Musculoskeletal disorders and work ability among dentists and dental students in Finland

Abstract

BACKGROUND:

Musculoskeletal disorders are leading causes for long sickness absences and early retirement. Dental work is physically strenuous, and many studies have shown a relation between work-related MSDs and dentistry. However, fewer studies have focused on how these conditions affect the work ability of dentists.

OBJECTIVE:

This study aimed to reveal the relationship between MSD, work ability and sickness absences in Finnish dentists and dental students.

METHODS:

A questionnaire was sent to 1200 dental workers and students. It inquired of age, gender, use of dental loupes, physical exercise, use of health care, and site, length and frequency of musculoskeletal complaints. Work ability was assessed with four parameters: work ability score (WAS), future work ability (FWA), self-estimation of MSD-related work disability, and sickness absence days.

RESULTS:

The questionnaire gained 255 responses (response rate 21%). The majority (90%) of the respondents had experienced MSD during the past year but only eleven percent of them had been on sick leave. MSDs correlated significantly with WAS, FWA and MSD-related work disability. Results remained significant even age adjusted. Age was a strong predictor of declined work ability, but gender, physical exercise or dental loupe use did not have a significant impact.

CONCLUSIONS:

Despite all the ergonomic advances in modern dentistry, the occurrence of MSD symptoms is still high. MSDs seem to affect dentists’ work ability significantly, but amount of sickness absence is relatively low, which may indicate a high level of presenteeism.

Keywords

Dentistry occupational health musculoskeletal diseases work ability health care

1 Introduction

1.1 Musculoskeletal problems of dentists

Several reviews have shown that prevalence of work-related musculoskeletal disorders (MSD) has remained high worldwide throughout the 21st century. The prevalence of MSD varies between studies from 61–100%, which is more likely to reflect the difference in question framing than in prevalence [1 –4]. In line with previous studies, two recent reviews both revealed that the most predominant regions for musculoskeletal disorders among dental professionals are the lower back, shoulder and neck [4, 5]. In many studies, female dentists seem to be more prone to MSD [4 , 7] as well as students and younger dentists [1, 3].

There is no recent information of the prevalence of MSD in dentists in Finland. A study from 1982 showed that 38% of dentist had diagnosed diseases or discomforts of occupational origin and 31% reported having been on sick leave during the two years prior to the survey due to some kind of an occupational problem, of which back and neck pain and stress were most frequent [8]. In another Finnish study the prevalence of MSD in dentists was 45% and 55%, in 1981 and 1985, respectively [9]. A few years later, the annual prevalence of neck and shoulder problems was 42% and of lower back problems 37%, the former being correlated to general health and stress and the latter to physical condition [10].

1.2 Ergonomic risk factors in dentistry

Dentists’ work is physically strenuous and demands prolonged and often static postures, primarily to meet the strict visual requirements of the job. Strongest occupational risk factors of MSD are static and awkward postures [11 –13], relatively high forces extorted by hand and fingers, and inadequate work equipment and work place design [12]. Other risk factors include vibration, repetition movements and poor lighting (both intensity and positioning) and positioning of both patient and dentist [3 , 13]. In addition, individual characteristics of dentist (height, weight, physical condition, general health, gender and age) may emphasize physical load [3 , 13–15].

A lot of resources have been spent to enhance ergonomics in dentistry. As major part of dentistry is manual work improving hand tools has gained remarkable attention [16, 17]. Other examples of ergonomic improvements are adjustable patient chairs, ergonomic saddle seats, establishment of four-hand work by dentist and dental assistant, and dental magnification loupes with or without lightning, which all have altered and improved the working positions of dentists [18 –21].

1.3 Work ability and lost work time due to MSDs of dentists

Work ability can be defined as the balance between human resources and the demands of work [22]. It reflects not only persons health, but also their occupational competence, motivation and job demands [23]. Declined work ability predicts sickness absences, early retirement [24, 25] disability and mortality [26], and is also associated with lower productivity and quality of work [27 –29] and thus, its economic significance is substantial.

Statistics concerning sickness absence and disability pension rates of dentists are not easy to find. They are usually combined with other healthcare personnel, which is the case also in Finland. However, according to a recent Finnish survey, their rate of absenteeism seems to be low [30].

In a recent study in Sweden about 20% of the dentists reported decreased productivity of their work due to pain and discomfort, and 32% reported reduced work ability [27]. Productivity loss was associated with poor sleep quality, a high amount of stress, and multi-site pain. A Chinese study suggested that high ergonomic risk exposure is a risk for reduced work ability among dentists [31].

