Hand Health. How to prevent and manage soft tissue disorders of

Indiana University - Purdue University Fort Wayne
Opus: Research & Creativity at IPFW
Dental Education Faculty Publications
Department of Dental Education
2011
Hand Health. How to prevent and manage soft
tissue disorders of the hands.
Nancy K. Mann
Indiana University - Purdue University Fort Wayne, mannn@ipfw.edu
Mary D. Cooper
Indiana University - Purdue University Fort Wayne, cooper@ipfw.edu
Follow this and additional works at: http://opus.ipfw.edu/dental_facpubs
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Opus Citation
Nancy K. Mann and Mary D. Cooper (2011). Hand Health. How to prevent and manage soft tissue disorders of the hands.. Dimensions
of Dental Hygiene.9 (4), 72-75. Santa Ana, CA: Belmont Publications, Inc..
http://opus.ipfw.edu/dental_facpubs/62
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see the card appearing at page 68.
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Hand Health
How to prevent and manage soft tissue disorders of the hands.
By Nancy Kane Mann, RDH, MSEd,
and Mary D. Cooper, RDH, MSEd
The frequently repeated movements so
common to the practice of dental hygiene
often lead to cumulative trauma disorders
(CTDs).1,2 Additional behaviors specific to
dental hygienists that increase their risk of CTDs include
limited hand movements, use of vibrating instruments, and
holding stressful body positions.3-5 The number of working hours, number of difficult patients treated, and
years of practice also affect dental hygienists’ risk
status.6 Mechanical stress caused by glove use
and instrument design may also
affect the well-being of
practitioners.6 Typically, the
upper extremities are more
prone to CTDs when performing
repetitive tasks.5
Carpal tunnel syndrome is
the most common type of CTD
experienced by dental hygienists.3
EDUCATIONAL OBJECTIVES
However, thoracic outlet syndrome,
After reading this course, the participant should be able to:
cubital and ulnar tunnel syndrome, extensor wad strain, and
1.
2.
3.
4.
glove-induced injuries are also common among dental pro-
List possible causes of cumulative trauma disorders.
Differentiate between de Quervain’s disease and Raynaud’s syndrome.
Discuss treatment and management options for de Quervain’s disease.
Identify possible risk factors associated with secondary Raynaud’s phenomenon.
5. Detail management options for Raynaud’s phenomenon.
fessionals.6 These CTDs have been extensively reviewed in
the literature. However, two soft tissue disorders that affect
the hands—de Quervain’s disease and Raynaud’s phenomenon—are not as frequently discussed but can have debilitating effects for dental hygienists.
Nancy Kane Mann, RDH, MSEd, is a clinical associate professor of
dental hygiene at Indiana University-Purdue University in Fort Wayne.
With more than 35 years’ experience in private practice
and dental hygiene education, she has presented
and published nationally and internationally.
Mann is also a member of Dimensions of Dental
Hygiene’s Peer Review Panel.
Mary D. Cooper, RDH, MSEd, is a professor
of dental hygiene at Indiana University-Purdue University. She has written textbooks,
book chapters, and several articles on topics applicable to practicing
dental hygienists.
74 Dimensions OF DENTAL HYGIENE www.dimensionsofdentalhygiene.com
ETIOLOGY OF DE QUERVAIN’S DISEASE
De Quervain’s disease is named for the Swiss surgeon, Fritz de
Quervain, who first identified it in five women in 1895.7 The
cause of de Quervain’s is idiopathic. However, repetitive
motions, such as ulnar (bending the wrist in the direction of
the little finger) and radial deviation of the wrist (bending the
wrist in the direction of the thumb), are considered contributing factors (Figure 1).8
Dental hygiene procedures increase the probability of
APRIL 2011
placing the wrist in ulnar deviation. To
ment of de Quervain’s disease with corticos-
RAYNAUD’S SYNDROME
maintain health, dental hygienists must con-
teroid injections is successful in approxi-
Raynaud’s syndrome is named for the French
centrate on keeping the wrist in neutral
mately 50% to 80% of patients.11
physician, Maurice Raynaud, who first recog-
position during instrumentation. Reaching
If conservative medical treatment is not
nized the condition in 1862.13 Raynaud’s syn-
for dental instruments is another common
successful, outpatient surgery may be rec-
drome, sometimes referred to as a disease or
cause of ulnar deviation. 8 To avoid this,
ommended. Surgery involves releasing the
phenomenon, is a type of vascular disease that
instruments should be placed within easy
tendon sheath to relieve pressure or con-
affects the arteries. There is an interruption of
reach of the patient treatment area.
