An assessment of musculoskeletal disorders and physical activity levels in dentists: A cross-sectional study

1 Introduction

Musculoskeletal health refers to the strength of muscles, bones, joints, and adjacent connective tissues, and the ability of the musculoskeletal system to function properly. Musculoskeletal discomfort is the most prevalent form of non-cancerous pain [1]. Musculoskeletal disorders (MSDs) include a variety of conditions characterized by chronic pain that affects nerves, muscles, blood vessels, ligaments, tendons, bones, joints, and spinal discs that lead to limitations in mobility and motor skills [2]. MSDs are caused by strenuous and repetitive physical movements such as bending, stretching, reaching, grasping, holding, twisting, turning, pinching, and reaching, all of which can damage tendons, muscles, nerves, and other soft tissues, causing pain, numbness, tingling, burning, stiffness, fatigue, a reduced range of motion and grip strength, loss of normal sensation, or a loss of movement and coordination. Moreover, as the factors that cause MSDs typically consist of strenuous and repetitive movements, the recovery period may be prolonged [2, 3].

Work-related musculoskeletal disorders (WRMSDs) are defined by the International Commission on Occupational Health and Safety as work-related disorders or diseases of the musculoskeletal system. The World Health Organization has defined the term ‘work-related’ as a condition caused by the influence of work performance and work-environment factors [1, 4]. Manual workers are reported to have greater rates of accidents and lower life expectancies. Conversely, administrative workers have better outcomes in these areas. However, administrative workers do report negative health outcomes, as sedentary jobs are an important factor in the development of MSDs and other health problems, including cardiovascular illnesses and weight gain [5].

Dentistry is a physically and mentally demanding profession that involves the application of technical treatments and high concentration levels [6]. Specifically, dentists work in a tight [7] and often positionally uncomfortable [8] area of the mouth, performing delicate and prolonged procedures. This leads to muscle imbalances and asymmetrical postures for long periods [9]. The fixed position of the neck and shoulders may be a factor in the development of MSDs. In general, workers must maintain balance in the shoulder-neck area during controlled movements of the upper limbs, and the muscles in the region must continuously contract to maintain a stable position for as long as the task requires. These contracted muscles compress the blood vessels, causing discomfort [10]. To perform repetitive and demanding tasks, dentists must spend considerable time in non-ergonomic positions, which can lead to chronic pain exacerbated by unhealthy postures over time [11, 12]. The irregular layout of workstations and the selection of inappropriate tools and equipment may also contribute to these unhealthy postures. Furthermore, the use of additional personal protective equipment that accompanied the onset of the COVID-19 pandemic increased mental stress and the risk of engaging in unstable postures, further reducing freedom of movement [6, 10]. In particular, neck-tilt rotation, forward bending with loss of cervical and lumbar lordosis, and raised arms working in prolonged static isometric/eccentric contractions are the primary risk factors for musculoskeletal pain [13].

Tasks involving repetitive wrist, elbow, and shoulder joint movements (beyond acceptable limits) can cause pain [10]. In particular, dentists are at risk for MSDs given their poor posture, repeated tasks, prolonged static positioning, overexertion with excessive use of minor muscles, tight grasping of instruments, prolonged arm elevation, and using vibrating instruments [2, 14]. Vibration is known to affect tendons, muscles, joints, and nerves, and dentists can experience numbness in their fingers, a decreased sense of touch and grip, and pain when using vibrating instruments [15]. According to a 2009 systematic review, the global prevalence of MSDs in dentists is 64% to 93% [2, 16]. The muscles most affected are the neck [2, 18], back [18, 19], lumbar spine [12, 20], and upper limbs [4, 12]; although, in rare cases, the lower limbs may also be affected.

