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Publicati<strong>on</strong> Date: July 2010<br />
Review Date: December 2010<br />
Expiry Date: November 2013<br />
Go Green, Go Online to take your course<br />
This course has been made possible through an unrestricted educati<strong>on</strong>al grant. The cost of this CE course is $49.00 for 2 CE credits.<br />
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Earn<br />
2 CE credits<br />
This course was<br />
written for dentists,<br />
dental hygienists,<br />
and assistants.<br />
<str<strong>on</strong>g>Getting</str<strong>on</strong>g> <str<strong>on</strong>g>the</str<strong>on</strong>g> <str<strong>on</strong>g>Upper</str<strong>on</strong>g> <str<strong>on</strong>g>Hand</str<strong>on</strong>g> <strong>on</strong> <strong>Pain</strong>:<br />
<strong>Preventing</strong> <str<strong>on</strong>g>Hand</str<strong>on</strong>g> and Wrist <strong>Pain</strong><br />
Syndromes in Dental Professi<strong>on</strong>als<br />
A Peer-Reviewed Publicati<strong>on</strong><br />
Written by Bethany Valachi, PT, MS, CEAS
Educati<strong>on</strong>al Objectives<br />
The overall goal of this article is to provide <str<strong>on</strong>g>the</str<strong>on</strong>g> reader with<br />
informati<strong>on</strong> <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> incidence, risk factors, preventi<strong>on</strong> and<br />
treatment of true carpal tunnel syndrome, as well as disorders<br />
in dentistry that mimic carpal tunnel syndrome but have a<br />
different etiology. Up<strong>on</strong> <strong>com</strong>pleti<strong>on</strong> of this course, <str<strong>on</strong>g>the</str<strong>on</strong>g> reader<br />
will be able to do <str<strong>on</strong>g>the</str<strong>on</strong>g> following:<br />
1. List and describe four of <str<strong>on</strong>g>the</str<strong>on</strong>g> primary risk factors associated<br />
with carpal tunnel syndrome<br />
2. List and describe erg<strong>on</strong>omic interventi<strong>on</strong>s that can help<br />
prevent carpal tunnel syndrome<br />
3. List and describe o<str<strong>on</strong>g>the</str<strong>on</strong>g>r c<strong>on</strong>diti<strong>on</strong>s that may mimic carpal<br />
tunnel syndrome<br />
4. Provide an overview of <str<strong>on</strong>g>the</str<strong>on</strong>g> diagnosis and treatment of<br />
carpal tunnel syndrome<br />
Abstract<br />
Chr<strong>on</strong>ic hand and wrist pain that can affect quality of life,<br />
productivity or career l<strong>on</strong>gevity is experienced by between 40<br />
and 70 percent of dental professi<strong>on</strong>als. Given that fewer dental<br />
professi<strong>on</strong>als fully recover from hand pain than <str<strong>on</strong>g>the</str<strong>on</strong>g>y do<br />
from neck, shoulder or elbow pain, it is imperative that injury<br />
be prevented. There are a number of risk factors for carpal<br />
tunnel syndrome that must be c<strong>on</strong>sidered, as well as researchbased<br />
erg<strong>on</strong>omic interventi<strong>on</strong>s. The use of erg<strong>on</strong>omic equipment<br />
and implementati<strong>on</strong> of preventi<strong>on</strong> techniques outside<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> operatory can help to reduce work-related pain and extend<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> career of <str<strong>on</strong>g>the</str<strong>on</strong>g> dental professi<strong>on</strong>al.<br />
Introducti<strong>on</strong><br />
“The right half of <str<strong>on</strong>g>the</str<strong>on</strong>g> brain c<strong>on</strong>trols <str<strong>on</strong>g>the</str<strong>on</strong>g> left half of <str<strong>on</strong>g>the</str<strong>on</strong>g> body.<br />
This means that <strong>on</strong>ly left-handed people are in <str<strong>on</strong>g>the</str<strong>on</strong>g>ir right mind.”<br />
—Source Unknown<br />
<str<strong>on</strong>g>Hand</str<strong>on</strong>g>, wrist and arm pain are much more prevalent<br />
am<strong>on</strong>g dental professi<strong>on</strong>als than <str<strong>on</strong>g>the</str<strong>on</strong>g> general public, due<br />
to <str<strong>on</strong>g>the</str<strong>on</strong>g> sustained grips and prol<strong>on</strong>ged awkward postures<br />
dentists and hygienists must employ throughout <str<strong>on</strong>g>the</str<strong>on</strong>g> day. 1<br />
Between 23 and 40 percent of dentists and nearly 75 percent<br />
of dental hygienists experience hand and wrist pain, 2-6<br />
nearly four times <str<strong>on</strong>g>the</str<strong>on</strong>g> prevalence found in <str<strong>on</strong>g>the</str<strong>on</strong>g> general working<br />
public. In <str<strong>on</strong>g>the</str<strong>on</strong>g> case of hygienists, hands, wrists and arms<br />
are <str<strong>on</strong>g>the</str<strong>on</strong>g> most <strong>com</strong>m<strong>on</strong> sites of pain reported. Since hands are<br />
integral to <str<strong>on</strong>g>the</str<strong>on</strong>g> work of dental professi<strong>on</strong>als, understanding<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> etiology of this pain and its preventi<strong>on</strong> are important. 6-9<br />
Fewer dental professi<strong>on</strong>als fully recover from hand pain<br />
syndromes than <str<strong>on</strong>g>the</str<strong>on</strong>g>y do from neck, shoulder and elbow<br />
pain. 7 Therefore, preventi<strong>on</strong> strategies and early attenti<strong>on</strong> to<br />
warning signs of <str<strong>on</strong>g>the</str<strong>on</strong>g> primary cumulative trauma disorders<br />
(CTDs) of <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and arm are imperative to <str<strong>on</strong>g>the</str<strong>on</strong>g> dental<br />
professi<strong>on</strong>al’s health and career l<strong>on</strong>gevity.<br />
The origins of pain in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand, wrist or arm are often<br />
elusive and may not be due to a problem in <str<strong>on</strong>g>the</str<strong>on</strong>g> same area;<br />
in fact, <str<strong>on</strong>g>the</str<strong>on</strong>g> source of <str<strong>on</strong>g>the</str<strong>on</strong>g> symptoms may be nowhere near<br />
where <str<strong>on</strong>g>the</str<strong>on</strong>g> symptoms are perceived. For example, numbness<br />
in <str<strong>on</strong>g>the</str<strong>on</strong>g> fingers, which is <strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> symptoms of carpal tunnel<br />
syndrome, sometimes has nothing to do with a problem in<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> hand or wrist but may be due to a problem in <str<strong>on</strong>g>the</str<strong>on</strong>g> cervical<br />
spine, thoracic outlet or trigger points in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm.<br />
There are numerous causes of hand, wrist and arm pain,<br />
including tend<strong>on</strong>itis (e.g., De Quervain’s tenosynovitis),<br />
arthritis (e.g., osteoarthritis of <str<strong>on</strong>g>the</str<strong>on</strong>g> basilar joint), nerve <strong>com</strong>pressi<strong>on</strong><br />
(e.g., thoracic outlet syndrome, cervical radiculopathy,<br />
carpal tunnel syndrome, cubital tunnel syndrome),<br />
trigger points (e.g., radial tunnel syndrome) and equipment<br />
issues (e.g., n<strong>on</strong>-erg<strong>on</strong>omic tools, poorly fitted gloves).<br />
However, <str<strong>on</strong>g>the</str<strong>on</strong>g> most <strong>com</strong>m<strong>on</strong>ly diagnosed CTD of <str<strong>on</strong>g>the</str<strong>on</strong>g> hand,<br />
wrist and arm am<strong>on</strong>g dentists and hygienists is carpal tunnel<br />
syndrome.<br />
Carpal Tunnel Syndrome<br />
Carpal tunnel syndrome (CTS) is <str<strong>on</strong>g>the</str<strong>on</strong>g> most <strong>com</strong>m<strong>on</strong> peripheral<br />
nerve entrapment in <str<strong>on</strong>g>the</str<strong>on</strong>g> arm 10-11 and c<strong>on</strong>tributes to<br />
<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> most frequently performed hand surgeries in <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
United States. 12 Caused by <strong>com</strong>pressi<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve<br />
at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist, 13 CTS can lead to pain, numbness or tingling in<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> thumb, index finger, middle finger and half of <str<strong>on</strong>g>the</str<strong>on</strong>g> ring<br />
finger. (Fig. 1)<br />
Figure 1. Carpal tunnel<br />
<strong>Pain</strong> or tingling in <str<strong>on</strong>g>the</str<strong>on</strong>g> distributi<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve (shaded)<br />
is often indicative of carpal tunnel syndrome. Numbness is usually<br />
felt in <str<strong>on</strong>g>the</str<strong>on</strong>g> fingertips <strong>on</strong>ly.<br />
One study found that while 71 percent of dentists experienced<br />
<strong>on</strong>e or more CTS symptoms, <strong>on</strong>ly 7 percent were<br />
actually diagnosed with CTS. 14 This should prompt dental<br />
professi<strong>on</strong>als with CTS-type symptoms to educate <str<strong>on</strong>g>the</str<strong>on</strong>g>mselves<br />
<strong>on</strong> all possible etiologies to avoid unnecessary surgery<br />
or ineffective <str<strong>on</strong>g>the</str<strong>on</strong>g>rapies.<br />
2 www.ineedce.<strong>com</strong>
Inc<strong>on</strong>sistencies abound in <str<strong>on</strong>g>the</str<strong>on</strong>g> literature regarding <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
