BY ANNE NUGENT GUIGNON, RDH, MPH
Readers contact me periodically with specific questions. Recently, two hygienists wrote about hand problems. Their situations deserve careful, critical analysis. Hand issues can be quite complex, often stemming from stress in another area of the body.
Eileen wrote: "I got my license a year ago and work at a periodontal office. From time to time, there is a sharp pain when I hand scale, but rarely when I use ultrasonics. On Sunday, there was a weird sensation in my hand that felt like a pop.
"Many of my hand instruments have narrow handles, and I'm doing a lot of finger scaling instead of wrist movement. I work with loupes and a Cavitron and can't see the anteriors due to the water. Most of my patients are easy and I work four 8-hour days with one hour per patient. I play tennis and that may be causing some of my pain. What am I doing wrong? What are some suggestions to help my career last?"
Tricia wrote: "After reading your article on properly fitted gloves, I have a question. Although I don't want to anticipate any injuries, last year was the first year in 18 years that my hands really started hurting. For years, I worked four 9-hour days plus 4-hour Saturdays twice a month. Two years ago, my schedule changed to four and a half days for a total of 36 hours a week. Do you recommend any company for disability insurance? I want to keep on working, but want to protect myself."
The tales told by these two hygienists are all too familiar, and my response to their queries is an amalgamation of thoughts, underscored by the notion of personal responsibility. No amount of therapy or second-guessing will resolve most workplace-related injuries as long as the reasons for the problem remain unchanged.
The opportunity to acquire disability coverage has changed dramatically over the past decade. Unfortunately, very few companies cover clinical dental hygiene anymore. The rate of claims has been so high that companies lost money. And companies will consider any preexisting condition before issuing a policy. ADHA members can apply for coverage under a group policy, a less expensive option than a custom policy.
While it may seem obvious that hand soreness is directly related to the instruments you use or how your gloves fit, many other factors can contribute to how you feel. Hand pain, soreness, or fatigue can actually be a symptom of nerve impingement or irritation in the neck or elbow area, or it could be limited to just the hand. Diagnostic testing is necessary to determine the exact cause.
What is happening to your hands could be the result of a singular event or behavior, but more likely it is the result of one or more events over a period of time. Underlying medical conditions such as arthritis or another autoimmune disorder can be responsible for the pain too. Referred pain further complicates the picture. Workplace-related injuries that show up over time, like hand pain, create perplexing diagnostic puzzles.
Six different areas need to be considered: personal factors, workplace-scheduling, type of instruments, hand postures, equipment design and positioning, and environmental factors that create or increase stress on the head, shoulders, arms, and hands.
Personal factors that merit consideration include how many years you've practiced, number of days per week, stress level, personal health and underlying medical conditions. Consider your level of physical fitness, core strength, stretching, weight, nutrition, and whether or not you're getting enough rest every night.
Take a look at the workplace schedule. Consider the hours per day, number of patients, length of an appointment, and clinical difficulty. Do you have a real lunch hour or do you work straight through? Is your lunch break actually a "lunch minute" with only enough time to bolt down half a sandwich or eat a piece of cheese? What about breaks during the day, time to stretch between patients or use the rest room?
Review your instruments. Dull hand instruments with skinny handles require more pinch/grip than ones with larger diameter handles and sharp blades. Many hold single-dose prophy paste units between their fingers, rather than utilizing a ring paste holder. Some clinicians use excessive force to remove deposits or grasp the mirror handle too tightly during cheek retraction.
Heavy, unbalanced tools also create problems, a common issue with polishing handpieces as well as power scalers. Unfortunately, there are still corded handpieces that have heavy or tightly coiled hoses or retraction devices that tug on the hands and wrist. Swiveling handpieces reduce hand and forearm stress. Sometimes the handpiece hoses are too short.
How often do you use power scaling to disrupt biofilm? Is your machine effective? What about the inserts or tips? Thick, robust tips create heavy vibrations that are hard on delicate hand structures. One needs a variety of insert shapes and diameters to meet a variety of clinical challenges, not just one universal robust tip to blast off big chunks of deposit.
Your patient's position relative to your body is important. The patient's oral cavity should be positioned to allow your hand to maintain a neutral posture with your forearm close to your side and parallel to the floor. The body has to work a lot harder when trying to scale if your wrist is bent in an awkward position such as extension, flexion, or radial or ulnar deviation. Contra-angled prophy angles and cordless polishing devices help keep the wrist neutral.
Some chairs won't go low enough to the ground, regardless of the patient size. At other times, patients refuse to let the chair be reclined, can't or won't turn their head, or their sheer physical size makes it impossible to maintain a neutral hand posture while working in the oral cavity.
Many treatment rooms are the size of a closet, and equipment is often placed in any open spot with little regard as to what it takes to access a device, much less work with it. Rear delivery is a nightmare for a nonassisted clinician, and fixed bracket tables don't offer an option for repositioning to a less stressful location. Physical stress also increases if it's hard to reach frequently used devices such as suction apparatus, power scaling controls, or overhead lights. Room temperatures also count. Working in a cold environment increases the risk for hand problems.
Traditional dental stools that position thighs parallel to the floor wreak havoc on the body and don't facilitate healthy upper body postures. Properly fitted loupes and sit/stand positioning saddles reduce stress on the neck, shoulders, arms, and back, using active seating postures, resulting in a stronger core.
Given more time and thought, the list could go on and on. So, what to do first? If you want to keep working, get disability coverage and begin to chip away at the ideas that create a healthier comfort zone. We're like a slow motion car wreck. Any decrease in trauma will slow the process down. Most injured dental hygienists have numerous problems, the sad legacy of years of multiple micro-traumas. It is never too late to develop a safer working environment.