Getting the Upper Hand on Pain - Dental Academy of Continuing

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4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Getting the Upper Hand on Pain:
Preventing Hand and Wrist Pain
Syndromes in Dental Professionals
A Peer-Reviewed Publication
Written by Bethany Valachi, PT, MS, CEAS
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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits.
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Educational Objectives
The overall goal of this article is to provide the reader with
information on the incidence, risk factors, prevention and
treatment of true carpal tunnel syndrome, as well as disorders
in dentistry that mimic carpal tunnel syndrome but have a
different etiology. Upon completion of this course, the reader
will be able to do the following:
1. List and describe four of the primary risk factors associated with carpal tunnel syndrome
2. List and describe ergonomic interventions that can help
prevent carpal tunnel syndrome
3. List and describe other conditions that may mimic carpal
tunnel syndrome
4. Provide an overview of the diagnosis and treatment of
carpal tunnel syndrome
Abstract
Chronic hand and wrist pain that can affect quality of life,
productivity or career longevity is experienced by between 40
and 70 percent of dental professionals. Given that fewer dental professionals fully recover from hand pain than they do
from neck, shoulder or elbow pain, it is imperative that injury
be prevented. There are a number of risk factors for carpal
tunnel syndrome that must be considered, as well as researchbased ergonomic interventions. The use of ergonomic equipment and implementation of prevention techniques outside
the operatory can help to reduce work-related pain and extend
the career of the dental professional.
in the fingers, which is one of the symptoms of carpal tunnel
syndrome, sometimes has nothing to do with a problem in
the hand or wrist but may be due to a problem in the cervical
spine, thoracic outlet or trigger points in the forearm.
There are numerous causes of hand, wrist and arm pain,
including tendonitis (e.g., De Quervain’s tenosynovitis),
arthritis (e.g., osteoarthritis of the basilar joint), nerve compression (e.g., thoracic outlet syndrome, cervical radiculopathy, carpal tunnel syndrome, cubital tunnel syndrome),
trigger points (e.g., radial tunnel syndrome) and equipment
issues (e.g., non-ergonomic tools, poorly fitted gloves).
However, the most commonly diagnosed CTD of the hand,
wrist and arm among dentists and hygienists is carpal tunnel
syndrome.
Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment in the arm10-11 and contributes to
one of the most frequently performed hand surgeries in the
United States.12 Caused by compression of the median nerve
at the wrist,13 CTS can lead to pain, numbness or tingling in
the thumb, index finger, middle finger and half of the ring
finger. (Fig. 1)
Figure 1. Carpal tunnel
Introduction
“The right half of the brain controls the left half of the body.
This means that only left-handed people are in their right mind.”
—Source Unknown
Hand, wrist and arm pain are much more prevalent
among dental professionals than the general public, due
to the sustained grips and prolonged awkward postures
dentists and hygienists must employ throughout the day.1
Between 23 and 40 percent of dentists and nearly 75 percent of dental hygienists experience hand and wrist pain,2-6
nearly four times the prevalence found in the general working public. In the case of hygienists, hands, wrists and arms
are the most common sites of pain reported. Since hands are
integral to the work of dental professionals, understanding
the etiology of this pain and its prevention are important.6-9
Fewer dental professionals fully recover from hand pain
syndromes than they do from neck, shoulder and elbow
pain.7 Therefore, prevention strategies and early attention to
warning signs of the primary cumulative trauma disorders
(CTDs) of the hand and arm are imperative to the dental
professional’s health and career longevity.
The origins of pain in the hand, wrist or arm are often
elusive and may not be due to a problem in the same area;
in fact, the source of the symptoms may be nowhere near
where the symptoms are perceived. For example, numbness
2
Pain or tingling in the distribution of the median nerve (shaded)
is often indicative of carpal tunnel syndrome. Numbness is usually
felt in the fingertips only.
One study found that while 71 percent of dentists experienced one or more CTS symptoms, only 7 percent were
actually diagnosed with CTS.14 This should prompt dental
professionals with CTS-type symptoms to educate themselves on all possible etiologies to avoid unnecessary surgery
or ineffective therapies.
