Journal of Indian Association of Public Health Dentistry

: 2019  |  Volume : 17  |  Issue : 3  |  Page : 241--246

Prevalence of musculoskeletal disorders affecting general dental practitioners in nagpur and proposal of a new composite classification system

Ajit D Joshi1, Harleen Kaur Soni2, Abha S Hedaoo3, Chandrashekhar R Bande3, Manu R Goel3, Akshay A Mishra3,  
1 Department of Dentistry, Government Medical College and Hospital, Chandrapur, Maharashtra, India
2 Department of Pedodontics and Preventive Dentistry, Manubhai Patel Dental College, Vadodara, Gujarat, India
3 Department of Oral and Maxillofacial Surgery, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India

Correspondence Address:
Dr. Ajit D Joshi
Department of Dentistry, Government Medical College and Hospital, Chandrapur - 442 401, Maharashtra


Background: Occupational hazards are common among dental professionals, and musculoskeletal disorders (MSDs) are very common. Aim: The aim is to report the prevalence and distribution of MSD among dental professionals practicing in Nagpur, India. Materials and Methods: A cross-sectional questionnaire study was conducted among 500 dental professionals from December 2016 to November 2017. The professionals were distributed in three groups (Group A, B, and C) based on the work experience in years. The questionnaire was designed to evaluate physical health related to MSD. Statistical analysis was performed by descriptive and inferential statistics using SPSS 17.0 version (Chicago, USA) software and the data were presented in counts and percentages, with P ≤ 0.05 is considered as the level of statistical significance. Results: In Group A, 24% of participants suffered pain in lower back while 4% of participants suffered from pain in multiple regions. In Group B, 27% of participants suffered pain in lower back whereas 5% experienced pain in multiple regions. In Group C, 34% of participants suffered pain in lower back whereas 17% experienced pain in multiple regions. The most common specific disorder among dental professionals was tendonitis of the shoulder and repetitive strain injury. There was an increasing trend in the presence of neurological pain with increase in number of years in dental practice. Conclusions: The musculoskeletal region most frequently affected in all three groups was lower and upper back contributing about 40% regions affected. However, there was no pain recorded among 32% in dental professionals. Pain involving the body parts depends on the posture, time, and procedures. Dental professionals always need to maintain multiple postures for prolonged periods; therefore, dental procedures should be divided into multiple appointments to minimize the time-consuming procedures. A daily routine should be followed with exercise or yoga for strain-free muscular activities.

How to cite this article:
Joshi AD, Soni HK, Hedaoo AS, Bande CR, Goel MR, Mishra AA. Prevalence of musculoskeletal disorders affecting general dental practitioners in nagpur and proposal of a new composite classification system.J Indian Assoc Public Health Dent 2019;17:241-246

How to cite this URL:
Joshi AD, Soni HK, Hedaoo AS, Bande CR, Goel MR, Mishra AA. Prevalence of musculoskeletal disorders affecting general dental practitioners in nagpur and proposal of a new composite classification system. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Nov 19 ];17:241-246
Available from:

Full Text


Occupational hazards are common among many professionals, including dental specialties. The occupational hazards found in dental practitioners are percutaneous injuries, inhalation of noxious chemicals, loss of hearing, and musculoskeletal disorders (MSDs).[1] The prevalence of MSD in dental professionals is reported to be between 60% and 90%.[2],[3] It represents both acute and chronic injuries affecting the muscles, tendons, nerves, joints, spinal discs, and ligament injuries particularly associated with wrist, fingers, elbow, shoulder, neck, and back.[4] Dental professionals are always at risk pertaining to the occupational health hazards and the development of cumulative trauma disorders. They often have to settle into static positions that are uncomfortable and asymmetric. The dental practitioners stand or sit for prolonged periods and maintain the head, neck, and shoulders in fixed positions for long intervals. In dentistry, uncomfortable working habits, improper posture, faulty ergonomics, and repetitive tasks, such as cavity preparation, root canal instrumentation, extractions and filling, scaling contribute greatly to MSD, and finally leads to fatigue.[5],[6] In the last decade, various researchers have cited high prevalence of MSD among dental professionals.[7],[8],[9],[10]

Multiple areas are affected due to MSD, but the most affected regions were found to be the back followed by the neck.[10] The necessity for the prevention of these disorders has been identified with the modification of risk factors associated with the profession.[4] The objective of this study is to report the occurrence of MSD among dental professionals practicing in Nagpur, India, and propose a new composite classification system of MSD affecting general dental practitioners (certified general dentists).

