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Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 61-66
Work-related musculoskeletal symptoms and coping strategies among dental auxiliaries at hospital universiti Sains Malaysia

1 School of Dental Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia
2 Klinik Pergigian Lundu, Hospital Lundu, Sarawak, Lundu, Malaysia

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Date of Submission17-May-2018
Date of Decision15-Oct-2018
Date of Acceptance19-Jan-2019
Date of Web Publication02-Apr-2020


Background: Dental personnel are vulnerable to work-related musculoskeletal symptoms (WMSS) due to the nature of their profession. Aim: To determine WMSS experienced by dental auxiliaries and their coping strategies toward these symptoms. Setting and Design: A cross-sectional study was conducted on 82 dental auxiliaries at a university dental hospital in Malaysia. Materials and Methods: Nordic musculoskeletal questionnaire and the Brief COPE questionnaire were used to measure the musculoskeletal symptoms and coping strategies of the respondents, respectively. Data were analyzed using IBM SPSS version 22.0. Results: Dental auxiliaries consisted of dental staff nurses (30.5%), dental surgery assistants (40.2%), dental technologists (18.3%), and healthcare assistants (11.0%). Their mean [standard deviation (SD)] age was 33.4 (7.60) years. Most of the respondents had been troubled with ache, pain, and discomfort at the neck, 54.9% (95% confidence interval 44.0%, 66.0%]. In addition, they were troubled mainly with distress at the low back (34.1%) and the ankle or feet (34.1%) which had prevented the respondents from doing their regular job over the past 12 months. The most common areas that had troubled the respondents over the past 7 days were the neck (36.6%), low back (36.6%), and ankle or feet (36.6%). The coping strategy most commonly practiced by the respondents was religion with a mean (SD) score of 3.70 (2.15), followed by active coping [3.13 (0.68)] and acceptance [3.13 (0.69)]. Conclusion: The prevalence of WMSS was high in the dental auxiliaries particularly in the neck region. The most common coping strategy used was religion. Awareness programs on the prevention of WMSS among the dental auxiliaries should be increased.

Keywords: Coping skills, dental auxiliaries, work-related musculoskeletal disease

How to cite this article:
Rahman NA, Adnan MM, Yusoff A, Shu JM, Rustam K. Work-related musculoskeletal symptoms and coping strategies among dental auxiliaries at hospital universiti Sains Malaysia. Indian J Dent Res 2020;31:61-6

How to cite this URL:
Rahman NA, Adnan MM, Yusoff A, Shu JM, Rustam K. Work-related musculoskeletal symptoms and coping strategies among dental auxiliaries at hospital universiti Sains Malaysia. Indian J Dent Res [serial online] 2020 [cited 2022 Oct 7];31:61-6. Available from:

   Introduction Top

The repetitive movements of the upper limbs and prolonged stressful postures during dental procedures cause repeated stress on the soft tissues, such as muscles, tendons, ligaments, joints, cartilages, and blood vessels among the dental hygienists.[1] The prevalence of back pain among dental personnel in the north-eastern state of Malaysia was 44.9%, of which the dental technicians (DTs) were the highest percentage at 52.4%.[2]

In another study, the prevalence of work-related musculoskeletal symptoms (WMSS) was reported in dental hygienist students (22%), the dental assistants (38%), and the dental hygienists (47%).[3] A systematic review conducted among the dentists, dental hygienists, and dental students has also concluded that WMSS were a significant burden for the dental profession.[4] For instance, DTs have higher prevalence of back pain (52%) than dental surgery assistants (DSAs; 48%) and dental staff nurses (44.8%) due to their different nature of work.[2] DSA is a nonoperating dental personnel. Besides assisting in clinical work, maintenance of dental surgery room, registration of patients, and updating patients' record were part of the daily routine. Dental nurses (DN) complement the dental officers in government oral healthcare service by providing dental examination, treatment, management, and prevention services to children and adolescent up to 17 years old under supervision of dentist. DTs are accountable to produce dental appliances in accordance to the prescriptions by dental officers. The construction of dentures, crowns, bridges, and appliances involved a few critical steps which required dental technicians to use small-diameter instruments such as lecron, wax knife, and vibratory tools such as handpiece. Besides, they were also involved in simple repair and maintenance of dental equipment under care. The high prevalence of back pain among DT might be due to the greater workload that required them to sit in abnormal body postures for hours in a day while fabricating prosthesis which precipitates wrist ache, lower backache, and neck pain.[2] The healthcare assistant (HCA) is involved in the registration of the patients and preparing the patients' treatment card, assisting the dentist and nurse in cleaning and preparing the dental instruments, and maintaining the clinical and dental laboratory environment according to the current infection control procedures.