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Inconsistencies abound in the literature regarding the
cause, proper evaluation and course of care of CTS.15-17 Noted
author and physical rehabilitation expert Dr. Rene Calliet
states, “Differentiation of median nerve wrist compression
from cervical radiculitis or thoracic outlet syndrome may be
the most challenging in clinical practice.”15 This is largely due
to the fact that the median nerve fibers run a long and twisting
course around bone and through soft tissue from the cervical
spine down to the fingertips. CTS symptoms may not always
be indicative of a structural problem in the hand and wrist;
often the problem originates more proximally in the muscles/
tendons that stabilize the arm during repetitive work.17 Any
compression or entrapment along the median nerve fibers can
result in CTS-type symptoms in the hand.18
The carpal tunnel
The carpal tunnel comprises a row of bones on the back of the
wrist, with a thick ligament in the front. For the hand to function properly, nine flexor tendons and the median nerve must
be able to glide easily within this space. Of these structures, the
median nerve is the softest and most vulnerable to pressure.
The positions that cause the most pressure in the carpal
tunnel are easy to identify. If you straighten your right wrist,
place your left thumb over the transverse carpal ligament and
then bend your right wrist back, you can feel the ligament
tighten over the tunnel. This is the position that compresses
the tunnel most. If you then make a fist, the tunnel will get
even tighter; if held in this position long enough, it may result in your hands and fingers going numb. If you bring your
wrist to neutral and then forward, the tightness will slacken
when you are in neutral and then slightly tighten again as
you move downward. If you try the above exercise gripping
a pencil, this “precision” grip creates more pressure in the
carpal tunnel. Sustained gripping while extending the wrist is
unhealthy for your median nerve. By performing this series
of movements, you have just demonstrated two of the four
primary risk factors for CTS in dental professionals—flexing
the wrist forward and gripping a small instrument forcefully.
The other two risk factors are high repetition (as in manual
scaling) and duration (e.g., how many heavy calculus patients
you schedule back-to-back). (Fig. 2) These risk factors cause
microtrauma in the carpal tunnel; fibrosis and edema of the
lining of the tendons at the wrist eventually cause increased
pressure within the carpal tunnel and decreased blood flow to
the median nerve within the tunnel. The swelling of the lining of the tendons is often painful, and it is the pressure on
the median nerve at the wrist from this swelling that causes
numbness in the fingers and weakness of the muscles at the
base of the thumb.
The causes of CTS are numerous and include anatomic,
physiologic, hereditary and traumatic factors that result in
compression or irritation of the median nerve at the wrist. For
instance, CTS is three times more prevalent in women than
men, and it is most common between the ages of 30 and 60 and
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among diabetics and in obese people. However, the literature
also reports an occupational cause in more than 47 percent of
cases.20 CTS symptoms (pain, numbness and tingling) are often worse at night and first thing in the morning. Weakness in
a precision grip may be present due to atrophy or weakness of
the thumb abductor muscles.19 Over time, visibly decreased
musculature may be noticed at the base of the thumb. Sensory
impairment is usually experienced before motor loss, so early
intervention is important. In addition to any therapies you
may consider, it is imperative that you address ergonomic
issues that are known to aggravate carpal tunnel symptoms to
minimize your risk and to prevent CTS.
Figure 2. Four of the primary risk factors contributing to CTS in
dentistry.
Keys to Success: Preventing Carpal Tunnel
Syndrome
The four primary risk factors that contribute to occupational
CTS in dentistry can be minimized with appropriate ergonomic interventions, as described below.
Avoiding sustained wrist flexion
Wrist flexion increases pressure in the carpal tunnel, and
working with your wrist bent toward the little finger—called
ulnar deviation—also increases this pressure.12-13 (Fig. 3a)
When performing scaling or other treatments, trying to keep
your wrist straight and moving your entire hand, wrist and
3
forearm as a unit transfers the load from smaller hand muscles
to larger arm and shoulder muscles. Using a finger rest position (either intra- or extra-oral) to stabilize the instrument
further reduces thumb pinch force and muscle workloads in
the hand.21 Extra-oral fulcrums also facilitate neutral wrist
posture and allow proper positioning for precision instrumentation.22 (Fig. 3b)
can be adjusted to prevent varying degrees of wrist flexion,
thereby retraining damaging wrist postures.
Figure 4. Ergonomic shank
Figure 3a. Poor wrist posture
Instruments with multiple exaggerated angles and longer terminal shanks can reduce the need to flex the wrist to access hard-toreach distal pockets.
Poor (deviated) posture of the wrist is a primary risk factor for CTS
in dentistry.