A Finnish follow-up study found that the Work Ability Score (WAS) (one’s own estimation of work ability from one to ten) of dentists in Finland was 8.1 (scale 1–10) [30]. That is somewhat lower compared to the working population, 8.7 in women and 8.6 in men [32]. In addition, the results of dentists have declined under the 16-year follow-up time, especially in younger workers. That study did not investigate musculoskeletal complaints specifically [30].

MSDs are one of the leading causes of both long sickness absences and disability pensions in general [33 –35], and it has been shown that MSD are common in dentists. However, information concerning dentists’ work ability in relation to MSD is scarce. A quite recent Swedish-American study [36] gave incompatible results on how much work-related MSD conditions cause disability and early retirement in dentists. In the United States statistics, dentists did not seem to have particularly many MSD problems, but in the Swedish data, the situation was the opposite. The difference is not necessarily due to a difference in the prevalence of MSD symptoms but is rather a reflection of a different social insurance system.

This study aimed to reveal the relationship between MSD, work ability and sickness absences in Finnish dentists and dental students. A few decades have passed since the previous Finnish study of MSD and dentists, and thus, there is no recent information available. In addition, the effect of MSD on work ability of dentists has been studied rather little and not at all in Finland.

2 Methods

The study was carried out in accord with the Declaration of Helsinki of 1964 and its later amendments and a positive statement by the University of Helsinki research ethics committee of the Faculty of Medicine was obtained, Number 20/2021.

2.1 Study group

The study group of 1 200 consisted of two separate groups: dental students and dentists. We included all the 600 dental students in the clinical phase (i.e., those who participate in patient work) in all four Finnish universities that provide dental education (Universities of Helsinki, Oulu, Turku and Eastern Finland).

Because we wanted two equal sized study groups, we took a randomized sample of 600 actively working dentists from the membership registry of the Finnish Dental Union in the Helsinki University hospital patient admission area, which is the largest in Finland. Because the union membership coverage of dentists in Finland is very high, over 90%, the sample is representative. No other inclusion or exclusion criteria were used.

2.2 Questionnaire

The questionnaire consisted of a modified version of the Finnish national Health 2000 –survey [32] and included questions of baseline characteristics such as age, gender, and work history but also physical workload, the use of dental magnification loupes, musculoskeletal complaints in the past year, the occurrence and effects of these complaints, the need to seek medical care, and finally work ability and sickness absence.

The electronic questionnaire was carried out with a questionnaire platform called E-lomake of the University of Helsinki and a link was sent by email to the respondents by universities (students) or Finnish Dental Union (dentists) in February 2022. Participation was voluntary and completely anonymous, and no payments were offered. All the respondents gave their informed consent when answering the questionnaire. The response time was three months.

2.3 Work ability analysis

We assessed work ability with four different parameters: work ability score (WAS), future work ability (FWA), number of sickness absence days during the past year, and finally own estimation how much MSD affects their own work ability.

WAS is a single-item question of the Work Ability Index (WAI). WAS is a self-estimation of current work ability compared to lifetime best on a scale of zero to ten. WAS is usually classified as either excellent–good (8–10) or reduced i.e., poor–moderate (scores 0–7). Reduced WAS is associated with thoughts of early pension, disability pensions and long sickness absences [25 , 37–39].

FWA is a person’s own estimation of their ability to continue their work in two years from now (yes, maybe, no). It has been shown to predict both long sickness absences, and disability pensions [38].

Even a short sickness absence indicates at least temporary decline in person’s work ability. However, both repeated absences and longer absences predict future disability pension [40, 41]. Thus, sickness absence was used as a third work ability parameter.

Because none of the above parameters is specific to MSD’s we inquired respondents’ own estimation how much MSD symptoms in particular have influenced their work ability, which is later called MSD-related work disability. Scale was from zero (no effect) to 10 (worst possible effect). The answers were classified as follows: no effect (0), mild effect (1–3), moderate effect (4–7) and strong effect (answers 8–10).

2.4 Statistical methods

The relationships between demographic variables and WAS, FWA, sickness absences, and the MSD-related work disability were studied using bivariate and partial correlation analyses. All four work ability parameters were correlated with age, work status (dentist/student), MSD frequency and MSD duration.

Growing age is such a strong risk factor for reduced work ability [20, 28], and it was also seen in this study. Thus, we chose to carry out age adjusted calculations using partial correlation analyses.

Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. All statistical analyses were carried out using SPSS (version 29.0.0.0).

3 Results

3.1 Demographics of the respondents

A total of 255 respondents answered the questionnaire, corresponding to a response rate of 21%. Table 1 summarized the demographics of the respondents. The average age of the respondents was approximately 36 years, and over 4/5 of them were females and 1/5 males. The age and gender distribution correlated well with the Finnish Dental Union’s annual statistics.