 Materials and Methods

Study participants

A cross-sectional questionnaire study was conducted among private dental practitioners in Nagpur District from December 2016 to November 2017. All the participants were general dentists practicing comprehensive dentistry.

Ethical committee clearance

The study protocol was sanctioned by the Institutional Review Board and Ethical Committee (SDKS/STRG/Fac1/OS/2016).

Study group consent

An informed consent and written permission were obtained from the study participants, after explaining the study in detail.

Inclusion criteria

Dentists willing to participate in the studyDentists with at least 1 year of clinical experience.

Exclusion criteria

Professionals with pregnancy, recent fractures, or surgeries.

Sample size

All the private practitioners (including specialists) practicing general dentistry in Nagpur city, Maharashtra and registered under the Dental Council of India were included in the study.


A questionnaire was designed and distributed in all the three groups to evaluate the physical health related to MSD, their self-reported general health, individual working environment, and work habits. The questionnaire was prepared in English and vernacular language for data collection. This was distributed among the dental practitioners, and completed questionnaires were collected from them within 1 week. They were given the opportunity to make inquiries or comments about the questions after the collection of questionnaire.

The validity of questionnaire was determined by carrying pilot study by asking the 20 practitioners to refill the questionnaire after 2 weeks and reliability of the questionnaire was determined using Cronbach's alpha coefficient test value degree 0.92.

Musculoskeletal disorder evaluation

The effect of MSD related to general dental professionals was evaluated according to the four criteria; (a) type of disorder; (b) body parts involved; (c) involvement of diseases, and (d) neurological signs, as described by the various literatures that fulfill the eligibility criteria.[10],[11],[12],[13],[14],[15]

Study design

Three groups were formulated, based on their experience of dentistry in years are as follows:

Group A: Experience of 1–4 years (n = 233)Group B: Experience of 5–9 years (n = 147)Group C: Experience of 10 or more than 10 years (n = 120).

Statistical analysis

Being an exploratory study, the data were presented in counts and percentages. Statistical analysis was performed by descriptive and inferential statistics using SPSS 17.0 (Chicago, USA) version software and Graph Pad Prism 6.0 version, (San Diego, California). P ≤ 0.05 is considered as the level of statistical significance.


Of 622 practicing dental practitioners, 86 were not willing to participate in the study. Total 536 dental practitioners filled the questionnaire, out of which 36 questionnaires were incomplete and were excluded from the study.

The study demographics included 500 dental practitioners, out of which 43% male and 57% were female. The age group of the participants under the study ranged from 21 to 50 years (mean = 28.4 years) [Figure 1] and [Figure 2]. The overall prevalence of MSD among study subjects was 67.8%.{Figure 1}{Figure 2}

Type of disorder

In Group A, 54.5% of participants had pain in a single specific region and 4.29% suffered from pain in multiple regions. Whereas, in Group B and Group C, 65.3% and 65.83% of participants had pain in a single specific region, respectively, and 4.29% and 16.67% suffered from pain in multiple regions [Table 1].{Table 1}

According to body parts affected

In Group A, the results revealed that out of 233 practitioners, 57 participants (24%) suffered pain in lower back while other regions affected in descending order were upper back (14%), shoulders (9%) and neck (7%). Whereas in Group B, of 147 practitioners, 39 participants (27%) suffered pain in lower back while 1 participant (1%) experienced pain in the elbow. Other regions affected in descending order were shoulders (15%), upper back (12%), neck (12%), and pain in multiple regions (5%). In Group C, of 120 practitioners, 40 participants (34%) suffered pain in lower back while 13 participants (11%) experienced pain in upper back, shoulders, and neck each. However, 20 practitioners suffered pain in multiple regions (17%). Cumulatively, when all three groups were compared, the most affected region among dental practitioners in the tested sample was lower back (27%), followed by upper back (13%), shoulders (11%), neck (9%), multiple (7%), and elbow (0.2%) [Table 2].{Table 2}