Figure 3b. Neutral wrist posture
Try to maintain neutral posture of the wrist, especially when scaling.
Rather than twisting the wrist to access hard-to-reach
areas, try moving the instrument or handpiece in your hand.
To access molar regions and distal pockets, select an instrument with multiple accentuated angles and a longer terminal
shank (Fig. 4), which can reduce twisting the wrist to access
these areas. It makes far more sense to use an accentuated
angled instrument rather than angle your wrist. You can retrain yourself to maintain near-neutral wrist postures using
a soft wrist wrap, such as a WrisTimer, to limit wrist flexion
to anywhere from 0 degrees to 20 degrees. A soft wrist wrap
4
Going ultrasonic
Compared to manual scaling, ultrasonic scaling requires less
force applied to the work surface and a less forceful precision grip. However, these ergonomic advantages are putting
ultrasonic instruments at the forefront and in some cases
overshadowing manual instruments as artifacts of the past.
The importance of precision manual scaling in delivering
quality dental care cannot be overstated, and the effectiveness of quality advanced periodontal instrumentation is often
hard to match with an ultrasonic unit. Proper ergonomic
periodontal instrumentation techniques should be a priority
for hygienists to safely implement sufficient hand scaling into
their patient care.22,23
The percentage of time spent providing ultrasonic versus
manual scaling care is an individual one that must take into
consideration personal health (some individuals are more
prone to CTS than others), patient periodontal history,
workload, depth and size of pockets, and numerous other
variables. Both manual and powered instrumentation have
unique strengths that can be effectively combined during
treatment.24 Furthermore, studies show that the duration of
use of either ultrasonic or manual instruments is positively
associated with upper extremity numbness/tingling.25
From a preventive perspective, ultrasonic instrumentation should be used periodically over the course of the day to
reduce muscle workload and provide rest to the intrinsic hand
muscles. Also consider swiveling ultrasonic inserts, which
can improve hand and arm posture as well as save time.
Instrument selection
Certain instrument features can reduce carpal tunnel compression:
Diameter – Instruments are available in a wide variety
of handle diameters, ranging from about 5.6 to 11.5 mm.
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Larger instrument handle diameters reduce hand muscle
load and pinch force, although handle diameters greater
than 10 mm (about 3/8 inch) have been shown to offer no
additional advantage.26 Alternating between handle diameter sizes may also help prevent CTS symptoms. When selecting instruments, try to include large diameters as well as
other sizes, but avoid very narrow diameter sizes (5.6 mm),
as these increase carpal tunnel pressure. Sleeves that fit over
mirror handles and increase their diameter have been shown
to reduce muscle load;27 however, sleeves on scaling instruments may not have the same benefits, due to the additional
force needed to perform scaling tasks.
Weight – Although instrument weight is not as significant
a risk factor as handle diameter, lightweight instruments (15
g or less) help reduce the muscle workload and pinch force.26
Texture – Textured handle surfaces may help decrease
forceful pinch grips.
Sharpness – Dull instruments can have a profoundly
deleterious impact on your musculoskeletal health, as they
require increased force. It is therefore essential to maintain
optimally sharpened instruments and perform visual inspections regularly. There are several methods for sharpening, including mechanical and manual23 methods and using
a high-speed handpiece.28
Reduce your grip – Forceful pinch grip has been
shown to increase pressure in the carpal tunnel; this pressure is even higher when combined with wrist ulnar deviation.12 Hygienists and dentists should try to use a palmar
grip when using the high volume evacuation (HVE) and
dentists should, of course, use the palmar grip instead of the
precision grip during extractions. Dentists with pain in the
dominant hand should consider using the non-dominant
hand intermittently for extractions, and they can begin by
supporting the extracting hand with the dominant hand.
Positioning on the opposite side of the patient for extractions may become more comfortable and easier when you
are acclimatized to using the non-dominant hand, and it
provides yet another opportunity to move around, thereby
varying the load on your muscles, bones and joints.
Cord management – Using 360-degree swivel instruments to maintain optimal neutral wrist and finger position
is helpful, as is positioning heavy cords over your arm
through a counter-mounted loop or across an armrest to
reduce muscle strain. Cord pullback can be prevented by
positioning your delivery system and ultrasound unit close
to you. It is also important to observe patient positioning
strategies to maintain neutral wrist posture.
Spread the work around – Moving the muscle workload helps to avoid structural damage.29 One way to do this
is by alternating between chairs with and without armrests.