striction around the tendon, which elimi-
blood flow to the fingers, toes, nose, and/or
In de Quervain’s disease, the extensor pol-
nates the friction that causes inflammation,
ears when a spasm occurs in the vessels of
licis brevis and the abductor pollicis longus
thus restoring the tendon’s smooth gliding
these areas. The hands are most commonly
tendons in the wrist at the base of the thumb
capability. 11 Following surgery, physi-
affected.14
7
become inflamed. Inflammation in these
cal/occupational therapy may be recom-
Raynaud’s syndrome can occur alone or in
tendons of the thumb can cause pain that
mended to strengthen the thumb and wrist.
association with other rheumatic diseases.
extends to the base of the wrist (tenosynovi-
Recovery times vary, depending on age,
When it occurs alone, it is referred to as Ray-
tis) and possibly into the forearm and shoul-
general health, and how long the symptoms
naud’s disease or primary Raynaud’s phenom-
der.5,8 Thumb motion may be difficult and
have been present. Individuals whose dis-
enon. Primary Raynaud’s phenomenon is the
painful, particularly when twisting or pinch-
ease has developed gradually may be more
most common form of the disorder and is not
ing/grasping objects. The pain may increase
resistant to treatment.
associated with any underlying disease or
with ulnar deviation of the wrist or if direct
The clinical management of any CTD is
pressure is applied to the area. De Quervain’s
based on identifying and treating individual
medical problem.
Secondary Raynaud’s typically accompa-
affects middle-aged women eight to 10
component pathologies. Referral to a knowl-
nies connective tissues diseases such as scle-
times more frequently than men.7,9 Its onset
edgeable physical/occupational therapist,
roderma, systemic lupus erythematosus, Sjö-
can occur gradually or suddenly.
with an understanding of ergonomic behav-
gren’s syndrome, rheumatoid arthritis, and
ioral, postural, and workspace modification,
polymyositis. 14 Although secondary Ray-
DIAGNOSIS AND TREATMENT
is recommended. Prevention and manage-
naud’s is less common, it can be more seri-
The Finkelstein test is most frequently used to
ment of the disease involves:
ous. Signs of secondary Raynaud’s initially
12
diagnose de Quervain’s disease. When con-
• Keeping hand/arm in neutral position
appear around the age of 40, whereas the
ducting this test, the patient makes a fist with
during instrumentation, avoiding repetitive
primary form of Raynaud’s occurs indiscrim-
fingers closed over the thumb and the wrist is
ulnar deviation of the wrist.
inately.
bent toward the fifth (little) finger (Figure 2).5,8
• Placing instruments within easy reach of
When the wrist is bent toward the outside,
patient treatment area to prevent ulnar devia-
CONTRIBUTING FACTORS
the swollen tendons are pulled through the
tion of the wrist.
Arterial spasms from Raynaud’s syndrome
space in the wrist and stretched, which causes
pain. A physical examination is also recom-
• Practicing ergonomically correct posi-
are caused by exposure to cold or emotional
tions.
stress. More important to dental hygienists,
Figure 1. Bending the wrist in the direction of the
little finger or ulnar deviation is a risk factor for
de Quervain’s disease.
Figure 2. The Finkelstein test, where a patient makes a fist
with fingers closed over the thumb and the wrist bends
toward the fifth finger to see if pain results, is the tool most
commonly used to diagnose de Quervain’s disease.
mended to rule out any other possible conditions that could cause pain in the same area,
such as osteoarthritis, scaphoid (navicular)
bone disorders, disruption of the scapholunate
ligament, and carpal tunnel syndrome.8
Initially, the patient continuously wears
a spica splint for 4 to 6 weeks (Figure 3,
page 76).5,8,10,11 This not only immobilizes
the affected area, but inhibits activities that
may aggravate the condition. Ice may be
applied to the affected area for 15 to 20
minutes to reduce inflammation. The area
should be warmed for 45 minutes before
icing again. If symptoms continue, a physician may prescribe anti-inflammatory medications, such as naproxen or ibuprofen, or
inject the area with corticosteroids to
decrease the pain and swelling.5,8,11 ManageAPRIL 2011
www.dimensionsofdentalhygiene.com Dimensions OF DENTAL HYGIENE 75
DISEASE MANAGEMENT
Table 1. Raynaud’s syndrome management for dental hygienists.
