Environ Sci Pollut Res
DOI 10.1007/s11356-017-8615-3
ENVIRONMENTAL POLLUTION: PROBLEMS AND SOLUTIONS
Knowledge, attitude, and practice towards ergonomics
among undergraduates of Faculty of Dentistry, Tanta
University, Egypt
Rania M. El-sallamy 1 & Salwa A. Atlam 2 & Ibrahim Kabbash 2 &
Sanaa Abd El-fatah 2 & Asmaa El-flaky 1
Received: 13 June 2016 / Accepted: 7 February 2017
# Springer-Verlag Berlin Heidelberg 2017
Abstract Ergonomics is the scientific study of people and
their working environment. Dentistry is a profession that gen-
erally produces various musculoskeletal disorders. If ergo-
nomic principles are applied in the field of dentistry, it helps
to prevent occupational ergonomic health hazards and pro-
vides more comfort to the dentist and patient. To assess
knowledge, attitudes, and practice of ergonomics during rou-
tine dental procedures among undergraduates of Faculty of
Dentistry, Tanta University, cross-sectional study was con-
ducted among dental students of Tanta University during the
year 2015–2016 using a predesigned selfadministered ques-
tionnaire. Knowledge, attitude, and practice were assessed by
16, 5, and 6 questions, respectively. The study included 479
dental students, of them, 291 (60.8%) were females, 359
(74.9%) were from urban areas, and 359 students (74.9%)
were 22 years old and below. Only one quarter of the students
had good knowledge whereas nearly half of the students
(48.9%) had fair knowledge concerning ergonomics. Out of
the participants, 84.8% had positive attitudes and 95.4% had
poor practice of ergonomics. Only 48.9% of the studied stu-
dents had fair knowledge regarding ergonomics; also 5% only
of students practice it. But about 84.8% of students have a
positive attitude towards studying ergonomics. Dental stu-
dents need to ensure involving ergonomics in the routine
Responsible editor: Philippe Garrigues
* Rania M. El-sallamy
rania.elsalamy@gmail.com
1
Occupational Medicine, Faculty of Medicine, Tanta University,
Tanta, Egypt
2
Public Health and Community Medicine, Faculty of Medicine, Tanta
University, Tanta, Egypt
dental practice. This may be achieved via addition of ergo-
nomics in their curriculum.
Keywords Ergonomics . Knowledge . Attitude . Practice .
Dental students . Egypt
Introduction
Ergonomic is the particular study of people and their work-
ing environment. Ergonomic was derived from a Greek
word BErgo^ means work and BNomos^ means natural
laws or systems (Kalghatgi et al. 2014). Ergonomic conse-
quently is the science concerned with designing products
and procedures for maximum efficiency and safety
(American Dental Association 2011).
The International Ergonomics Association defines ergo-
nomics as the scientific regulations concerned with the rela-
tions between humans, main beliefs, and methods to design
workplace in order to optimize human comfort and largely
system performance (Kritika et al. 2014).
Dentistry is a profession where clinically operational skills
are restricted to region covering merely few tens of millime-
ters (the mouth) that require frequent strength while delivering
oral health. These situations claim a permanently uncomfort-
able position that can generate job musculoskeletal hazards for
the dentist (Dul and Weerdmeester 2004).Consequently, it is
very imperative to sustain a sufficient work posture and the
instruments and furniture the dentists are working with have
ample functioning uniqueness (Bramson et al. 1998).
Worldwide, there is increased awareness and conscious-
ness among population regarding the importance of maintain-
ing appropriate oral health and seeking dental health care pro-
viders. Wrong working postures among dentists while treating
the dental patients and long working hours without periods of