Using a chair with armrests moves the workload to the
smaller muscles of the hand and wrist, while using no armrests incorporates the larger muscles of the arm and shoulder
girdle into the movement.
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Temperature – Avoid positioning your neck, shoulders and hands directly in the draft of an air conditioner,
and avoid working in a particularly cold environment, since
exposure to cold is another aggravating risk factor associated
with CTS.
Stretch – Frequent stretch breaks were the most helpful intervention for hand/wrist pain in one dental study.30
Stretching helps to increase blood flow and reduce formation
of trigger points. If you have mild carpal tunnel symptoms,
you should be gently stretching three to five times per day.
CTS Diagnosis
Accurate diagnosis of CTS is difficult and requires evaluation by a highly skilled healthcare practitioner, preferably
a board-certified hand surgeon. A certified hand therapist
can also be extremely helpful in addressing adaptation, ergonomics, splinting and using various modalities to reduce
your symptoms. Positive results from several tests (EMG
and nerve conduction velocity testing, hand pain mapping,
and sensitivity testing) and the presence of wrist/hand pain
are highly suggestive of CTS.12 The following physical exam
findings are often seen in people with this syndrome:
1. Tinel’s sign: an electric shock–type sensation in the hand
when the median nerve is tapped gently at the wrist
2. Positive Phalen’s test: numbness in the hand in less than
60 seconds when the wrist is flexed 90 degrees
3. Weakness of the thenar muscles at the base of the thumb
4. In severe cases, persistent numbness in the distribution
of the distal median nerve (thumb, index finger, middle
finger) and continuous numbness can represent permanent damage to the nerve; surgery should be considered
prior to this point, as surgery will reliably prevent further
damage to the nerve, but recovery of a damaged nerve is
not as predictable
CTS Treatment
Conservative treatment options for CTS include the following:
• Modification of activities to decrease tendon excursion
• Therapeutic interventions such as ice, massage,
ultrasound or acupuncture
• Anti-inflammatories or cortisone injections
• An immobilizing splint across the wrist (often most
helpful at night)
• Nerve or tendon gliding exercises
• B6 vitamins if the problem is due to a vitamin deficiency
It is advisable to avoid strengthening the hands/fingers
with repetitive finger flexion exercises, as these can increase
carpal tunnel pressures and worsen pain.16,31 However, when
completely pain-free, a program of very lightweight tubing
exercises focused on the wrist flexor, extensor, pronator and
supinator groups may be of benefit in preventing CTS and for
trigger points.16
Dentists and hygienists should implement ergonomic interventions, consider all CTS-mimicking conditions and undergo
5
conservative CTS therapies before considering CTS surgery.
Surgical patients treated three to five years after the onset of
symptoms are less likely to have complete symptom resolution.
Therefore, early diagnosis and treatment are important.12 It is far
easier to prevent carpal tunnel syndrome than to cure it.
Pain Syndromes That Mimic Carpal Tunnel
Syndrome
Several problems may mimic CTS, including cervical
radiculopathy, thoracic outlet syndrome, median nerve
entrapment in the forearm and trigger points, and poorly
fitting gloves. (Fig. 5)
Figure 5. Problems that may mimic CTS
trapment.16,33-34 Neuromuscular technique and myofascial
release are two popular approaches that have been used to
treat this type of pain. Initially, dental professionals should
work with a healthcare professional, such as a certified
neuromuscular therapist or a therapist who specializes in
trigger point therapy, to resolve pain of this origin. After reduction of symptoms, dentists may learn to self-treat their
trigger points, since their jobs are a perpetuating factor.35
Median nerve entrapment in the forearm can be treated
successfully if a holistic approach is taken to address the
sum of compression and tension on the nerves in the upper
extremity.18
Thoracic outlet syndrome (TOS)
TOS is a neurovascular disorder resulting from pressure on
the nerves and/or blood vessels that supply the arm, fingers
and hand. (Fig. 6)
Figure 6. Thoracic outlet
1. Cervical radiculopathy, 2. Thoracic outlet syndrome, 3. Median
nerve entrapment in the forearm and trigger points, 4. CTS, 5.
Poorly fitting gloves.