cause, proper evaluati<strong>on</strong> and course of care of CTS. 15-17 Noted<br />
author and physical rehabilitati<strong>on</strong> expert Dr. Rene Calliet<br />
states, “Differentiati<strong>on</strong> of median nerve wrist <strong>com</strong>pressi<strong>on</strong><br />
from cervical radiculitis or thoracic outlet syndrome may be<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> most challenging in clinical practice.” 15 This is largely due<br />
to <str<strong>on</strong>g>the</str<strong>on</strong>g> fact that <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve fibers run a l<strong>on</strong>g and twisting<br />
course around b<strong>on</strong>e and through soft tissue from <str<strong>on</strong>g>the</str<strong>on</strong>g> cervical<br />
spine down to <str<strong>on</strong>g>the</str<strong>on</strong>g> fingertips. CTS symptoms may not always<br />
be indicative of a structural problem in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and wrist;<br />
often <str<strong>on</strong>g>the</str<strong>on</strong>g> problem originates more proximally in <str<strong>on</strong>g>the</str<strong>on</strong>g> muscles/<br />
tend<strong>on</strong>s that stabilize <str<strong>on</strong>g>the</str<strong>on</strong>g> arm during repetitive work. 17 Any<br />
<strong>com</strong>pressi<strong>on</strong> or entrapment al<strong>on</strong>g <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve fibers can<br />
result in CTS-type symptoms in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand. 18<br />
The carpal tunnel<br />
The carpal tunnel <strong>com</strong>prises a row of b<strong>on</strong>es <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> back of <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
wrist, with a thick ligament in <str<strong>on</strong>g>the</str<strong>on</strong>g> fr<strong>on</strong>t. For <str<strong>on</strong>g>the</str<strong>on</strong>g> hand to functi<strong>on</strong><br />
properly, nine flexor tend<strong>on</strong>s and <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve must<br />
be able to glide easily within this space. Of <str<strong>on</strong>g>the</str<strong>on</strong>g>se structures, <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
median nerve is <str<strong>on</strong>g>the</str<strong>on</strong>g> softest and most vulnerable to pressure.<br />
The positi<strong>on</strong>s that cause <str<strong>on</strong>g>the</str<strong>on</strong>g> most pressure in <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal<br />
tunnel are easy to identify. If you straighten your right wrist,<br />
place your left thumb over <str<strong>on</strong>g>the</str<strong>on</strong>g> transverse carpal ligament and<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g>n bend your right wrist back, you can feel <str<strong>on</strong>g>the</str<strong>on</strong>g> ligament<br />
tighten over <str<strong>on</strong>g>the</str<strong>on</strong>g> tunnel. This is <str<strong>on</strong>g>the</str<strong>on</strong>g> positi<strong>on</strong> that <strong>com</strong>presses<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> tunnel most. If you <str<strong>on</strong>g>the</str<strong>on</strong>g>n make a fist, <str<strong>on</strong>g>the</str<strong>on</strong>g> tunnel will get<br />
even tighter; if held in this positi<strong>on</strong> l<strong>on</strong>g enough, it may result<br />
in your hands and fingers going numb. If you bring your<br />
wrist to neutral and <str<strong>on</strong>g>the</str<strong>on</strong>g>n forward, <str<strong>on</strong>g>the</str<strong>on</strong>g> tightness will slacken<br />
when you are in neutral and <str<strong>on</strong>g>the</str<strong>on</strong>g>n slightly tighten again as<br />
you move downward. If you try <str<strong>on</strong>g>the</str<strong>on</strong>g> above exercise gripping<br />
a pencil, this “precisi<strong>on</strong>” grip creates more pressure in <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
carpal tunnel. Sustained gripping while extending <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist is<br />
unhealthy for your median nerve. By performing this series<br />
of movements, you have just dem<strong>on</strong>strated two of <str<strong>on</strong>g>the</str<strong>on</strong>g> four<br />
primary risk factors for CTS in dental professi<strong>on</strong>als—flexing<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> wrist forward and gripping a small instrument forcefully.<br />
The o<str<strong>on</strong>g>the</str<strong>on</strong>g>r two risk factors are high repetiti<strong>on</strong> (as in manual<br />
scaling) and durati<strong>on</strong> (e.g., how many heavy calculus patients<br />
you schedule back-to-back). (Fig. 2) These risk factors cause<br />
microtrauma in <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel; fibrosis and edema of <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
lining of <str<strong>on</strong>g>the</str<strong>on</strong>g> tend<strong>on</strong>s at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist eventually cause increased<br />
pressure within <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel and decreased blood flow to<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve within <str<strong>on</strong>g>the</str<strong>on</strong>g> tunnel. The swelling of <str<strong>on</strong>g>the</str<strong>on</strong>g> lining<br />
of <str<strong>on</strong>g>the</str<strong>on</strong>g> tend<strong>on</strong>s is often painful, and it is <str<strong>on</strong>g>the</str<strong>on</strong>g> pressure <strong>on</strong><br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist from this swelling that causes<br />
numbness in <str<strong>on</strong>g>the</str<strong>on</strong>g> fingers and weakness of <str<strong>on</strong>g>the</str<strong>on</strong>g> muscles at <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb.<br />
The causes of CTS are numerous and include anatomic,<br />
physiologic, hereditary and traumatic factors that result in<br />
<strong>com</strong>pressi<strong>on</strong> or irritati<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist. For<br />
instance, CTS is three times more prevalent in women than<br />
men, and it is most <strong>com</strong>m<strong>on</strong> between <str<strong>on</strong>g>the</str<strong>on</strong>g> ages of 30 and 60 and<br />
am<strong>on</strong>g diabetics and in obese people. However, <str<strong>on</strong>g>the</str<strong>on</strong>g> literature<br />
also reports an occupati<strong>on</strong>al cause in more than 47 percent of<br />
cases. 20 CTS symptoms (pain, numbness and tingling) are often<br />
worse at night and first thing in <str<strong>on</strong>g>the</str<strong>on</strong>g> morning. Weakness in<br />
a precisi<strong>on</strong> grip may be present due to atrophy or weakness of<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> thumb abductor muscles. 19 Over time, visibly decreased<br />
musculature may be noticed at <str<strong>on</strong>g>the</str<strong>on</strong>g> base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb. Sensory<br />
impairment is usually experienced before motor loss, so early<br />
interventi<strong>on</strong> is important. In additi<strong>on</strong> to any <str<strong>on</strong>g>the</str<strong>on</strong>g>rapies you<br />
may c<strong>on</strong>sider, it is imperative that you address erg<strong>on</strong>omic<br />
issues that are known to aggravate carpal tunnel symptoms to<br />
minimize your risk and to prevent CTS.<br />
Figure 2. Four of <str<strong>on</strong>g>the</str<strong>on</strong>g> primary risk factors c<strong>on</strong>tributing to CTS in<br />
dentistry.<br />
Keys to Success: <strong>Preventing</strong> Carpal Tunnel<br />
Syndrome<br />
The four primary risk factors that c<strong>on</strong>tribute to occupati<strong>on</strong>al<br />
CTS in dentistry can be minimized with appropriate erg<strong>on</strong>omic<br />
interventi<strong>on</strong>s, as described below.<br />
Avoiding sustained wrist flexi<strong>on</strong><br />
Wrist flexi<strong>on</strong> increases pressure in <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel, and<br />
working with your wrist bent toward <str<strong>on</strong>g>the</str<strong>on</strong>g> little finger—called<br />
ulnar deviati<strong>on</strong>—also increases this pressure. 12-13 (Fig. 3a)<br />
When performing scaling or o<str<strong>on</strong>g>the</str<strong>on</strong>g>r treatments, trying to keep<br />
your wrist straight and moving your entire hand, wrist and<br />
www.ineedce.<strong>com</strong> 3
forearm as a unit transfers <str<strong>on</strong>g>the</str<strong>on</strong>g> load from smaller hand muscles<br />
to larger arm and shoulder muscles. Using a finger rest positi<strong>on</strong><br />
(ei<str<strong>on</strong>g>the</str<strong>on</strong>g>r intra- or extra-oral) to stabilize <str<strong>on</strong>g>the</str<strong>on</strong>g> instrument<br />
fur<str<strong>on</strong>g>the</str<strong>on</strong>g>r reduces thumb pinch force and muscle workloads in<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> hand. 21 Extra-oral fulcrums also facilitate neutral wrist<br />
posture and allow proper positi<strong>on</strong>ing for precisi<strong>on</strong> instrumentati<strong>on</strong>.<br />
22 (Fig. 3b)<br />
Figure 3a. Poor wrist posture<br />
Poor (deviated) posture of <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist is a primary risk factor for CTS<br />
in dentistry.<br />
Figure 3b. Neutral wrist posture<br />