A physician may prescribe medication to relax
Instrumentation
Position
Daily Schedule
Recommendations
Avoid
1. Alternate use
of vibrating
instruments
with hand
scaling.
1. Maintain
neutral
seating and
hand/arm
positions.
1. Incorporate brief
(5-10 minutes)
breaks in the
daily work
schedule for rest
and stretching
exercises.
2. Alternate
ultrasonic/sonic
scaling
appointments
with routine
maintenance
patients.
1. Consult with a physical
or occupational
therapist or
rheumatologist.
2. Practice stress
reduction protocol.
3. Assess activity-based
risk factors.
4. Take niacin (vitamin
B3).21
5. Wear gloves when
handling cold or
frozen items.
6. Exercise regularly.21
1. Prolonged use of
vibrating instruments.15
2. Prolonged exposure to
cold.21
3. Smoking.21
4. Nonwork-related activities
that constrict the wrist
and hand, such as typing,
playing the piano, and/or
gardening.22
5. Stress.21
6. Direct contact with frozen
foods or cold drinks.22
7. Caffeine.21
the walls of the blood vessels to prevent
smooth muscle contraction and arterial damage. Medications prescribed include topical
nitroglycerin, angiotensin-converting enzyme
(ACE) inhibitors, and calcium-channel blockers, especially nifidepine and sildenafil (Viagra).18,19 Transdermal, oral, or topical nitrates
may cause adverse effects such as headaches,
which can limit their use.14 Nondrug treatments and self-help measures can also
decrease the severity of Raynaud’s attacks and
promote overall well-being. Keeping the body,
hands, and feet warm is helpful. Other measures include not smoking (constricts blood
Additionally, occupational Raynaud’s phe-
vessels), minimizing stress, exercising regularly,
nomenon may be caused by thrombosis or
and having regular physical examinations.20 In
clot of the ulnar artery. Raynaud’s phenome-
addition, dental hygienists with Raynaud’s
non related to ulnar artery thrombosis is typ-
should limit their use of instruments that pro-
ically unilateral and associated with small
duce vibration.
blood clots.15
Lifestyle changes and supplements that
encourage better circulation may be effective
SYMPTOMS
alternatives for managing Raynaud’s. Niacin,
Due to an imbalance of vasoconstriction and
also known as vitamin B3, causes blood ves-
vasodilation in Raynaud’s disease, the affected
sels to dilate, increasing blood flow to the
area turns white, then blue, followed by bright
skin.21 Although niacin supplements may be
red over the course of the attack (Figure 4).
useful in treating Raynaud’s, they do cause
Skin discoloration occurs because an abnor-
flushing of the skin, most commonly in the
Raynaud’s also can be caused by repetitive
mal spasm of the blood vessels causes a
face and trunk.21
trauma that damages the nerves supplying
diminished blood supply to the local tissues. In
Other complementary and alternative med-
the blood vessels in the hands. Use of vibrat-
addition, there may be associated tingling,
icines used to treat Raynaud’s have been tested
ing, hand-held power instruments over time
swelling, or painful throbbing. Chemotherapy
with positive results. In a double-blind,
can produce a type of secondary Raynaud’s
is a risk factor for developing these symptoms,
phenomenon known as vibration white fin-
especially for patients being treated for ovar-
ger or hand-arm vibration syndrome
ian cancer.16 Figure 4 shows the fingers of a
(HAVS). HAVS is characterized by excessively
dental hygienist, who is undergoing
reduced blood flow; blanching of the fin-
chemotherapy for ovarian cancer, experienc-
gers; and limited supply of blood to the
ing Raynaud’s symptoms—red, white and
muscles, nerves, and tendons. Symptoms of
blue fingers—when exposed to prolonged
HAVS include pain and/or tingling and
cold temperatures.
Figure 3. Spica splint used in the management of De Quervain’s
disease.
numbness of the hand leading to loss of
manual dexterity.
