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Getting the Upper Hand on Pain:Preventing Hand and Wrist Pain Syndromes in Dental ProfessionalsA Peer-Reviewed Publication Written by Bethany Valachi, PT, MS, CEAS

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Educational ObjectivesThe overall goal of this article is to provide the reader with information on the incidence, risk factors, prevention and treatment of true carpal tunnel syndrome, as well as disorders in dentistry that mimic carpal tunnel syndrome but have a different etiology. Upon completion of this course, the reader will be able to do the following:1. List and describe four of the primary risk factors associ-

ated with carpal tunnel syndrome2. List and describe ergonomic interventions that can help

prevent carpal tunnel syndrome3. List and describe other conditions that may mimic carpal

tunnel syndrome4. Provide an overview of the diagnosis and treatment of

carpal tunnel syndrome

AbstractChronic hand and wrist pain that can affect quality of life, productivity or career longevity is experienced by between 40 and 70 percent of dental professionals. Given that fewer den-tal professionals fully recover from hand pain than they do from neck, shoulder or elbow pain, it is imperative that injury be prevented. There are a number of risk factors for carpal tunnel syndrome that must be considered, as well as research-based ergonomic interventions. The use of ergonomic equip-ment and implementation of prevention techniques outside the operatory can help to reduce work-related pain and extend the career of the dental professional.

Introduction“The right half of the brain controls the left half of the body. This means that only left-handed people are in their right mind.” —Source Unknown

Hand, wrist and arm pain are much more prevalent among dental professionals than the general public, due to the sustained grips and prolonged awkward postures dentists and hygienists must employ throughout the day.1 Between 23 and 40 percent of dentists and nearly 75 per-cent of dental hygienists experience hand and wrist pain,2-6 nearly four times the prevalence found in the general work-ing public. In the case of hygienists, hands, wrists and arms are the most common sites of pain reported. Since hands are integral to the work of dental professionals, understanding the etiology of this pain and its prevention are important.6-9 Fewer dental professionals fully recover from hand pain syndromes than they do from neck, shoulder and elbow pain.7 Therefore, prevention strategies and early attention to warning signs of the primary cumulative trauma disorders (CTDs) of the hand and arm are imperative to the dental professional’s health and career longevity.

The origins of pain in the hand, wrist or arm are often elusive and may not be due to a problem in the same area; in fact, the source of the symptoms may be nowhere near where the symptoms are perceived. For example, numbness

in the fingers, which is one of the symptoms of carpal tunnel syndrome, sometimes has nothing to do with a problem in the hand or wrist but may be due to a problem in the cervical spine, thoracic outlet or trigger points in the forearm.

There are numerous causes of hand, wrist and arm pain, including tendonitis (e.g., De Quervain’s tenosynovitis), arthritis (e.g., osteoarthritis of the basilar joint), nerve com-pression (e.g., thoracic outlet syndrome, cervical radicu-lopathy, carpal tunnel syndrome, cubital tunnel syndrome), trigger points (e.g., radial tunnel syndrome) and equipment issues (e.g., non-ergonomic tools, poorly fitted gloves). However, the most commonly diagnosed CTD of the hand, wrist and arm among dentists and hygienists is carpal tunnel syndrome.

Carpal Tunnel SyndromeCarpal tunnel syndrome (CTS) is the most common pe-ripheral nerve entrapment in the arm10-11 and contributes to one of the most frequently performed hand surgeries in the United States.12 Caused by compression of the median nerve at the wrist,13 CTS can lead to pain, numbness or tingling in the thumb, index finger, middle finger and half of the ring finger. (Fig. 1)

Figure 1. Carpal tunnel

Pain or tingling in the distribution of the median nerve (shaded) is often indicative of carpal tunnel syndrome. Numbness is usually felt in the fingertips only.

One study found that while 71 percent of dentists expe-rienced one or more CTS symptoms, only 7 percent were actually diagnosed with CTS.14 This should prompt dental professionals with CTS-type symptoms to educate them-selves on all possible etiologies to avoid unnecessary surgery or ineffective therapies.