Try to maintain neutral posture of <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist, especially when scaling.<br />
Ra<str<strong>on</strong>g>the</str<strong>on</strong>g>r than twisting <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist to access hard-to-reach<br />
areas, try moving <str<strong>on</strong>g>the</str<strong>on</strong>g> instrument or handpiece in your hand.<br />
To access molar regi<strong>on</strong>s and distal pockets, select an instrument<br />
with multiple accentuated angles and a l<strong>on</strong>ger terminal<br />
shank (Fig. 4), which can reduce twisting <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist to access<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g>se areas. It makes far more sense to use an accentuated<br />
angled instrument ra<str<strong>on</strong>g>the</str<strong>on</strong>g>r than angle your wrist. You can retrain<br />
yourself to maintain near-neutral wrist postures using<br />
a soft wrist wrap, such as a WrisTimer, to limit wrist flexi<strong>on</strong><br />
to anywhere from 0 degrees to 20 degrees. A soft wrist wrap<br />
can be adjusted to prevent varying degrees of wrist flexi<strong>on</strong>,<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g>reby retraining damaging wrist postures.<br />
Figure 4. Erg<strong>on</strong>omic shank<br />
Instruments with multiple exaggerated angles and l<strong>on</strong>ger terminal<br />
shanks can reduce <str<strong>on</strong>g>the</str<strong>on</strong>g> need to flex <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist to access hard-toreach<br />
distal pockets.<br />
Going ultras<strong>on</strong>ic<br />
Compared to manual scaling, ultras<strong>on</strong>ic scaling requires less<br />
force applied to <str<strong>on</strong>g>the</str<strong>on</strong>g> work surface and a less forceful precisi<strong>on</strong><br />
grip. However, <str<strong>on</strong>g>the</str<strong>on</strong>g>se erg<strong>on</strong>omic advantages are putting<br />
ultras<strong>on</strong>ic instruments at <str<strong>on</strong>g>the</str<strong>on</strong>g> forefr<strong>on</strong>t and in some cases<br />
overshadowing manual instruments as artifacts of <str<strong>on</strong>g>the</str<strong>on</strong>g> past.<br />
The importance of precisi<strong>on</strong> manual scaling in delivering<br />
quality dental care cannot be overstated, and <str<strong>on</strong>g>the</str<strong>on</strong>g> effectiveness<br />
of quality advanced period<strong>on</strong>tal instrumentati<strong>on</strong> is often<br />
hard to match with an ultras<strong>on</strong>ic unit. Proper erg<strong>on</strong>omic<br />
period<strong>on</strong>tal instrumentati<strong>on</strong> techniques should be a priority<br />
for hygienists to safely implement sufficient hand scaling into<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g>ir patient care. 22,23<br />
The percentage of time spent providing ultras<strong>on</strong>ic versus<br />
manual scaling care is an individual <strong>on</strong>e that must take into<br />
c<strong>on</strong>siderati<strong>on</strong> pers<strong>on</strong>al health (some individuals are more<br />
pr<strong>on</strong>e to CTS than o<str<strong>on</strong>g>the</str<strong>on</strong>g>rs), patient period<strong>on</strong>tal history,<br />
workload, depth and size of pockets, and numerous o<str<strong>on</strong>g>the</str<strong>on</strong>g>r<br />
variables. Both manual and powered instrumentati<strong>on</strong> have<br />
unique strengths that can be effectively <strong>com</strong>bined during<br />
treatment. 24 Fur<str<strong>on</strong>g>the</str<strong>on</strong>g>rmore, studies show that <str<strong>on</strong>g>the</str<strong>on</strong>g> durati<strong>on</strong> of<br />
use of ei<str<strong>on</strong>g>the</str<strong>on</strong>g>r ultras<strong>on</strong>ic or manual instruments is positively<br />
associated with upper extremity numbness/tingling. 25<br />
From a preventive perspective, ultras<strong>on</strong>ic instrumentati<strong>on</strong><br />
should be used periodically over <str<strong>on</strong>g>the</str<strong>on</strong>g> course of <str<strong>on</strong>g>the</str<strong>on</strong>g> day to<br />
reduce muscle workload and provide rest to <str<strong>on</strong>g>the</str<strong>on</strong>g> intrinsic hand<br />
muscles. Also c<strong>on</strong>sider swiveling ultras<strong>on</strong>ic inserts, which<br />
can improve hand and arm posture as well as save time.<br />
Instrument selecti<strong>on</strong><br />
Certain instrument features can reduce carpal tunnel <strong>com</strong>pressi<strong>on</strong>:<br />
Diameter – Instruments are available in a wide variety<br />
of handle diameters, ranging from about 5.6 to 11.5 mm.<br />
4 www.ineedce.<strong>com</strong>
Larger instrument handle diameters reduce hand muscle<br />
load and pinch force, although handle diameters greater<br />
than 10 mm (about 3/8 inch) have been shown to offer no<br />
additi<strong>on</strong>al advantage. 26 Alternating between handle diameter<br />
sizes may also help prevent CTS symptoms. When selecting<br />
instruments, try to include large diameters as well as<br />
o<str<strong>on</strong>g>the</str<strong>on</strong>g>r sizes, but avoid very narrow diameter sizes (5.6 mm),<br />
as <str<strong>on</strong>g>the</str<strong>on</strong>g>se increase carpal tunnel pressure. Sleeves that fit over<br />
mirror handles and increase <str<strong>on</strong>g>the</str<strong>on</strong>g>ir diameter have been shown<br />
to reduce muscle load; 27 however, sleeves <strong>on</strong> scaling instruments<br />
may not have <str<strong>on</strong>g>the</str<strong>on</strong>g> same benefits, due to <str<strong>on</strong>g>the</str<strong>on</strong>g> additi<strong>on</strong>al<br />
force needed to perform scaling tasks.<br />
Weight – Although instrument weight is not as significant<br />
a risk factor as handle diameter, lightweight instruments (15<br />
g or less) help reduce <str<strong>on</strong>g>the</str<strong>on</strong>g> muscle workload and pinch force. 26<br />
Texture – Textured handle surfaces may help decrease<br />
forceful pinch grips.<br />
Sharpness – Dull instruments can have a profoundly<br />
deleterious impact <strong>on</strong> your musculoskeletal health, as <str<strong>on</strong>g>the</str<strong>on</strong>g>y<br />
require increased force. It is <str<strong>on</strong>g>the</str<strong>on</strong>g>refore essential to maintain<br />
optimally sharpened instruments and perform visual inspecti<strong>on</strong>s<br />
regularly. There are several methods for sharpening,<br />
including mechanical and manual 23 methods and using<br />
a high-speed handpiece. 28<br />
Reduce your grip – Forceful pinch grip has been<br />
shown to increase pressure in <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel; this pressure<br />
is even higher when <strong>com</strong>bined with wrist ulnar deviati<strong>on</strong>.<br />
12 Hygienists and dentists should try to use a palmar<br />
grip when using <str<strong>on</strong>g>the</str<strong>on</strong>g> high volume evacuati<strong>on</strong> (HVE) and<br />
dentists should, of course, use <str<strong>on</strong>g>the</str<strong>on</strong>g> palmar grip instead of <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
precisi<strong>on</strong> grip during extracti<strong>on</strong>s. Dentists with pain in <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
dominant hand should c<strong>on</strong>sider using <str<strong>on</strong>g>the</str<strong>on</strong>g> n<strong>on</strong>-dominant<br />
hand intermittently for extracti<strong>on</strong>s, and <str<strong>on</strong>g>the</str<strong>on</strong>g>y can begin by<br />
supporting <str<strong>on</strong>g>the</str<strong>on</strong>g> extracting hand with <str<strong>on</strong>g>the</str<strong>on</strong>g> dominant hand.<br />
Positi<strong>on</strong>ing <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> opposite side of <str<strong>on</strong>g>the</str<strong>on</strong>g> patient for extracti<strong>on</strong>s<br />
may be<strong>com</strong>e more <strong>com</strong>fortable and easier when you<br />
are acclimatized to using <str<strong>on</strong>g>the</str<strong>on</strong>g> n<strong>on</strong>-dominant hand, and it<br />
provides yet ano<str<strong>on</strong>g>the</str<strong>on</strong>g>r opportunity to move around, <str<strong>on</strong>g>the</str<strong>on</strong>g>reby<br />
varying <str<strong>on</strong>g>the</str<strong>on</strong>g> load <strong>on</strong> your muscles, b<strong>on</strong>es and joints.<br />
Cord management – Using 360-degree swivel instruments<br />
to maintain optimal neutral wrist and finger positi<strong>on</strong><br />
is helpful, as is positi<strong>on</strong>ing heavy cords over your arm<br />
through a counter-mounted loop or across an armrest to<br />
reduce muscle strain. Cord pullback can be prevented by<br />
positi<strong>on</strong>ing your delivery system and ultrasound unit close<br />
to you. It is also important to observe patient positi<strong>on</strong>ing<br />
strategies to maintain neutral wrist posture.<br />
Spread <str<strong>on</strong>g>the</str<strong>on</strong>g> work around – Moving <str<strong>on</strong>g>the</str<strong>on</strong>g> muscle workload<br />
helps to avoid structural damage. 29 One way to do this<br />
is by alternating between chairs with and without armrests.<br />
Using a chair with armrests moves <str<strong>on</strong>g>the</str<strong>on</strong>g> workload to <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
smaller muscles of <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and wrist, while using no armrests<br />