While there is no single blood test that
identifies Raynaud’s, blood work can rule out
Vibrations also may cause injury to sym-
the presence of autoimmune antibodies asso-
pathetic (unmyelinated) fibers, leading to
ciated with scleroderma, lupus, mixed con-
sympathetic overactivity. When the myelin
nective tissue disease, undifferentiated con-
sheath starts to degrade, nerve impulses are
nective tissue disease, Sjögren’s syndrome,
conducted improperly or lost completely,
and other diseases that may have Raynaud’s as
leading to tingling sensations or heat sensitiv-
a possible component. Differential diagnostic
ity. Signs of sympathetic overactivity include
tests include dopplar ultrasound, nailfold cap-
increased color changes (blue/red), sweating,
illaroscopy, antinuclear antibody test, and ery-
and cold periphery with vasoconstriction.
throcyte sedimentation rate.17
76 Dimensions OF DENTAL HYGIENE www.dimensionsofdentalhygiene.com
Figure 4. Skin discoloration experienced with
Raynaud’s disease.
APRIL 2011
Hand Health
placebo-controlled study, the consumption of
nated since it impairs circulation. Recognizing
fish oil showed an increase in digital systolic
and avoiding stressful situations may also help
CE Questions—The answer sheet and
pressure as well as the time of onset of symp-
control the number and severity of attacks.23
further instructions are located on the tear-out
card that appears at page 68.
toms after exposure to cold.
22
In addition,
evening primrose oil, which is a rich source of
Specific recommendations for dental hygienists are listed in Table 1.
1. Which behavior increases dental hygienists’ risk
of cumulative trauma disorders?
gamma-linolenic acid (GLA), demonstrated a
A. Repetitive movements in the wrist and arm
decrease in the frequency of Raynaud’s attacks.
CONCLUSION
GLA is an omega-6 essential fatty acid that can-
Dental hygienists routinely use instruments
C. Use of vibrating instruments
not be made by the body and, therefore, must
that vibrate and perform hand–intensive,
D. All of the above
be obtained from food. Also known as polyun-
repetitive movements often in cramped con-
2. Which area is more prone to cumulative
saturated fatty acids, GLAs are found predomi-
ditions. Therefore, they are at greater risk for
trauma disorders when repetitive tasks are per-
nately in plant-based oils and are effective in
developing hand disorders from lack of
reducing inflammation and stimulating skin
proper circulatory flow, pinched nerves, and
B. Lower back
growth.14 Before beginning complementary
compromised hand positions. Once symp-
C. Upper extremities
and alternative medicine treatments, a physi-
toms develop, timely intervention is essen-
cian should always be consulted.
B. Limited hand movements
formed?
B. Lower extremities
D. Pelvis
tial. A medical evaluation and diagnostic tests
3. Which cumulative trauma disorder is most com-
provide supplementary information to the
mon among dental hygienists?
A. Carpal tunnel syndrome
PREVENTION
physical examination and history. A compre-
General exercise improves circulation and,
hensive strategy for treatment and preven-
C. Extensor wad strain
therefore, may help prevent or minimize
tion is essential for a life-long career in dental
D. All of the above
attacks. In addition, smoking should be elimi-
hygiene. D
B. Thoracic outlet syndrome
4. De Quervain’s disease is more common in
women than men.
References
1. Liskiewicz ST, Kerschbaum WE. Cumulative
trauma disorders: an ergonomic approach for
prevention. J Dent Hyg. 1997;4:162-167.
2. Werner RA, Hamann C, Franzblau A, Rodgers
PA. Prevalence of carpal tunnel syndrome and
upper extremity tendinitis among dental
hygienists. J Dent Hyg. 2002;2:126-132.
3. Willard P. Patient reception and ergonomic
practice. In: Wilkins EM. Clinical Practice of the
Dental Hygienist. 10th ed. Philadelphia:
Lippincott Williams & Wilkins; 2009:92.
4. Carpal Tunnel Syndrome Health Center. Carpel
Tunnel Syndrome. Available at: www.webmd.
com/pain-management/carpal-tunnel/carpaltunnel-syndrome. Accessed March 23, 2011.
5. Hamann C, Werner RA, Rhode N, Rodgers PA,
Sullivan K. Upper extremity musculoskeletal
disorders in dental hygiene: diagnosis and
options for management. Contemporary Oral
Hygiene. 2004;4:2-8.
