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Musculoskeletal Disorders Among Dental Students

Article in Journal of Research in Medical and Dental Science · April 2020

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Musculoskeletal Disorders Among Dental Students

Noor Sam Ahmad1, Asma Alhusna Abang Abdullah2, Ooi Kee Thyng3, Teong Ling Xin3

1Department of Family Dental Health, Orthodontic Unit, Faculty of Dentistry, Universiti Kebangsaan

Malaysia, Kuala Lumpur, Malaysia

2Faculty of Dentistry, National University of Malaysia

3Doctor of Dental Surgery (DDS). Ministry of Health, Malaysia

ABSTRACT
Introduction: Dentistry is a profession that requires prolonged repetitive movement, sustained various body posture and
stress that can contribute significantly to the development of musculoskeletal discrepancy (MSD), psychological stress and
fatigue. MSD can occur in any part of the body, ranging from postural muscle, upper extremities and the lower extremities. If
left untreated, MSD can cause severe degenerative and inflammatory disorders. The aim of this study is to determine the
prevalence of musculoskeletal disorders (MSD) among dental students.
Methods: This was a descriptive cross-sectional survey involving a convenient sample of 244 undergraduate and
postgraduate dental students in UKM. A previously validated self-reporting questionnaire measuring MSD prevalence,
derived from the Standardized Nordic Questionnaire, was distributed to students. The questionnaire included demographic
data and areas where the dental students experienced trouble (ache, pain, discomfort and numbness). Data were analyzed
using SPSS 22.0. Ethics approval was obtained from UKM Research Ethics Committee. Results: The neck was the most
commonly affected area among UKM dental students, followed by lower back and shoulders. Neck and lower back were the
regions which showed increased pattern of pain prevalence in relation to years of working experience. Shoulder pain was
reported highest in 3 years of working experience.
Conclusion: This study showed the increasing evidence that MSD could be developing in students, before the starting of a
professional career. It also highlighted the need to place further emphasis on ergonomic education.

Key words: Dental, Musculoskeletal disorders, Students

HOW TO CITE THIS ARTICLE: Noor Sam Ahmad, Asma Alhusna Abang Abdullah, Ooi Kee Thyng, Teong Ling Xin, Musculoskeletal Disorders Among
Dental Students, J Res Med Dent Sci, 2020, 8(3): 32-38

Corresponding author: Noor Sam Ahmad are works or tasks that put high force loads on human
e-mail✉: [email protected]
body. This forceful exertion requires high muscle efforts
Received: 28/01/2020
Accepted: 20/04/2020 will cause fatigue which later may lead to MSD. Workers
that work in an awkward posture and sustained in that
posture will place an excessive force on the joints and
INTRODUCTION
muscles and tendons around the joints. MSD will develop
Musculoskeletal disorders (MSD) are defined as muscular if there is no adequate recovery period [2]. Individual risk
pain or injuries to the human support system that can factor is another category of risk factor for MSD. This risk
occur after a single event or cumulative trauma, hence factor comprise of poor work practices, poor overall health
causing negative impact on daily activities [1]. MSD can practices, poor rest and recovery, poor nutrition, fitness
vary from discomfort, numbness, ache, pain and it can and hydration. This category is related to individual
even prevent normal daily activities. MSD can occur in any worker who has poor work practices, wrong lifting
part of the body, ranging from postural muscle, upper and techniques, smoking, taking alcohol, obese, do not get
lower extremities. enough rest and recovery, malnourished, frequently
dehydrated and has poor level of physical fitness [2].
One of the risk factor categories for MSD is work related
Individuals that have one or more of the above risk factors,
(ergonomic) risk factors. The primary ergonomic risk
they are at greater risk of developing a musculoskeletal
factors can further be broken into three parts which are
imbalance and eventually an MSD.
high task repetition, forceful exertions and sustained
awkward postures. There are many works or tasks that Dentistry requires the dentist to keep their head, neck,
are repetitive in nature which usually controlled by hourly shoulder and other body parts in a fixed position as a
or daily production targets. If this high task repetition routine of daily work. In this situation, the dentists are
combines with other risk factor, MSD can develop. There more susceptible to have MSD, psychological stress,