incorporates <str<strong>on</strong>g>the</str<strong>on</strong>g> larger muscles of <str<strong>on</strong>g>the</str<strong>on</strong>g> arm and shoulder<br />
girdle into <str<strong>on</strong>g>the</str<strong>on</strong>g> movement.<br />
Temperature – Avoid positi<strong>on</strong>ing your neck, shoulders<br />
and hands directly in <str<strong>on</strong>g>the</str<strong>on</strong>g> draft of an air c<strong>on</strong>diti<strong>on</strong>er,<br />
and avoid working in a particularly cold envir<strong>on</strong>ment, since<br />
exposure to cold is ano<str<strong>on</strong>g>the</str<strong>on</strong>g>r aggravating risk factor associated<br />
with CTS.<br />
Stretch – Frequent stretch breaks were <str<strong>on</strong>g>the</str<strong>on</strong>g> most helpful<br />
interventi<strong>on</strong> for hand/wrist pain in <strong>on</strong>e dental study. 30<br />
Stretching helps to increase blood flow and reduce formati<strong>on</strong><br />
of trigger points. If you have mild carpal tunnel symptoms,<br />
you should be gently stretching three to five times per day.<br />
CTS Diagnosis<br />
Accurate diagnosis of CTS is difficult and requires evaluati<strong>on</strong><br />
by a highly skilled healthcare practiti<strong>on</strong>er, preferably<br />
a board-certified hand surge<strong>on</strong>. A certified hand <str<strong>on</strong>g>the</str<strong>on</strong>g>rapist<br />
can also be extremely helpful in addressing adaptati<strong>on</strong>, erg<strong>on</strong>omics,<br />
splinting and using various modalities to reduce<br />
your symptoms. Positive results from several tests (EMG<br />
and nerve c<strong>on</strong>ducti<strong>on</strong> velocity testing, hand pain mapping,<br />
and sensitivity testing) and <str<strong>on</strong>g>the</str<strong>on</strong>g> presence of wrist/hand pain<br />
are highly suggestive of CTS. 12 The following physical exam<br />
findings are often seen in people with this syndrome:<br />
1. Tinel’s sign: an electric shock–type sensati<strong>on</strong> in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand<br />
when <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve is tapped gently at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist<br />
2. Positive Phalen’s test: numbness in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand in less than<br />
60 sec<strong>on</strong>ds when <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist is flexed 90 degrees<br />
3. Weakness of <str<strong>on</strong>g>the</str<strong>on</strong>g> <str<strong>on</strong>g>the</str<strong>on</strong>g>nar muscles at <str<strong>on</strong>g>the</str<strong>on</strong>g> base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb<br />
4. In severe cases, persistent numbness in <str<strong>on</strong>g>the</str<strong>on</strong>g> distributi<strong>on</strong><br />
of <str<strong>on</strong>g>the</str<strong>on</strong>g> distal median nerve (thumb, index finger, middle<br />
finger) and c<strong>on</strong>tinuous numbness can represent permanent<br />
damage to <str<strong>on</strong>g>the</str<strong>on</strong>g> nerve; surgery should be c<strong>on</strong>sidered<br />
prior to this point, as surgery will reliably prevent fur<str<strong>on</strong>g>the</str<strong>on</strong>g>r<br />
damage to <str<strong>on</strong>g>the</str<strong>on</strong>g> nerve, but recovery of a damaged nerve is<br />
not as predictable<br />
CTS Treatment<br />
C<strong>on</strong>servative treatment opti<strong>on</strong>s for CTS include <str<strong>on</strong>g>the</str<strong>on</strong>g> following:<br />
• Modificati<strong>on</strong> of activities to decrease tend<strong>on</strong> excursi<strong>on</strong><br />
• Therapeutic interventi<strong>on</strong>s such as ice, massage,<br />
ultrasound or acupuncture<br />
• Anti-inflammatories or cortis<strong>on</strong>e injecti<strong>on</strong>s<br />
• An immobilizing splint across <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist (often most<br />
helpful at night)<br />
• Nerve or tend<strong>on</strong> gliding exercises<br />
• B6 vitamins if <str<strong>on</strong>g>the</str<strong>on</strong>g> problem is due to a vitamin deficiency<br />
It is advisable to avoid streng<str<strong>on</strong>g>the</str<strong>on</strong>g>ning <str<strong>on</strong>g>the</str<strong>on</strong>g> hands/fingers<br />
with repetitive finger flexi<strong>on</strong> exercises, as <str<strong>on</strong>g>the</str<strong>on</strong>g>se can increase<br />
carpal tunnel pressures and worsen pain. 16,31 However, when<br />
<strong>com</strong>pletely pain-free, a program of very lightweight tubing<br />
exercises focused <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist flexor, extensor, pr<strong>on</strong>ator and<br />
supinator groups may be of benefit in preventing CTS and for<br />
trigger points. 16<br />
Dentists and hygienists should implement erg<strong>on</strong>omic interventi<strong>on</strong>s,<br />
c<strong>on</strong>sider all CTS-mimicking c<strong>on</strong>diti<strong>on</strong>s and undergo<br />
www.ineedce.<strong>com</strong> 5
c<strong>on</strong>servative CTS <str<strong>on</strong>g>the</str<strong>on</strong>g>rapies before c<strong>on</strong>sidering CTS surgery.<br />
Surgical patients treated three to five years after <str<strong>on</strong>g>the</str<strong>on</strong>g> <strong>on</strong>set of<br />
symptoms are less likely to have <strong>com</strong>plete symptom resoluti<strong>on</strong>.<br />
Therefore, early diagnosis and treatment are important. 12 It is far<br />
easier to prevent carpal tunnel syndrome than to cure it.<br />
<strong>Pain</strong> Syndromes That Mimic Carpal Tunnel<br />
Syndrome<br />
Several problems may mimic CTS, including cervical<br />
radiculopathy, thoracic outlet syndrome, median nerve<br />
entrapment in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm and trigger points, and poorly<br />
fitting gloves. (Fig. 5)<br />
Figure 5. Problems that may mimic CTS<br />
1. Cervical radiculopathy, 2. Thoracic outlet syndrome, 3. Median<br />
nerve entrapment in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm and trigger points, 4. CTS, 5.<br />
Poorly fitting gloves.<br />
Trigger points and nerve entrapment<br />
Although muscle-referred pain is a well-documented and<br />
researched phenomen<strong>on</strong>, 15,32 it is often overlooked as a possible<br />
source of pain syndromes. Trigger points in certain<br />
muscles may refer CTS-like symptoms into <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and<br />
wrist. 32<br />
Trigger points in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm muscles such as <str<strong>on</strong>g>the</str<strong>on</strong>g> pr<strong>on</strong>ator<br />
teres can cause <strong>com</strong>pressi<strong>on</strong> <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve and<br />
cause CTS-like pain in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and wrist. Since <str<strong>on</strong>g>the</str<strong>on</strong>g> median<br />
nerve runs through <str<strong>on</strong>g>the</str<strong>on</strong>g> pr<strong>on</strong>ator teres muscle, dental<br />
professi<strong>on</strong>als who operate with <str<strong>on</strong>g>the</str<strong>on</strong>g> forearms in a pr<strong>on</strong>ated<br />
(palms-down) positi<strong>on</strong> are at greater risk for this nerve en-<br />
trapment. 16,33-34 Neuromuscular technique and myofascial<br />
release are two popular approaches that have been used to<br />
treat this type of pain. Initially, dental professi<strong>on</strong>als should<br />
work with a healthcare professi<strong>on</strong>al, such as a certified<br />
neuromuscular <str<strong>on</strong>g>the</str<strong>on</strong>g>rapist or a <str<strong>on</strong>g>the</str<strong>on</strong>g>rapist who specializes in<br />
trigger point <str<strong>on</strong>g>the</str<strong>on</strong>g>rapy, to resolve pain of this origin. After reducti<strong>on</strong><br />
of symptoms, dentists may learn to self-treat <str<strong>on</strong>g>the</str<strong>on</strong>g>ir<br />
trigger points, since <str<strong>on</strong>g>the</str<strong>on</strong>g>ir jobs are a perpetuating factor. 35<br />
Median nerve entrapment in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm can be treated<br />
successfully if a holistic approach is taken to address <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
sum of <strong>com</strong>pressi<strong>on</strong> and tensi<strong>on</strong> <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> nerves in <str<strong>on</strong>g>the</str<strong>on</strong>g> upper<br />
extremity. 18<br />
Thoracic outlet syndrome (TOS)<br />
TOS is a neurovascular disorder resulting from pressure <strong>on</strong><br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> nerves and/or blood vessels that supply <str<strong>on</strong>g>the</str<strong>on</strong>g> arm, fingers<br />
and hand. (Fig. 6)<br />
Figure 6. Thoracic outlet<br />
The thoracic outlet, showing nerves and arteries that supply<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> arm.<br />
Tightness and/or trigger points in <str<strong>on</strong>g>the</str<strong>on</strong>g> pectoralis, anterior<br />
or middle scalenes may restrict <str<strong>on</strong>g>the</str<strong>on</strong>g> size of <str<strong>on</strong>g>the</str<strong>on</strong>g> thoracic<br />
outlet. 15,33,36 Compressi<strong>on</strong> of this neurovascular bundle may<br />
cause numbness and tingling that can mimic CTS; however,<br />
TOS may also include vascular symptoms (edema, coldness<br />
