Scaling and exercise strategies to prevent hand, wrist ... · Imagine working as a dental hygienist and never being concerned about work-related hand or arm pain. Certainly with all

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Imagine working as a dental hygienist and never being concerned about work-related hand or arm pain. Certainly with all the available literature on neutral ergonomic hand, wrist, and arm positions, preventive scaling techniques, and healthy stretch-ing exercises, practicing pain free should be simple, right? This is wishful thinking. Having available literature and knowledge is only beneficial if it’s implemented rou-tinely. How can a different result be expect-ed if knowledge isn’t translated into action?

Unfortunately, evidence shows that work-related musculoskeletal disorders (MSD) are recognized as a considerable problem for the dental hygiene profes-sion, with a majority of the professionals reporting musculoskeletal pain.1 While practicing, a dental hygienist must have a

conscious awareness of instrument grasp, pinch force, finger rest positions, fulcrum pivoting, intraoral and extraoral fulcrum rest positions, and neutral hand, wrist, and arm positions in order to employ produc-tive and preventive techniques while scal-ing.

The dominant hand must work as a unit with the instrument in order to enhance precision and stability. Orchestrating these skills can be a challenge depending on learned techniques in dental hygiene school. The risk factors associated with carpal tunnel syndrome and other hand disorders include repetitive hand motions, forceful pinching or gripping, sustained awkward wrist postures, and vibration.2 Attention must be given to these funda-

mentals since dental hygienists are predis-posed to hand, wrist, and arm injuries.

Musculoskeletal disorders (MSD) have been reported among registered dental hygienists and dental hygiene students, ad-versely impacting their daily performance and career longevity. RDHs and DHSs have reported pain in the following areas — neck,1,3-5 shoulder,1,3-5 lower back,1,3,4 fore-arm,1 wrist/hand,3 and upper back.3 RDHs working in a general dental office reported pain more frequently in the shoulder re-gion, and those working in a periodontal office reported forearm pain. Hand scaling caused neck pain among RDHs, and the use of ultrasonic scalers caused shoulder, upper back, or lower back pain for longer than two days.1 RDHs who reported wear-

BY Aubreé M. ChisMArk, RDH, MS, anD DiAne MillAr, RDH, Ma

Scaling and exercise strategies to prevent hand, wrist, and arm injuriesI n s t r u m e n t a t I o n t e c h n I q u e s a n d e x e r c I s e s u c h a s y o g a c a n m I n I m I z e o c c u p a t I o n a l I n j u r I e s .

RDH | May 2014 rdhmag.com | 3

Scaling and exerciSe StrategieS to prevent hand, wriSt, and arm injurieS

to a clinician’s hands and arms, and to en-hance scaling efficacy with biomechanical and ergonomic principles:• Establish amodified pen grasp where

the thumb and finger oppose one an-other and the instrument handle is vis-ible between the fingers.

• All fingers should work together as aunit while scaling.

• Use large diameter handles and lightinstruments to reduce excessive pinch force.

• Consider using 11 mm diameter sili-cone or resin handles in conjunction with power scaling for every patient ap-pointment to prevent injury.

• Alwaysestablishaneutralhand,wrist,and arm position while scaling.

• Orient the instrument with the toothsurface to be instrumented, taking into consideration the angulation of all teeth.

• Keeptheinstrumentparalleltothelongaxis of the surface of the tooth. This will encourage a neutral hand, wrist, and arm posture.

• Useintraoralandextraoralfulcrumstoenhance a neutral position of the hand, wrist, and arm.

• Avoidflexionandextensionofthehandas much as possible while scaling.

• Avoid sustained awkward wrist pos-tures to prevent carpal tunnel syn-drome.

• Practice palm up fulcrums as oftenas possible, and avoid palm down ful-crums that increase strain on the hand and wrist.

• Establisha“built-up”fulcrum,keepingfingers together as a unit while scaling.

• Keep the ring finger straight,with thetip of the finger supporting the weight of the hand when using intraoral ful-crums.

• Pivotonthe fulcrumfingertosupportthe hand as it turns to allow for hand repositioning.

• Use advanced reinforced fulcrums us-ing intraoral and extraoral rests to gain access to root surfaces and to prevent hand stress and strain.