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Noor Sam Ahmad et al J Res Med Dent Sci, 2020, 8 (3):32-38

fatigue [3], cumulative trauma disorder and occupational JEP-2018-440). Participants included in the study were
health hazard [4]. The prevalence of working all undergraduate students in their second year (UG2),
musculoskeletal disorders (WMSD) was found as high as third year (UG3), fourth year (UG4) and fifth year (UG5)
64% to 93% from a systemic review [5]. Prolonged of Doctor of Dental Surgery (DDS) programme and all
awkward postures (rotation or forward bending of the postgraduate students (PG). Exclusion criteria was
head, neck and body to one side) will lead to the applied to the students who absent on the day of
strengthening and contraction of muscle on the preferred conducting research. The participants were recruited via
side of bending or rotation and weakening and convenience sampling as this is the most time-efficient
elongation of the antagonistic muscle. This will cause and effective method to obtain an appropriate sample
muscle imbalance [6]. The weakened and elongated relevant to the research question.
muscles are under stress and susceptible to ischemia or
necrosis [7]. Study design
Under normal circumstances, damaged tissues are This study was carried out as descriptive and exploratory
repaired during periods of rest. However, in dentistry due research, using a cross-sectional approach. The study
to the insufficient recovery time for muscle, necrosis of examined the prevalence of MSD in undergraduate and
muscles is prone to occur as the rate of damage exceeds postgraduate dental students. A cross-sectional design
the rate of repair. Currently, muscle substitution occur as was selected as this was identified as the most
the body compensates by using other parts of muscles to appropriate method to answer the research question.
maintain posture and protect damaged muscle from
further stress [8] and this eventually leads to The survey
development of MSDs.
The questionnaire was in Google forms. It was eight
Increased in MSD occurrence had caused the reduction in pages long and included a plain-language (English)
the amount of the productivity, early retirement and statement explaining the study. The questionnaire was an
increased number of sick leave among dental adapted version of an original tool by Smith and Leggat
practitioners. This had subsequently led to the increase [8] that has been previously validated and used among
of global awareness towards the MSD issue [8,9]. It has medical, dental, nursing and occupational therapy
been proven that the ergonomic practices and students, dental hygienists and dentists [4,13]. The
application of ergonomic in dental instruments and questionnaires include age, gender, year of experience,
facilities design can help to reduced or prevent MSD working hours per week, dominant hand, locations
related injury [10]. Stretching exercise, operator chairs where subject had trouble (ache, pain, discomfort,
with lumbar support, dental loupes, working with elbows numbness) during the last 12 months and severity of
lower than shoulders have been encouraged to improve lower back, neck and shoulder pain. The recruitment
posture during clinical works thus reducing stress and strategy involved the student researchers approaching
the risk of developing MSD [11]. students during timetabled lecture or tutorial sessions
Few studies showed that the prevalence of MSD was in and inviting them to complete the questionnaire. Link
negative correlation with years of experience [11,12]. It and bar code were distributed to the subjects and they
is believed that dentists gained experience through their were required to enter the link or scan the bar code to
clinical practices and learn to adjust their work posture access the questionnaire. We obtained a voluntary, signed
to avoid pain or discomfort [8]. Thus, this proposes that informed consent from the participants before the start
dental student can start showing the sign of MSD even of the study. The students were given 10 minutes to
during their early years of training. This statement was complete the questionnaire during the session.
supported by research that concluded more than 70% of
dental students experienced neck, shoulder and lower Data analysis
back pain as early as the third year of their dental Data collected from the questionnaires were analysed
training [12]. using Statistical Package for the Social Science (SPSS)
Thus, the aim of this study was to determine the software version 22.0 (IBM Corporation, Armonk, NY,
prevalence of musculoskeletal disorders among dental USA). First, descriptive analysis was performed for
students by measuring MSD prevalence using a self- demographic data to have a general view of the sample’s
administered questionnaire. The objectives of this study gender, age, year of experience and working hours per
were to determine the mostly affected area of pain week, as well as dominant hand. A chi-square test was
among dental students and to compare the prevalence of chosen to analyse the data comparatively as the variables
MSD based on year of experience. were nominal and consist of two or more categorical,
independent groups.
MATERIAL AND METHODS
RESULTS
Ethics approval and study sample A total of 244 questionnaires were distributed and
The ethics approval was obtained from Universiti completed. A high response rate (91.8%) was able to be
Kebangsaan Malaysia (UKM) Institutional Review Board attained, due to very few numbers of absentees when the
for Research and Ethics (UKM PPI/111/8/ research was carried out. UKM undergraduate and

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Noor Sam Ahmad et al J Res Med Dent Sci, 2020, 8 (3):32-38

postgraduate dental students were predominantly made With regards to the hours of working, UG2 students has
up of female students (~70% +). Data detailing the the least working hours [13.31(± 2.222)], followed by
number of participants in each year was presented in UG3 [20.75(± 3.054)], UG4 [22.58(± 3.488)] and UG5
Table 1. Years of working experience for UG2, UG3, UG4, [25.28(± 3.483)]. PG students had the longest working
UG5 students were 1, 2, 3 and 4 years and, respectively hours which was 35.97(± 4.194) (Table 2).
while PG students had 8.40(±1.718) years of experiences.