or discolorati<strong>on</strong>) in <str<strong>on</strong>g>the</str<strong>on</strong>g> hands and fingers. A thorough<br />
clinical evaluati<strong>on</strong> is <str<strong>on</strong>g>the</str<strong>on</strong>g> most important <strong>com</strong>p<strong>on</strong>ent for<br />
diagnosis of TOS; this should include subjective and objective<br />
findings as well as a review of daily activities and work<br />
6 www.ineedce.<strong>com</strong>
habits. The development of TOS has no involvement with<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> tend<strong>on</strong>s and soft tissues at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist, but that is where <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
symptoms tend to be perceived. In additi<strong>on</strong> to true TOS,<br />
patients may have thoracic outlet symptoms due to forward<br />
head posture, working with shoulders <strong>on</strong> a tilted axis,<br />
breathing from <str<strong>on</strong>g>the</str<strong>on</strong>g> chest and improper body mechanics. 15,36<br />
Thoracic outlet symptoms from <str<strong>on</strong>g>the</str<strong>on</strong>g>se sources can often be<br />
resolved with physical <str<strong>on</strong>g>the</str<strong>on</strong>g>rapy.<br />
Cervical radicular pain (cervical radiculopathy)<br />
<strong>Pain</strong> or pares<str<strong>on</strong>g>the</str<strong>on</strong>g>sia in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand may also originate in <str<strong>on</strong>g>the</str<strong>on</strong>g> cervical<br />
spine. 15 Nerve roots that supply <str<strong>on</strong>g>the</str<strong>on</strong>g> arm and hand may<br />
be<strong>com</strong>e <strong>com</strong>pressed as <str<strong>on</strong>g>the</str<strong>on</strong>g>y exit <str<strong>on</strong>g>the</str<strong>on</strong>g> spinal vertebrae, resulting<br />
in cervical radiculopathy. This may occur simultaneously<br />
with CTS (also known as “double crush” syndrome 33 ).<br />
Numbness in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand may be produced by changes in neck<br />
positi<strong>on</strong>, and muscle stretch reflexes tend to be diminished.<br />
Electrodiagnostic studies in this situati<strong>on</strong> would reveal<br />
a normal nerve c<strong>on</strong>ducti<strong>on</strong> velocity; however, <str<strong>on</strong>g>the</str<strong>on</strong>g> EMG<br />
may be abnormal in <str<strong>on</strong>g>the</str<strong>on</strong>g> distributi<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> involved nerve<br />
root. 15 A skilled electromyographer, usually a neurologist or<br />
physiatrist, is essential for accurate test results. The cause<br />
of cervical radiculopathy, more often than not, is due to forward<br />
head posture <strong>com</strong>bined with degenerative changes in<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> facet joints of <str<strong>on</strong>g>the</str<strong>on</strong>g> cervical spine.<br />
Poorly fitted gloves<br />
Improperly fitted gloves may cause CTS-type pain, primarily<br />
at <str<strong>on</strong>g>the</str<strong>on</strong>g> base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb. Ambidextrous gloves are generally<br />
molded with <str<strong>on</strong>g>the</str<strong>on</strong>g> hand in a flat (neutral) positi<strong>on</strong> and<br />
were originally designed for brief medical examinati<strong>on</strong>s. 37<br />
When gloves are used for l<strong>on</strong>ger procedures, as in dentistry,<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> operator’s hand must pull <str<strong>on</strong>g>the</str<strong>on</strong>g> glove into a working positi<strong>on</strong>,<br />
which may <strong>com</strong>press <str<strong>on</strong>g>the</str<strong>on</strong>g> back of <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and strain<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> muscles at <str<strong>on</strong>g>the</str<strong>on</strong>g> base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb, simultaneously reducing<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> blood flow to <str<strong>on</strong>g>the</str<strong>on</strong>g> hand. Ambidextrous gloves exert<br />
<strong>on</strong>e-third more force than do fitted gloves, 37 and muscle<br />
ischemia, nerve <strong>com</strong>pressi<strong>on</strong> and pain may result. Older<br />
practiti<strong>on</strong>ers may be more pr<strong>on</strong>e than younger practiti<strong>on</strong>ers<br />
to glove-related pain in <str<strong>on</strong>g>the</str<strong>on</strong>g> hands. 38 Tight gloves may also<br />
result in <str<strong>on</strong>g>the</str<strong>on</strong>g> above symptoms.<br />
Summary<br />
The cause of hand pain in dental professi<strong>on</strong>als may be multifactorial,<br />
and <str<strong>on</strong>g>the</str<strong>on</strong>g> etiology may not necessarily be related to<br />
a single structural problem at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist. There are numerous<br />
o<str<strong>on</strong>g>the</str<strong>on</strong>g>r pain syndromes of <str<strong>on</strong>g>the</str<strong>on</strong>g> hand/wrist and elbow to which<br />
dental professi<strong>on</strong>als are predisposed, including De Quervain’s<br />
syndrome, osteoarthritis of <str<strong>on</strong>g>the</str<strong>on</strong>g> carpometacarpal joint<br />
of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb, lateral epic<strong>on</strong>dylitis and o<str<strong>on</strong>g>the</str<strong>on</strong>g>rs.<br />
Regardless of <str<strong>on</strong>g>the</str<strong>on</strong>g> etiology of hand/wrist pain, dental<br />
professi<strong>on</strong>als should realize that <str<strong>on</strong>g>the</str<strong>on</strong>g>ir occupati<strong>on</strong> is a<br />
perpetuating factor for <str<strong>on</strong>g>the</str<strong>on</strong>g> development of this pain. 12,16,32<br />
Preventi<strong>on</strong> is of great importance, and interventi<strong>on</strong> strate-<br />
gies should be<strong>com</strong>e an integral habit in <str<strong>on</strong>g>the</str<strong>on</strong>g> operatory in <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
office and at home.<br />
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2. Alexopoulos EC, Stathi I, Charizani F. Prevalence<br />
of musculoskeletal disorders in dentists. BMC<br />
Musculoskelet Disord. 2004;5:16.<br />
3. Finsen L, Christensen H, Bakke M. Musculoskeletal<br />
disorders am<strong>on</strong>g dentists and variati<strong>on</strong> in dental<br />
work. Applied Erg<strong>on</strong>omics. 1997;29(2):119-25.<br />
4. Marshall ED, Dun<strong>com</strong>be LM, Robins<strong>on</strong> RQ,<br />
Kilbreath, SL. Musculoskeletal symptoms in New<br />
South Wales dentists. Aust Dent J. 1997;42(4):240-6.<br />
5. Rucker LM, Sunell S. Erg<strong>on</strong>omic Risk Factors<br />
Associated with Clinical Dentistry. CDA J.<br />
2002;30(2):139-48.<br />
6. Lalumandier J, McPhee S. Prevalence and risk factors<br />
of hand problems and carpal tunnel syndrome am<strong>on</strong>g<br />
dental hygienists. J Dent Hyg. 2001;75:130-3.<br />
7. Akess<strong>on</strong> I, Johnss<strong>on</strong> B, Rylander L, Moritz U,<br />
Skerfving S. Musculoskeletal disorders am<strong>on</strong>g female<br />
dental pers<strong>on</strong>nel—clinical examinati<strong>on</strong> and a 5-year<br />
follow-up study of symptoms. Int Arch Occup Envir<strong>on</strong><br />
Health. 1999;72:395-403.<br />
8. Akess<strong>on</strong> I, Schutz A, Horstmann V, Skerfving S,<br />
Moritz U. Musculoskeletal symptoms am<strong>on</strong>g dental<br />
pers<strong>on</strong>nel—lack of associati<strong>on</strong> with mercury and<br />
selenium status, overweight and smoking. Swed<br />
Dental J. 2000;24:23-8.<br />
9. Werner R, Hamann C, Franzblau A, Rodgers P.<br />
Prevalence of carpal tunnel syndrome and upper<br />
extremity tendinitis am<strong>on</strong>g dental hygienists. J Dent<br />
Hyg. 2002;76:126-32.<br />
10. Anto C, Aradhya P. Clinical diagnosis of peripheral<br />
nerve <strong>com</strong>pressi<strong>on</strong> in <str<strong>on</strong>g>the</str<strong>on</strong>g> upper extremity. Orthop<br />
Clin North Am. 1996;27:227-36.<br />
11. Phalen G. The carpal-tunnel syndrome: seventeen<br />
years’ experience in diagnosis and treatment of six<br />
hundred fifty-four hands. J B<strong>on</strong>e Joint Surg Am.<br />
1966;48:221-8.<br />
12. Mackin EJ, Callahan AD, Osterman AL, Skirven TM,<br />
Schneider LH. Rehabilitati<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> <str<strong>on</strong>g>Hand</str<strong>on</strong>g> and <str<strong>on</strong>g>Upper</str<strong>on</strong>g><br />
Extremity, 4th ed. St. Louis, MO: Mosby; 2002:644-<br />
67.<br />
13. Karwowski W, Marras WS. The Occupati<strong>on</strong>al<br />
Erg<strong>on</strong>omics <str<strong>on</strong>g>Hand</str<strong>on</strong>g>book. Boca Rat<strong>on</strong>, FL: CRC Press;<br />
1999:775-7, 821-5 1643-4.<br />
14. Rice VJ, Nindel B, Pentikis JS. Dental workers,<br />
musculoskeletal cumulative trauma, and carpal tunnel<br />
syndrome: who is at risk? A pilot study. Int J Occup<br />
Saf Erg<strong>on</strong>.1996;2(3):218-33.<br />
15. Cailliet R. Neck and Arm <strong>Pain</strong>. 3rd ed. Philadelphia,<br />
PA: F.A. Davis; 1991:195-7, 212, 215-8.<br />
16. Whyte-Fergus<strong>on</strong> L, Gerwin R. Clinical Mastery in<br />
www.ineedce.<strong>com</strong> 7
<str<strong>on</strong>g>the</str<strong>on</strong>g> Treatment of Myofascial <strong>Pain</strong>. Philadelphia, PA:<br />
Lippincott Williams & Wilkins; 2005:145-66.<br />