In Malaysia, there is limited study done on the problems related to WMSS among dental auxiliaries. This study was conducted to determine the prevalence of WMSS as experienced by dental auxiliaries at one of the teaching hospitals in the state of Kelantan, Malaysia, and their coping strategies toward these symptoms.

   Materials and Methods Top

A cross-sectional study was carried out on dental auxiliaries at a hospital from August 16, 2015 to September 3, 2015. The ethical approval was obtained from the Human Research Ethics Committee, USM (No: USM/JEPeM/15060218) on August 6, 2015. DSAs, DN, dental technicians (DTs), and HCAs were included in this study. The DSA, DN, and HCA were recruited from the hospital clinic, whereas the DTs were enrolled from the hospital dental technology laboratory. Those with carpal tunnel syndrome were excluded from the study after they reported through a clinical questionnaire on the symptoms of pain, tingling, or numbness in the wrist that awakened them at night.[5] Power and sample size software was used to calculate the sample size based on a previous study[6] of DTs in Norway who had shoulder pain at 31% with a precision rate of 10%. After considering 20% of nonresponse rate, a total of 98 dental auxiliaries were required in this study. However, during the data collection period, 82 eligible dental auxiliaries consented and they were given a set of questionnaires to answer. A face-to-face interview was conducted by one of the authors.

The questionnaire was divided into three sections. In the first section, a sociodemographic profile was taken, which included age, sex, ethnic group, body mass index, household income, history of dislocated or fractured wrist, working experience in years, years of using dental instruments, hours of using dental instrument per day, intervals between the use of dental instruments, and duration of rest in between use.

The second section comprised the NORDIC Musculoskeletal Questionnaire which is a validated questionnaire to analyze the musculoskeletal symptoms in an ergonomic or occupational health context.[7] This questionnaire may serve as a diagnostic tool to evaluate the work environment. It helps respondent locate the parts of the body that are in trouble. It was an English language and comprised a standardized questionnaire allowing the respondent to indicate whether they were troubled with pain, ache, or discomfort at the area of the body (neck, shoulders, elbows, wrist/hands, upper back, lower back, hips/thigh, knees, and ankles/feet) any time over the past 12 months. Those who answered “yes” were further questioned about whether in the past 12 months such troubles had prevented them from doing their daily work at home or away from home and whether they experienced any trouble at the same area of the body at any time over the past seven days.

The third section was the Malay version of Brief COPE, a validated questionnaire that was adapted from another previous study[8] and was given to those who had reported to have WMSS. It was used to evaluate how the respondents handled the stress associated with their problem. The questionnaire comprised 14 domains: (1) self-distraction (2) active coping (3) denial (4) substance abuse (5) the use of emotional support (6) the use of instrumental support (7) behavioral disengagement (8) venting (9) positive reframing (10) planning (11) humor (12) acceptance (13) religion and (14) self-blame. Each of the domain comprised two items. The respondents are required to rate the degree of strategies they had used to cope with their troubles. The ratings were 1 = “I usually don't do this at all,” 2 = “I usually do this a little bit, 3 = “I usually do this with a medium amount,” and 4 = “I usually do this a lot.” The domains were further classified into (1) problem focused (active coping, planning, using instrumental support), (2) emotionally focused (using emotional support, positive reframing, acceptance, denial, religion), and (3) less useful (venting, behavioral disengagement, self-distraction, humor, substance use, self-blame). Each coping strategy domain was scored by summing the score for both items in the respective domain. The domain score may range from 2 to 8. If the score was exactly 2.00, it means that the coping strategy is not used at all. A score from 2.01 to 4.00 means the coping strategy had been used minimally, a score from 4.01 to 6.00 shows that the coping strategy had been used moderately, and a score from 6.01 to 8.00 indicates that the coping strategy had been used maximally.