• Incorporatethenondominanthandby

andarmpain.Thedefinitionof“reinforce”is to strengthen with some added piece of support.7 The increase in strength while using reinforced fulcrums and rests occurs from the use of both hands. The thumbs are also beneficial to incorporate while using reinforced instrumentation. When the nondominant thumb bridges over to the dominant thumb of the working hand, both hands have the opportunity to work together as a unit. When both hands work in unison, the larger muscle groups of both arms can also work in unison.8

Intraoral and extraoral fulcrum techniques combined for stability and precision — Intraoral fulcrum techniques are established by placing the pad of the ful-crum finger on a tooth surface adjacent or close to the tooth being instrumented. This technique has been the standard school of thought in the dental hygiene profession for many years. All dental hygiene schools introduce intraoral fulcrums before teach-ing extraoral fulcrums, which requires sta-bilization of the clinician’s dominant hand against the patient’s cheeks, jaws, and chin. Extraoral fulcrums require the front orback of the fingers to be used as hand rests to provide support, rather than the tips or pads of the fingers as with intraoral ful-crums. Using both intraoral and extraoral fulcrum hand rests simultaneously will in-crease stabilization of the hand and arm, as well as precision while scaling, versus us-ing just one or the other.

Strategies for injury prevention to the hands and arms while scaling — The following recommendations are worth considering to help prevent pain and injury

ing loupes were less likely to report shoul-der and wrist/hand pain, and less likely to have neck or upper back pain for more than two days.1

Dental hygiene students who do not exercise regularly have reported a higher incidence of low back pain, and working on a computer increases shoulder and upper back pain.4 Consequently, the daily lives of DHSs have been affected by musculoskel-etal pain, causing them to seek medical treatment.4 RDHs with pain were less likely to seek treatment if ergonomics were rein-forced in the clinic during their dental hy-giene education.3 In view of that, reinforc-ing ergonomics and incorporating the use of loupes and reinforced instrumentation into the dental hygiene curriculum may benefit the career longevity of RDHs.

Reinforced fulcrums for optimum scaling efficacy and injury preven-tion — Dental hygiene instrumentation techniques have dramatically improved throughout the years to prevent MSDs. New and innovative techniques using protective reinforced instrumentation techniques require scaling teeth with two hands instead of one to ensure optimum performance and to promote occupational health and career longevity. These tech-niques allow the nondominant hand to as-sist the dominant hand and instrument for more stability, lateral pressure, and preci-sion.6

Using the index finger to press on the long terminal shank with the nondomi-nant hand while using extraoral fulcrums helps the operator to adapt the instru-ments and attain more lateral pressure. As the dominant hand adapts and angu-lates the blade of an instrument to tooth surfaces, the nondominant hand provides additional pressure in the same direction to which the dominant hand’s fingers are directing pressure. This helps operator pro-tection during strenuous and extensive in-strumentation processes by engaging the large muscle groups over the small muscle groups in the hand and wrist.

If a clinician experiences pain, the uti-lization of reinforced instrumentation techniques helps to decrease hand, wrist,



Adverse effects of MSD and the use of complementary and alternative medicine (CAM) — MSDs are frequently reported by practicing RDHs due to the physical de-mands placed on the body caused by poor ergonomics, repetitive motion, pinch force, and grasp.2 RDHs who reported MSDs re-duced the number of hours they worked,3 took time off from work, called in sick,1,3 considered changing careers,1,3 and even left clinical practice.1 CAM therapies in-cluding massage, herbal supplements, chi-ropractic care, yoga, and acupuncture are being used by RDHs to reduce musculo-skeletal pain.3 RDHs are more likely to use a combination of CAM and conventional therapies to manage their MSDs, although RDHs who use CAM therapies alone are

to-side rocking strokes in order to en-hance instrument placement to the epithelial attachment and reduce re-petitive motions.

• Usesharpinstrumentstominimizelat-eral pressure and number of strokes.

• Consider using XP sharpen-free tech-nology instruments (American EagleInstruments) to reduce lateral pressure while scaling.

• Makeeverystrokecount to reduce re-petitive motion injuries.

• Implement intermittent rests betweenstrokes to prevent pain and injury.

• Listentoyourbodyandtakemini-breaksto avoid prolonged, static postures.

• Stretch hands, arms, and upper bodyroutinely to prevent pain and injury.

pressing on the instrument for more lat-eral pressure, power, and precision.

• Implementthumb-to-thumbreinforce-ment for more stability and precision, and to engage the use of the larger mus-cle groups in both arms while scaling.

• Consider bringing the elbow out andover the patient at times to keep wrist in alignment with the long axis of the forearm.

• Keephandneutraltopreventradialandulnar deviation while scaling.

• Usefulcrumpressureequaltothepres-sure of the instrument blade against the root surface being scaled.

• Increasefulcrumpressureifslippingorlack of lateral pressure occurs.

• Implementpullstrokesinsteadofside-

benefits of extrAorAl fulCruMsExtraoral fulcrums are routinely used for advanced periodontal instrumentation. When properly established, extraoral fulcrums can allow optimal access and angula-tion, while providing adequate stabilization while scaling. To have optimal control, the entire front or back surface area of the fingers and hand need to be placed on the patient’s face to provide the greatest degree of stability. It is the fulcrum pressure rather than the grasp that determines whether or not a stroke will be well controlled.



