European Journal of Dental Education ISSN 1396-5883

Ergonomics in dentistry: experiences of the practice by dental

students
P. P. N. S. Garcia1, A. C. A. Gottardello1, D. Wajngarten2, C. D. Presoto2 and J. A. D. B. Campos1
1
~o Paulo, Brazil,
Department of Social Dentistry, Araraquara Dental School, UNESP, Univ Estadual Paulista, Araraquara, Sa
2
Department of Restorative Dentistry, Araraquara Dental School, UNESP, Univ Estadual Paulista, Araraquara, S~
ao Paulo, Brazil

keywords Abstract
interview; students; occupational diseases.
Objective: The aim of this study was to qualitatively evaluate the experiences of stu-
Correspondence dents enrolled in the last year of dentistry school with ergonomic practice.
Patrıcia Petromilli Nordi Sasso Garcia
Rua Humait a 1680
Methods: This is a qualitative, observational and cross-sectional study, with a non-
Centro - Araraquara, SP CEP: 14.801-903,
probabilistic sample design. The sample comprised students enrolled in the last year of
Brazil
dentistry in Araraquara–UNESP (n = 29). The data were collected by means of open
Tel: +55 16 3301 6405
semi-structured and individual interviews, captured by a digital voice recorder. The stu-
Fax: +55 16 3301 6343
dents were interviewed in their own university at a time that was previously scheduled,
e-mail: psgarcia@foar.unesp.br
and care was taken to provide a private and welcoming environment to carry out the
Accepted: 16 February 2016 interviews. A script containing questions related to practices in ergonomics was prepared
at the university. Data analysis was carried out using the qualitative–quantitative Collec-
doi: 10.1111/eje.12197 tive Subject Discourse technique with the aid of Qualiquantisoft
software program.

Results: It was found that more than half of the students (58.6%) believe that adopt-
ing an ergonomic posture is important to prevent future problems, pain and occupa-
tional diseases, and 62.1% of the students confirm having difficulties in adopting
ergonomic postures due to the types of treatment required and the regions of the
mouth being treated. The main reasons stated for the fact that their colleagues do not
adopt ergonomic postures are lack of attention, practice and forgetfulness (44.8%) and
difficulty in visualising the operatory field or the procedure performed (27.6%).

Conclusion: It is possible to conclude that the students interviewed know ergonomic

principles and their importance in occupational health. However, they found it diffi-
cult to put these principles into practice.

retical concepts (1). Ergonomic theory is taught at the Faculty

Introduction
Ergonomics in dentistry contributes to maintaining the occupa-
tional health of dental surgeons through preserving the balance
between technologies available in the dental office, the muscu-
loskeletal system of the professional and the operative field (1).
Moreover, the application of ergonomics to dentistry improves
work quality, thus rendering it easier and faster. Hence, the
main objective of ergonomics in dentistry is to streamline the
work, increase productivity and maintain the quality of life of
the professional (2).
Although this science critically contributes to good dental
practice in general, its approach in dentistry is focused on theo-
of Dentistry of Araraquara/Brazil by dental surgeons specialis-
ing in the area of ergonomics. Teaching is divided into theoretical
lessons and practical follow-up (2).
Theoretical lessons are taught in the second year of the
course, with weekly classes totalling approximately 25 h. The
theoretical teaching of ergonomics includes topics such as con-
cepts of productivity and ergonomics as applied to dentistry,
requirements for ergonomic posture in dentistry (working posi-
tion of the operator, the assistant and the patient; use of high-
power suction for various clinical procedures; working positions
for procedures related to restorative dentistry in the six sextants
of the mouth), organisation of trays and assistant tables to

ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Ergonomics experience in dental students
perform clinical and laboratory procedures, occupational health,
management of cross-infection and biosafety, dental equipment
(use and maintenance) and delegating roles (activities per-
formed by assistants). This course provides students with basic
training in ergonomics for application in clinical practice.
The practical follow-up of ergonomic starts during the pre-
clinical activities of the Restorative Dentistry course, when stu-
dents are still enrolled in the second year of this degree course,
a total of 45 h of training. Clinical activities are also carried
out during patient care in the Restorative Dentistry course,
during the third year of this degree course (2–4), a total of
90 h of training. The major emphasis of the discipline of Ergo-
nomics in Dentistry in this Faculty is to conduct streamlined
work together with the maintenance of occupational health.
However, Garcia et al. (3) and Corrocher et al. (2) observed
that there is a high risk for musculoskeletal disorders in stu-
dents that received theoretical and practical training in ergo-
nomics. This was also observed in other studies that included
students from different universities (5–9).
Taking into account that the high risk for musculoskeletal dis-
orders in individuals that are still undergoing vocational training
may compromise their careers, resulting, for instance, in their
early withdrawal from the profession (10, 11), it is important to
understand the reasons why these students present with a high
prevalence of musculoskeletal disorders (12, 13). There are few
published studies considering students’ experiences and practice
in relation to ergonomics and occupational health. Obtaining
this information may guide the teaching of ergonomics in den-
tistry and assist in maintaining good occupational health.
Qualitative studies are usually recommended to obtain this
type of information, as they allow access to beliefs, reasons, val-
ues and attitudes (14–16) expressed through a common lan-
guage, which is the core of qualitative research (17, 18).
Amongst the qualitative methods that can be employed, the
Collective Subject Discourse (CSD) technique allows for the
organisation of one synthesised discourse, which is synthesised
from several individuals, considering social and institutional
equivalents (14).
Therefore, the aim of this study was to observe, through
qualitative techniques, the experiences and ergonomic practices
of students enrolled in the last year of dentistry school.
Materials and methods
Sample design
This is an observational, cross-sectional and qualitative study,
with a non-probabilistic sample design. The sample consisted
of students enrolled in the final year of the undergraduate
course of dentistry at the Faculty of Dentistry of Araraquara–
UNESP in 2014. Students of both genders agreed to freely par-
ticipate in the study (n = 29), which was approved by the
Research Ethics Committee of the Faculty of Dentistry of
Araraquara–UNESP (CAAE: 23503613.0.0000.5416).
Data collection
The data were collected through an open semi-structured and
individual interview captured by a digital voice recorder. Once
2 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Garcia et al.
the files were transferred to the computer, the students’
discourse was transcribed in Microsoft Word 2010 for further
analysis.
Dental students were interviewed in their own university and
at a time that was previously scheduled, and care was taken to
provide a private and welcoming environment to carry out the
interview. A script was prepared containing questions related to
ergonomics and the experience of students in adopting ergo-
nomic postures whilst performing clinical work. The students
were asked the following questions:
1 How do you understand (see) ergonomics?
2 Do you adopt the principles of ergonomic postures in clini-
cal practice? Why?
3 Do you think that adopting ergonomic postures while pro-
viding clinical care is important? Why?
4 In the last week, during your laboratory/clinical activities,
what is the inappropriate posture that you most frequently
adopted? Why do you think that this happened?
5 Do you think that your colleagues adopt ergonomic postures
during their clinical practice? Why?
Data analysis
Data analysis was carried out using the CSD qualitative–quanti-
tative technique (14) with the aid of Qualiquantisoft
software
program (SPI - Sales & Pascoal Company, S~ao Paulo, SP,
Brazil). Following the recommendations of this technique, we
evaluated the response of each individual to our questions as
follows: (i) selecting key expressions that represent continuous
or discontinuous discourse segments revealing the most signifi-
cant passages of the discourse content; (ii) identifying core
ideas corresponding to each key expression that represent the
summary of each expression’s content, that is, what they really
mean. For each question, categories are determined based on
key expressions. Each question may have several categories of
responses. To facilitate the visualisation of the results in this
study, the categories were identified by alphabet letters. (iii)
identifying similar or complementary core ideas; (iv) combin-
ing key expressions that refer to similar or complementary core
ideas in a discourse synthesis, written in the first singular per-
son and representing CSD, in which the thought of the group
or collectivity appears as one.
In addition to qualitative analysis using the CSD, this soft-
ware allowed a quantitative evaluation of the results through
descriptive statistics. The relative frequency distribution of the
results was then presented according to the categories assigned.
Results
The qualitative results are summarised in Table 1.
Discussion
Observing the experiences of students enrolled in the last year
of Dentistry in relation to the adoption of ergonomic postures
while providing clinical care allows access to the reality of indi-
vidual and collective practical learning as well as the application
of previously acquired knowledge. The participating dental stu-
dents were taught ergonomics while enrolled in the second and
Garcia et al. Ergonomics experience in dental students

TABLE 1. Summary of Collective Subject Discourse analysis according to the categories referring to each question

Question 1 – How do you understand (see) ergonomics?