Table 1: Demographic data.

UG2 UG3 UG4 UG5 PG

n % n % n % n % n %

Male 15 27.80% 15 28.80% 11 22.90% 16 28.10% 9 27.30%

Gender Female 39 72.70% 37 71.20% 37 77.10% 41 71.90% 24 72.70%

Range 20- 22 21-24 23-25 23-26 29-38

21.0
7(±0.
Age Mean 381) 22.17(±0.474) 23.23(±0.472) 24.37(±0.587) 33.03(±1.723)

Table 2: Years of working experience and hours of working.

UG2 UG2 UG3 UG4 UG5 PG

Years of working experience(n) - 1 2 3 4 10-May

Mean - - - - 8.40(±1.718)

Hours of working (n) - 10-16 17-26 18-27 20-30 30-40

Mean 13.31(±2.222) 20.75(±3.054) 22.58(±3.488) 25.28(±3.483) 35.97(±4.194)

The consistently reported body regions with high rates of studying oral and maxillofacial surgery (OMFS) had the
MSD for all participants were the neck (65.6%), the lower least prevalence of MSD, with only 50.0% suffered from
back (56.6%) and the shoulder (52.9%) (Figure 1). lower back pain and none of them (0.0%) had neck and
Elbow pain was the least commonly reported region of shoulder pain. Endodontic and periodontic students
MSD among students, with only 7.8% of them were reported the highest prevalence of neck pain (83.3%).
affected (Figure 1). Shoulder pain was most developed in paediatric students
(80.0%). Most of the postgraduate programmes showed
The prevalence of MSDs by body region for all
high prevalence in lower back pain (83.3%, 80.0% and
postgraduate programmes was presented in Figure 2.
80.0% of periodontic students, paediatric students and
Students studying paediatric had the highest prevalence
orthodontic students, respectively).
of MSD, with 80.0% of them were suffered from neck,
shoulder and lower back pain. In contrast, students

Figure 1: Location of pain among UKM dental students.

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Noor Sam Ahmad et al J Res Med Dent Sci, 2020, 8 (3):32-38

Figure 2: Prevalence of MSDs in different postgraduate programmes.

Figure 3 showed prevalence of MSD based on years of affected students with more than 5 years of experience
working experience. The prevalence of neck pain was the most (71.8%). Both neck and lower back pain
increased based on years of experience. Students with 1 showed an increasing pattern of pain based on years of
year of working experience had the least neck pain experience. However, the prevalence of shoulder pain
(59.6%) while students with more than 5 years of was the highest in students with 3 years of working
working experience had the most neck pain (72.2%). experience (70.5%). The pattern of MSD in shoulder pain
Lower back pain had a direct correlation with years of was increased from 1 to 3 years of working experience,
experience too. Lower back pain affected student with 1 followed by decreased from 3 to more than 5 years of
year of working experience was the least (40.5%) while working experience.

Figure 3: MSDs prevalence based on years of working experience.

The changes in MSD prevalence in neck, shoulder and dental students had symptoms of MSDs. Similar studies
lower back, in comparison of different cohorts studied conducted by different researchers have shown similar
shown changes either increasing or decreasing. However, results [16]. It was found that 86.6% of all students
all the changes were insignificant as all their P values surveyed suffered from MSD associated with clinical
obtained through data analysis were less than 0.05. requirements of their training. Movahhed et al. reported
that 82% of undergraduate students and 90% of
DISCUSSION postgraduate students reported pain in at least one body
region [17]. This finding suggests that oral health
The incidence of musculoskeletal problems, especially
professionals may have an increased risk of developing
work-related is increasing. One of the occupations that
MSD even before the starting of a professional career.
are encountering with these problems are dentists
[14,15]. In current study, it was found that most of the

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Noor Sam Ahmad et al J Res Med Dent Sci, 2020, 8 (3):32-38

