Data period9. Our results are more consistent with
“active,” “associate,” “life,” and “retired” Respondents were 74% male and 26% outcomes reported in the literature regarding
members was obtained from the AAE. female. Eighty-four percent of participants MSDs in dentists. The systematic review by
The distribution e-mail contained a brief reported using a microscope for magnification Chenna et al3 found MSDs in approximately
description of the survey along with the survey .50% of the time. The majority of 70% of dental health care providers. In other
link and was e-mailed to the aforementioned endodontists (51%) in the study worked systematic reviews among dental
AAE membership lists containing 5394 e-mail between 30–39.9 clinical hours each week, professionals, Soo et al10 identified MSD
addresses on April 19, 2023. Informed with another 17% exceeding 40 clinical h/wk. prevalence at 68%–100%, and Hayes et al11
consent was obtained on the first page of the The adoption of awkward postures found MSDs among dental personnel ranging
survey and affirmed by participant continuation during treatment was reported as a “rarely” or between 64%–93%.

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TABLE 1 - Risk Factor Data

% of endodontists % Difference from

No. of with at least 1 MSD overall 73.5% with
endodontists with in the past MSD in the past
Categoric variables No. of participants at least 1 MSD 12 months 12 months P value
Age (y) .052
30–39 103 82 79.6 6.1
40–49 146 100 68.5 25.0
50–59 108 88 81.5 8.0
60–69 98 68 70.1 23.4
70–79 71 47 67.1 26.4
Gender ,.001
Male 391 271 69.7 23.8
Female 136 115 84.6 11.1
Years since completing .409
residency training
,10 158 118 74.7 1.2
10–19 121 93 76.9 3.4
20–29 115 85 74.6 1.1
301 129 87 68.0 25.5
Clinical hours per week .171
,20 82 52 63.4 210.1
20–29.9 85 64 75.3 1.8
30–39.9 267 201 75.6 2.1
.40 89 66 74.2 0.7
Magnification utilization .107
.50% of the time
Yes: microscope 442 317 71.9 21.6
Yes: loupes 70 56 80.0 6.5
No magnification 13 12 92.3 18.8
Sitting while providing .345
treatment
Always 476 349 73.5 0.0
Usually 44 33 75.0 1.5
Often 1 0 0.0 273.5
Rarely 2 1 50.0 223.5
Never 3 3 100.0 26.5
Adopt awkward postures ,.001
during treatment
Always 17 15 88.2 14.7
Usually 66 58 87.9 14.4
Often 189 161 85.2 11.7
Rarely 238 148 62.4 211.1
Never 15 4 26.7 246.8
Practice 4-handed .492
endodontics
Always 386 283 73.3 20.2
Usually 88 69 79.3 5.8
Often 33 24 72.7 20.8
Rarely 12 7 58.3 215.2
Never 5 3 60.0 213.5
Provider height .214
,50 600 98 77 78.6 5.1
50 6"–60 000 318 235 73.9 0.4
.60 000 110 74 67.9 25.6
BMI .215
,18.5 (underweight) 12 8 66.7 26.8
18.5–24.9 (healthy) 349 263 75.4 1.9
25.0–29.9 (overweight) 150 103 69.1 24.4
30.0 or greater 11 10 90.9 17.4
Main contributor to MSD(s) ,.001
Work-related 389 326 84.0 10.5
ergonomics
Non–work-related injury 109 58 53.2 220.3
.063
(continued on next page )

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TABLE 1 - Continued

% of endodontists % Difference from

No. of with at least 1 MSD overall 73.5% with
endodontists with in the past MSD in the past
Categoric variables No. of participants at least 1 MSD 12 months 12 months P value
Which side of the body
was most affected
Dominant-hand side 303 251 83.1 9.6
Non–dominant-hand 157 119 75.8 2.3
side
Primary symptom .291
Pain 400 321 80.5 7.0
Numbness 50 43 86.0 12.5
Weakness 22 15 68.2 25.3
Paresthesia 10 7 70.0 23.5
Missed any work because ,.001
of MSDs in the last
12 months
Yes 50 49 98.0 24.5
No 471 334 71.1 22.4
Have you ever missed work ,.001
due to MSDs
Yes 134 119 88.8 15.3
No 387 265 68.7 24.8

MSD, musculoskeletal disease.

Significant findings (P values , .05) are in bold.