   Results Top

A total of 82 eligible dental auxiliary had participated in the study. The majority of the respondents were DSA [33 (40.2%)], followed by DN [25 (30.5%)], DT [15 (18.3%)], and HCA [9 (11.0%)].

[Table 1] shows the demographic profile of the 82 respondents. Most of them were female (67.1%) with a mean [standard deviation (SD)] age of 33.4 (7.60) years and Malay (96.3%). Some of them (12.2%) had a history of dislocated or fractured wrist, mostly (60%) on the right. Their working experience was mostly between 5 and 9 years. The dental auxiliaries used dental instruments on average (SD) 5.0 (2.95) h/day and the majority (63.5%) took breaks while using the dental instruments at the median (interquartile range) of 2 (3.70) h after work. They took a rest for about 0.15 (0.90) h or almost 10 min, in between their work.
Table 1: Sociodemographic profile of the dental auxiliaries (n=82)

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Prevalence of WMSS in dental auxiliaries

Based on NORDIC Musculoskeletal Questionnaire, the most commonly affected region as per respondent complaint was the neck at a prevalence of 54.9% (95% confidence interval: 44.0%, 66.0%). The other common areas of the body as shown in [Table 2] were upper back and lower back (47%), pain in ankles or feet (45.1%), and pain in both shoulders (42.7%).
Table 2: Respondents having trouble at the area of the body over the past 12 months (n=82)

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As shown in [Table 3], there was a high prevalence of neck pain among 29% of the respondents that caused trouble for the past 12 months, and 36.6% of them claimed that it had caused them trouble within the last seven days. Those who had reported to have trouble over the upper and lower back also complained to have had trouble over the last seven days (36.6% and 34.1%, respectively). Pain in ankles or feet for the past 12 months had prevented 34.1% of dental auxiliaries from doing regular job, and 36.6% complained that it had caused trouble over the last seven days. The respondents had trouble over the shoulder (30.5%) and wrist (29.3%) over the last seven days and reported that this had prevented them from doing regular job.
Table 3: Respondents prevented from doing regular work due to trouble (ache, pain, discomfort) and had trouble over the past 7 days

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[Table 4] shows that DN reported to have more pain mostly at the left shoulder (62.5%), both elbows particularly on the left (50.0%), and left wrist or hand (42.9%). On the other hand, the DSAs mostly reported pain in their neck (48.9%), both shoulders (51.4%), upper back (43.6%), lower back (56.2%), one or both hips or thigh (42.3%), one or both knees (53.3%), one or both ankles (40.5%), right elbow (60.0%), and right wrist or hand (40.9%). As for DTs, the most common region reported was both hands and wrist (33.3%) and for HCA was at the right shoulder (50.0%).
Table 4: Distribution of musculoskeletal symptoms by respondents' job category

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The COPE questionnaire was given to 67 respondents who had at least one pain or discomfort at any area of the body. [Table 5] shows that the highest coping strategies among the dental auxiliaries were religion, with a mean (SD) score of 3.70 (2.15), followed by active coping and acceptance at 3.13 (0.68). Substance abuse was the least coping method [1.12 (0.43)]. Problem focused and emotional focused, mean (SD) of 3.02 (0.46) and 3.03 (0.77), respectively, became the main coping strategies used by the dental auxiliaries.
Table 5: The coping strategies toward WMSS among dental auxiliaries as laid out in the Brief COPE (n=67)

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   Discussion Top

This study included a slightly younger age range of dental auxiliaries that worked in dental setting at the university hospital. The dentists recruited by Feng et al. (2014) had an average of 11.6 years of working experience, whereas most of our respondents (50%) have working experience of less than 10 years. The Chinese dentists (79% of them) claimed to treat 5–15 patients per day and over 90% spent 10–60 min on one patient.[9] On the other hand, the dental auxiliaries in at our study hospital work for eight hours daily and their job scopes were varied according to their job categories.