Physical activity (PA) is a widely recognized therapeutic intervention for a range of medical problems, including vasculopathic conditions such as coronary artery disease, stroke, type-2 diabetes, and obesity. Furthermore, performing more PA is a therapeutic approach to improving musculoskeletal well-being [21]. To prevent WRMSDs, physical exercise, specifically personalized exercises, for a minimum of 10– 15 minutes, 3– 5 days per week, has been found to help relieve musculoskeletal pain among office workers [22, 23]. Several studies have examined the health-promoting benefits of PA (both within and outside of the workplace) on the physical and mental health of workers. Their results have demonstrated that PA can effectively minimize the incidence of MSDs, improve physical fitness [24], improve mental health [25], and indirectly enhance work performance [5]. Moreover, exercise during leisure time can prevent injuries, improve health, and increase the longevity of dentists’ careers [3, 27]. Thus, PA can substantially affect the quality and quantity of MSDs experienced by dentists [28].

This study aimed to analyze the distribution of MSDs in a sample of dentists in Turkey and evaluate whether PA led to differences in musculoskeletal problems.

2 Materials and methods

3 Results

A total of 327 questionnaires were distributed and the response rate was 35.47% (116/327). A total of 116 dentists (63 females (54.3% ), and 53 males (45.7% )) between the ages of 24 to 60 years (mean±standard deviation: 36.37±7.32) participated in the study.

Table 1 shows the proportion of yes/no responses regarding pain areas, with 93.1% of the participants answering ‘yes’ to the question, “Do you have pain?” The ratio between dentists with and without pain was statistically significant (p <  0.001), with the rate of pain in the neck and shoulder regions was higher and statistically significant (p <  0.05). In the elbows, hips, thighs, knees, and ankles, the proportion of participants reporting no pain was significantly higher (p <  0.001) than those reporting pain. There was no statistically significant difference between the rates of pain experienced in the upper back, wrists, hands, and lower back (p > 0.05).

Table 1 shows the participants’ responses regarding pain and where it was experienced. Pain was primarily reported in the neck, shoulder, upper back, and waist regions, with less pain in the elbows, wrists, hands, hips, thighs, knees, ankles, and feet. No significant difference was found between males and females regarding the occurrence of pain and the body region where it was felt (p > 0.05) (Table 2).

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Table 2

Comparison between gender and pain regions

	Gender
	Female (n = 63)		Male (n = 53)
	Count	N%	Count	N%	p-value &
Have you ever had trouble (ache, pain or discomfort)	60	55.6%	48	44.4%	0,466
Neck	51	55.4%	41	44.6%	0.634
Shoulder	37	54.4%	31	45.6%	0.897
Upper back	36	54.5%	30	45.5%	0.968
Elbow	12	57.1%	9	42.9%	0.773
Wrists/Hands	27	52.9%	24	47.1%	0.793
Lower back	36	55.4%	29	44.6%	0.793
Hip/Thigh	9	47.4%	10	52.6%	0.507
Knees	17	51.5%	16	48.5%	0.703
Ankles/Feet	7	43.8%	9	56.3%	0.361

 ^&Pearson’s chi-squared test; p <  0.05 is considered statistically significant.

Forty-eight participants (41.4% ) engaged in low levels of PA (LLPAs), 56 (48.3% ) engaged in moderate levels of PA (MLPA), and 12 participants (10.3% ) reported high levels of PA (HLPA) (Table 3). No significant differences were found between PA levels and gender (p = 0.224) (Table 4). Similarly, no significant differences were found (p > 0.05) between age and gender and different PA levels (Table 5).

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Table 3

Frequency of engagement in different levels of physical activity among dentists in Turkey

		N	N%
Physical	Low level of physical activity	48	41.4%
Activity	Moderate level of physical activity	56	48.3%
Level	High level of physical activity	12	10.3%

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Table 4

Comparison of physical activity levels with gender

		Physical Activity Level
		Low level of		Moderate level		High level
		physical		of physical		of physical
		activity		activity		activity
		Count	N%	Count	N%	Count	N%	X2	p-value
Gender	Female	22	34.92%	35	55.56%	6	9.52%	2.994	0.224
	Male	26	49.06%	21	39.62%	6	11.32%

p <  0.05 is considered statistically significant; X²: Chi-Square test value.