6. Tavoc T, Gutmann ME. Preventive strategies
can keep practice pain-free and ensure a long
career in clinical dental hygiene. Dimensions of
Dental Hygiene. 2005;3(1):16-21.
7. Lamphier TA, Long NG, Dennehy T. De
Quervain’s disease an analysis of 52 cases. Ann
Surg. 1953;6:832-841.
8. Stitik TP, Conte M, Foye PM, Schoen D, Marini
JS. An analysis of cumulative trauma disorders in
dental hygienists. Journal of Practical Hygiene.
2000;9(2):19-25.
9. Arthritis Health Center. De Quervain’s Disease—
Topic Overview. Available at:
http://arthritis.webmd.com/tc/de-quervainsdisease-topic-overview. Accessed March 23, 2011.
10. Ilyas AM. Nonsurgical treatment for de
Quervain’s tenosynovitis. J Hand Surg Am.
2009;5:928-929.
11. Hazani R, Engineer NJ, Cooney D, Wilhelmi BJ.
Anatomic landmarks for the first dorsal
compartment. Eplasty. 2008;8:53.
12. Chin DH, Jones NF. Repetitive motion hand
disorders. J Calif Dent Assoc. 2002;2:149-160.
13. Belch JJ. The phenomenon, syndrome and
disease of Maurice Raynaud. Br J Rheumatol.
1990;3:162-165.
APRIL 2011
True
14. Pope JE. The diagnosis and treatment of
Raynaud’s Pphenomenon—a practical approach.
Drugs. 2007;4:517-525.
15. Al Qattan MM, Bowen V. Cumulative trauma
disorders of the hand and wrist. Current Opinion
in Orthopaedics. 1993;4(4):68-71.
16. Matei D, Miller AM, Monahan P, et al. Chronic
physical effects and health care utilization in
long-term ovarian germ cell tumor survivors: a
gynecologic oncology group study. J Clin Oncol.
2009;27:4142-4149.
17. Kim SH, Kim HO, Jeong YG, et al. The
diagnostic accuracy of power Doppler
ultrasonography for differentiating secondary
from primary Raynaud’s phenomenon in
undifferentiated connective tissue disease. Clin
Rheumatol.2008;6:783-786.
18. Bakst R, Merola JF, Franks AG Jr, Sanchez M,
Perelman RO. Raynaud’s phenomenon:
pathogenesis and management. J Am Acad
Dermatol. 2008;59:633-653.
19. Olin JW. Other peripheral arterial diseases. In:
Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia: Saunders
Elsevier; 2007:80.
20. National Institute of Arthritis and
Musculoskeletal and Skin Disease. Raynaud’s
Phenomenon. Available at: www.niams.nih.gov/
Health_Info/Raynauds_Phenomenon/default.asp
#5. Accessed March 23, 2011.
21. Mayo Clinic. Raynaud’s Disease. Available at:
www.mayoclinic.com/health/raynaudsdisease/DS00433/DSECTION=alternativemedicine. Accessed March 23, 2011.
22. DiGiacomo RA, Kremer JM, Shah DM. Fish-oil
dietary supplementation in patients with
Raynaud’s phenomenon: a double-blind,
controlled, prospective study. Am J Med.
1989;2:164-185.
23. NYU Langone Medical Center. Raynaud’s
Disease and Phenonomen. Available at:
www.med.nyu.edu/content?ChunkIID=11600.
Accessed March 23, 2011.
False
5. Which test is used to diagnose de Quervain’s
disease?
A. Finkelstein test
B. FibroTest
C. ACTH stimulation test
D. All of the above
6. How long is a spica splint typically worn during
treatment for de Quervain’s disease?
A. 1 to 2 weeks
B. 4 to 6 weeks
C. 8 to 12 weeks
D. None of the above
7. When was Raynaud’s syndrome discovered?
A. 1778
B. 1823
C. 1862
D. 1959
8. Secondary Raynaud’s syndrome is the most
common form of the disorder.
True
False
9. Which is a symptom of Raynaud’s syndrome?
A. Skin discoloration
B. Tingling
C. Swelling
D. All of the above
10. Which medication is prescribed to treat Raynaud’s syndrome?
A. Topical nitroglycerin
B. ACE inhibitors
C. Calcium-channel blockers
D. All of the above
www.dimensionsofdentalhygiene.com Dimensions OF DENTAL HYGIENE 77