Cross-sectional studies measure exposures and outcomes Figure 3 showed the prevalence of MSD in neck, shoulder
at a single point in time, and, as such, are useful for and lower back based on years of working experience as
yielding prevalence estimates. This study design is these areas were most reported areas of pain in
efficient in terms of cost and time, as it allows several correlates with other studies. A study showed that the
factors to be studied; given that this project is required to most prevalent MSD in dentist during the previous 12
be completed in less than 12 months, a cross-sectional months were reported at the neck (57.5%), lower back
approach was considered the most appropriate choice. (53.7 %) and shoulder (53.3%) [8]. Neck and lower back
showed the highest prevalence of MSD in subjects with 5
Majority of the participants in this study were females.
to 10 years of experience doing work, which was the
Since the proportions of male students were small in our
postgraduate cohort, as detailed in Figure 3. In
study, it was not appropriate to determine the differences
comparison with PG, UG2 (1 year of working experience)
in musculoskeletal pain prevalence rates by gender. This
had the lowest prevalence of MSD in neck and lower
was since the intake of dental students of UKM was
back. Khan et al. reported there was an increase in pain
dominated by females.
prevalence with the number of years spent in the dental
Site of MSD in the current study was mostly neck, school and this was more related to students which were
followed by lower back and shoulders and this is in clinical years, acquiring clinical skills and doing the
supported by other study [18]. Study conducted by routine dental procedures [13].
Rehman et al. also reported that lower back (57.8%),
The gradual increases of prevalence of MSD in neck,
neck (37.5%) and shoulders (29.6%) were the three
shoulder and lower back from UG2 to UG4 can be
commonly affected sites of dental practitioners [19]. In
hypothesized that it was due to the changes in nature of
another studied also found that neck (69%) was the
work, practicing pattern and working hours based on the
predominant site of pain followed by shoulders (51%),
timetable and curriculum of respective cohorts. UG2
upper back (51%) and lower back (39%) [20]. The
students had the lowest MSD prevalence as they did not
results of study by Gupta et al. shows the neck pain with
have any clinical session of treating patients yet and were
the most prevalence rate (57.5%) and back pain with
only started to be introduced towards simulation practice
moderate prevalence rate (53.7%) [21].The variations in
on dummy and prosthetic laboratory work. The least
reported prevalence may be due to issues such as various
prevalence of MSD in UG2 can also due to the ergonomics
measurement methods, cultural differences and the
subject that was taught in their curriculum and the
individual’s tasks. High level of incidence in this group
supervisor that kept on emphasized more on their
may be related to ergonomic problems such as unsuitable
posture during the simulation practices. UG3 (2 years of
repetitive movements [22], using vibrating instruments,
working experience) was the year they start to have their
bending forward at an angle of 15° or sometimes up to
clinical session and start to treat real life patient. Hence,
30° for a long time (in 86% of the working time) with
their prevalence of MSD increased, and this was probably
keeping up shoulder that caused a lot of pressure on the
due to their difficulty in adaptation towards changes
neck and shoulder [8].
from doing simulation practice on dummy and clinical
The distribution of pain was different in postgraduate work on actual patient. The prevalence of MSD in
students (PG) from different specialized field in dentistry. shoulder for UG3 showed a drastic increase in
In our studies, students studying paedodontics had the comparison with neck and lower back. This may be due
highest prevalence of MSD. This result also supported by to the introduction of Prosthodontic clinical work, which
other study which reported paedodontists seemed to be required the student to work with arms above the
at the most risk of developing musculoskeletal disorder shoulder and forceful arm movement s.
with 91% of them reporting some work-related pain
Regarding UG4 (3 years of working experience), the
[23]. Aghahi et al. stated that musculoskeletal pain in
prevalence of MSD continues to increase as they were
pedodontists might be due to not placing children in a
introduced to more different and various clinical works
proper position, the lack of a special unit for children,
and practices such as Periodontology, Orthodontic,
lack of good vision, lack of patient cooperation and
Paediatric, Oral surgery and Oral Pathology and Medicine
striving for greater control [24]. In our study, OMFS
and also increase in working hours. Interestingly, the
students had the lowest prevalence of MSDs. However,
prevalence of MSD in neck, shoulder and lower back
this may due to a very small sample size of OMFS
among UG5 (4 years working experience) decreased in
students which was only two students. In orthodontics,
compare to the UG4. This might be due changes and
80% of students reported pain in lower back region. In
adaptation in work posture to avoid problem or muscle
endodontic students, the neck region was reported to be
pain/ache aided by the experiences gaining through
a major area of pain. In restorative students and
clinical work.
periodontics students, pain in the neck and lower back
was the most reported MSD. Such differences in the In comparison to UG5, PG (5 to 10 years of experience
prevalence of various MSDs among dentists from doing work) showed higher MSD prevalence in neck and
different specialties have been observed in previous lower back region with the lower back region having
studies [25] and can be accounted for by the difference in more steeply increases. This correlated with other study
nature of the duties they perform and whether they have which stated that MSDs were most commonly reported in
direct patient contact or not. the neck (66 to 68%) and lower back (61 to 68%), with a
marked increase in reported lower back pain by the final

Journal of Research in Medical and Dental Science | Vol. 8 | Issue 3 | May 2020 36
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