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Inconsistencies abound in the literature regarding the cause, proper evaluation and course of care of CTS.15-17 Noted author and physical rehabilitation expert Dr. Rene Calliet states, “Differentiation of median nerve wrist compression from cervical radiculitis or thoracic outlet syndrome may be the most challenging in clinical practice.”15 This is largely due to the fact that the median nerve fibers run a long and twisting course around bone and through soft tissue from the cervical spine down to the fingertips. CTS symptoms may not always be indicative of a structural problem in the hand and wrist; often the problem originates more proximally in the muscles/tendons that stabilize the arm during repetitive work.17 Any compression or entrapment along the median nerve fibers can result in CTS-type symptoms in the hand.18

The carpal tunnelThe carpal tunnel comprises a row of bones on the back of the wrist, with a thick ligament in the front. For the hand to func-tion properly, nine flexor tendons and the median nerve must be able to glide easily within this space. Of these structures, the median nerve is the softest and most vulnerable to pressure.

The positions that cause the most pressure in the carpal tunnel are easy to identify. If you straighten your right wrist, place your left thumb over the transverse carpal ligament and then bend your right wrist back, you can feel the ligament tighten over the tunnel. This is the position that compresses the tunnel most. If you then make a fist, the tunnel will get even tighter; if held in this position long enough, it may re-sult in your hands and fingers going numb. If you bring your wrist to neutral and then forward, the tightness will slacken when you are in neutral and then slightly tighten again as you move downward. If you try the above exercise gripping a pencil, this “precision” grip creates more pressure in the carpal tunnel. Sustained gripping while extending the wrist is unhealthy for your median nerve. By performing this series of movements, you have just demonstrated two of the four primary risk factors for CTS in dental professionals—flexing the wrist forward and gripping a small instrument forcefully. The other two risk factors are high repetition (as in manual scaling) and duration (e.g., how many heavy calculus patients you schedule back-to-back). (Fig. 2) These risk factors cause microtrauma in the carpal tunnel; fibrosis and edema of the lining of the tendons at the wrist eventually cause increased pressure within the carpal tunnel and decreased blood flow to the median nerve within the tunnel. The swelling of the lin-ing of the tendons is often painful, and it is the pressure on the median nerve at the wrist from this swelling that causes numbness in the fingers and weakness of the muscles at the base of the thumb.

The causes of CTS are numerous and include anatomic, physiologic, hereditary and traumatic factors that result in compression or irritation of the median nerve at the wrist. For instance, CTS is three times more prevalent in women than men, and it is most common between the ages of 30 and 60 and

among diabetics and in obese people. However, the literature also reports an occupational cause in more than 47 percent of cases.20 CTS symptoms (pain, numbness and tingling) are of-ten worse at night and first thing in the morning. Weakness in a precision grip may be present due to atrophy or weakness of the thumb abductor muscles.19 Over time, visibly decreased musculature may be noticed at the base of the thumb. Sensory impairment is usually experienced before motor loss, so early intervention is important. In addition to any therapies you may consider, it is imperative that you address ergonomic issues that are known to aggravate carpal tunnel symptoms to minimize your risk and to prevent CTS.

Figure 2. Four of the primary risk factors contributing to CTS in dentistry.

Keys to Success: Preventing Carpal Tunnel SyndromeThe four primary risk factors that contribute to occupational CTS in dentistry can be minimized with appropriate ergo-nomic interventions, as described below.

Avoiding sustained wrist flexionWrist flexion increases pressure in the carpal tunnel, and working with your wrist bent toward the little finger—called ulnar deviation—also increases this pressure.12-13 (Fig. 3a) When performing scaling or other treatments, trying to keep your wrist straight and moving your entire hand, wrist and

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forearm as a unit transfers the load from smaller hand muscles to larger arm and shoulder muscles. Using a finger rest posi-tion (either intra- or extra-oral) to stabilize the instrument further reduces thumb pinch force and muscle workloads in the hand.21 Extra-oral fulcrums also facilitate neutral wrist posture and allow proper positioning for precision instru-mentation.22 (Fig. 3b)

Figure 3a. Poor wrist posture

Poor (deviated) posture of the wrist is a primary risk factor for CTS in dentistry.

Figure 3b. Neutral wrist posture

Try to maintain neutral posture of the wrist, especially when scaling.

Rather than twisting the wrist to access hard-to-reach areas, try moving the instrument or handpiece in your hand. To access molar regions and distal pockets, select an instru-ment with multiple accentuated angles and a longer terminal shank (Fig. 4), which can reduce twisting the wrist to access these areas. It makes far more sense to use an accentuated angled instrument rather than angle your wrist. You can re-train yourself to maintain near-neutral wrist postures using a soft wrist wrap, such as a WrisTimer, to limit wrist flexion to anywhere from 0 degrees to 20 degrees. A soft wrist wrap

can be adjusted to prevent varying degrees of wrist flexion, thereby retraining damaging wrist postures.