Involvement of diseases

In Group A, the involvement of disease is found to be 0.6% specific and 1.2% nonspecific whereas, in Group B and Group C, the involvement of disease is found to be 0.6% and 0.8% specific and 1.4% and 1.2% nonspecific, respectively. The most common specific disorder among dental professionals was tendonitis of the shoulder and repetitive strain injury (RSI). The cumulative involvement of 2% specific and 3.8% nonspecific was found in 500 general dental practitioners [Table 3].{Table 3}

Neurological signs

In Group A, the involvement of neurological signs was found to be present in 58.80% of participants whereas, in Group B and Group C, the involvement was 72.11% and 83.33% [Table 4].{Table 4}


MSDs are conditions that affect the muscles, nerves, tendons, and supporting structures. MSD occur with symptoms that range from mild, short-lasting pain, or discomfort to a more severe, prolonged, intense, and chronic pain.[16] Musculoskeletal pain can be an occupational health problem for medical professionals, particularly surgeons and dental surgeons, who maintain static postures using precision hand and wrist movements.[17],[18] These disorders commonly affect neck, shoulders, upper and lower back, and wrist regions.

There are limited studies about musculoskeletal pain among Indian dentists' population, and there is no classification for the same. The mean values of the disorders affecting back, neck, and shoulders worldwide were found to be 47%, 44%, and 29%, respectively.[19] Since all the dental practitioners' work revolves around the usage of their hands, with long hours in the seated-bent position most of the time, MSD will have a negative impact on the productivity and efficiency of work.[20] Therefore, the present study was undertaken to assess the impact of MSD affecting the dental practitioners.

The present study reveals that the musculoskeletal region most frequently affected in all the three groups: Group A, Group B, and Group C were the lower back with 24%, 27%, and 34%, respectively. The less frequently affected region was neck with 7%, 12%, and 11% incidence, respectively. A rare finding of pain in elbow (1%) was found in Group B. An identical study conducted by Alghadir et al. stated that regions most commonly affected were lower back (60%), neck/shoulder (48%), hand (27%), upper back (23%), foot, lower back/buttocks (14%), lower leg (7%), thighs/knee (5%), others (3%), and elbow (2%).[11]

Similar results were obtained by Chandra et al. who reported the incidence of lower back pain is 38.01% and 13.02% in the neck.[12] However, a study conducted by Bhagwat et al. concluded that the most affected region is back (39%) and least affected regions were knees and legs (1%).[13]

Contrary to our results, in a study by Muralidharan et al., the most commonly affected by MSD in order of magnitude were neck (52%), low back (41%), shoulders (29%), and wrist (26%).[14] Similarly, in a study by Nagarajappa and Thakur, the most common areas affected by MSD in order of magnitude were neck and upper back (52.3%), lower back (30.2%), hands and fingers (11.6%), and forearm (5.8%).[15]

There number of practitioners with neurological signs increased progressively among the groups. 83.33% of practitioners with an experience of more than 10 years' experienced positive neurological signs.

In a study by Rambabu and Suneetha, they evaluated MSDs in terms of the perception of pain experienced by physicians, surgeons, and dental surgeons during professional work. They concluded that there is a higher prevalence of MSDs experienced by dental surgeons than physicians and surgeons.[21]

MSD affect various body parts and can be broadly classified based on various factors. Classification helps clinicians and researchers to communicate about the impact of disorder over various body regions and zones and its prognosis. Beaton et al. categorized MSD affecting upper limb based on zones, type of disorder, neurological signs, and duration.[19] Various authors have reported MSD in different occupations such as health professionals, laborers, office, and factory workers.[22],[23],[24],[25],[26],[27],[28],[29] However, there has not been any classification, collaborating all the factors causing MSD affecting them. Therefore, according to the findings, MSD can be classified compositely for general dental practitioners.

AJ's classification of musculoskeletal disorders in general dental practitioners

This classification is based on the following four factors [Figure 3]:{Figure 3}

Type of disorderBody parts involvedInvolvement of diseasesNeurological signs.

Type of disorder

MSD can be broadly categorized into (1) asymptomatic (no pain or discomfort), (2) regional (one or two zones involvement on one side), (3) single specific (one specific disorder on one side), (4) multiple specific (one or more specific disorders on one or both sides), and (5) diffuse (more than two zones on one or both sides or one zone on each side).[20]

Body parts involved

Considering the body parts, MSD can be classified as disorders affecting (1) upper body parts, (2) lower, (3) central, and (4) peripheral body parts. This division of body parts can also include the category of the regional type of MSD.