Yoga and pain reductionYoga is a CAM therapy that unites the body, mind, and spirit using breathing methods and a series of standing and seated postures. It is a mindful type of practice where individuals focus their breath and attention on proper align-ment in order to gain the full benefits

feel that CAM therapies are acceptable methods of pain management that should be covered by medical insurance, and they would use CAM as an alternative method to conventional medicine.3 CAM thera-pies have a positive effect on RDHs’ overall health and career satisfaction,3 and should be considered for use early on.

less likely to temporarily quit work, expe-rience improvement in musculoskeletal pain, and report higher career satisfaction.3

Using CAM therapies has increased job happiness and security and overall health and well-being, contributed to career lon-gevity, and enabled RDHs to work the num-ber of hours they prefer.3 RDHs with MSDs

YogA Poses to Do At hoMe

staff Pose15 Benefits: Strengthens the chest, back, shoul-ders, wrists, and spine

How to get into the pose: Sit onto the floor and extend your legs out in front of you flexing your feet. Place the hands next to your hips, roll the shoulders back, move the navel toward the spine, sitting up nice and tall. Hold for 4-5 breaths then release.

Warrior ii15

Benefits: Strengthens ankles, legs, arms, shoulders, chest, back, wrists (good for carpal tunnel)

How to get into the pose: Torso will be parallel with a wall, turn one foot forward bending the knee (knee is directly above the ankle), back leg is straight, keep the shoulders directly above the hips, extend the arms out to the side taking the eye gaze over the front arm. Hold for 4-5 breaths then repeat on the other side.

upward Plank Pose15 Benefits: Strengthens the arms, wrists, shoulders, ankles, legs, chest

How to get into the pose: Sit onto the floor, bend the knees and place the feet flat onto the floor. Place the hands behind the hips with the fingertips pointing forward toward the heels. Lift the hips off the floor bringing the torso parallel with the floor, move the navel toward the spine. Hold for 4-5 breaths then release.

Cat-Cow stretches15

Benefits: Strengthens the arms, wrists, shoulders, back, torso, neck and spineHow to get into the pose: Come onto your hands and knees, bring the shoulders over the wrists and hips over the knees. Inhale as you move your chest forward arching the back for cow, exhale moving the chin toward the chest rounding through the spine for cat. Repeat 5-8 times then release.



YogA stretChes to Do ChAirsiDe

hand Clenching14

Benefits: Stretches the hands and fingers

How to do the stretch: Either sitting in a chair or standing up, extend the arms out parallel in front of you, palms facing each other. Inhale as you extend the fingers wide, exhale making fists with your hands with the thumbs tucked in. Repeat 5-8 times then release.

shoulder rolls14

Benefits: Stretches the shoulders, upper back, and chest

How to do the stretch: Either sitting in a chair or standing up, inhale as you bring the shoulders up toward the ears, exhale moving the shoulders away from the ears and down the back. Repeat 5-8 times then release.

Wrist bending14

Benefits: Stretches the hands and wrists

How to do the stretch: Either sitting in a chair or standing up, extend the arms out parallel in front of you. Inhale as you point the fingers up toward the ceiling, exhale as you point the fingers toward the floor. Repeat 5-8 times then release.

Wing and Prayer14

Benefits: Stretches the shoulders, upper back, and chest

How to do the stretch: Either sitting in a chair or standing up, bring the hands together at the heart into a prayer position. Inhale as you move the palms away from each other moving the shoulder blades close together behind the back, exhale as you bring your hands back to prayer posi-tion in front of the heart. Repeat 5-8 times then release.



ence.com/browse.Reinforce.8. Millar D. Reinforced periodontal instrumen-tation and ergonomics: the best practice to ensure optimal performance and career longevity. Journal of the California Dental Hygienists’ association. 2009; 24(3):10-17.9. Sarosky S, Stilp S, akuthota V. Yoga and Pilates in the management of low back pain. Curr Rev Musculoskeletal Med [Internet]. 2007 [cited 2014 Feb 10]; 1:39-47. available from http://link.springer.com/article/10.1007/s12178-007-9004-1/fulltext.html.10. Saper RB, Boah aR, Keosaian J, et al. Comparing once- versus twice-weekly yoga classes for chronic low back pain in predomi-nantly low income minorities: a randomized dosing trial. Evidence-Based Complementary and alternative Medicine [Internet]. 2013 [cit-ed 2014 Feb 10]. available from www.hindawi.com/journals/ecam/2013/658030/.11. Sherman KJ, Cherkin DC, Wellman RD, et al. a randomized trial comparing yoga, stretch-ing, and a self-care book for chronic low back pain. archives of Internal Medicine [Internet]. 2011 [cited 2014 Feb 10]. available from: http://archinte.jamanetwork.com/article.aspx?articleid=1106098.12. Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back pain. ann Intern Med [Inter-net]. 2011 [cited 2014 Feb 10];155(9):569-578. available from http://annals.org/issue.aspx?journalid=90&issueID=20366&direction=P.13. Williams K, abildso C, Steinberg L, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine. 2009; 34(19):2066-2076.14. Payne L, Usatine R. Yoga Rx: a step-by-step program to promote health, wellness, and healings for common ailments. 1st ed. new York, nY. Broadway Books. 2002. pp.146-148.15. Yoga Poses. Yoga Journal.com [Internet]. 2014 [cited 2014 Feb 19]. available from http://www.yogajournal.com/poses/finder/browse_index.