Figure 4. Ergonomic shank

Instruments with multiple exaggerated angles and longer termi-nal shanks can reduce the need to flex the wrist to access hard-to-reach distal pockets.

Going ultrasonicCompared to manual scaling, ultrasonic scaling requires less force applied to the work surface and a less forceful preci-sion grip. However, these ergonomic advantages are putting ultrasonic instruments at the forefront and in some cases overshadowing manual instruments as artifacts of the past. The importance of precision manual scaling in delivering quality dental care cannot be overstated, and the effective-ness of quality advanced periodontal instrumentation is often hard to match with an ultrasonic unit. Proper ergonomic periodontal instrumentation techniques should be a priority for hygienists to safely implement sufficient hand scaling into their patient care.22,23

The percentage of time spent providing ultrasonic versus manual scaling care is an individual one that must take into consideration personal health (some individuals are more prone to CTS than others), patient periodontal history, workload, depth and size of pockets, and numerous other variables. Both manual and powered instrumentation have unique strengths that can be effectively combined during treatment.24 Furthermore, studies show that the duration of use of either ultrasonic or manual instruments is positively associated with upper extremity numbness/tingling.25

From a preventive perspective, ultrasonic instrumenta-tion should be used periodically over the course of the day to reduce muscle workload and provide rest to the intrinsic hand muscles. Also consider swiveling ultrasonic inserts, which can improve hand and arm posture as well as save time.

Instrument selectionCertain instrument features can reduce carpal tunnel com-pression:

Diameter – Instruments are available in a wide variety of handle diameters, ranging from about 5.6 to 11.5 mm.

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Larger instrument handle diameters reduce hand muscle load and pinch force, although handle diameters greater than 10 mm (about 3/8 inch) have been shown to offer no additional advantage.26 Alternating between handle diam-eter sizes may also help prevent CTS symptoms. When se-lecting instruments, try to include large diameters as well as other sizes, but avoid very narrow diameter sizes (5.6 mm), as these increase carpal tunnel pressure. Sleeves that fit over mirror handles and increase their diameter have been shown to reduce muscle load;27 however, sleeves on scaling instru-ments may not have the same benefits, due to the additional force needed to perform scaling tasks.

Weight – Although instrument weight is not as significant a risk factor as handle diameter, lightweight instruments (15 g or less) help reduce the muscle workload and pinch force.26

Texture – Textured handle surfaces may help decrease forceful pinch grips.

Sharpness – Dull instruments can have a profoundly deleterious impact on your musculoskeletal health, as they require increased force. It is therefore essential to maintain optimally sharpened instruments and perform visual in-spections regularly. There are several methods for sharpen-ing, including mechanical and manual23 methods and using a high-speed handpiece.28

Reduce your grip – Forceful pinch grip has been shown to increase pressure in the carpal tunnel; this pres-sure is even higher when combined with wrist ulnar de-viation.12 Hygienists and dentists should try to use a palmar grip when using the high volume evacuation (HVE) and dentists should, of course, use the palmar grip instead of the precision grip during extractions. Dentists with pain in the dominant hand should consider using the non-dominant hand intermittently for extractions, and they can begin by supporting the extracting hand with the dominant hand. Positioning on the opposite side of the patient for extrac-tions may become more comfortable and easier when you are acclimatized to using the non-dominant hand, and it provides yet another opportunity to move around, thereby varying the load on your muscles, bones and joints.

Cord management – Using 360-degree swivel instru-ments to maintain optimal neutral wrist and finger position is helpful, as is positioning heavy cords over your arm through a counter-mounted loop or across an armrest to reduce muscle strain. Cord pullback can be prevented by positioning your delivery system and ultrasound unit close to you. It is also important to observe patient positioning strategies to maintain neutral wrist posture.

Spread the work around – Moving the muscle work-load helps to avoid structural damage.29 One way to do this is by alternating between chairs with and without armrests. Using a chair with armrests moves the workload to the smaller muscles of the hand and wrist, while using no arm-rests incorporates the larger muscles of the arm and shoulder girdle into the movement.

Temperature – Avoid positioning your neck, shoul-ders and hands directly in the draft of an air conditioner, and avoid working in a particularly cold environment, since exposure to cold is another aggravating risk factor associated with CTS.

Stretch – Frequent stretch breaks were the most help-ful intervention for hand/wrist pain in one dental study.30 Stretching helps to increase blood flow and reduce formation of trigger points. If you have mild carpal tunnel symptoms, you should be gently stretching three to five times per day.