rest and stretching exercises expose them the risk of multiple
occupational musculoskeletal problems (Dul and
Weerdmeester 2004).
There is always a neutral zone of motion for each joint and
muscle. Injury risks increase whenever work requires a person
to perform tasks with body segments outside of his or her
neutral range in a deviated posture (CDP, Council on Dental
Practice, 2004). Dentists usually complain a variety of mus-
culoskeletal symptoms varying from uneasiness, pain, to func-
tional limitations, and decreased work performance due to
uncomfortable and wrong working postures (Boyd 1994;
Rucker and Sunell 2002). Symptoms are sluggish to emerge
and are usually ignored until they become chronic, and per-
manent lesions become evident (Diaz-Caballero et al. 2010).
Even with technological advances in the dental tool indus-
try, locomotor system damage is still an everyday hazard,
resulting in the decline of the working capability of the dental
practitioners (Lydia et al. 2012).
Literature reported that 55–93% of dentists suffer a variety
of work-linked musculoskeletal disorders with the uppermost
risk among elderly and women, due to lack of information
interrelated to knowledge, attitude, and practice of applying
ergonomic principles in everyday dental practice (Kritika et al.
2014).Among the wide range of musculoskeletal disorders,
back pain was the most common among dentists, followed
by neck pain (Yousef and Al-Zain 2009). Shoulders, elbows,
and hands are possible areas of the body to suffer (Pargali and
Jowkar 2010; Sartprio et al. 2005).
Pargali and Jowkar (2010) reported that out of 82 dental
students, 27 (33%) dentists had low back pain, 23 (28%) had
neck pain, and 10 (12%) had both. Of these 60 dentists who
had pain, 27 (45%) had radicular pain and 28 (47%) felt
numbness and/or paraesthesia in their limbs. According to
Ratzon et al. (2000), musculoskeletal symptoms among 60
dentists were localized primarily in the lower back and
in the neck in 33 (55%) and 23 (38.3%) respectively
which were well interrelated to the long working hours
and uncomfortable stance while working. Brown et al.
(2010) reported that out of 189 retired dentists, the most
common cause of ill-health retirement in 104 (55%) of
them was due to musculoskeletal disorders.
It is very essential to uphold a sufficient work posture and
the instruments and furniture that the dentists are working with
have adequate working characteristics (Kritika et al. 2014).If
ergonomic principles are applied in the field of dentistry, it
helps to prevent occupational ergonomic health hazards and
provides more comfort to the dentist and patient (Castro and
Figlioli 1999). So the goal of ergonomics is to stabilize a
secure, healthy, and comfortable working environment, there-
by preventing health problems and improving productivity
(Dul and Weerdmeester 2004). According to Riziq Allah
et al. (2015), dentists are at high risk for neck and back pain.
Awkward working postures, repetitive work, and prolonged
Environ Sci Pollut Res
standing can result in damage to muscles, joints, bones, liga-
ments, tendons, nerves, and blood vessels, which can then
lead to pain, fatigue, and various musculoskeletal disorders.
The type of pain varies, ranging from a stiff feeling to definite
pain. Low back pain (LBP) is the most frequent complaint,
and almost all dentists worldwide have experienced this dur-
ing their careers (Riziq Allah et al. 2015). In another study,
204 dentists and dental auxiliary (87 males and 117 females)
in Riyadh city, Saudi Arabia, were surveyed to determine the
prevalence of postural problems. The data obtained showed
that 111 (54.4%) of the subjects complained of neck pain and
150 (73.5%) complained of back pain. Only 37% of those
complaining of back pain sought medical help. The neck
and back pain among dental personnel are not of a severe
nature (Al Wazzan et al. 2001).
So ergonomic working principles should be taught to the
budding dental graduates at the dental colleges and should be
incorporated into the curriculum. Unfortunately, in Egypt, a
very little importance is given to this increasing problem.
Hence, the aim of this study is to assess the knowledge, atti-
tude, and practice of the ergonomic principles among dental
students during their clinical stage to determine the areas of
weakness in these aspects to be enforced when doing educa-
tion programs concerning ergonomic application during rou-
tine dental practice.
Objectives of the study
Immediate objectives
The immediate objectives of the study were to assess knowl-
edge, attitudes, and practice of ergonomics among undergrad-
uates of Faculty of Dentistry, Tanta University.
Ultimate objective
The ultimate objective of the study is to prevent work-related
musculoskeletal disorders among dentists.
Materials and methods
Study design and setting
A cross-sectional study was conducted over a period from
January 2016 till March 2016.
Place of the study and study populations
Faculty of Dentistry, Tanta University, was the place of study.
Undergraduate dental students from 3rd and 4th year dental
college and house officers were our study population. The
Environ Sci Pollut Res
undergraduate dental students start the clinical training and
dealing with patients from the 3rd year of college courses