Similarly, each region is further divided into its parts which can be considered as affected by single specific types of MSD. Upper body parts can be divided into shoulder and upper arm which inadvertently fall into regions affected by single specific type of MSD. The lower body parts can be further divided into lower back and thigh, while central into neck along with upper back and periphery into wrist, elbow, knee, ankle, and phalanges which can be included in single-specific type of MSD too.

Involvement of diseases

MSD can also be categorized into nonspecific (local/acquired) and specific (systemic). MSD affecting locally or not associated with any systemic disorders are termed as nonspecific MSD. Nonspecific MSD includes inflammation in tendons of the shoulder leading to tendinitis, work-related disorders, wrist, and forearm injuries may lead to carpal tunnel syndrome, RSI, de Quervain's Syndrome, and Elbow injury leading to Epicondylitis (Tennis or Golfer's elbow).[30]

MSD associated with systemic disorders can be termed as specific MSD. Systemic MSD can be listed as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, fibromyalgia, gout, polymyalgia, rheumatica lupus, and juvenile arthritis which can be categorized into the specific or systemic type of MSD.

Neurological signs

According to the involvement of nerves, MSD can simply be classified as disorders with positive neurological signs and with no signs.[19]

This is just an attempt to club, summarize, and put forward a composite classification system of pathological conditions causing pain to correlate the occupational hazards with involvement of regions along with body parts, types, and involvement of diseases with presence or absence or any possible neurological signs and symptoms (pain, tenderness, and numbness) contributing the medical terms categorized by the various authors.[19],[20],[30]


The study sample constituted of only 500 dental practitioners practicing in Nagpur city, Maharashtra, India. Validity and applicability of the classification need to be tested further with a larger sample group. Self-reported accounts of the study subjects in regards of involvement of diseases and neurological symptoms would lead to reporting of false increased prevalence of the disease among them. These subjective findings are to be confirmed with valid diagnostic tests for reducing the margin of error in recording the prevalence.


Many classifications have been given to address various factors and properties of MSD among professionals and workers. However, there is no classification specifically designed for dental professionals. Thereby, an attempt has been made to provide a comprehensive classification for MSD affecting dental professionals and is recommended for the ease of identifying and isolating the MSDs affecting dentists.


Pain involving various body parts depends on the posture, time, and the procedures performed by the operator. Depending on the work, dental practitioners need to maintain the posture for prolonged periods. Ergonomics and proper posture should be given utmost importance at all times. All long dental procedures should be divided into multiple short breaks in a single appointment, while some procedures should be divided into multiple appointments. We advocate that all dental practitioners must make exercise and yoga, a daily regimen to maintain muscle tone and strain-free posture to avoid physical exhaustion, fatigue, and MSD.