Category A: As rules and measures adopted to optimise our work and/or to maintain occupational health (68.97%)
Category B: Related to working posture (27.59%)
Category C: Related to work movements (3.45%)
Question 2 – Do you adopt the principles of ergonomic postures in clinic practice? Why?
Category A: Adopt or try to adopt to prevent future problems (51.72%)
Category B: Adopt or try to adopt because already experiencing pain (10.34%)
Category C: Sometimes, but not always, due to distraction, inability to visualise the operative field, difficulties in providing care, being in a rush (31.03%)
Category D: Never adopt because of the difficulty of the case or unable to (6.90%)
Question 3 – Do you think that adopting ergonomic postures whilst providing clinical care is important? Why?
Category A: Yes. To prevent occupational diseases, pain, musculoskeletal disorders, and future problems (58.62%)
Category B: Yes. To facilitate/improve patient care and work (3.45%)
Category C: Yes. To facilitate/improve patient care/work and prevent diseases/occupational problems (27.59%)
Category D: Yes. To decrease fatigue (3.45%)
Category E: Yes. To create appropriate habits since the beginning (6.90%)
Question 4 – In the last week during clinical practice, which is the inappropriate posture that you most frequently adopt?
Category A: Working with raised arms (10.34%)
Category B: Often getting up from the stool to retrieve instruments that were distant from my working area (17.24%)
Category C: Inappropriate positioning of the spine (31.03%)
Category D: Inappropriate positioning of the neck (13.79%)
Category E: Crossing legs (3.45%)
Category F: Working with raised arm and twisted spine (6.90%)
Category G: Response incompatible with the question (13.79%)
Category H: I did not adopt an inappropriate posture (3.45%)
Question 5 – Do you think that your colleagues adopt ergonomic postures whilst working in the clinic? Why?
Category A: No. Due to distraction, forgetfulness, lack of habit, lack of practice, and problems at work (20.69%)
Category B: No. Because they do not think it is natural (10.34%)
Category C: Yes. Because they learnt about it at the university (13.79%)
Category D: Yes. Because they want to prevent occupational diseases (13.79%)
Category E: Yes. Because they developed this habit (3.45%)
Category F: Sometimes, not always. Due to forgetfulness or lack of attention (24.14%)
Category G: Sometimes, not always. Due to the difficulty in putting ergonomic principles into practice (10.34%)
Category H: Sometimes, not always. Due to the fact that they do not believe it is important (3.45%)

third year of dentistry. In addition, beginning with the fourth
year, they started to consolidate the knowledge acquired in other
clinical disciplines. Therefore, their experiences might guide the
establishment of strategies aimed at improving the teaching of
ergonomics in dentistry with the objective of subsequently
maintaining the occupational health of future dental surgeons.
We noticed that the majority of the respondents (68.9%)
understand ergonomics as ‘. . .a set of attitudes, postures and
preparations to work faster and adopt a more suitable position
as well as in order to avoid future problems’. This is consistent
with ergonomic principles and demonstrates that students in
general can understand ergonomics as something important,
which may benefit their health in the future. This is also sup-
ported by the fact that these students practiced ergonomic
principles while they were supervised by professors specialising
in the area during their pre-clinical and clinical activities for a
period of 2 years.
The awareness of the students of the importance of ergo-
nomics in occupational health and in preventing future prob-
lems was demonstrated and confirmed by the responses given
when asked about reasons to adopt ergonomic postures in their
work environment. 51.7% of the students tried to put into
practice ergonomic principles with the aim of ‘. . .avoiding
health problems in the future’ and’. . .always maintaining the
best possible posture. . . especially considering that we will work
this way for the rest of our life’. It was also possible to perceive
the following ‘. . . we will have to adopt it for much of our life
and it makes a big difference’, which demonstrates ergonomic
awareness among the students. To make a difference in the
lives of professionals, ergonomics is not something that should
be taken into consideration only during the phase of vocational
training. Moreover, it is important to highlight the fact that
understanding that neglecting to adopt ergonomic postures at
work may cause progressive functional damage: ‘. . . we know
that if we do not sit correctly or raise our shoulders too much,
we will have problems, pain. . .’.
Several respondents (10.3%) confessed that they have begun
to adopt ergonomic postures because they are already suffering
from pain: ‘my back already hurts, therefore if I adopt an inap-
propriate posture. . . it will get worse. . . when I adopt the
proper posture. . . the pain on my back improves. . . I try, I
really try to. . . improve my pain’. Although it is worrisome that
students already experience pain due to their occupation, it is
possible to assess whether this pain may lead students to truly
understand the positive effect of adopting ergonomic postures
for occupational health. On the other hand, it should be noted

ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3
Ergonomics experience in dental students
that some students (31.0%) do not always succeed in adopting
ergonomic postures due to a number of reasons such as ‘. . . It
varies according to the case that needs to be treated in clinical
practice, the emotion related to the moment. . . due to distrac-
tion. . . Because sometimes. . . you are very excited at work
and. . . then you lose track, you know. . . We cannot always
manage, since depending on the type of work we need to per-
form, we are forced to adopt an inappropriate position or we
end up forgetting. . .’.
Other students (6.9%) confessed that they are not adopting
ergonomic postures and they explained this attitude as follows
‘. . . it is not possible and this is due to the position of the
patient and also possibly due to lack of practice. . .’. In the dis-
course of students, it is clear that they do not always adopt
ergonomic postures. Often this seems to be because they are
more concerned about the procedure they are performing than
how they are carrying it out, that is, the position they adopt.
This concern and the concentration required to perform the
procedure leads them to prioritise the work in the patient’s
mouth, putting their own health in second place (3).
It is possible that this is due to the technical characteristics
of the work that dental students need to perform, which
requires manual dexterity and procedure control. Moreover, it
seems that the students feel that adopting ergonomic postures
may hinder their work, as appeared in their discourse ‘I find
very difficult to adopt ergonomic postures, because if I adopt
the posture I was taught I cannot work properly. I prefer to
adopt the more suitable position for me at that moment. . ...’.
This idea is not correct and should be changed because adopt-
ing ergonomic postures at work should facilitate visualising the
operating field. This idea should also be modified among the
professors teaching this clinical course, as they often reinforce
this misconception.
Although several students reported and explained their rea-
sons for not adopting ergonomic postures, we observed that all
respondents claimed that this is important to adopt during
their work and most of them (86.2%) were concerned with
maintaining their health.
Based on the discourse of the students, it was possible to rea-
lise that teaching ergonomics in Dentistry at the Faculty of
Dentistry of Araraquara allows students to understand the
importance of adopting ergonomic postures to maintain occu-
pational health, that is, the existence of theoretical knowledge
on the subject (12). However, when they need to put ergo-
nomic principles into practice, they face some obstacles. Ana-
lysing the responses given to Question 4, it was possible to
verify that all postural inadequacies, referring to the difficulties
encountered in visualising the operative field, are due to poor
positioning of the patient in the dental chair and the resulting
difficulty in working with an indirect view of the area. Dental
chair positioning was also a problem reported by Garcia et al.
(19) and Garcia et al. (20). To increase the practical application
of ergonomic principles, we suggest the removal of its main
obstacle, visualisation of the operative field. Considering the
clarity of vision plays an important role in the balanced pos-
ture, a strategy that has been studied at the Faculty of Dentistry
of Araraquara is the implementation of a training programme
for working with indirect vision and loupes magnification since
pre-clinical training.
4 ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Garcia et al.
Most of the questions that were used in this survey were
aimed at understanding the experiences and attitudes of the
students in relation to ergonomics. However, a number of situ-
ations, which depend on social desirability, lead the students to
feel intimidated in expressing their real thoughts, especially in
the educational environment in which they know they are con-
stantly evaluated. The strategy adopted to minimise this situa-
tion was to ask the students about colleagues that are in a
similar situation, namely Question 5 of this survey. This
allowed us to assess that most students (69.9%) believe that
their colleagues do not adopt ergonomic postures, and if they
do, it is not always. Among the reasons provided, lack of
attention, forgetfulness, rushing and difficulty with the proce-
dure were the main ones reported. In this context, there are
several discourses that drew our attention, such as ‘. . . they are
not aware of the importance of these postures’, ‘it is easier to
ignore the pain than to adopt ergonomic postures. . .’, ‘I hear
people complaining that it is very difficult to properly adopt
the posture that was taught. Because it is complicated, you
know, to adapt to an already established posture model, since
you do not feel comfortable in that position’. We observed that
students perceive ergonomics as an established and not an indi-
vidualised model. Therefore, they prefer to suffer pain rather
than face the initial difficulty to develop a healthy habit. This is
a very limited view with respect to the rationalising of work