Table 1
Demographics of the respondents

Variable All % Students % Dentists %

Respondents 255 100% 137 54% 118 46%

Gender

Female (%) 206 81% 111 81% 95 81%

Male (%) 48 19% 26 19% 22 19%

Other (%) 1 4% 0 0% 1 1%

Age

–30 years 137 54% 125 91% 12 10%

31–40 42 17% 11 8% 31 26%

41–50 15 6% 1 1% 14 12%

51–60 34 13% 0 0% 34 29%

61- 27 11% 0 0% 27 23%

Work hours / week

< 16 h 120 47% 104 75% 16 14%

16–30 h 89 35% 28 20% 61 52%

31–40 h 37 15% 5 4% 32 27%

> 40 h 9 4% 0 0% 9 8%

Variable	All	%	Students	%	Dentists	%
Respondents	255	100%	137	54%	118	46%
Gender
Female (%)	206	81%	111	81%	95	81%
Male (%)	48	19%	26	19%	22	19%
Other (%)	1	4%	0	0%	1	1%
Age
–30 years	137	54%	125	91%	12	10%
31–40	42	17%	11	8%	31	26%
41–50	15	6%	1	1%	14	12%
51–60	34	13%	0	0%	34	29%
61-	27	11%	0	0%	27	23%
Work hours / week
< 16 h	120	47%	104	75%	16	14%
16–30 h	89	35%	28	20%	61	52%
31–40 h	37	15%	5	4%	32	27%
> 40 h	9	4%	0	0%	9	8%

The responding dentists had an average work experience of approximately 20 years. The dental students had not accumulated professional work experience as dentists, but approximately 75% of them were working part-time (less than 16 hours a week).

An analysis of the differences between the dentists and dental students indicates that there were no significant differences when it comes to the frequency and the location of MSD symptoms. Nor was there any difference in the level of experienced pain from MSD. The only significant difference was found in the duration of MSD symptoms, where duration was longer in dentists compared to students. However, this difference disappeared when adjusting for respondents’ age (see also Table 3). Thus, we present our results with dentists and dental students combined.

Table 3

Correlation analysis of age, work status and musculoskeletal disorder (MSD) frequency and duration on four parameters of work ability: WAS, FWA, MSD-related work disability and sickness absence

	Work ability score (WAS)		Future work ability (FWA)		MSD-related work disability		Sickness absence
	Pearson correlation	Age-adjusted correlation	Pearson correlation	Age-adjusted correlation	Pearson correlation	Age-adjusted correlation	Pearson correlation	Age-adjusted correlation
Age	–0.39^^	–	–0.38^^^*	–	–0.36^^	–	0.45^^	–
Work status	–0.34^^	–0.08	–0.25^^	0.08	–0.31^^	–0.05	0.33^^	–0.03
MSD frequency	–0.41^^	–0.42^^	–0.27^^	–0.26^^	–0.19^^	–0.18^^	0.24^^	0.24^^
MSD duration	–0.39^^	–0.33^^	–0.30^^	–0.24^^	–0.23^^	–0.17^^	0.30^^	0.22^^

Work status (dentist = 1; student = 0) MSD frequency and duration, N = 255 Pearson correlation coefficients, ^*p < 0.05; ^*^*p < 0.01.

3.2 Musculoskeletal symptoms

Almost all, 90% of the respondents had experienced MSD during the past year, and 58% had experienced them often or continuously. The duration of the symptoms had mostly been relatively short, as 62% had experienced them for approximately a week, 6% for less than month, 9% for 1–6 months, and 10% for over six months.

Out of the MSD symptoms the most common ones were shoulder and neck pains (66% for both). Symptoms were experienced in both upper (37%) and lower back (38%) as well as in arms (21%) and fingers (17%). 13% of the respondents experienced pain reflecting to lower extremities, 10% above and 3% below the knee level.

In total 56% of the respondents had sought professional help for their MSD: from physicians (19%), physiotherapists (30%), professional massagers (43%), or some other professional (19%).

The majority of the respondents (82%) used dental loupes, and 57% use them with the loupe light. Those who utilize dental loupes in their work, use it regularly, 69% over 90% of the time, and 8.6% over 75% of the time, and the rest less often.

Only 4.3% of the respondents exercised less than one hour weekly, 32.5% exercised 1–3 hours, 43.9% 4–6 hours, 13.7% 7–10 hours, and 5.5% more than 10 hour per week.

3.3 Work ability

The mean WAS of the whole respondent group was 8.7. The WAS was reduced (0–7) in 14.5% and good or excellent (8–10) in 85,5% of the respondents.