The authors would like to acknowledge the Institute “Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India” for their support and resources.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Finsen L, Christensen H, Bakke M. Musculoskeletal disorders among dentists and variation in dental work. Appl Ergon 1998;29:119-25.
2Dawson OM, Hallett M, Millender LH. Digital nerve entrapment in the hand. In: Entrapment Neuropathies. Boston, Toronto: Little, Brown and Company; 1983. p. 18594.
3Fish DR, Morris-Allen DM. Musculoskeletal disorders in dentists. N Y State Dent J 1998;64:44-8.
4Gambhir RS, Singh G, Sharma S, Brar R, Kakar H. Occupational health hazards in current dental profession – A review. Open Occup Health Saf J 2011;3:57-64.
5Akesson I, Hansson GA, Balogh I, Moritz U, Skerfving S. Quantifying work load in neck, shoulders and wrists in female dentists. Int Arch Occup Environ Health 1997;69:461-74.
6Valachi B, Valachi K. Mechanisms leading to musculoskeletal disorders in dentistry. J Am Dent Assoc 2003;134:1344-50.
7Szymańska J. Disorders of the musculoskeletal system among dentists from the aspect of ergonomics and prophylaxis. Ann Agric Environ Med 2002;9:169-73.
8Akesson I, Lundborg G, Horstmann V, Skerfving S. Neuropathy in female dental personnel exposed to high frequency vibrations. Occup Environ Med 1995;52:116-23.
9Sharma P, Golchha V. Awareness among Indian dentist regarding the role of physical activity in prevention of work related musculoskeletal disorders. Indian J Dent Res 2011;22:381-4.
10Hayes M, Cockrell D, Smith DR. A systematic review of musculoskeletal disorders among dental professionals. Int J Dent Hyg 2009;7:159-65.
11Alghadir A, Zafar H, Iqbal ZA. Work-related musculoskeletal disorders among dental professionals in Saudi Arabia. J Phys Ther Sci 2015;27:1107-12.
12Chandra S, Shahi AK, Bhargava R. Prevalence of neck and lower back pain among dentists from three dental colleges in Patna city: A questionnaire study. Int J Sci Stud 2015;3:71-6.
13Bhagwat S, Hegde S, Mandke L. Prevalence of MSD among Indian dental professionals: A pilot survey with assessment by rapid entire body assessment. World J Dent 2015;6:39-44.
14Muralidharan D, Fareed N, Shanthi M. Musculoskeletal disorders among dental practitioners: Does it affect practice? Epidemiol Res Int 2013;2013:1-6.
15Nagarajappa R, Thakur P. Prevalence of work-related musculoskeletal disorders among dental practitioners in Kanpur, India. Natl J Integr Res Med 2015;6:67-73.
16Amell T, Kumar S. Work-related musculoskeletal disorders: Design as a prevention strategy. A review. J Occup Rehabil 2001;11:255-65.
17European Commission. Work and health in the EU, a statistical portrait. Luxembourg. Luxembourg Publishers; 2003. ISBN No. 92-894-7006-2.
18Szeto GP, Ho P, Ting AC, Poon JT, Cheng SW, Tsang RC. Work-related musculoskeletal symptoms in surgeons. J Occup Rehabil 2009;19:175-84.
19Beaton DE, Bombardier C, Cole DC, Hogg-Johnson S, Van Eerd D. A pattern recognition approach to the development of a classification system for upper-limb musculoskeletal disorders of workers. Scand J Work Environ Health 2007;33:131-39.
20Murtomaa H. Work-related complaints of dentists and dental assistants. Int Arch Occup Environ Health 1982;50:231-6.
21Rambabu T, Suneetha K. Prevalence of work related musculoskeletal disorders among physicians, surgeons and dentists: A comparative study. Ann Med Health Sci Res 2014;4:578-82.
22Akrouf QA, Crawford JO, Al-Shatti AS, Kamel MI. Musculoskeletal disorders among bank office workers in Kuwait. East Mediterr Health J 2010;16:94-100.
23Harcombe H, McBride D, Derrett S, Gray A. Prevalence and impact of musculoskeletal disorders in New Zealand nurses, postal workers and office workers. Aust N Z J Public Health 2009;33:437-41.
24Goldsheyder D, Weiner SS, Nordin M, Hiebert R. Musculoskeletal symptom survey among cement and concrete workers. Work 2004;23:111-21.
25Yu W, Yu IT, Li Z, Wang X, Sun T, Lin H, et al. Work-related injuries and musculoskeletal disorders among factory workers in a major city of China. Accid Anal Prev 2012;48:457-63.
26Fernandes Rde C, Assunção AA, Silvany Neto AM, Carvalho FM. Musculoskeletal disorders among workers in plastic manufacturing plants. Rev Bras Epidemiol 2010;13:11-20.
27Ruess L, O'Connor SC, Cho KH, Hussain FH, Howard WJ 3rd, Slaughter RC, et al. Carpal tunnel syndrome and cubital tunnel syndrome: Work-related musculoskeletal disorders in four symptomatic radiologists. AJR Am J Roentgenol 2003;181:37-42.
28Wang PC, Rempel DM, Harrison RJ, Chan J, Ritz BR. Work-organisational and personal factors associated with upper body musculoskeletal disorders among sewing machine operators. Occup Environ Med 2007;64:806-13.
29Berberoǧlu U, Tokuç B. Work-related musculoskeletal disorders at two textile factories in Edirne, Turkey. Balkan Med J 2013;30:23-7.
30Van Eerd D, Beaton D, Cole D, Lucas J, Hogg-Johnson S, Bombardier C. Classification systems for upper-limb musculoskeletal disorders in workers: A review of the literature. J Clin Epidemiol 2003;56:925-36.