The WMSS risk factors were age, female gender, repetitive work, physically demanding, localized pressure, posture, environmental temperature, exposure to vibration, and job design.[10] Apparently, most of our respondents were overweight (43.9%) and obesity is one of the risk factors for the development and progression of musculoskeletal disease such as low back pain and osteoarthritis.[11] However, various studies have shown that BMI was not found to be associated with back pain.[2],[12],[13]

Dental procedures are usually long and require high concentration during work. In this study, the high prevalence of WMSS at the neck area (54.9%), followed by upper and lower back, ankles, shoulders, and knees is consistent with other studies.[4],[6],[9] Based on the job categories, the DN and the DSA seem to present symptoms mainly around the neck area. The dental auxiliaries also experience back problems (47.6%) which were associated with the nature of their work, and as such were similar to the findings with a study done in Saudi Arabia, where 74% of dentists and dental auxillaries complained of back pain.[14] A study had reported that the DN were significantly associated with back pain as measured using Branson's Posture Assessment Index.[2] In this study, over the past 12 months, 34.1% of the respondents had experienced low back pain which prevented them from doing regular job at home or away from work. Over the period of the last seven days, 36.6% of the respondents had claimed that they had trouble in the neck, upper back, one or both ankles/feet.

The teachings on ergonomic practices for DN, DSA, and DT needed to be evaluated and included in their dental trainee curriculum.[15] As for the HCA, a training course would be benefited to give them awareness on ergonomic issues while working in the dental settings.

In this study, the majority of dental auxiliaries use religion as coping strategies toward WMSS with a mean (SD) of 3.70 (2.15). Active coping and acceptance were also the coping strategies used with the same mean (SD) of 3.13 (0.68). As the majority of the respondents are Malay (96.3%) and Muslim, they might have resorted to prayers in coping with their troubles. Although they had coped using religion and acceptance, the consequences of WMSS toward their quality of life still needed to be highlighted.

Identifying the most common coping skill used by the dental auxiliaries is important. If they had used an inappropriate coping skill, an intervention program and counseling to change the coping skill is highly needed. Promoting a positive coping skill will help in reducing the trouble and therefore improve their function as individual and consequently contributing to the community and the organization. In addition, a referral to the orthopedic surgeons could be proposed for respondents that have chronic symptoms for further professional management.

There is no known study on WMSS among dental auxiliaries that evaluate the coping strategies. There were various studies that have been done on dentist themselves, but the studies on dental auxiliaries who are also at risk are lacking. To protect and improve their health status, all dentists and dental auxiliaries should receive education about all aspects of dental ergonomics.[16] The awareness on ergonomics should be applied to dental auxiliaries regardless of their job category. Proper education and acquisition of ergonomics knowledge to all staffs hopefully will help in preventing the development of WMSS.

This study involved a smaller group of respondents from only one institution. Therefore, further research on prevalence among dental auxiliaries in Malaysian population is warranted before implementation of preventive educational programs for them.

   Conclusion Top

The prevalence of WMSS among dental auxiliaries at the neck region was the most common. The coping strategies used were mainly religion-based practices. Awareness on the prevention of this problem among the dental auxiliaries staff needs to be increased.

Financial support and sponsorship

USM short-term grant 304/PPSG/6315118.

Conflicts of interest

There are no conflicts of interest.

   References Top

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Hayes M, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg 2009;7:159-65.  Back to cited text no. 4
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Yusoff N, Low WY, Yip CH. Reliability and validity of the Malay version of Brief COPE scale: A study on Malaysian women treated with adjuvant chemotherapy for breast cancer. Malays J Psychiatry 2009;18:1-9.  Back to cited text no. 8
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Yieng CWP. The prevalence and causes of low back pain in staff nurses and community. Nurs Physiother Bull 2007;3:3-9.  Back to cited text no. 12
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Correspondence Address:
Normastura Abd Rahman
Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian, 16150, Kelantan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_430_18

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