CTS DiagnosisAccurate diagnosis of CTS is difficult and requires evalua-tion by a highly skilled healthcare practitioner, preferably a board-certified hand surgeon. A certified hand therapist can also be extremely helpful in addressing adaptation, er-gonomics, splinting and using various modalities to reduce your symptoms. Positive results from several tests (EMG and nerve conduction velocity testing, hand pain mapping, and sensitivity testing) and the presence of wrist/hand pain are highly suggestive of CTS.12 The following physical exam findings are often seen in people with this syndrome: 1. Tinel’s sign: an electric shock–type sensation in the hand

when the median nerve is tapped gently at the wrist2. Positive Phalen’s test: numbness in the hand in less than

60 seconds when the wrist is flexed 90 degrees3. Weakness of the thenar muscles at the base of the thumb4. In severe cases, persistent numbness in the distribution

of the distal median nerve (thumb, index finger, middle finger) and continuous numbness can represent perma-nent damage to the nerve; surgery should be considered prior to this point, as surgery will reliably prevent further damage to the nerve, but recovery of a damaged nerve is not as predictable

CTS TreatmentConservative treatment options for CTS include the following:• Modification of activities to decrease tendon excursion• Therapeutic interventions such as ice, massage,

ultrasound or acupuncture• Anti-inflammatories or cortisone injections• An immobilizing splint across the wrist (often most

helpful at night)• Nerve or tendon gliding exercises• B6 vitamins if the problem is due to a vitamin deficiency

It is advisable to avoid strengthening the hands/fingers with repetitive finger flexion exercises, as these can increase carpal tunnel pressures and worsen pain.16,31 However, when completely pain-free, a program of very lightweight tubing exercises focused on the wrist flexor, extensor, pronator and supinator groups may be of benefit in preventing CTS and for trigger points.16

Dentists and hygienists should implement ergonomic inter-ventions, consider all CTS-mimicking conditions and undergo

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conservative CTS therapies before considering CTS surgery. Surgical patients treated three to five years after the onset of symptoms are less likely to have complete symptom resolution. Therefore, early diagnosis and treatment are important.12 It is far easier to prevent carpal tunnel syndrome than to cure it.

Pain Syndromes That Mimic Carpal Tunnel SyndromeSeveral problems may mimic CTS, including cervical radiculopathy, thoracic outlet syndrome, median nerve entrapment in the forearm and trigger points, and poorly fitting gloves. (Fig. 5)

Figure 5. Problems that may mimic CTS

1. Cervical radiculopathy, 2. Thoracic outlet syndrome, 3. Median nerve entrapment in the forearm and trigger points, 4. CTS, 5. Poorly fitting gloves.

Trigger points and nerve entrapmentAlthough muscle-referred pain is a well-documented and researched phenomenon,15,32 it is often overlooked as a pos-sible source of pain syndromes. Trigger points in certain muscles may refer CTS-like symptoms into the hand and wrist.32

Trigger points in the forearm muscles such as the pro-nator teres can cause compression on the median nerve and cause CTS-like pain in the hand and wrist. Since the me-dian nerve runs through the pronator teres muscle, dental professionals who operate with the forearms in a pronated (palms-down) position are at greater risk for this nerve en-

trapment.16,33-34 Neuromuscular technique and myofascial release are two popular approaches that have been used to treat this type of pain. Initially, dental professionals should work with a healthcare professional, such as a certified neuromuscular therapist or a therapist who specializes in trigger point therapy, to resolve pain of this origin. After re-duction of symptoms, dentists may learn to self-treat their trigger points, since their jobs are a perpetuating factor.35 Median nerve entrapment in the forearm can be treated successfully if a holistic approach is taken to address the sum of compression and tension on the nerves in the upper extremity.18

Thoracic outlet syndrome (TOS)TOS is a neurovascular disorder resulting from pressure on the nerves and/or blood vessels that supply the arm, fingers and hand. (Fig. 6)

Figure 6. Thoracic outlet

The thoracic outlet, showing nerves and arteries that supply the arm.

Tightness and/or trigger points in the pectoralis, ante-rior or middle scalenes may restrict the size of the thoracic outlet.15,33,36 Compression of this neurovascular bundle may cause numbness and tingling that can mimic CTS; however, TOS may also include vascular symptoms (edema, cold-ness or discoloration) in the hands and fingers. A thorough clinical evaluation is the most important component for diagnosis of TOS; this should include subjective and objec-tive findings as well as a review of daily activities and work

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habits. The development of TOS has no involvement with the tendons and soft tissues at the wrist, but that is where the symptoms tend to be perceived. In addition to true TOS, patients may have thoracic outlet symptoms due to forward head posture, working with shoulders on a tilted axis, breathing from the chest and improper body mechanics.15,36 Thoracic outlet symptoms from these sources can often be resolved with physical therapy.