and alternative medicine to reduce chronic musculoskeletal pain. She can be contacted at: [email protected].

DiAne MillAr, RDH, Ma, graduated from the West Los angeles College dental hygiene program in 1981. Her career in dental hygiene has embraced working in private practice and teaching advanced instrumentation techniques at University of Southern California, Cerritos College, and currently at West Coast University. She is a national speaker and is also the published author of “Reinforced Peri-odontal Instrumentation and Ergonomics for the Dental Care Provider.” Diane is a CE Pro-vider for the Ca Dental Board and conducts seminars and hands-on workshops to help dental professionals learn how to practice more efficiently and ergonomically safe to en-sure career longevity. She can be contacted

at [email protected].

references1. Hayes MJ, Taylor Ja, Smith DR. Predictors of work-related musculoskeletal disorders among dental hygienists. Int J Dent Hygiene. 2012;10:265-269.2. Dong H, Barr a, Loomer P, Rempel D. The effects of finger rest positions on hand and muscle load and pinch force in simulated dental hygiene work. J Dent Hyg [Internet]. 2005 [cited 2014 Feb 10]; 69(4): 453-460. avail-able from http://www.adha.org. Registration required for access.3. Chismark a, asher G, Stein M, Tavoc T, Curran a. Use of complementary and alternative medicine for work-related pain correlates with career satisfaction among dental hygienists. J Dent Hyg [Internet]. 2011 [cited 2014 Feb 10]; 85(4):273-284. available from http://www.adha.org. Registration required for access.4. Hayes MJ, Smith DR, Cockrell D. Prevalence and correlates of musculoskeletal disorders among australian dental hygiene students. Int J Dent Hygiene. 2009; 7:176-181.5. Morse T, Bruneau H, Michalak-Turcotte C, et al. Musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students. J Dent Hyg [Internet]. 2007 [cited 2014 Feb 10]; 81(1):e16. available from http://www.adha.org. Registration required for access.6. Millar D. Reinforced periodontal instrumen-tation and ergonomics for the dental care provider. 1st ed. Baltimore, MD. Lippincott, Williams, & Wilkins. 2007. pp. 1-38.7. Reinforce. Dictionary.com, Random House Publishing [Internet]. 2014 Jan [cited 2014 Jan 3]. available from http://dictionaryrefer-

of each pose. There are many types of yoga styles, including but not limited to Hatha, Vinyasa, Kundalini, and Iy-engar. Yoga targets a number of muscle groups, leading to improved posture and spinal alignment.9 Yoga has been shown to reduce pain,9,10,11,13 the need for medication,10 and to improve func-tion9-13 among the general population. Pain reduction has been reportedwhenindividuals practiced yoga at least once a week for a minimum of 12 consecutive weeks.10-12 Yoga has also been shown to reduce stress and bring a sense of peace and well-being to the mind.9 Since yoga has been shown to reduce pain among the general population, serious consid-eration should be taken to incorporate yoga into the dental hygiene curriculum to prevent pain while in school and later in the career.

MSDs have been reported among RDHs and DHSs, causing a negative im-pact on their daily lives, and eventually leading to reduced work hours, calling in sick, or leaving the profession. Re-inforced instrumentation techniques should be introduced during school and used throughout a dental hygiene career in order to reduce hand, wrist, and arm pain. Ultimately, ergonomics should be reinforced in the clinical setting, and CAM education, such as yoga, should be incorporated into the dental hygiene curriculum to prevent MSDs from occur-ring. Incorporating change is not always easy for clinicians to accept or adapt to, although action must be taken in order to get a different result so as to increase career satisfaction and longevity of the dental hygiene profession. RDH

Aubreé M. ChisMArk, RDH, MS, is an assis-tant professor in the dental hygiene depart-ment at West Coast University in anaheim, Calif., and is a member of the CDHa Journal advisory Board. She is registered yoga teacher with the Yoga alliance (200-plus hours) and is currently working toward her 500-hour certification. Her research interests include ergonomics and the use of complementary

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Scaling and exercise strategies to prevent hand, wrist ... · Imagine working as a dental hygienist and never being concerned about work-related hand or arm pain. Certainly with all