Trigger points and nerve entrapment
Although muscle-referred pain is a well-documented and
researched phenomenon,15,32 it is often overlooked as a possible source of pain syndromes. Trigger points in certain
muscles may refer CTS-like symptoms into the hand and
wrist.32
Trigger points in the forearm muscles such as the pronator teres can cause compression on the median nerve and
cause CTS-like pain in the hand and wrist. Since the median nerve runs through the pronator teres muscle, dental
professionals who operate with the forearms in a pronated
(palms-down) position are at greater risk for this nerve en6
The thoracic outlet, showing nerves and arteries that supply
the arm.
Tightness and/or trigger points in the pectoralis, anterior or middle scalenes may restrict the size of the thoracic
outlet.15,33,36 Compression of this neurovascular bundle may
cause numbness and tingling that can mimic CTS; however,
TOS may also include vascular symptoms (edema, coldness or discoloration) in the hands and fingers. A thorough
clinical evaluation is the most important component for
diagnosis of TOS; this should include subjective and objective findings as well as a review of daily activities and work
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habits. The development of TOS has no involvement with
the tendons and soft tissues at the wrist, but that is where the
symptoms tend to be perceived. In addition to true TOS,
patients may have thoracic outlet symptoms due to forward
head posture, working with shoulders on a tilted axis,
breathing from the chest and improper body mechanics.15,36
Thoracic outlet symptoms from these sources can often be
resolved with physical therapy.
Cervical radicular pain (cervical radiculopathy)
Pain or paresthesia in the hand may also originate in the cervical spine.15 Nerve roots that supply the arm and hand may
become compressed as they exit the spinal vertebrae, resulting in cervical radiculopathy. This may occur simultaneously with CTS (also known as “double crush” syndrome33).
Numbness in the hand may be produced by changes in neck
position, and muscle stretch reflexes tend to be diminished.
Electrodiagnostic studies in this situation would reveal
a normal nerve conduction velocity; however, the EMG
may be abnormal in the distribution of the involved nerve
root.15 A skilled electromyographer, usually a neurologist or
physiatrist, is essential for accurate test results. The cause
of cervical radiculopathy, more often than not, is due to forward head posture combined with degenerative changes in
the facet joints of the cervical spine.
Poorly fitted gloves
Improperly fitted gloves may cause CTS-type pain, primarily at the base of the thumb. Ambidextrous gloves are generally molded with the hand in a flat (neutral) position and
were originally designed for brief medical examinations.37
When gloves are used for longer procedures, as in dentistry,
the operator’s hand must pull the glove into a working position, which may compress the back of the hand and strain
the muscles at the base of the thumb, simultaneously reducing the blood flow to the hand. Ambidextrous gloves exert
one-third more force than do fitted gloves,37 and muscle
ischemia, nerve compression and pain may result. Older
practitioners may be more prone than younger practitioners
to glove-related pain in the hands.38 Tight gloves may also
result in the above symptoms.
Summary
The cause of hand pain in dental professionals may be multifactorial, and the etiology may not necessarily be related to
a single structural problem at the wrist. There are numerous
other pain syndromes of the hand/wrist and elbow to which
dental professionals are predisposed, including De Quervain’s syndrome, osteoarthritis of the carpometacarpal joint
of the thumb, lateral epicondylitis and others.
Regardless of the etiology of hand/wrist pain, dental professionals should realize that their occupation is a
perpetuating factor for the development of this pain.12,16,32
Prevention is of great importance, and intervention stratewww.ineedce.com
gies should become an integral habit in the operatory in the
office and at home.
References
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et al. The effects of periodontal instrument handle
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27.Simmer-Beck M, Bray KK, Branson B, Glaros A,
Weeks J. Comparison of muscle activity associated
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28.Glasscoe D. The better way to sharpen dental
instruments—CD. Professional Dental Management
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29.Kumar C. Biomechanics in Ergonomics. Philadelphia,
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30.Stockstill JW, Harn SD, Stickland D, Hruska R.
Prevalence of upper extremity neuropathy in a clinical
dentist population. J Am Dent Assoc. 1993;124:67-72.
31.Weiss S, Falkenstein N. Hand Rehabilitation: a Quick
Reference Guide and Review, 2nd ed. St. Louis, MO:
Elsevier Mosby; 2005:346.
32.Travell JG, Simons DG, Simons LS. Myofascial Pain
and Dysfunction: The Trigger Point Manual, Vol. 1.
Baltimore, MD: Lippincott Williams & Wilkins; 1999.