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Table 5

Comparison of gender and physical activity level with age

		Age
		Mean	Standard deviation	Median	Minimum	Maximum	Test value	p-value
Gender	Female	35.29	6.78	35.00	25.00	48.00	–1.611 ¥	0.107
	Male	37.66	7.79	36.00	27.00	59.00
Physical activity level	Low level of physical activity	36.40	6.87	35.00	26.00	51.00	1.515£	0.469
	Moderate level of physical activity	36.48	6.84	35.00	25.00	55.00
	High level of physical activity	35.75	11.11	31.50	27.00	59.00

p < 0.05 is considered statistically significant;  ^¥: Mann-Whitney U Test; ^£: Kruskal-Wallis test

When comparing pain areas with different PA levels (Table 6), significant differences were found between the groups regarding pain in the neck, shoulders, upper back, wrists, hands, waist, hips, thighs, and ankles (p <  0.05). However, there were no significant differences between the PA groups regarding pain in the elbows and knees (p > 0.05). Discomfort was significantly less in the HLPA group, while there was no significant difference between the LLPA and MLPA groups. The ordinal logistic regression model found no significant relationship (p > 0.05) between PA levels and MSDs between PA level and musculoskeletal pain region (Table 7).

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Table 6

The frequency of pain in different body regions according to levels of physical activity

		Physical activity level
		Low level of		Moderate level		High level
		physical		of physical		of physical
		activity (n = 48)		activity (n = 56)		activity (12)
		N	N%	N	N%	N	N%	One-sample- X2	p-value
Have you ever had trouble (ache, pain or discomfort)	Yes	45	41.67% a	52	48.15% a	11	10.19% b	26.722	0.000**
Neck	Yes	40	43.48% a	44	47.83% a	8	8.70% b	25.391	0.000**
Shoulder	Yes	23	33.82% a	39	57.35% b	6	8.82% c	24.029	0.000**
Upper back	Yes	29	43.94% a	31	46.97% a	6	9.09% b	17.545	0.000**
Elbow	Yes	10	47.62%	9	42.86%	2	9.52%	5.429	0.066
Wrists/Hands	Yes	20	39.22% a	25	49.02% a	6	11.76% b	11.412	0.003*
Lower back	Yes	26	40.00% a	32	49.23% a	7	10.77% b	15.723	0.000**
Hip/Thigh	Yes	9	47.37% a	9	47.37% a	1	5.26% b	6.737	0.034*
Knees	Yes	13	39.39%	15	45.45%	5	15.15%	5.091	0.078
Ankles/Feet	Yes	9	56.25% a	6	37.50% a	1	6.25% b	6.125	0.047*

Statistical significance: **: p <  0.001; *: p <  0.05; One-sample-X²: One-Sample Chi-Square test value; Superscript letters refer to statistical differences between groups.

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Table 7

Results of a multinomial logistic regression test of association between physical activity level and pain regions

Predictor	Odds ratio	95% Lower CI	95% Upper CI	p-value
Neck	0.606	0.205	1.720	0.352
Shoulder	1.565	0.383	6.570	0.533
Upper back	0.741	0.212	2.480	0.628
Elbow	0.151	0.006	1.390	0.137
Wrists/Hand	1.848	0.570	6.190	0.310
Lower back	0.806	0.295	2.160	0.669
Hip/Thigh	0.727	0.149	3.440	0.683
Knees	1.606	0.328	8.240	0.560
Ankles/Feet	1.486	0.246	9.260	0.664
R2CS	0.019
R2N	0.041

Statistical significance: p <  0.05; CI: Confidence interval; R²_CS: Cox & Snell’s R²; R²_N: Nagelkerke’s R².

A number of research studies have investigated the musculoskeletal health of dental professionals [12]. Some have also assessed the prevalence of PA in the general population and different categories of healthcare professionals, including physicians, physiotherapists, and medical students. However, there is a lack of studies investigating PA among dental professionals [39]. Therefore, this cross-sectional study is one of the few to assess the prevalence of MSDs and PA levels among Turkish dentists.