onward. At least 384 students should be included as partici-
pants via a purposive sampling. This sample size was estimat-
ed using Epi info program version 7, with 5% confidence
limits and 95% confidence level. For better accuracy and to
cover any losses due to an incomplete questionnaire, 479 stu-
dents were included. Students from other faculties than
Faculty of Dentistry, Tanta University, were excluded. Also,
students from grades other than 3rd and 4th year and house
officers were excluded from the study.
Study tools
The study participants were asked to fill a predesigned ques-
tionnaire sheet .The questionnaire was selfadministered and
closed-ended. The items for the questionnaire were collected
from other studies which were valid and reliable (Kritika et al.
2014, Kalghatgi SR et al.2014). The questionnaire consisted
of 27 items with 16, 5, and 6 items assessing knowledge,
attitude, and practices respectively in addition to some ques-
tions related to sociodemographic data, duration of work
hours per day, and practicing physical exercise. Knowledge
was assessed by a total of 16 questions focused on principles
of ergonomics in routine dental procedures. The attitude was
assessed on a 5-point Likert scale: definitely yes, yes, neutral,
no, and definitely no. The response options for practices were
also a 5-point Likert scale as follows: always, very often,
often, rare, and never. Questions related to attitude included
the following: whether ergonomics should be a part of the
dental curriculum, dentists should follow the ergonomic prin-
ciples in routine dental practice, dental chair and instruments
play any role in following ergonomic principles in the routine
dental practice, dentist should alternate between sitting and
standing posture in between two patient appointments, and
various dental institutions should conduct continuing dental
education. Questions relevant to practices assessed how fre-
quently the respondents make an effort to maintain neutral
posture while working, how frequent they orient beam of light
perpendicular to the observational direction and how frequent
they work in the upright position, how frequent the spine is
resting on the back of the stool, and how frequently they used
dental loupes for magnification purposes.
Scores of knowledge, attitude, and practice
As regards the knowledge, there were 16 questions, answered
as yes, to some extent, and no answer and scored as 2, 1, and
0. (Ayma 2011) The total score of knowledge ranged from 0 to
32. Those who achieved ≥75% from the total score (≥24) were
considered to have good knowledge, those from 50–<75%
(16–23) were of fair knowledge, and below 50% (below 16)
were considered as had poor knowledge.
Regarding the attitude, there were five questions. The total
score ranged from 0 to 20. Those who achieved ≥75% from
the total score (≥15) were considered to have a positive atti-
tude while less than 75% (less than 15) considered having a
negative attitude.
For practice, there were six questions scored from 0 to 24.
Those who achieved ≥75% from the total score (≥18) consid-
ered as having a good practice while those who achieved less
than 18 as having bad ergonomic practice.
Statistical analysis of data
Statistical analysis was performed using SPSS for Microsoft
Windows, version 16. Descriptive statistical data were tabu-
lated and summarized in proportions and percentage, using
the chi-square test. Less than 5% significance was adopted
in this study (p < 0.05).
Administrative consideration Written approval to imple-
ment the study in the dental hospital was obtained from the
head of the institution to ensure maximum cooperation.
Ethical consideration Subjects were informed about the pur-
pose and procedures of the study and benefits of sharing it.
Oral consent and approval were obtained from each subject to
participate in the study and those who refused participation
were excluded. Confidentiality and privacy were guaranteed
during the whole period of the study. Approval of the ethical
committee of Faculty of Medicine, Tanta University, was ob-
tained before starting the study.
Results
Table 1 displays the characteristics of the studied students,
where three quarters of them (74.9%) were less than or
equal to 22 years old. Nearly two thirds of the students
(60.8%) were females. Of them, 359 (74.9%) students
were urban residents. Most of the participants (85.4%)
were in the 5th year (grade 4) of their university study.
Nearly two thirds of the students (60.1%) used to work
for 6 h or more/day. More than half of the participants did
not do any physical exercise outside their work.
Table 2 shows the knowledge of the students relevant to
ergonomics, where only one third of the students (39.0%)
knew what is meant by ergonomics. More than three quarters
of the students (77.0%) knew the health hazards of their job
without ergonomics. Moreover, more than two thirds of the
participants knew the benefits of its application. Most of the
students (83.3%) knew the best posture of the dentist sitting.
Nearly two thirds of the students (64.3%) knew the points on
the body that come in contact with patients and objects for
stable control and sightings of the operating points. Only
 Environ Sci Pollut Res