and occupational diseases, which depends on how dentistry is
taught. So far, great emphasis is still given to technical rather
than behavioural processes related to the promotion of health
(15).
With this study, we observed that despite their clinical expe-
riences and ergonomic educational approach, there is still a
constant need to further promote ergonomics. It is also neces-
sary to revise how the practical teaching of ergonomics is car-
ried out, in order to change it into a more rewarding and
enjoyable experience for the students. This may be achieved
using an approach that leads the student to adopt proper atti-
tudes through understanding the impact that these would have
on long-term health (5, 21) and to not only apply these tech-
niques while studying ergonomics in dentistry in order to
obtain good grades.
The experiences and practices of the students in relation to
ergonomics demonstrated that, although aware of its meaning
and importance, students do not often feel motivated to adopt
ergonomic postures in clinical practice, explaining this attitude
with difficulties related to external problems. This should be
carefully studied within dentistry courses with the aim of moti-
vating students to create a conscious ergonomic dental practice.
With this, we help students to develop their social control,
aiming to improve their quality of life.
Conclusion
Students have knowledge regarding ergonomics and are aware
of its importance for occupational health. However, they have
difficulty adopting ergonomic postures.
Conflicts of interest
There are no conflict of interests to declare.
Garcia et al.
References
1 Garbin AJ, Garbin CA, Diniz DG, Yarid SD. Dental students’
knowledge of ergonomic postural requirements and their
application during clinical care. Eur J Dent Educ 2011: 15: 31–
55.
2 Corrocher PA, Presoto CD, Campos JADB, Garcia PPNS. The
association between restorative pre-clinical activities and
musculoskeletal disorders. Eur J Dent Educ 2014: 18: 142–146.
3 Garcia PPNS, Pinelli C, Derceli JR, Campos JADB. Musculoskeletal
disorders in upper limbs in dental students: exposure level to risk
factors. Braz J Oral Sci 2012: 11: 148–153.
4 Garcia PPNS, Presoto CD, Campos JADB. Perception of risk of
musculoskeletal disorders among Brazilian dental students. J Dent
Educ 2013a: 77: 1543–1548.
5 Morse TF, Michalak-Turcotte C, Atwood-Sanders M, et al. A pilot
study of hand and arm musculoskeletal disorders in dental hygiene
students. J Dent Hyg 2003: 77: 173–179.
6 Alexopoulos EC, Stachi IC, Charizani F. Prevalence of
musculoskeletal disorders in dentists. BMC Musculoskelet Disord
2004: 5: 16–23.
7 Rising DW, Bennett BC, Hursh K, Plesh O. Reports of body pain in
a dental student population. J Am Dent Assoc 2005: 136: 81–86.
8 Lindfors P, Thiele U, Lundberg U. Work characteristics and upper
extremity disorders in female dental health workers. J Occup Health
2006: 48: 192–197.
9 Thornton LJ, Barr AE, Stuart-Buttle C, et al. Perceived
musculoskeletal symptoms among dental students in the clinic work
environment. Ergonomics 2008: 51: 573–586.
10 Leggat PA, Kedjarune U, Smith DR. Occupational health problems
in modern dentistry: a review. Ind Health 2007: 45: 611–621.
11 Kanteshwari K, Sridhar R, Mishra AK, Shirahatti R, Maru R,
Bhusari P. Correlation of awareness and practice of working
ª 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Ergonomics experience in dental students
postures with prevalence of musculoskeletal disorders among dental
professionals. Gen Dent 2011: 59: 476–483.
12 Garcia PPNS, Gottardello ACA, Presoto CD, Campos JADB.
Ergonomic work posture in undergraduate dentistry students:
correlation between theory and practice. Work Course Conclusion,
Araraquara Dental School, 2014.
13 Khan SA, Chew KY. Effect of working characteristics and taught
ergonomics on the prevalence of musculoskeletal disorders amongst
dental students. BMC Musculoskelet Disord 2013: 14: 118.
14 Lefevre F, Lefevre AM, Marques MC. Discourse of the collective
subject, complexity and self-organization. Cien Saude Colet 2009:
14: 1193–1204.
15 Mialhe FL, Silva CM. Health education and their representations among
dental students. Cien Saude Colet 2011: 16(Suppl. 1): 1555–1561.
16 Choo EK, Garro AC, Ranney ML, Meisel ZF, Morrow Guthrie K.
Qualitative research in emergency care part I: research principles
and common applications. Acad Emerg Med 2015: 22: 1096–1102.
17 Dicicco-Bloom B, Crabtree BF. The qualitative research interview.
Med Educ 2006: 40: 314–321.
18 Carter SM, Ritchie JE, Sainsbury P. Doing good qualitative research
in public health: not as easy as it looks. N S W Public Health Bull
2009: 20: 105–111.
19 Garcia PPNS, Campos JADB, Zuanon ACC. Posturas de trabalho
de alunos no atendimento odontol ogico de criancßas. Pesq Bras
Odontoped Clin Integr 2008: 8: 31–37.
20 Garcia PPNS, Wajngarten D, Gottardello ACA, Campos JADB.
Occupational ergonomics: work posture among Brazilian dental
students. In: 13 International Symposium on Occupational Safety
and Hygiene – SHO2013, 2013b, Guimar~aes. Occupational Safety
and Hygiene. London, UK: CRC Press, 2013: 1–646.
21 Barry RM, Woodal WR, Mahan JM. Postural changes in dental
hygienists. Four-year longitudinal study. J Dent Hyg 1992: 66: 147–
150.
5