The NMQ-E has been used in both international and national studies of dentists [40, 41]. In our study, the NMQ-E was used to measure MSDs. The ‘yes’ response to the question “Have you ever had problems (aches, pains, or discomfort)” was significantly higher among the study participants (p <  0.001; Table 1). Our findings are consistent with other studies in the literature. According to a study by Kerosuo et al [42], the prevalence of MSDs in dentists was 70% . In another study by Kandemir et al. [43], the authors found the prevalence of MSDs in dentists to be 82% . In studies by Nokhostin and Zafarmand [44] and Gopinath et al. [45] found that 67.5% and 73.9% of dentists, respectively, had musculoskeletal problems. One study investigating the prevalence of work-related musculoskeletal pain among dentists in Slovenia found that most of the participants suffered from pain [46]. Factors such as frequent bending, pushing and pulling, static work posture, weightlifting, repetitive movements, vibration, and prolonged, heavy, and intense work, were considered physical risk factors and the causes of musculoskeletal pain [47]. Dental working positions have also been implicated in causing cumulative microtrauma and muscle imbalances, neuromuscular limitations, pain, and dysfunction [6]. It has been reported that dentists must contract more than 50% of their body muscles to maintain their bodies in a fixed position against gravity. These postures often result in prolonged, repetitive muscle contractions characterized by classic muscular imbalances [48].

In our study, we found that the neck (79.3%, p <  0.001) and shoulder (59.1%, p <  0.001) regions most commonly experienced musculoskeletal problems, followed by the upper back (57.9%, p = 0.092) and lower back (56.0%, p = 0.194) (Table 1). Similarly, in their meta-analysis of 41 studies conducted in Western countries, Lietz et al. [49] found that the neck was most affected (58.5% ), followed by the lower back (56.4% ), shoulder (43.1% ), and upper back (41.1% ). Akesson et al. [50] also reported that MSDs were more common in the neck and shoulder regions. Likewise, other studies in the literature have shown that the most common sites of pain in dentists are the neck and shoulder regions, and the back, lower back, and wrist [43–45, 47]. A study investigating general dentists, orthodontists, and office workers showed that the neck (53% ) and shoulders (56% ) were the sites most involved in MSDs, followed by back pain (28% ) and pain in the arms and hands (17% ). In our study, less pain was reported in the elbow (18.1%, p <  0.00) and lower body (hip/thigh, knee, and ankle/feet; p <  0.001) than in other body regions. (Table 1). In the literature, the elbows, wrists, and finger joints are less commonly reported as the location of musculoskeletal symptoms [42]. Prolonged static postures (sitting or standing) are characteristic of a dentist’s work and are associated with neck, shoulder, and lower back symptoms [51]. Furthermore, micro-injuries and pain are frequently caused by insufficient time for tissues to regenerate due to overuse [52]. The working position of the dentist can also influence the location where the pain appears. Pain in the spine, neck, shoulders, and upper limbs is more common when working in a sitting position. While, standing has led to lower back pain, varicose veins, poor posture, and flat feet in dentists [48]. Moreover, there is a clear correlation between the total number of hours dentists work and the severity of the MSDs [51].

In our study, no significant differences were found between MSDs and gender (Table 2; p > 0.05). However, conflicting results have been reported with both similar [53, 54] and different [43, 45] results from ours. Ohlendorf et al. [55] also found no significant differences between females and males regarding the overall occurrence of pain. However, other studies have found significant differences in the occurrence of MSDs between males and females in the overall population and within the dental profession [56]. A higher prevalence of MSDs in females has been found and could be attributable to a heightened sensitivity to pain, as well as the effects of sociocultural, psychological, and biological factors, or hormonal and reproductive factors (e.g., estrogen levels) [57]. Moreover, the musculoskeletal system of females can exert only two-thirds of the force compared to the male system. Thus, women may face greater difficulty in stabilizing their bodies and compensating for the physical strain associated with delivering dental care [55].