Cervical radicular pain (cervical radiculopathy)Pain or paresthesia in the hand may also originate in the cer-vical spine.15 Nerve roots that supply the arm and hand may become compressed as they exit the spinal vertebrae, result-ing in cervical radiculopathy. This may occur simultaneous-ly with CTS (also known as “double crush” syndrome33). Numbness in the hand may be produced by changes in neck position, and muscle stretch reflexes tend to be diminished. Electrodiagnostic studies in this situation would reveal a normal nerve conduction velocity; however, the EMG may be abnormal in the distribution of the involved nerve root.15 A skilled electromyographer, usually a neurologist or physiatrist, is essential for accurate test results. The cause of cervical radiculopathy, more often than not, is due to for-ward head posture combined with degenerative changes in the facet joints of the cervical spine.

Poorly fitted glovesImproperly fitted gloves may cause CTS-type pain, primar-ily at the base of the thumb. Ambidextrous gloves are gen-erally molded with the hand in a flat (neutral) position and were originally designed for brief medical examinations.37 When gloves are used for longer procedures, as in dentistry, the operator’s hand must pull the glove into a working posi-tion, which may compress the back of the hand and strain the muscles at the base of the thumb, simultaneously reduc-ing the blood flow to the hand. Ambidextrous gloves exert one-third more force than do fitted gloves,37 and muscle ischemia, nerve compression and pain may result. Older practitioners may be more prone than younger practitioners to glove-related pain in the hands.38 Tight gloves may also result in the above symptoms.

SummaryThe cause of hand pain in dental professionals may be mul-tifactorial, and the etiology may not necessarily be related to a single structural problem at the wrist. There are numerous other pain syndromes of the hand/wrist and elbow to which dental professionals are predisposed, including De Quer-vain’s syndrome, osteoarthritis of the carpometacarpal joint of the thumb, lateral epicondylitis and others. Regardless of the etiology of hand/wrist pain, den-tal professionals should realize that their occupation is a perpetuating factor for the development of this pain.12,16,32 Prevention is of great importance, and intervention strate-

gies should become an integral habit in the operatory in the office and at home.

References1. HamannC,WernerR,FranzblauA,etal.Prevalenceof

carpaltunnelsyndromeandmedianmononeuropathyamongdentists.J Am Dent Assoc.2001;132:163-70.

2. Alexopoulos EC, Stathi I, Charizani F. Prevalenceof musculoskeletal disorders in dentists. BMC Musculoskelet Disord. 2004;5:16.

3. FinsenL,ChristensenH,BakkeM.Musculoskeletaldisorders among dentists and variation in dentalwork.Applied Ergonomics.1997;29(2):119-25.

4. Marshall ED, Duncombe LM, Robinson RQ,Kilbreath, SL. Musculoskeletal symptoms in NewSouthWalesdentists.Aust Dent J.1997;42(4):240-6.

5. Rucker LM, Sunell S. Ergonomic Risk FactorsAssociated with Clinical Dentistry. CDA J.2002;30(2):139-48.

6. LalumandierJ,McPheeS.Prevalenceandriskfactorsofhandproblemsandcarpaltunnelsyndromeamongdentalhygienists.J Dent Hyg.2001;75:130-3.

7. Akesson I, Johnsson B, Rylander L, Moritz U,SkerfvingS.Musculoskeletaldisordersamongfemaledentalpersonnel—clinicalexaminationanda5-yearfollow-upstudyofsymptoms.Int Arch Occup Environ Health.1999;72:395-403.

8. Akesson I, Schutz A, Horstmann V, Skerfving S,MoritzU.Musculoskeletalsymptomsamongdentalpersonnel—lack of association with mercury andselenium status, overweight and smoking. Swed Dental J. 2000;24:23-8.

9. Werner R, Hamann C, Franzblau A, Rodgers P.Prevalence of carpal tunnel syndrome and upperextremity tendinitisamongdentalhygienists.J Dent Hyg.2002;76:126-32.

10.Anto C, Aradhya P. Clinical diagnosis of peripheralnerve compression in the upper extremity. Orthop Clin North Am.1996;27:227-36.

11.Phalen G. The carpal-tunnel syndrome: seventeenyears’ experience in diagnosis and treatment of sixhundred fifty-four hands. J Bone Joint Surg Am.1966;48:221-8.