17. Chin DH, J<strong>on</strong>es NF. Repetitive moti<strong>on</strong> hand<br />
disorders. CDA J. 2002; 30(2):149-60.<br />
18. Erics<strong>on</strong>, WB. Median Nerve Entrapment in<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> Forearm: Diagnosis and Treatment, Poster<br />
presentati<strong>on</strong>, American Society for Surgery of <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
<str<strong>on</strong>g>Hand</str<strong>on</strong>g>, 59th Annual Meeting, NewYork, NY, 2004.<br />
19. Feldman RG, Goldman R, KeyserlingWM. Peripheral<br />
nerve entrapment syndromes and erg<strong>on</strong>omic factors.<br />
Am J Ind Med. 1983;4(5):661-81.<br />
20. Centers for Disease C<strong>on</strong>trol. Occupati<strong>on</strong>al disease<br />
surveillance: carpal tunnel syndrome. MMWR.<br />
1989;18:36-44.<br />
21. D<strong>on</strong>g H, Barr A, Loomer P, Rempel D. The effects of<br />
finger rest positi<strong>on</strong>s <strong>on</strong> hand muscle load and pinch<br />
force in simulated dental hygiene work. J Dent Educ.<br />
2005; 69(4):453-60.<br />
22. Pattis<strong>on</strong> AM, Matsuda S, Pattis<strong>on</strong> GL. Extraoral<br />
fulcrums—<str<strong>on</strong>g>the</str<strong>on</strong>g> essentials of using extraoral fulcrums<br />
for period<strong>on</strong>tal instrumentati<strong>on</strong>. Dimensi<strong>on</strong>s of Dental<br />
Hygiene. 2004;2(10):20, 21-3.<br />
23. Matsuda S. Technique—proper grasp. Dimensi<strong>on</strong>s of<br />
Dental Hygiene. 2005;3(9):26, 28.<br />
23. Matsuda S. Troubleshooting technique—sharpening.<br />
Dimensi<strong>on</strong>s of Dental Hygiene. 2005; 3(6):32, 34.<br />
24. Matsuda S. Instrumentati<strong>on</strong> of biofilm. Dimensi<strong>on</strong>s of<br />
Dental Hygiene. 2003;1(1):26-8, 30.<br />
25. Morse TF, Michalak-Turcotte C, Atwood-Sanders M,<br />
Warren N, Paters<strong>on</strong> DR, et al. A pilot study of hand<br />
and arm musculoskeletal disorders in dental hygiene<br />
students. J Dent Hyg. 2003; 77(30):173-9.<br />
26. D<strong>on</strong>g H, Barr A, Loomer P, LaRoche C, Young E,<br />
et al. The effects of period<strong>on</strong>tal instrument handle<br />
design <strong>on</strong> hand muscle load and pinch force. J Am<br />
Dent Assoc. 2006;137(8): 1123-30.<br />
27. Simmer-Beck M, Bray KK, Brans<strong>on</strong> B, Glaros A,<br />
Weeks J. Comparis<strong>on</strong> of muscle activity associated<br />
with structural differences in dental hygiene mirrors. J<br />
Dent Hyg. 2006; 80(1):8.<br />
28. Glasscoe D. The better way to sharpen dental<br />
instruments—CD. Professi<strong>on</strong>al Dental Management<br />
Inc. 2006.<br />
29. Kumar C. Biomechanics in Erg<strong>on</strong>omics. Philadelphia,<br />
PA: Taylor & Francis; 1999:165-75.<br />
30. Stockstill JW, Harn SD, Stickland D, Hruska R.<br />
Prevalence of upper extremity neuropathy in a clinical<br />
dentist populati<strong>on</strong>. J Am Dent Assoc. 1993;124:67-72.<br />
31. Weiss S, Falkenstein N. <str<strong>on</strong>g>Hand</str<strong>on</strong>g> Rehabilitati<strong>on</strong>: a Quick<br />
Reference Guide and Review, 2nd ed. St. Louis, MO:<br />
Elsevier Mosby; 2005:346.<br />
32. Travell JG, Sim<strong>on</strong>s DG, Sim<strong>on</strong>s LS. Myofascial <strong>Pain</strong><br />
and Dysfuncti<strong>on</strong>: The Trigger Point Manual, Vol. 1.<br />
Baltimore, MD: LippincottWilliams &Wilkins; 1999.<br />
33. Novak CB, Mackinn<strong>on</strong> SE. Repetitive use and static<br />
postures: a source of nerve <strong>com</strong>pressi<strong>on</strong> and pain. J<br />
<str<strong>on</strong>g>Hand</str<strong>on</strong>g> Ther. 1997;10(2):151-9.<br />
34. Adelman S, Eisner K. Arm pain in a dentist: pr<strong>on</strong>ator<br />
syndrome. J Am Dent Assoc. 1982; 105:61-2.<br />
35. Valachi B, Valachi K. Mechanisms c<strong>on</strong>tributing to<br />
musculoskeletal disorders in dentistry. J Am Dent<br />
Assoc. 2003;134:1344-50.<br />
36. Ritter A, Sensat M, Harn, S.Thoracic outlet syndrome:<br />
a review of <str<strong>on</strong>g>the</str<strong>on</strong>g> literature. J Dent Hyg. 1999;73:205-7.<br />
37. Powell BJ, Winkley GP, Brown JO, Etersque S.<br />
Evaluating <str<strong>on</strong>g>the</str<strong>on</strong>g> fit of ambidextrous and fitted gloves:<br />
implicati<strong>on</strong>s for hand dis<strong>com</strong>fort. J Am Dent Assoc.<br />
1994; 125:1235-42.<br />
38. Christensen G. Operating gloves: <str<strong>on</strong>g>the</str<strong>on</strong>g> good and <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
bad. J Am Dent Assoc. 2001;132:1455-57.<br />
Resources<br />
• This CE course is Chapter 5 from <str<strong>on</strong>g>the</str<strong>on</strong>g> author’s book,<br />
Practice Dentistry <strong>Pain</strong>-Free: Evidence-based Strategies to<br />
Prevent <strong>Pain</strong> & Extend Your Career – B. Valachi·<br />
• It’s Not Carpal Tunnel Syndrome! – S Damany/J.<br />
Bellis· Physics Forceps extracti<strong>on</strong> instrument at www.<br />
physicsforceps.<strong>com</strong><br />
• The following related resources are available <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> author’s<br />
website: www.postured<strong>on</strong>tics.<strong>com</strong>: Osteoarthritis<br />
vs. DeQuervain’s Disease in Dental Professi<strong>on</strong>als (newsletter<br />
archives) WrisTimer – for preventing carpal tunnel·<br />
Wrist/hand exercises for dental professi<strong>on</strong>als.<br />
Author Profile<br />
Bethany Valachi, PT, MS, CEAS.<br />
Ms. Valachi is a physical <str<strong>on</strong>g>the</str<strong>on</strong>g>rapist, dental erg<strong>on</strong>omic c<strong>on</strong>sultant<br />
and author of <str<strong>on</strong>g>the</str<strong>on</strong>g> book, “Practice Dentistry <strong>Pain</strong>-Free”.<br />
She is CEO of Postured<strong>on</strong>tics ® , a <strong>com</strong>pany that provides<br />
research-based dental erg<strong>on</strong>omic educati<strong>on</strong> and also lectures<br />
internati<strong>on</strong>ally—including <str<strong>on</strong>g>the</str<strong>on</strong>g> 2009 Internati<strong>on</strong>al Dental<br />
Erg<strong>on</strong>omics C<strong>on</strong>gress in Krakow, Poland. Clinical instructor<br />
of erg<strong>on</strong>omics at OHSU School of Dentistry in Portland, Oreg<strong>on</strong>,<br />
Bethany has provided expertise <strong>on</strong> dental erg<strong>on</strong>omics<br />
to faculty and students at numerous dental universities. She<br />
has been widely published in various peer-reviewed dental<br />
journals and has developed patient positi<strong>on</strong>ing, chairside<br />
stretching and home exercise DVDs specifically for dental<br />
professi<strong>on</strong>als. She offers free newsletters, articles and product<br />
reviews <strong>on</strong> her website at www.postured<strong>on</strong>tics.<strong>com</strong>.<br />
Disclaimer<br />
The author(s) of this course has/have no <strong>com</strong>mercial ties with<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> sp<strong>on</strong>sors or <str<strong>on</strong>g>the</str<strong>on</strong>g> providers of <str<strong>on</strong>g>the</str<strong>on</strong>g> unrestricted educati<strong>on</strong>al<br />
grant for this course.<br />
Reader Feedback<br />
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For your c<strong>on</strong>venience, an <strong>on</strong>line feedback form is available at<br />
www.ineedce.<strong>com</strong>.<br />
8 www.ineedce.<strong>com</strong>
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1. <str<strong>on</strong>g>Hand</str<strong>on</strong>g>, wrist and arm pain are much more<br />
prevalent am<strong>on</strong>g dental professi<strong>on</strong>als<br />
than <str<strong>on</strong>g>the</str<strong>on</strong>g> general public, due to ________.<br />
a. intermittent grips and sustained awkward postures<br />
b. sustained grips and prol<strong>on</strong>ged awkward postures<br />
c. sustained grips and erg<strong>on</strong>omic postures<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
2. Between _________ of dentists and nearly<br />
_________ of dental hygienists experience<br />
hand and wrist pain.<br />
a. 8 and 20 percent; 55 percent<br />
b. 13 and 25 percent; 65 percent<br />
c. 18 and 30 percent; 75 percent<br />
d. 23 and 40 percent; 75 percent<br />
3. The origins of pain in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand, wrist or<br />
arm are _________.<br />
a. never due to a problem in <str<strong>on</strong>g>the</str<strong>on</strong>g> same area<br />
b. always due to a problem in <str<strong>on</strong>g>the</str<strong>on</strong>g> same area<br />
c. always due to multiple problems<br />
d. sometimes due to a problem in ano<str<strong>on</strong>g>the</str<strong>on</strong>g>r area<br />
4. Carpal tunnel syndrome is <str<strong>on</strong>g>the</str<strong>on</strong>g> _________<br />
entrapment in <str<strong>on</strong>g>the</str<strong>on</strong>g> arm.<br />
a. least <strong>com</strong>m<strong>on</strong> peripheral nerve<br />
b. most <strong>com</strong>m<strong>on</strong> peripheral nerve<br />
c. least <strong>com</strong>m<strong>on</strong> regi<strong>on</strong>al nerve<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
5. For <str<strong>on</strong>g>the</str<strong>on</strong>g> hand to functi<strong>on</strong> properly,<br />
________ flexor tend<strong>on</strong>s and <str<strong>on</strong>g>the</str<strong>on</strong>g> median<br />
nerve must be able to glide easily within<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel.<br />