Table 1 Characteristics of the studied students dentist should alternate between sitting and standing between
Characteristics Number 479 % 100 patients’ appointments. Regarding continuous dental educa-
tion, less than half (41.1%) definitely think that dental institu-
Mode of age tion should conduct it.
22 years 285 59.5 Table 4 displays the practice of the studied dental
Age groups students regarding ergonomics. More than half of the
≤22 years 359 74.9 students (54.3%) never work with the legs separated
>22 years 120 25.1 and the feet flat on the floor. Also half of the students
Gender (50.3%) work in the upright position and the spine rest-
Males 188 39.2 ing on the back of the stool. Only 24.2% of the stu-
Females 291 60.8 dents always orient the operating field to the elbow
Residence level of the working hand. What’s more, only 8.6% of
Urban 359 74.9 the participants always made an effort to maintain neu-
Rural 120 25.1 tral posture while working compared to 37.8% of them
Academic level who never did that. Only 12.1% of the participants al-
3rd 45 9.4 ways orient beam of light perpendicular to the observa-
4th 409 85.4 tional direction compared to 27.8% of them who never
House officer 25 5.2 did that .All of the studied students reported that they
Work duration/day never use loops for magnification purposes.
Mode Table 5 reveals the knowledge, attitude, and practice of
6 h/day 122 25.5 the participants and its relationship with sociodemographic
Frequency of work duration/day characteristics, work duration/hours, and practicing physi-
≥6 h 288 60.1
cal exercise. Quarter of the students with their age 22 years
<6 h 191 39.9
or less had good ergonomic knowledge compared with
Physical activities outside the work
20.8% of students more than 22 years with no significant
association between knowledge and age. Half of the males
Yes 222 46.3
(50.5%) and the females (47.8%) had fair knowledge with
No 257 53.7
no significant association between gender and knowledge.
Also, there was no significant association between resi-
dence and knowledge regarding ergonomics, where only
60.1% of the studied students knew what are the specifics 24.2 and 25% of urban and rural residents respectively
should the dentist look for upon designing and equipping the had good knowledge. There was a significant association
treatment room. More than half of the students (57.6%) knew between academic level and ergonomic where house offi-
the human supports and material objects that account for body cers followed by the 4th year and the 3rd year had fair
space, paths of motion of body parts, and the location of in- knowledge regarding ergonomics (80.0, 60.0, and 45.7%,
strument support. About two thirds of the participants knew respectively, p = 0.001). There was no significant associa-
the orbit range around the patients’ head and the ergonomic tion between work duration/day and doing physical exer-
head rest and its benefits (64.3 and 68.5%, respectively). Only cise (p = 0.599 and 0.212, respectively). Most of the stu-
one third of the students (35.35) knew the ideal distance from dents aged 22 years or less (84.1%) and (86.7%) of stu-
the floor to the position. More than half of the studied students dents less than 22 years had positive attitude with no sig-
(56.2%) knew the moving exercise and stretch exercise be- nificant association between age and attitude. Most of the
tween patients’ appointments. Less than half of the partici- males and females students (81.9 and 86.6%, respectively)
pants knew how to maintain a comfortable environment, light, had positive attitude towards ergonomics without signifi-
and temperature in the treatment room. cant association between gender and attitude. All the house
Table 3 shows the attitude of the students towards ergo- officers had positive attitude regarding ergonomics follow-
nomics, where more than two thirds of the students (69.1%) ed by 4th year and 3rd year students (85.1 and 73.3%,
think that ergonomics should definitely be a part of their cur- respectively) with a significant association between atti-
riculum. About two thirds of the dental students (63.7%) think tude and academic level (p = 0.011). Moreover, there was
that dentist should follow the ergonomic principles in their no significant association between work duration/day or
routine dental practice. More than half of the participants practicing physical exercises among students and their at-
(56.4%) think that the dental chair and instruments play a role titudes towards ergonomics. Only 5% of students
in following ergonomic principles in routine dental practice. 22 years and below had good practice compared with
Only one third of the students (38.6%) think definitely that the students aged more than 22 years 3.3% with no
Environ Sci Pollut Res