12.MackinEJ,CallahanAD,OstermanAL,SkirvenTM,SchneiderLH.Rehabilitation of the Hand and Upper Extremity, 4th ed.St.Louis,MO:Mosby;2002:644-67.

13.Karwowski W, Marras WS. The Occupational Ergonomics Handbook.BocaRaton,FL:CRCPress;1999:775-7,821-51643-4.

14.Rice VJ, Nindel B, Pentikis JS. Dental workers,musculoskeletalcumulativetrauma,andcarpaltunnelsyndrome:whoisatrisk?Apilotstudy.Int J Occup Saf Ergon.1996;2(3):218-33.

15.CaillietR.Neck and Arm Pain. 3rd ed.Philadelphia,PA:F.A.Davis;1991:195-7,212,215-8.

16.Whyte-Ferguson L, Gerwin R. Clinical Mastery in

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the Treatment of Myofascial Pain. Philadelphia, PA:LippincottWilliams&Wilkins;2005:145-66.

17.Chin DH, Jones NF. Repetitive motion handdisorders.CDA J.2002;30(2):149-60.

18.Ericson, WB. Median Nerve Entrapment inthe Forearm: Diagnosis and Treatment, Posterpresentation, American Society for Surgery of theHand,59thAnnualMeeting,NewYork,NY,2004.

19.FeldmanRG,GoldmanR,KeyserlingWM.Peripheralnerveentrapmentsyndromesandergonomicfactors.Am J Ind Med.1983;4(5):661-81.

20.Centers for Disease Control. Occupational diseasesurveillance: carpal tunnel syndrome. MMWR. 1989;18:36-44.

21.DongH,BarrA,LoomerP,RempelD.Theeffectsoffingerrestpositionsonhandmuscleloadandpinchforceinsimulateddentalhygienework.J Dent Educ.2005;69(4):453-60.

22.Pattison AM, Matsuda S, Pattison GL. Extraoralfulcrums—theessentialsofusingextraoral fulcrumsforperiodontalinstrumentation.Dimensions of Dental Hygiene.2004;2(10):20,21-3.

23.MatsudaS.Technique—propergrasp.Dimensions of Dental Hygiene.2005;3(9):26,28.

23.MatsudaS.Troubleshootingtechnique—sharpening.Dimensions of Dental Hygiene.2005;3(6):32,34.

24.MatsudaS.Instrumentationofbiofilm.Dimensions of Dental Hygiene.2003;1(1):26-8,30.

25.MorseTF,Michalak-TurcotteC,Atwood-SandersM,WarrenN,PatersonDR,etal.Apilotstudyofhandandarmmusculoskeletaldisordersindentalhygienestudents.J Dent Hyg.2003;77(30):173-9.

26.Dong H, Barr A, Loomer P, LaRoche C,Young E,et al. The effects of periodontal instrument handledesign on hand muscle load and pinch force. J Am Dent Assoc.2006;137(8):1123-30.

27.Simmer-Beck M, Bray KK, Branson B, Glaros A,Weeks J. Comparison of muscle activity associatedwithstructuraldifferencesindentalhygienemirrors.J Dent Hyg.2006;80(1):8.

28.Glasscoe D. The better way to sharpen dentalinstruments—CD.ProfessionalDentalManagementInc.2006.

29.KumarC.Biomechanics in Ergonomics.Philadelphia,PA:Taylor&Francis;1999:165-75.

30.Stockstill JW, Harn SD, Stickland D, Hruska R.Prevalenceofupperextremityneuropathyinaclinicaldentistpopulation.J Am Dent Assoc.1993;124:67-72.

31.WeissS,FalkensteinN.Hand Rehabilitation: a Quick Reference Guide and Review, 2nd ed.St.Louis,MO:ElsevierMosby;2005:346.

32.TravellJG,SimonsDG,SimonsLS.Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1. Baltimore,MD:LippincottWilliams&Wilkins;1999.

33.NovakCB,MackinnonSE.Repetitiveuseandstaticpostures:asourceofnervecompressionandpain.J

Hand Ther.1997;10(2):151-9.34.AdelmanS,EisnerK.Armpaininadentist:pronator

syndrome.J Am Dent Assoc.1982;105:61-2.35.Valachi B, Valachi K. Mechanisms contributing to

musculoskeletal disorders in dentistry. J Am Dent Assoc.2003;134:1344-50.

36.RitterA,SensatM,Harn,S.Thoracicoutletsyndrome:areviewoftheliterature.J DentHyg.1999;73:205-7.