a. five<br />
b. seven<br />
c. nine<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
6. Flexing <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist forward and gripping a<br />
small instrument forcefully are two of <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
primary risk factors for _________.<br />
a. regi<strong>on</strong>al nerve pares<str<strong>on</strong>g>the</str<strong>on</strong>g>sia<br />
b. carpal tunnel syndrome<br />
c. trigger syndrome<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
7. _________ are primary risk factors for<br />
carpal tunnel syndrome.<br />
a. Low repetiti<strong>on</strong> work and l<strong>on</strong>g durati<strong>on</strong><br />
b. Low repetiti<strong>on</strong> work and short durati<strong>on</strong><br />
c. High repetiti<strong>on</strong> work and short durati<strong>on</strong><br />
d. High repetiti<strong>on</strong> work and l<strong>on</strong>g durati<strong>on</strong><br />
8. Trying to keep your wrist straight and<br />
moving your entire hand, wrist and<br />
forearm as a unit ________, and is an<br />
appropriate erg<strong>on</strong>omic interventi<strong>on</strong> to<br />
help prevent carpal tunnel syndrome.<br />
a. transfers <str<strong>on</strong>g>the</str<strong>on</strong>g> load from larger hand muscles to<br />
smaller arm and shoulder muscles<br />
b. transfers <str<strong>on</strong>g>the</str<strong>on</strong>g> load from smaller hand muscles to<br />
smaller arm and shoulder muscles<br />
c. transfers <str<strong>on</strong>g>the</str<strong>on</strong>g> load from smaller hand muscles to<br />
larger arm and shoulder muscles<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
9. Using an _________ instrument is<br />
preferable to angling your wrist while<br />
performing dental procedures.<br />
a. adjusted straight<br />
b. accentuated straight<br />
c. accentuated angled<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
10. _________ requires less force applied<br />
to <str<strong>on</strong>g>the</str<strong>on</strong>g> work surface and a less forceful<br />
precisi<strong>on</strong> grip than _________.<br />
a. Manual scaling; ultras<strong>on</strong>ic scaling<br />
b. Ultras<strong>on</strong>ic scaling; manual scaling<br />
c. Ultras<strong>on</strong>ic extracti<strong>on</strong>s; manual extracti<strong>on</strong>s<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
Questi<strong>on</strong>s<br />
11. The durati<strong>on</strong> of use of ei<str<strong>on</strong>g>the</str<strong>on</strong>g>r ultras<strong>on</strong>ic<br />
or manual instruments is positively associated<br />
with _________ numbness/tingling.<br />
a. lower extremity<br />
b. upper extremity<br />
c. upper and lower extremity<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
12. Larger instrument handle diameters<br />
_________ and pinch force.<br />
a. decrease arm muscle load<br />
b. increase arm muscle load<br />
c. increase hand muscle load<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
13. Alternating between _________ may<br />
help prevent CTS symptoms.<br />
a. pitch sizes<br />
b. handle diameter sizes<br />
c. chairs<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
14. _________ and lightweight instruments<br />
help reduce pinch forces and forceful<br />
pinch grips.<br />
a. Smooth<br />
b. Textured<br />
c. Mottled<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
15. _________ require <str<strong>on</strong>g>the</str<strong>on</strong>g> use of more<br />
force, and have a deleterious effect <strong>on</strong><br />
musculoskeletal health.<br />
a. fast instruments<br />
b. sharp instruments<br />
c. dull instruments<br />
d. a and c<br />
16. _________ has been shown to increase<br />
pressure in <str<strong>on</strong>g>the</str<strong>on</strong>g> carpal tunnel.<br />
a. Light pinch grip<br />
b. Forceful pinch grip<br />
c. Forceful back angulati<strong>on</strong><br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
17. Hygienists and dentists should try to use<br />
a _________ when possible.<br />
a. plantar grip<br />
b. palmar grip<br />
c. ulnar grip<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
18. Using 360-degree swivel instruments<br />
helps to _________.<br />
a. maintain neutral wrist and optimal finger<br />
positi<strong>on</strong><br />
b. maintain optimal neutral wrist and a lateral finger<br />
positi<strong>on</strong><br />
c. maintain optimal neutral wrist and finger positi<strong>on</strong><br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
19. Alternating between chairs with and<br />
without _________ can help avoid<br />
structural damage.<br />
a. rollers<br />
b. headrests<br />
c. armrests<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
20. Exposure to _________ is an aggravating<br />
risk factor associated with CTS.<br />
a. warmth<br />
b. cold<br />
c. humidity<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
21. Tinel’s sign is an electric shock–type sensati<strong>on</strong><br />
in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand when <str<strong>on</strong>g>the</str<strong>on</strong>g> _________ is<br />
tapped gently at <str<strong>on</strong>g>the</str<strong>on</strong>g> wrist and is often seen<br />
in patients with carpal tunnel syndrome.<br />
a. superior palmar nerve<br />
b. inferior palmar nerve<br />
c. median nerve<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
22. Weakness of <str<strong>on</strong>g>the</str<strong>on</strong>g> _________ muscles at <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
base of <str<strong>on</strong>g>the</str<strong>on</strong>g> thumb is often seen in patients<br />
with carpal tunnel syndrome.<br />
a. plantar<br />
b. <str<strong>on</strong>g>the</str<strong>on</strong>g>nar<br />
c. phenar<br />
d. n<strong>on</strong>e of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
23. Therapeutic interventi<strong>on</strong>s for <str<strong>on</strong>g>the</str<strong>on</strong>g> treatment<br />
of carpal tunnel syndrome include<br />
_________.<br />
a. ice<br />
b. massage<br />
c. ultrasound or acupuncture<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
24. _________ is a c<strong>on</strong>servative treatment<br />
opti<strong>on</strong> for carpal tunnel syndrome.<br />
a. Nerve or tend<strong>on</strong> gliding exercises<br />
b. Modificati<strong>on</strong> of activities to decrease tend<strong>on</strong> excursi<strong>on</strong><br />
c. The use of anti-inflammatories or cortis<strong>on</strong>e<br />
injecti<strong>on</strong>s<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
25. _________ may mimic carpal tunnel<br />
syndrome.<br />
a. Cervical radiculopathy<br />
b. Poorly fitting gloves<br />
c. Thoracic outlet syndrome<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
26. _________ can mimic carpal tunnel<br />
syndrome.<br />
a. median nerve entrapment<br />
b. cervical radiculopathy<br />
c. thoracic outlet syndrome<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
27. Ambidextrous gloves exert <strong>on</strong>e-third<br />
more force than do fitted gloves, and <str<strong>on</strong>g>the</str<strong>on</strong>g>ir<br />
use may result in _________.<br />
a. muscle ischemia<br />
b. nerve <strong>com</strong>pressi<strong>on</strong><br />
c. pain<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
28. Trigger points in <str<strong>on</strong>g>the</str<strong>on</strong>g> forearm muscles<br />
such as <str<strong>on</strong>g>the</str<strong>on</strong>g> _________ can cause <strong>com</strong>pressi<strong>on</strong><br />
<strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> median nerve and cause pain<br />
in <str<strong>on</strong>g>the</str<strong>on</strong>g> hand and wrist similar to that of<br />
carpal tunnel syndrome.<br />
a. pr<strong>on</strong>ator peretes<br />
b. dispator teres<br />
c. pr<strong>on</strong>ator teres<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
29. Older practiti<strong>on</strong>ers may be more pr<strong>on</strong>e<br />
than younger practiti<strong>on</strong>ers to _________<br />
pain in <str<strong>on</strong>g>the</str<strong>on</strong>g> hands.<br />
a. glove-related<br />
b. chair-related<br />
c. leg-related<br />
d. all of <str<strong>on</strong>g>the</str<strong>on</strong>g> above<br />
30. Interventi<strong>on</strong> strategies should be<strong>com</strong>e an<br />
integral habit _________ to help prevent<br />
carpal tunnel syndrome.<br />
a. in <str<strong>on</strong>g>the</str<strong>on</strong>g> operatory<br />
b. at home<br />
c. <strong>on</strong>ly while working<br />
d. a and b<br />
www.ineedce.<strong>com</strong> 9
ANSWER SHEET<br />
<str<strong>on</strong>g>Getting</str<strong>on</strong>g> <str<strong>on</strong>g>the</str<strong>on</strong>g> <str<strong>on</strong>g>Upper</str<strong>on</strong>g> <str<strong>on</strong>g>Hand</str<strong>on</strong>g> <strong>on</strong> <strong>Pain</strong>:<br />
<strong>Preventing</strong> <str<strong>on</strong>g>Hand</str<strong>on</strong>g> and Wrist <strong>Pain</strong> Syndromes in Dental Professi<strong>on</strong>als<br />
Name: Title: Specialty:<br />
Address: E-mail:<br />
City: State: ZIP: Country:<br />
Teleph<strong>on</strong>e: Home ( ) Office ( ) Lic. Renewal Date:<br />
Requirements for successful <strong>com</strong>pleti<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> course and to obtain dental c<strong>on</strong>tinuing educati<strong>on</strong> credits: 1) Read <str<strong>on</strong>g>the</str<strong>on</strong>g> entire course. 2) Complete all<br />
