Evidence Based Analysis on Neck and Low Back Pain among Dental Practitioners- A Systematic Review

Abstract

This systematic review was undertaken to assess neck and back pain in dental practitioners. Published articles from 2015 onwards were explored in search engines of Pubmed, Medline, Scopus and Journal of web for outcomes of neck and back pain in dental practitioners. A total of 13 articles were reviewed, after carefully considering the eligibility criteria. The prevalence of neck and back pain was considerably higher, with neck pain occurrence ranging from 13.02% to 84.6% and back pain observed in 15.7% - 88.9% of reviewed studies. A higher prevalence of musculoskeletal pain was observed stressing appropriate interventional measures to reduce the same.

INTRODUCTION

The dental profession plays a key role in the maintenance of personal hygiene. Though the profession is rewarding, it is physically demanding, leading to various complications.[1] Literature documentation shows an increased incidence of pain associated with prolonged working hours.[2,3,4] Specialization of oral surgery, endodontics, and prosthodontics demand greater physical activity.

Shorter rest periods between working times and continuous characteristic working position resulting in rotation and repetition of arms and joints results in pain, spasms, and rigidity of joints.[5]

The literature has demonstrated a higher prevalence of musculoskeletal injuries in various body parts of dental professionals when compared to other professions. Prevalence of 63%–93% is reported across the globe in the waist, neck, and back.[6,7,8,9]

Recent technological advancements in dental materials and techniques boast of shorter working times and flexibility. The varied prevalence of musculoskeletal pain disorder and questionable benefit bestowed by newer techniques warrants this review to be conducted. Hence, a methodological review was conducted to assess low back pain and neck pain in dental practitioners.

METHODOLOGY

PRISMA checklist as per the criteria of Moher et al.[10] employed for reporting of systematic review and meta-analysis was used for the present review. This review was done by three reviewers. Comprehensive review manager software was used for this systematic review article collection.

Inclusion criteria

Cross-sectional descriptive studies assessing the prevalence of back pain and neck pain in dental health professionals in the time range of 2015–2020 published in high-quality peer-reviewed journals were included. No particular classification for back or neck pain was considered.

Exclusion criteria

Editorials, case reports, commentaries, and articles written in a language other than English were excluded. Articles assessing prevalence in dental students, interns, or any other health professionals and beyond the pre-decided time range were also excluded.

Information sources

Search engines such as MEDLINE, PubMed, Scopus, and Journal on Web databases were explored for literature search. All searches were performed via EBSCO. All pertaining articles were identified and obtained in full through electronic and other search methods. The authors conducted the literature search till the end of November 2020.

Search strategy

Keywords

Key terms used for the search were 1) dental health professionals, 2) dentists, 3) back pain, 4) neck pain, 5) spinal pain, 6) musculoskeletal disorders, 7) musculoskeletal pain, and 8) prevalence.

RESULTS

The search results yielded a total of 318 manuscripts, 252 articles were removed as only abstracts were available in search engines, and 23 were removed because of duplication. Additionally, another 30 articles had to be excluded as parameters other than periodontal health was assessed. After assessing the eligibility, 13 articles were included for qualitative evaluation [Figure 1].

Figure 1.

Flowchart for article inclusion

All reviewed articles employed a cross-sectional study design for assessing the prevalence of neck and back pain in dentists irrespective of gender or age. Eight of them were multi-center studies, and two were conducted in a single center. Gender, years of dental practice, specialization, and work hours per day were the most commonly assessed risk factors in the studies included. Neck pain prevalence ranged from 13.02% to 84.6%, while back pain was observed in 15.7%–88.9% of reviewed studies. A low risk of bias was noted in eight studies, while five of them showed a high risk of bias. The study characteristics are summarized in Table 1.

Table 1.