37.Powell BJ, Winkley GP, Brown JO, Etersque S.Evaluating thefitofambidextrousandfittedgloves:implications for hand discomfort. J Am Dent Assoc. 1994;125:1235-42.

38.Christensen G. Operating gloves: the good and thebad.J Am Dent Assoc.2001;132:1455-57.

Resources• This CE course is Chapter 5 from the author’s book,

Practice Dentistry Pain-Free: Evidence-based Strategies to Prevent Pain & Extend Your Career – B. Valachi·

• It’s Not Carpal Tunnel Syndrome! – S Damany/J. Bellis· Physics Forceps extraction instrument at www.physicsforceps.com

• The following related resources are available on the au-thor’s website: www.posturedontics.com: Osteoarthritis vs. DeQuervain’s Disease in Dental Professionals (newslet-ter archives) WrisTimer – for preventing carpal tunnel· Wrist/hand exercises for dental professionals.

Author ProfileBethany Valachi, PT, MS, CEAS. Ms. Valachi is a physical therapist, dental ergonomic consul-tant and author of the book, “Practice Dentistry Pain-Free”. She is CEO of Posturedontics®, a company that provides research-based dental ergonomic education and also lectures internationally—including the 2009 International Dental Ergonomics Congress in Krakow, Poland. Clinical instructor of ergonomics at OHSU School of Dentistry in Portland, Or-egon, Bethany has provided expertise on dental ergonomics to faculty and students at numerous dental universities. She has been widely published in various peer-reviewed dental journals and has developed patient positioning, chairside stretching and home exercise DVDs specifically for dental professionals. She offers free newsletters, articles and product reviews on her website at www.posturedontics.com.

DisclaimerThe author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

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Online CompletionUse this page to review the questions and answers. Return towww.ineedce.comand sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. Hand, wrist and arm pain are much more prevalent among dental professionals than the general public, due to ________.a. intermittent grips and sustained awkward posturesb. sustained grips and prolonged awkward postures c. sustained grips and ergonomic posturesd. none of the above

2. Between _________ of dentists and nearly _________ of dental hygienists experience hand and wrist pain.a. 8 and 20 percent; 55 percentb. 13 and 25 percent; 65 percentc. 18 and 30 percent; 75 percentd. 23 and 40 percent; 75 percent

3. The origins of pain in the hand, wrist or arm are always due to a problem in the same area.a. Trueb. False

4. Carpal tunnel syndrome is the least common peripheral nerve entrapment in the arm.a. Trueb. False

5. For the hand to function properly, ________ flexor tendons and the median nerve must be able to glide easily within the carpal tunnel.a. fiveb. sevenc. nined. none of the above

6. Flexing the wrist forward and gripping a small instrument forcefully are two of the primary risk factors for carpal tunnel syndrome. a. Trueb. False

7. High repetition work (such as manual scaling) and long duration (e.g., how many heavy calculus patients you schedule back-to-back) are primary risk factors for carpal tunnel syndrome.a. True b. False

8. Trying to keep your wrist straight and moving your entire hand, wrist and forearm as a unit ________, and is an appropriate ergonomic intervention to help prevent carpal tunnel syndrome.a. transfers the load from larger hand muscles to

smaller arm and shoulder muscles b. transfers the load from smaller hand muscles to

smaller arm and shoulder musclesc. transfers the load from smaller hand muscles to

larger arm and shoulder musclesd. none of the above

9. Using an accentuated angled instrument is preferable to angling your wrist while performing dental procedures.a. Trueb. False

10. Ultrasonic scaling requires less force applied to the work surface and a less forceful precision grip than manual scaling.a. Trueb. False

11. The duration of use of either ultrasonic or manual instruments is positively as-sociated with upper extremity numbness/tingling. a. Trueb. False

12. Larger instrument handle diameters increase hand muscle load and pinch force.a. Trueb. False

13. Alternating between handle diameter sizes may help prevent CTS symptoms.a. Trueb. False

14. Textured and lightweight instruments help reduce pinch forces and forceful pinch grips.a. Trueb. False

15. While dull instruments require the use of more force, they do not have a deleterious effect on musculoskeletal health.a. Trueb. False

16. Forceful pinch grip has been shown to increase pressure in the carpal tunnel, but this pressure is lowered when combined with wrist ulnar deviation.a. True b. False

17. Hygienists and dentists should try to use a _________ when possible.a. plantar gripb. palmar gripc. ulnar gripd. none of the above