33.Novak CB, Mackinnon SE. Repetitive use and static
postures: a source of nerve compression and pain. J
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Hand Ther. 1997;10(2):151-9.
34.Adelman S, Eisner K. Arm pain in a dentist: pronator
syndrome. J Am Dent Assoc. 1982; 105:61-2.
35.Valachi B, Valachi K. Mechanisms contributing to
musculoskeletal disorders in dentistry. J Am Dent
Assoc. 2003;134:1344-50.
36.Ritter A, Sensat M, Harn, S. Thoracic outlet syndrome:
a review of the literature. J Dent Hyg. 1999;73:205-7.
37.Powell BJ, Winkley GP, Brown JO, Etersque S.
Evaluating the fit of ambidextrous and fitted gloves:
implications for hand discomfort. J Am Dent Assoc.
1994; 125:1235-42.
38.Christensen G. Operating gloves: the good and the
bad. J Am Dent Assoc. 2001;132:1455-57.
Resources
• This CE course is Chapter 5 from the author’s book,
Practice Dentistry Pain-Free: Evidence-based Strategies to
Prevent Pain & Extend Your Career – B. Valachi·
• It’s Not Carpal Tunnel Syndrome! – S Damany/J.
Bellis· Physics Forceps extraction instrument at www.
physicsforceps.com
• The following related resources are available on the author’s website: www.posturedontics.com: Osteoarthritis
vs. DeQuervain’s Disease in Dental Professionals (newsletter archives) WrisTimer – for preventing carpal tunnel·
Wrist/hand exercises for dental professionals.
Author Profile
Bethany Valachi, PT, MS, CEAS.
Ms. Valachi is a physical therapist, dental ergonomic consultant and author of the book, “Practice Dentistry Pain-Free”.
She is CEO of Posturedontics®, a company that provides
research-based dental ergonomic education and also lectures
internationally—including the 2009 International Dental
Ergonomics Congress in Krakow, Poland. Clinical instructor
of ergonomics at OHSU School of Dentistry in Portland, Oregon, Bethany has provided expertise on dental ergonomics
to faculty and students at numerous dental universities. She
has been widely published in various peer-reviewed dental
journals and has developed patient positioning, chairside
stretching and home exercise DVDs specifically for dental
professionals. She offers free newsletters, articles and product
reviews on her website at www.posturedontics.com.
Disclaimer
The author(s) of this course has/have no commercial ties with
the sponsors or the providers of the unrestricted educational
grant for this course.
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Questions
1. Hand, wrist and arm pain are much more
prevalent among dental professionals
than the general public, due to ________.
a.
b.
c.
d.
intermittent grips and sustained awkward postures
sustained grips and prolonged awkward postures
sustained grips and ergonomic postures
none of the above
2. Between _________ of dentists and nearly
_________ of dental hygienists experience
hand and wrist pain.
a.
b.
c.
d.
8 and 20 percent; 55 percent
13 and 25 percent; 65 percent
18 and 30 percent; 75 percent
23 and 40 percent; 75 percent
3. The origins of pain in the hand, wrist or
arm are always due to a problem in the
same area.
a. True
b. False
4. Carpal tunnel syndrome is the least
common peripheral nerve entrapment in
the arm.
a. True
b. False
5. For the hand to function properly,
________ flexor tendons and the median
nerve must be able to glide easily within
the carpal tunnel.
a.
b.
c.
d.
five
seven
nine
none of the above
6. Flexing the wrist forward and gripping
a small instrument forcefully are two of
the primary risk factors for carpal tunnel
syndrome.
a. True
b. False
7. High repetition work (such as manual
scaling) and long duration (e.g., how
many heavy calculus patients you
schedule back-to-back) are primary risk
factors for carpal tunnel syndrome.
a. True
b. False
8. Trying to keep your wrist straight and
moving your entire hand, wrist and
forearm as a unit ________, and is an
appropriate ergonomic intervention to
help prevent carpal tunnel syndrome.
a. transfers the load from larger hand muscles to
smaller arm and shoulder muscles
b. transfers the load from smaller hand muscles to
smaller arm and shoulder muscles
c. transfers the load from smaller hand muscles to
larger arm and shoulder muscles
d. none of the above
9. Using an accentuated angled instrument
is preferable to angling your wrist while
performing dental procedures.
a. True
b. False
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10. Ultrasonic scaling requires less force
applied to the work surface and a less
forceful precision grip than manual
scaling.