Age was a strong risk factor for reduced work ability (WAS 0–7) in comparison to the youngest age group: OR was 10.13 (CI 3,60–28,54) among those aged 51–60 and OR was 12,77 (CI 4,33–37,62) among respondents older than 60 years. (Table 1)

Gender did not affect WAS significantly. Instead, students had significantly better work ability than dentists in univariate analysis OR 5,27 (CI 2.30–12.01), but it was not seen after age adjustment, and thus, was due to their younger age.

Frequency of MSD symptoms had a significant effect on WAS only in those whose symptoms were continuous OR 22.62 (CI 2.79–183.40), and the result remained also age adjusted OR 11.36 (CI 3.68–351.02). Duration of symptoms had a significant effect on WAS in those with symptoms lasting more than a week, but the effect disappeared when age adjusted.

Meanwhile, the extent of dental loupe usage or the amount of physical exercise per week did not have an impact on WAS.

All in all, 7.5% considered themselves unable to work as a dentist at the time of the survey. However, the majority, 94.5%, believed they can continue working after two years.

Considering MSD-related work disability, 18.4% experienced that MSD had no effect (answer 0) on their work ability, 54.9% experienced a mild effect (1–3), 23.4% a moderate effect (4–7) and 3.2% a strong effect (8–10).

The majority of the respondents, 89% had not been on a sick leave due to MSD symptoms. In addition, 7.1% had been on sick leave ranging from one to six days, 2.4% 1–3 weeks, 1.2% 1–3 months, and 0.4% 3–6 months. None of the respondents had been on sick leave longer than that. However, longer sick leaves (week or longer) concerned only nine respondents.

In the correlation analysis of the four different work ability parameters, age correlated with all the four work ability parameters (WAS, FWA, MSD-related work disability and sickness absences), and thus also these analyses were carried out age adjusted.

Both MSD symptom frequency and MSD symptom duration correlated significantly with all four work ability parameters, and the result remained also age adjusted. Instead, the significant effect of work status (student or dentist) disappeared after age adjustment. (Table 2)

Table 2
Logistic regression results on age group, gender, work status (dentist or student), frequency of experienced MSD symptoms and the duration of MSD symptoms on work ability

WAS^a OR 95% CI OR^b 95% CI

AGE group

–30 years 9.14 1

31–40 years 8.43 3.10 0.98 9.79

41–50 years 8.80 1.33 0.15 11.58

51–60 years 8.15 10.13 3.60 28.54

> 60 years 7.67 12.77 4.33 37.62

Gender

Male 8.63 1 1

Female 9.08 1.61 0.57 4.50 1.08 0.31 3.69

Work status

Student 9.11 1 1

Dentist 8.25 5.27 2.30 12.01 0.99 0.21 4.721

Frequency of MSD symptoms

None 9.27 1 1

Seldom 9.14 0.63 0.06 7.28 0.57 0.19 17.19

Often 8.72 4.03 0.51 32.01 2.98 0.11 83.14

Continuosly 7.48 22.62 2.79 183.40 11.36 3.68 351.02

Duration of symptoms

No symptoms 9.36 1 1

approx. 1 week 8.87 3.43 0.44 26.94 2.79 0.11 72.09

< 1 month 8.07 12.73 1.28 126.14 15.09 0.43 530.31

1–6 months 8.27 10.29 1.11 95.15 3.06 0.10 98.14

> 6 months 7.56 37.92 4.47 321.31 3.87 0.12 126.59

	WAS^a	OR	95% CI	OR^b		95% CI
AGE group
–30 years	9.14	1
31–40 years	8.43	3.10	0.98	9.79
41–50 years	8.80	1.33	0.15	11.58
51–60 years	8.15	10.13	3.60	28.54
> 60 years	7.67	12.77	4.33	37.62
Gender
Male	8.63	1			1
Female	9.08	1.61	0.57	4.50	1.08	0.31	3.69
Work status
Student	9.11	1			1
Dentist	8.25	5.27	2.30	12.01	0.99	0.21	4.721
Frequency of MSD symptoms
None	9.27	1			1
Seldom	9.14	0.63	0.06	7.28	0.57	0.19	17.19
Often	8.72	4.03	0.51	32.01	2.98	0.11	83.14
Continuosly	7.48	22.62	2.79	183.40	11.36	3.68	351.02
Duration of symptoms
No symptoms	9.36	1			1
approx. 1 week	8.87	3.43	0.44	26.94	2.79	0.11	72.09
< 1 month	8.07	12.73	1.28	126.14	15.09	0.43	530.31
1–6 months	8.27	10.29	1.11	95.15	3.06	0.10	98.14
> 6 months	7.56	37.92	4.47	321.31	3.87	0.12	126.59

MSD = musculoskeletal disorders; ^aWAS = Work ability score (scale: 0–10), OR = odds ratio, CI = confidence interval. In the logistic regression WAS was calculated as reduced (0–7) or good (8–10). ^bAge-adjusted OR. All the statistically significant results are marked with bold.

