Seeing the bigger view

July 15, 2014
Only a handful of dentists used loupes decades ago. At the time, it was even more rare for a dental hygienist to use magnification.

By Anne Nugent Guignon, RDH, MPH

Only a handful of dentists used loupes decades ago. At the time, it was even more rare for a dental hygienist to use magnification. Clinicians using these devices experienced fewer aches and pains, found it easier to diagnose oral conditions, and felt the quality of their therapeutic treatments improved.

Over time, more clinicians began using loupes, and many schools currently encourage or even mandate their use.1,2 What started out as a casual, individual equipment decision is now considered the standard of care by many. As with any technology or behavioral shift, however, some clinicians resist using loupes. The reasons for not using magnification vary widely. Typical comments include: they are too expensive, my doctor won't buy them, I don't work enough, loupes are too heavy, I work in multiple offices, or I only work with children.


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While each reason is legitimate, numerous research studies report high rates of physical injuries among practicing hygienists, with neck and shoulder injuries predominating. Both conditions are directly affected by leaning one's head forward in an unsupported position for protracted periods of time.3-5 In response to injuries, hygienists shorten their clinical hours and take both prescribed and OTC medications. Some even leave the profession. The physical, emotional, and financial tolls of developing a workplace-related musculoskeletal disorder are enormous and life-altering.3-6

With this information in mind, it was interesting to reflect on some recent, intense exchanges among dental hygienists in an online forum. A member posted a story that a dentist employer was now requiring all of the hygienists and expanded-function dental assistants to wear magnification, and they were required to purchase their own pair. The debate raged on. Most were horrified at this requirement and felt it was illegal. As a two-decade loupes user, I believe the doctor's motivation was to improve and standardize the level of care provided by his team members. As an employee, I can also understand the concerns of an employee who has a very restricted budget, with no immediate accommodation for this kind of purchase.

Even if the dentist employer saw the value of everyone wearing magnification, was there a middle ground? Mandating a purchase like this without any financial support does not boost employee loyalty, nor does reminding staff members that 11 of the patients in the practice were currently enrolled in the dental hygiene school just down the road, a program that is pumping out a couple of dozen new graduates a year. Actions like these will eventually backfire. Employees who feel valued and secure will focus on building a better dental practice if the betterment of all involved is at the center of the change.

There are numerous ways by which the financial impact could be softened. The cost of the loupes could be taken out of employees' paychecks in a series of deductions throughout the coming year. Or the dentist employer could pay for a portion of the loupes in a number of ways. Every employee could receive the same support in terms of dollars or a percentage of the cost of the magnification, or the percentage could rise according to the length of service in the practice. For example, employees with 10-plus years or more could get 75% coverage, while employees with six to 10 years could get 50%. Employees with less than five years could get 25%. There could also be an agreement that the loupes would become the property of the employee after one or two years. All of these approaches reward everyone.

From a legal standpoint, the question is more complex and depends on each state's labor laws. While it is unlikely that it is legal to mandate that current employees supply this type of equipment, it is wise to call the state labor board for clarification. OSHA regulations were formulated to protect worker safety. While employers are required to provide workers with protective eyewear, the rules list safety glasses that protect workers from chemical splashes, bloodborne pathogens and particulate matter and debris. One could argue that magnification loupes provide that type of function, but so do safety glasses. Unfortunately, the issue of work-related musculoskeletal disorders (WRMSDs) in dentistry has not been well addressed for dental health-care workers.

The discussion heated up when another forum member came across an ad that required all potential applicants to have loupes. Some hygienists were outraged, and others were supportive. Again, the question of legality surfaced. Unlike the previous situation, the terms for employment were clearly stated by the dentist in advance. Employers have the right to set the terms of employment: office hours, dress code, education and experience levels, and yes, even required equipment. If one willingly takes a position with such a requirement, then the new employee is agreeing to the terms of employment.

While many academic institutions are mandating magnification, there are still faculty members who do not agree that loupes are a necessary practice asset.1 Several years ago, I spoke to the students at two different dental hygiene schools in one state about ergonomics, WRMSDs, and career sustainability. The faculty at the four-year baccalaureate program advised students not to purchase magnification, while the director at the community college program decided that all of her faculty and students would have magnification and a headlight. Fast-forward 18 months. The graduates who did not have loupes quickly found out that prospective employers expected them to have their own magnification. Since they had already graduated, the opportunity to purchase products at student price points was long gone. The new graduates also had to unlearn dangerous postural habits.2

The biggest conundrum about requiring magnification loupes is faced by those who have trouble adapting to magnification. Typically, the problems revolve around motion sickness or headaches. Sometimes the inability to adapt comes from products assembled with poor quality components, such as plastic oculars or frames that cannot be adjusted to a person's facial geometry. Others have issues when they purchase a pair of loupes from a site such as eBay that were designed to fit another customer. Sometimes, to save a few dollars, doctors will expect several workers to use the same pair or an older secondhand pair -- a plan that rarely works.

This is not a personal diatribe. Studies have shown improved postures and less risk for injury with loupes, but they have also revealed faculty resistance to adopting magnification.1,2 The perceived savings of not adopting magnification is clearly lost as hygienists grapple with injuries, cut back on workdays, and struggle with gaining much-needed employment.3-5

The big picture revolves around career sustainability, the ability to provide quality care without increasing the risk of a WRMSD, and personal accountability. Fifteen years ago this month, the first Comfort Zone column was published in RDH. The topic was magnification. It's funny how everything comes full circle.

ANNE NUGENT GUIGNON, RDH, MPH, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971.


1. Congdon LM, Tolle SL, Darby ML. Magnification loupes in US entry-level dental hygiene programs – Occupational health and safety. JADHA. 2012 Summer; 86(3):215-222.
2. Maillet JP, Millar AM, et al. Effect of magnification loupes on dental hygiene student posture. J Dent Educ. 2008 Jan;72(1):33-44.
3. Amyot C, Brunson D, Conroy P, et al. Survey of dental hygienists in the United States, 2007: executive summary. American Dental Hygienists' Association. 2009.
4. MJ, Smith DR, Cockrell D. Prevalence and correlates of musculoskeletal disorders among Australian dental hygiene students. Int J Dent Hyg. 2009,7(3):176–181.
5. Guignon AN, Purdy CM. Dental hygiene 2012 - workplace demograph¬ics, practice habits, injuries and disorders, academic awareness and professional attitudes. Unpublished data collected October/November 2012.
6. Chismark A, Asher G, Stein M, et al. Use of complementary and alternative medicine for work-related pain correlates with career satisfaction among dental hygienists J Dent Hyg. 2011; 85(4): 273-283.

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