In the review by Hayes et al11, the back position12. The neutral operating position is One of the reasons for excluding AAE
and the neck were the most prevalent regions when the operator keeps the head and entirety members who are not endodontists within
of MSDs for dentists. Our own results mirror of the spine and down through the pelvis the United States was to help better control
those, with the neck and lower back being the aligned in all planes. Both shoulders should be for similar training and working conditions.
MSD areas of highest prevalence and the relaxed back and low with the elbows in close One such variable of interest was the
shoulders/arms coming in third. These regions to the torso and the wrists and hands at or implementation of the DOM, which had high
also coincide with reports that the prevalence slightly below the level of the elbows and also utilization rates in this study population.
of MSDs among dentists, specifically in the in neutral alignment. This ergonomic Eighty-four percent of respondents reported
neck, shoulder, and back areas, was positioning will maintain normal circulation and using DOM magnification .50% of the
significantly higher than in the general reduce required forces exerted on the joints time. Although the DOM has been identified
population4. and musculature. as an instrument that improves ergonomics
A significant proportion of the MSDs in The 2 most common prevention over magnification loupes and no
the last 12 months were attributed to work- strategies used by our survey population were magnification, the prevalence rates of MSDs
related ergonomics rather than outside injury. stretching and strength training at 70% and in these United States endodontists was
Although many MSDs can be chronic and 64%, respectively. Holzgreve et al13 similar to those reported for other dental
cumulative in nature, it was noted that recommended a 10-week resistance training professionals who do not implement DOM
endodontists who have been practicing longer program for dental providers as having effects utilization as broadly.
did not have any significantly higher prevalence on reducing pain intensity and being helpful in One of the strengths of the study was
of MSDs than endodontists who have less the prevention against MSDs in dental the large sample size overall. In the most
years of practice. The same inference can be professionals. Letafatkar et al14 found recently published 2021 Member Needs
made with the weekly workload of clinical therapeutic exercise for female dentists, Survey results from the AAE, they had a 20%
hours having no significant difference in the specifically for those suffering from chronic membership response rate and similar
prevalence of MSDs. However, providers that neck pain, as a means to successfully alleviate demographic data. Our respondents were
adopt awkward procedures on a “always,” pain, disability, posture, and health status. 26% female and that unrelated AAE survey
“usually,” or “often” basis were found to report Female endodontists in this study was 27% female. This gives greater
a significantly higher prevalence of MSDs in the experienced MSDs in the previous 12 months confidence when extrapolating our data for
past 12 months. This information may highlight at a significantly higher rate than their male application to endodontists in the United
the significance of poor postures or poor colleagues. Eighty-five percent of them States.
ergonomics leading to more physical reported experiencing MSDs in the past Some limitations of the study include a
breakdowns and symptoms compared to the 12 months. Similar findings are present in potential for bias because respondents who
natural aging process or continued working many other studies. Female endodontists in have had to manage MSDs or those with close
later into a career. Greece were found to have significantly higher acquaintances such as coworkers or family
An awkward posture is one that takes a rates of MSDs9, and higher rates of MSDs members suffering from MSDs may be more
provider out of their neutral operating were also found in female dentists3,15. likely to respond. The presence of an MSD in

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our study includes self-reported experiencing microscope training, ergonomics, and States, with 74% of respondents reporting
of symptoms in addition to medically implementation may provide the missing link having experienced MSDs in the last
diagnosed MSDs. This may lead to certain between the more ergonomic position of using 12 months and 88% reporting having
respondents missing an MSD that may the microscope and subsequent improvement experienced at least 1 MSD thus far during
present, whereas others might have declared in reducing MSDs. Another specific area of their career. The neck and lower back were the
an MSD while experiencing the same or similar concern is the higher prevalence rates seen areas of highest MSD prevalence. Female sex
symptoms. Self-reporting of MSDs is the most among female endodontists and female dental and the frequent adoption of awkward
common method used in these studies and is providers in general, which necessitates postures were factors associated with
a factor to consider when comparing data deeper study. With such a high prevalence, significantly higher rates of reported MSDs in
across different studies. better evidence and findings of more specific the last 12 months.
This alarmingly high prevalence of MSDs risk factors, effective preventions, and efficient
among endodontists in the United States management can have a significant impact for
should serve to promote further awareness this population.
ACKNOWLEDGMENTS
and investigation into prevention and In conclusion, MSDs have a high The authors deny any conflicts of interest
management. Identifying deficiencies in prevalence among endodontists in the United related to this study.

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