4 Discussion

This study is the first one to reveal the relation between MSD’s and work ability in Finnish dentists and dental students. Our study suggest that MSD have a negative effect on dentists’ work ability. This result is in line with studies that have shown MSDs association with self-assessed work ability [42] and sickness absences [33].

However, despite the decline of work ability due to MSD it does not appear in sickness absences. Majority of respondents had no or very short sickness absences. Result is in line with previous studies where both physicians and dentists sickness absences are low compared to other occupations [43]. This might be an indication of high presenteeism rate among dentist, i.e., attending work despite health problems [44]. Presenteeism can be a manifestation of high commitment to work, which in itself is a good thing. According to previous studies, both dentists’ work engagement [45, 46] and rate of presenteeism [30] are high. However, presenteeism does bring a lot of challenges such as decreased work efficiency, prolongation and worsening of the illness, sometimes exposing others to infectious diseases and even jeopardizing patient safety [43]. A high proportion of Finnish dentists work as entrepreneurs, which might raise the threshold for sick leave even more, and a previous Finnish study showed the lower sickness absence amongst private sector dentists compared to those working in public sector [30].

All in all, 90% of the respondents reported that they have MSDs. The high proportion is partially explained by the fact that symptoms of all durations were included, and a majority (62%) lasted no more than a week. Even if this study setting does not allow us to approximate prevalence of MSD in Finnish dentists, it does indicate that MSD are still very common and seem to affect work ability even in young dentist.

In many previous studies, female dentist have more MSD symptoms than male [6 , 47–49]. However, in our study this was not the case. This might be due to rather small sample or the high usage of different ergonomic aids in Finland, which might benefit especially female dentists with on average smaller body size. In addition, on contrary to many other countries, dentistry has always been female dominated in Finland, and thus, workplaces are planned to suit them.

One strength of this study is that work ability was measured, not with one but four different parameters and the results were in line no matter which of them was used. MSDs correlated significantly with all of them.

The major limitation of this study is the low response rate, which is in line with the unfortunate international trend of declining response rates of postal surveys [50]. However, as this study didn’t concern the prevalence of MSD but the relation between them and work ability instead, it was not as sensitive to response rate.

In questionnaire surveys there is always a risk for non-respondent bias, i.e., those with symptoms might be either more eager to answer or avoid responding. In this study, the non-respondent analysis was not possible, due to the method of selection and sending the questionnaire: both randomized selection of dentists and sending the questionnaire were carried out by the Finnish Dental Association, and thus we do not have access to non-respondents’ information. However, the age and gender distribution correlates well with the ones of dentists in Finland, which reduces the possibility of relevant non-respondent bias.

This study was conducted in a highly industrialized country, where dental clinics are commonly equipped with ergonomic instruments such as saddle chairs and adjustable units. Latest ergonomic tools are available basically to all dental workers. However, we cannot know how many utilizes them correctly or at all. Consequently, future research should assess to what extent these commonly used ergonomic solutions impact the comfort and work ability experienced by dentists, as well as how they interact with more specialized equipment like magnification loupes.

That being said, we have to recognize that even the current solutions are not globally available to everyone [16] and work ability reduction due to MSD might be even more important in developing countries, where working ergonomics might be more inadequate.

To allow full understanding of the nature of these problems, further studies are needed to reveal the reasons behind high prevalence of MSD amongst dentists, and to further improve their working conditions. The importance of continuous education in good working habits from the beginning of the studies throughout the whole career and global availability of ergonomic tools cannot be emphasized enough. However, based on the results of this study, it can be recommended that investing in good ergonomic equipment alone is not enough in dental practices. It is also essential to encourage everybody to utilize them and ensure that they know how to.

5 Conclusions

MSDs seem to affect dentists’ work ability, but it does not appear in sickness absences. This might be an indication of high level of presenteeism.

Ethics approval

Conduction of this study was approved by the University of Helsinki research ethics committee of the Faculty of Medicine, Approval number 20/2021.

Informed consent

Written informed consent was obtained from all participants.

Footnotes

Acknowledgments

The authors are grateful for all participants for data collection support.

Reporting guidelines

Not applicable.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

The authors report no funding.

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