a. True
b. False
11. The duration of use of either ultrasonic
or manual instruments is positively associated with upper extremity numbness/
tingling.
a. True
b. False
12. Larger instrument handle diameters
increase hand muscle load and pinch
force.
a. True
b. False
13. Alternating between handle diameter
sizes may help prevent CTS symptoms.
a. True
b. False
14. Textured and lightweight instruments
help reduce pinch forces and forceful
pinch grips.
a. True
b. False
15. While dull instruments require the use of
more force, they do not have a deleterious
effect on musculoskeletal health.
a. True
b. False
16. Forceful pinch grip has been shown to
increase pressure in the carpal tunnel, but
this pressure is lowered when combined
with wrist ulnar deviation.
a. True
b. False
17. Hygienists and dentists should try to use
a _________ when possible.
a.
b.
c.
d.
plantar grip
palmar grip
ulnar grip
none of the above
18. Using 360-degree swivel instruments
helps to _________.
a. maintain neutral wrist and optimal finger
position
b. maintain optimal neutral wrist and a lateral finger
position
c. maintain optimal neutral wrist and finger position
d. all of the above
21. Tinel’s sign is an electric shock–type sensation in the hand when the _________ is
tapped gently at the wrist and is often seen
in patients with carpal tunnel syndrome.
a.
b.
c.
d.
superior palmar nerve
inferior palmar nerve
median nerve
none of the above
22. Weakness of the thenar muscles at the
base of the thumb is often seen in patients
with carpal tunnel syndrome.
a. True
b. False
23. Therapeutic interventions for the treatment of carpal tunnel syndrome include
_________.
a.
b.
c.
d.
ice
massage
ultrasound or acupuncture
all of the above
24. _________ is a conservative treatment
option for carpal tunnel syndrome.
a. Nerve or tendon gliding exercises
b. Modification of activities to decrease tendon excursion
c. The use of anti-inflammatories or cortisone
injections
d. all of the above
25. _________ may mimic carpal tunnel
syndrome.
a.
b.
c.
d.
Cervical radiculopathy
Poorly fitting gloves
Thoracic outlet syndrome
all of the above
26. Median nerve entrapment is one of the
conditions that does not mimic carpal
tunnel syndrome.
a. True
b. False
27. Ambidextrous gloves exert one-third
more force than do fitted gloves, and their
use may result in _________.
a.
b.
c.
d.
muscle ischemia
nerve compression
pain
all of the above
28. Trigger points in the forearm muscles
such as the pronator teres can cause
compression on the median nerve and
cause pain in the hand and wrist similar to
that of carpal tunnel syndrome.
a. True
b. False
19. Alternating between chairs with and
without armrests can help avoid structural
damage.
29. Older practitioners may be more prone
than younger practitioners to gloverelated pain in the hands.
20. Exposure to _________ is an aggravating
risk factor associated with CTS.
30. Intervention strategies should become
an integral habit in the operatory in the
office and at home to help prevent carpal
tunnel syndrome.
a. True
b. False
a.
b.
c.
d.
warmth
cold
humidity
all of the above
a. True
b. False
a. True
b. False
9
ANSWER SHEET
Getting the Upper Hand on Pain:
Preventing Hand and Wrist Pain Syndromes in Dental Professionals
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
Country:
Lic. Renewal Date:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
If not taking online, mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
1. List and describe four of the primary risk factors associated with carpal tunnel syndrome
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. List and describe ergonomic interventions that can help prevent carpal tunnel syndrome
3. List and describe other conditions that may mimic carpal tunnel syndrome
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
4. Provide an overview of the diagnosis and treatment of carpal tunnel syndrome
Course Evaluation
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met?
Objective #1: Yes No
Objective #3: Yes No
Objective #2: Yes No
Objective #4: Yes No
If paying by credit card, please complete the following:
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Acct. Number: _______________________________
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives. 5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic? 5
4
3
2
1
0
6. Please rate the instructor’s effectiveness. 5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Do you feel that the references were adequate? Yes
No
Yes
No
9. Would you participate in a similar program on a different topic?
Exp. Date: _____________________
Charges on your statement will show up as PennWell
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
AGD Code 130
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The author(s) of this course has/have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.
10
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 4527. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
Customer Service 216.398.7822
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PennWell maintains records of your successful completion of any exam. Please contact our
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all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2010 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
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