18. Using 360-degree swivel instruments helps to _________.a. maintain neutral wrist and optimal finger

positionb. maintain optimal neutral wrist and a lateral finger

positionc. maintain optimal neutral wrist and finger positiond. all of the above

19. Alternating between chairs with and without armrests can help avoid structural damage.a. Trueb. False

20. Exposure to _________ is an aggravating risk factor associated with CTS.a. warmthb. coldc. humidityd. all of the above

21. Tinel’s sign is an electric shock–type sen-sation in the hand when the _________ is tapped gently at the wrist and is often seen in patients with carpal tunnel syndrome.a. superior palmar nerveb. inferior palmar nervec. median nerved. none of the above

22. Weakness of the thenar muscles at the base of the thumb is often seen in patients with carpal tunnel syndrome.a. Trueb. False

23. Therapeutic interventions for the treat-ment of carpal tunnel syndrome include _________.a. iceb. massagec. ultrasound or acupunctured. all of the above

24. _________ is a conservative treatment option for carpal tunnel syndrome.a. Nerve or tendon gliding exercisesb. Modification of activities to decrease tendon excursionc. The use of anti-inflammatories or cortisone

injectionsd. all of the above

25. _________ may mimic carpal tunnel syndrome. a. Cervical radiculopathyb. Poorly fitting glovesc. Thoracic outlet syndromed. all of the above

26. Median nerve entrapment is one of the conditions that does not mimic carpal tunnel syndrome.a. Trueb. False

27. Ambidextrous gloves exert one-third more force than do fitted gloves, and their use may result in _________.a. muscle ischemiab. nerve compressionc. paind. all of the above

28. Trigger points in the forearm muscles such as the pronator teres can cause compression on the median nerve and cause pain in the hand and wrist similar to that of carpal tunnel syndrome.a. Trueb. False

29. Older practitioners may be more prone than younger practitioners to glove-related pain in the hands.a. Trueb. False

30. Intervention strategies should become an integral habit in the operatory in the office and at home to help prevent carpal tunnel syndrome.a. Trueb. False

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

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ANSWER SHEET

Getting the Upper Hand on Pain:Preventing Hand and Wrist Pain Syndromes in Dental Professionals

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Requirementsforsuccessfulcompletionofthecourseandtoobtaindentalcontinuingeducationcredits:1)Readtheentirecourse.2)Completeallinformationabove.3)Completeanswersheetsineitherpenorpencil.4)Markonlyoneanswerforeachquestion.5)Ascoreof70%onthistestwillearnyou4CEcredits.6)CompletetheCourseEvaluationbelow.7)MakecheckpayabletoPennWellCorp.For Questions Call 216.398.7822

Educational Objectives1. Listanddescribefouroftheprimaryriskfactorsassociatedwithcarpaltunnelsyndrome

2. Listanddescribeergonomicinterventionsthatcanhelppreventcarpaltunnelsyndrome

3. Listanddescribeotherconditionsthatmaymimiccarpaltunnelsyndrome

4. Provideanoverviewofthediagnosisandtreatmentofcarpaltunnelsyndrome

Course EvaluationPleaseevaluatethiscoursebyrespondingtothefollowingstatements,usingascaleofExcellent=5toPoor=0.

1.Weretheindividualcourseobjectivesmet? Objective#1:YesNo Objective#3:YesNo

Objective#2:YesNo Objective#4:YesNo

2.Towhatextentwerethecourseobjectivesaccomplishedoverall? 5 4 3 2 1 0

3.Pleaserateyourpersonalmasteryofthecourseobjectives. 5 4 3 2 1 0

4.Howwouldyouratetheobjectivesandeducationalmethods? 5 4 3 2 1 0

5.Howdoyouratetheauthor’sgraspofthetopic? 5 4 3 2 1 0

6.Pleaseratetheinstructor’seffectiveness. 5 4 3 2 1 0

7.Wastheoveralladministrationofthecourseeffective? 5 4 3 2 1 0

8.Doyoufeelthatthereferenceswereadequate? Yes No

9.Wouldyouparticipateinasimilarprogramonadifferenttopic? Yes No

10.Ifanyofthecontinuingeducationquestionswereunclearorambiguous,pleaselistthem.

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11.Wasthereanysubjectmatteryoufoundconfusing?Pleasedescribe.

___________________________________________________________________

___________________________________________________________________

12.Whatadditionalcontinuingdentaleducationtopicswouldyouliketosee?

___________________________________________________________________

___________________________________________________________________

AUTHOR DISCLAIMERThe author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

SPONSOR/PROVIDERThis course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMERThe opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPINGPennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

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