informati<strong>on</strong> above. 3) Complete answer sheets in ei<str<strong>on</strong>g>the</str<strong>on</strong>g>r pen or pencil. 4) Mark <strong>on</strong>ly <strong>on</strong>e answer for each questi<strong>on</strong>. 5) A score of 70% <strong>on</strong> this test will earn<br />
you 2 CE credits. 6) Complete <str<strong>on</strong>g>the</str<strong>on</strong>g> Course Evaluati<strong>on</strong> below. 7) Make check payable to PennWell Corp. For Questi<strong>on</strong>s Call 216.398.7822<br />
Educati<strong>on</strong>al Objectives<br />
1. List and describe four of <str<strong>on</strong>g>the</str<strong>on</strong>g> primary risk factors associated with carpal tunnel syndrome<br />
2. List and describe erg<strong>on</strong>omic interventi<strong>on</strong>s that can help prevent carpal tunnel syndrome<br />
3. List and describe o<str<strong>on</strong>g>the</str<strong>on</strong>g>r c<strong>on</strong>diti<strong>on</strong>s that may mimic carpal tunnel syndrome<br />
4. Provide an overview of <str<strong>on</strong>g>the</str<strong>on</strong>g> diagnosis and treatment of carpal tunnel syndrome<br />
Course Evaluati<strong>on</strong><br />
Please evaluate this course by resp<strong>on</strong>ding to <str<strong>on</strong>g>the</str<strong>on</strong>g> following statements, using a scale of Excellent = 5 to Poor = 0.<br />
1.Were <str<strong>on</strong>g>the</str<strong>on</strong>g> individual course objectives met? Objective #1: Yes No Objective #3: Yes No<br />
Objective #2: Yes No Objective #4: Yes No<br />
2.To what extent were <str<strong>on</strong>g>the</str<strong>on</strong>g> course objectives ac<strong>com</strong>plished overall? 5 4 3 2 1 0<br />
3. Please rate your pers<strong>on</strong>al mastery of <str<strong>on</strong>g>the</str<strong>on</strong>g> course objectives. 5 4 3 2 1 0<br />
4. How would you rate <str<strong>on</strong>g>the</str<strong>on</strong>g> objectives and educati<strong>on</strong>al methods? 5 4 3 2 1 0<br />
5. How do you rate <str<strong>on</strong>g>the</str<strong>on</strong>g> author’s grasp of <str<strong>on</strong>g>the</str<strong>on</strong>g> topic? 5 4 3 2 1 0<br />
6. Please rate <str<strong>on</strong>g>the</str<strong>on</strong>g> instructor’s effectiveness. 5 4 3 2 1 0<br />
7.Was <str<strong>on</strong>g>the</str<strong>on</strong>g> overall administrati<strong>on</strong> of <str<strong>on</strong>g>the</str<strong>on</strong>g> course effective? 5 4 3 2 1 0<br />
8. Do you feel that <str<strong>on</strong>g>the</str<strong>on</strong>g> references were adequate? Yes No<br />
9.Would you participate in a similar program <strong>on</strong> a different topic? Yes No<br />
10. If any of <str<strong>on</strong>g>the</str<strong>on</strong>g> c<strong>on</strong>tinuing educati<strong>on</strong> questi<strong>on</strong>s were unclear or ambiguous, please list <str<strong>on</strong>g>the</str<strong>on</strong>g>m.<br />
___________________________________________________________________<br />
11.Was <str<strong>on</strong>g>the</str<strong>on</strong>g>re any subject matter you found c<strong>on</strong>fusing? Please describe.<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
12.What additi<strong>on</strong>al c<strong>on</strong>tinuing dental educati<strong>on</strong> topics would you like to see?<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
AUTHOR DISCLAIMER<br />
The author(s) of this course has/have no <strong>com</strong>mercial ties with <str<strong>on</strong>g>the</str<strong>on</strong>g> sp<strong>on</strong>sors or <str<strong>on</strong>g>the</str<strong>on</strong>g> providers of<br />
<str<strong>on</strong>g>the</str<strong>on</strong>g> unrestricted educati<strong>on</strong>al grant for this course.<br />
SPONSOR/PROVIDER<br />
This course was made possible through an unrestricted educati<strong>on</strong>al grant. No<br />
manufacturer or third party has had any input into <str<strong>on</strong>g>the</str<strong>on</strong>g> development of course c<strong>on</strong>tent.<br />
All c<strong>on</strong>tent has been derived from references listed, and or <str<strong>on</strong>g>the</str<strong>on</strong>g> opini<strong>on</strong>s of clinicians.<br />
Please direct all questi<strong>on</strong>s pertaining to PennWell or <str<strong>on</strong>g>the</str<strong>on</strong>g> administrati<strong>on</strong> of this course to<br />
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.<strong>com</strong>.<br />
COURSE EVALUATION and PARTICIPANT FEEDBACK<br />
We encourage participant feedback pertaining to all courses. Please be sure to <strong>com</strong>plete <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
survey included with <str<strong>on</strong>g>the</str<strong>on</strong>g> course. Please e-mail all questi<strong>on</strong>s to: macheleg@pennwell.<strong>com</strong>.<br />
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.<br />
INSTRUCTIONS<br />
All questi<strong>on</strong>s should have <strong>on</strong>ly <strong>on</strong>e answer. Grading of this examinati<strong>on</strong> is d<strong>on</strong>e<br />
manually. Participants will receive c<strong>on</strong>firmati<strong>on</strong> of passing by receipt of a verificati<strong>on</strong><br />
form. Verificati<strong>on</strong> forms will be mailed within two weeks after taking an examinati<strong>on</strong>.<br />
EDUCATIONAL DISCLAIMER<br />
The opini<strong>on</strong>s of efficacy or perceived value of any products or <strong>com</strong>panies menti<strong>on</strong>ed<br />
in this course and expressed herein are those of <str<strong>on</strong>g>the</str<strong>on</strong>g> author(s) of <str<strong>on</strong>g>the</str<strong>on</strong>g> course and do not<br />
necessarily reflect those of PennWell.<br />
Completing a single c<strong>on</strong>tinuing educati<strong>on</strong> course does not provide enough informati<strong>on</strong><br />
to give <str<strong>on</strong>g>the</str<strong>on</strong>g> participant <str<strong>on</strong>g>the</str<strong>on</strong>g> feeling that s/he is an expert in <str<strong>on</strong>g>the</str<strong>on</strong>g> field related to <str<strong>on</strong>g>the</str<strong>on</strong>g> course<br />
topic. It is a <strong>com</strong>binati<strong>on</strong> of many educati<strong>on</strong>al courses and clinical experience that<br />
allows <str<strong>on</strong>g>the</str<strong>on</strong>g> participant to develop skills and expertise.<br />
If not taking <strong>on</strong>line, mail <strong>com</strong>pleted answer sheet to<br />
Academy of Dental Therapeutics and Stomatology,<br />
A Divisi<strong>on</strong> of PennWell Corp.<br />
P.O. Box 116, Chesterland, OH 44026<br />
or fax to: (440) 845-3447<br />
COURSE CREDITS/COST<br />
All participants scoring at least 70% <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> examinati<strong>on</strong> will receive a verificati<strong>on</strong><br />
form verifying 2 CE credits. The formal c<strong>on</strong>tinuing educati<strong>on</strong> program of this sp<strong>on</strong>sor<br />
is accepted by <str<strong>on</strong>g>the</str<strong>on</strong>g> AGD for Fellowship/Mastership credit. Please c<strong>on</strong>tact PennWell for<br />
current term of acceptance. Participants are urged to c<strong>on</strong>tact <str<strong>on</strong>g>the</str<strong>on</strong>g>ir state dental boards<br />
for c<strong>on</strong>tinuing educati<strong>on</strong> requirements. PennWell is a California Provider. The California<br />
Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.<br />
Many PennWell self-study courses have been approved by <str<strong>on</strong>g>the</str<strong>on</strong>g> Dental Assisting Nati<strong>on</strong>al<br />
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet<br />
DANB’s annual c<strong>on</strong>tinuing educati<strong>on</strong> requirements. To find out if this course or any o<str<strong>on</strong>g>the</str<strong>on</strong>g>r<br />
PennWell course has been approved by DANB, please c<strong>on</strong>tact DANB’s Recertificati<strong>on</strong><br />
Department at 1-800-FOR-DANB, ext. 445.<br />
For immediate results, go to www.ineedce.<strong>com</strong><br />
and click <strong>on</strong> <str<strong>on</strong>g>the</str<strong>on</strong>g> butt<strong>on</strong> “take tests Online.” answer<br />
sheets can be faxed with credit card payment to<br />
(440) 845-3447, (216) 398-7922, or (216) 255-6619.<br />
Payment of $49.00 is enclosed.<br />
(Checks and credit cards are accepted.)<br />
If paying by credit card, please <strong>com</strong>plete <str<strong>on</strong>g>the</str<strong>on</strong>g><br />
following: MC Visa AmEx Discover<br />
Acct. Number: ______________________________<br />
Exp. Date: _____________________<br />
Charges <strong>on</strong> your statement will show up as PennWell<br />
AGD Code 130<br />
RECORD KEEPING<br />
PennWell maintains records of your successful <strong>com</strong>pleti<strong>on</strong> of any exam. Please c<strong>on</strong>tact our<br />
offices for a copy of your c<strong>on</strong>tinuing educati<strong>on</strong> credits report. This report, which will list<br />
all credits earned to date, will be generated and mailed to you within five business days<br />
of receipt.<br />
CANCELLATION/REFUND POLICY<br />
Any participant who is not 100% satisfied with this course can request a full refund by<br />
c<strong>on</strong>tacting PennWell in writing.<br />
© 2010 by <str<strong>on</strong>g>the</str<strong>on</strong>g> Academy of Dental Therapeutics and Stomatology, a divisi<strong>on</strong><br />
of PennWell<br />
10 Customer Service 216.398.7822 www.ineedce.<strong>com</strong>