Characteristics of the studies included

Study ID	Location	Sample	Outcome assessor	Findings	Risk factor	Medication/Therapy	Number of centers
Ehab N. Alshouibi et al., 2020[12]	Jeddah, Saudi Arabia	300 dentists with a mean age of 35.3+10.7 years and a male predominance accounting for 59%	Standardized Nordic Musculoskeletal Questionnaire (SNMQ was used for assessing the prevalence of musculoskeletal pain	53.9% of dentists experienced back pain and neck pain in 28.9%.	Significant association was noted with the frequency of cases treated per day, Not using a dental loupe, stress, and lack of regular exercise	38.98% of the dentists with pain regularly exercised	Both dental college and clinics
Kuldeep Singh Shekhawat et al., 2020.[13]	Puducherry, India	72 dentists with a mean age of 33.2±7.4 years, and 26 males and 46 females	Close-ended, self-administered questionnaire	82% of the study respondents had neck pain, while 88.9 had back pain	Gender, years of practice, work hours per day, and specialization were evaluated for their relation with musculoskeletal pain	Stretching exercises and analgesics were pain-relieving factors employed by the dentists	Private dental clinics of Puducherry
Rohail Amir Babker et al., 2020 [14]	Islamabad and Rawalpindi, Pakistan	385 dentists; 120 males and 265 females	Neck Disability Index	44.7% of them experienced mild disability and 33.8% had moderate disability	Work experience (in years), Specialty and location of neck pain were assessed. Pain was common in the upper cervical region (44.4%) followed by the lower cervical region and near the shoulder blades	Not assessed	Multicenter
Dalia E Meisha et al., 2019[15]	Jeddah, Saudi Arabia	234 dentists, with 127 males and 107 females in both government and private sector	Diaz-Caballero et al.’s questionnaire which compromised questions Regarding ergonomic practices, musculoskeletal pain location which was adopted from Nordic questionnaire for the analysis of musculoskeletal symptoms and severity of pain utilizing a numeric pain rating scale from 0 (no pain) to 10 (worst pain possible).	Low back pain was seen in 85% and neck pain in 84.6% of dental practitioners	Females were 2.8 times more significantly affected by musculoskeletal pain when compared to male counterparts. Private dentists were 2.3 times at greater risk than government sector dentists	Those dentists who did not exercise had a greater prevalence of musculoskeletal pain	Multi-center
Jaspreet Kaur et al., 2018.[16]	Hisar, India	110 dental professionals,	VAS scale for pain intensity	Neck and Back pain was noted in 30% of the study sample	Pain was not significantly associated with either age or gender	-	Single-center
Nancy Ajwa et al., 2018.[17]	Riyadh	715 participants; 278 males and 437 females	Self-reported questionnaire	51.9% of dentists experienced neck pain while 53.7% were affected with lower back pain	Pain was significantly associated with gender, level of education, working sector, and frequency of patients treated per day	3.8% took medications for relief of pain	Multi-center
Artenio Jose Isper Garbin et al., 2017[18]	Northwest of Sao Paulo, Brazil	204 dentists working in public health clinics	Pain Disability Questionnaire (PDQ) and the Numeric Pain Scale	Neck pain was reported in 15.7%, and lower back pain in 15.7%.	Females had significantly higher neck pain than men (P<0.001). Coincidentally, they had normal weight in BMI when compared to men.	75.9% of dentists reported a “moderate” disability for work resulting due to pain.	Single dental college
Marin Vodanovic et al., 2016[19]	Croatia	506 individuals; 310 females, 196 males	Self-reported questionnaire in an online survey	36.8% of female dentists reported upper back pain, while 36.1% of males reported lower back pain. UB pain prevalence in Males versus females was 36.8% versus 21.6%, which was highly significant at P<0.001.	Study assessed the relationship of pain with years of practice and age.	No measures taken by any dentist to alleviate pain
Phedy P et al., 2016[20]	Indonesia	241 dentists, all general practitioners	Nordic Musculoskeletal Questionnaire	The prevalence of neck pain, upper back, and lower back pain was 25.7, 22.4, and 20.7%, respectively.	Risk factors of gender, length of practice, four-handed dentistry smoking status, occupational stress, body mass index, hand dominance, and exercise were assessed	Exercise relieved symptoms in 35.3% of dentists	Indonesian Dentist Association, Regional branch
Omar A Al Mohrej et al., 2016[21]	Riyadh, Saudi Arabia	204 dentists; 101 males and 103 females with a mean age of 38.0±10.6 years	0-10 numeric scale for pain rating was used	Back pain was experienced in 68.1% and neck pain in 34.3% of dentists.	Gender, marital status, and age were predicted risk factors for musculoskeletal pain.	-	Multicenter – 150 hospitals and private clinics
Mohammad Aljanakh et al., 2015[22]	Hail Region, Saudi Arabia	68 dentists, with a 1.7:1 male to female ratio	Nordic Musculoskeletal questionnaire	A total of 77.9% of dental professionals suffered from Work-related musculoskeletal disorders. Back pain was observed in 73.5% (39/55) and neck pain in 66% (35/53) of the total population	Duration of dental practice, gender, and age were taken into consideration. For gender, no significant difference was noted between males and females at P=0.754.
Subhash Chandra et al., 2015[23]	Patna, India	132 dentists, with 52 females and 80 males	Self-reported questionnaire with 14 specific questions eliciting musculoskeletal pain	38.01% of dentists complained of back pain and 13.02% had pain in the neck region	No correlation was reported between age and severity or incidence of pain. But, most of the respondents fell in the age range of 21–30 years	57.85% of dentists opted for exercise and yoga as treatment modalities to relieve the pain.	Multicenter – done in 3 dental college
Beibei Feng et al. 2014[24]	China	272 dentists; 121 females and 151 males	Visual Analogue Scale	83.8% of them suffered from neck pain. In the multivariate analysis, working hours per day were significantly related to neck pain with an OR of 1.43 (CI: 1.03–1.98). A significant finding noted was right side was more commonly affected than the left in the shoulder, wrist, and arm pain	High job demand was a significant psychosocial risk factor to be observed. Smoking was another risk factor associated with neck pain, observed in 19.1% of the study population	Regular physical exercise reduced neck pain in most of the dentists	Multicenter study – done in 52 hospitals

DISCUSSION

All the studies included were in the time period of the previous 5 years. Musculoskeletal pain in the neck and back was commonly reported in the present review. This finding closely matches with several studies, approximating a 70% prevalence of WMDs in dentists.[11,12]

Neck pain as a result of excessive elongated static load with resultant sustained muscular activity in the sternocleidomastoid or trapezius muscle makes it a common work-related musculoskeletal disorder occurrence among dental professionals.[13]

As the outcome is of subjective assessment, over-reporting or under-reporting of cases cannot be overlooked. Also, the bias arising in the questionnaire study must be considered. Irrespective of this, the findings and hence the review has marked significance considering the higher prevalence of the issue and the consequences resulting from it. Owing to the cross-sectional study design, a causal relationship between risk factors and musculoskeletal pain could not be established.

CONCLUSION

Neck and back pain was commonly prevalent occupational musculoskeletal disorders observed in dental professionals. Remedial measures such as adequate deployment of staff to reduce the patient–dentist ratio, appropriate ergonomic posture and work conditions, less working hours, and alleviation of stress are recommended in the workplace. Dentists must be adequately and appropriately trained and educated regarding ergonomics and the benefits bestowed by exercise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.