According to the World Health Organization, physical fitness is a state of health and well-being, which can be achieved through regular exercise or PA [56]. Physical fitness may also influence professional success by improving work performance with fewer health problems. Dentists must work under stress for long periods, which leads to numerous work-related disorders, especially neck, back, and shoulder pain. Therefore, a dentist needs excellent stamina and strength throughout the working day to minimize fatigue and increase productivity. Thus, engaging in physical fitness is important to avoid work-related hazards, especially MSDs [57].

The IPAQ was developed by a group of specialists in 1998 to facilitate the monitoring of PA using a global standard. The IPAQ-SF has since become a widely used questionnaire and is recommended as a cost-effective way to assess PA [58]. According to the IPAQ-SF results in this study, 58.6% of the dentists were either highly or moderately physically active ((Table 3). The prevalence of PA among healthcare providers (HCPs) varies in the literature. Some studies have reported HCPs having higher levels of PA than the general population but but others suggested that HCPs are less active than the general population [39]. Sri Latha et al. [59] reported that 61% of dental HCPs were physically active. Sapna et al. [57] showed a maximum (72% ) of dental postgraduates were physically active. However, Singh A. et al. [60] reported that 68% of dental HCPs had LLPA. Öztürk and Çelik [61] reported that only 15% of dentists included in their study were physically active, and 66% were reported to be minimally active in Turkey. In our investigation, 41.4% of our study population were deficient in PA (Table 3). The primary factors contributing to this may be attributed to the operating hours of the clinics, which predominantly appeal to the working population by offering evening appointments. Some dentists also teach at dental institutions or work in dental hospitals during the day and subsequently pursue their private practice in the evenings [62]. Another potential factor may be long working hours [39, 61].

The PA of our subjects according to gender was similar, with no significant differences between males and females (Table 4; p = 0.224). These findings are in contrast to the studies by Thakar et al. [62] who found female dental students to be more active than males and Roshini et al. [63], who reported that male students were more physically active. However, the present findings are similar to the results by Sapna et al. [57], which showed similar PA levels in both genders. No relationship was found between the PA levels and participants’ mean age (Table 5; p = 0.469).

MSDs are multifactorial health problems influenced by factors such as prolonged static muscle tension, repetitive tasks, gender, and PA levels. Reports in the literature have found a strong correlation between PA level and health status in adults [64]. However, the literature is inconsistent in its findings regarding the relationship between PA and MSDs, suggesting a lack of consensus on this issue [64].

Our results found that dentists in the HLPA group had reduced musculoskeletal pain, aches, or discomfort (Table 6; p <  0.05). Other studies have confirmed strong and significant correlations between regular and frequent PA and a reduction in musculoskeletal pain and the number of sites where pain is felt [65]. Furthermore, participation in PA helps the body adjust to muscle weariness that may arise while working [66]. Dentists with low PA have a significantly higher number of sites with musculoskeletal pain compared to those who regularly perform PA [67]. Moreover, dentists who perform LLPA are more likely to experience less flexibility in their joints and less extensibility in their connective tissue. As a result, they have a higher likelihood of experiencing musculoskeletal pain compared to those who routinely participate in physical exercise [68]. A study by Sharma and Golchha reported that 75% of dentists were at risk of developing occupational MSDs and that the prevalence and severity of musculoskeletal complaints were reduced by 20% and 80%, respectively, by regular, specific exercise [69]. Individuals who are not physically active have been reported to have a higher risk of developing MSDs due to decreased nutrient and oxygen flow to the muscles. Thus, 20 minutes of aerobic physical exercises three to four times weekly is advised for dental professionals [48, 70]. In addition, the incidence and risk of MSDs can be reduced by dentists working in appropriate postures, with intermittent working hours, and targeted and personalized PA [70].

5 Conclusion

Our results revealed a high prevalence of musculoskeletal pain among dentists. The most common areas of musculoskeletal pain were the neck and shoulder. Most dentists participating in this study indicated either low or moderate levels of PA. These findings emphasize the need to address musculoskeletal conditions and improve PA levels in dentists to reduce their pain and discomfort.