Table 2 Knowledge of the participant students

Knowledge-related questions Answers

Yes To some extent No

No (%) No (%) No (%)

1. Do you know what is meant by ergonomics? 187 (39.0) 199 (41.5) 93 (19.4)
2. Do you know what are the health 369 (77.0) 42 (8.8) 68 (14.2.)
hazards of your job without ergonomics?
3. Do you know the benefits of ergonomic application? 313 (65.3) 88 (18.4) 78 (16.3)
4. Do you know the popular operating posture 381 (79.5) 35 (5.3) 63 (13.2)
that may cause musculoskeletal disorders?
5. Do you know the best posture of the dentist sitting? 399 (83.3) 58 (12.1) 22 (4.6)
6. Do you know the best level of the dentist 399 (83.3) 58 (12.1) 22 (4.6)
shoulders and site of elbow and upper arms?
7. Do you know the best site for forearms and operating 360 (75.2) 37 (7.7) 82 (17.1)
fingers of the dentist?
8. Do you know the degree of the sight-line and the light-line? 355 (74.1) 42 (8.8) 82(17.1)
9. Do you know the points on the body, including fingertips 308 (64.3) 85 (17.7) 86 (18.0)
and feet, that come in contact with patients and objects for
stable control and sightings of the operating points?
10. Do you know, when designing and equipping the treatment 288 (60.1) 68 (14.2) 123 (25.7)
room, what specifics should dentists be looking for?
11. Do you know human supports and material objects that account 276 (57.6) 99 (20.7) 104 (21.7)
for body space, paths of motion of body parts, and location of
instrument supports?
12. Do you know the orbit range around the patients’ head? 308 (64.3) 91 (19.0) 80 (16.7)
13. Do you know the ergonomic head rest and its benefits? 328 (68.5) 65 (13.6) 86 (18.0)
14. Do you know the ideal distance from the floor to the position? 169 (35.3) 186 (38.8) 124 (25.9)
15. Do you know the moving, exercise, and stretch exercise 269 (56.2) 83 (17.3) 127 (26.5)
between patient’s appointments?
16. Do you know how to maintain a comfortable environment, light, 227 (47.4) 102 (21.3) 150 (31.3)
and temperature in the treatment room?

significant association between practice and age. Also the urban and rural resident students respectively had
only 4.8% of males and 4.5% of females had good bad practice with no significant association. All of the
practice of ergonomics with no significant association house officers followed by the 3rd year and the 4th one
between gender and practice. Ninety-five and 96.7% of had bad practice of ergonomics (95.65 and 95.1%,

Table 3 Attitude of the participant students

Relevant attitude questions Answers

Definitely yes Yes Neutral No Definitely no

4 3 2 1 0
No (%) No (%) No (%) No (%) No (%)

1. Do you think ergonomics should be a part of the 331 (69.1) 120 (25.1) 12 (2.5) 10 (2.1) 6 (1.3)
dental curriculum?
2. Do you think dentists should follow the ergonomic 305 (63.7) 139 (29.0) 25 (5.2) 9 (1.9) 1 (0.2)
principles in routine dental practice?
3. Do you think the dental chair and instruments play any 270 (56.4) 160 (33.4) 36 (7.5) 11 (2.3) 2 (0.4)
role in following ergonomic principles in routine dental
practice?
4. Do you think the dentist should alternate between sitting 185 (38.6) 198 (41.3) 56 (11.7) 35 (7.3) 5 (1.0)
and standing between patient appointments?
5. Do you think various dental institutions should conduct 197 (41.1) 198 (41.3) 65 (13.6) 9 (1.9) 10 (2.1)
continuing dental education?
 Environ Sci Pollut Res

Table 4 Practice of the participant students

Relevant practice questions Always Very often Often Rarely Never

4 3 2 1 0
No (%) No (%) No (%) No (%) No (%)

1. How frequent do you work with your legs 68 (14.2) 52 (10.9) 51 (10.6) 48 (10.0) 560 (54.3)
separated and your feet flat on the floor?
2. How frequent do you work in the upright position 72 (15.0) 54 (11.3) 54 (11.3) 58 (12.1) 241 (50.3)
and your spine resting on the back of the stool?
3. How frequent do you orient the operating field to 116 (24.2) 98 (20.5) 158 (33.0) 69 (14.4) 38 (7.9)
the elbow level of your working hand?
4. How frequently do you made an effort to maintain 41 (8.6) 71 (14.8) 113 (23.6) 73 (15.2) 181 (37.8)
neutral posture while working?
5. How frequent do you orient beam of light 58 (12.1) 44 (9.2) 139 (29.0) 105 (21.9) 133 (27.8)
perpendicular to the observational direction?
6. How frequently do you use dental loupes for 0 0 0 0 479 (100)
magnification purposes?

respectively) with no significant association between
practice and academic level. There was no significant
association between work duration/day or doing physical
exercise and practice of ergonomics.
Table 6 displays the relationship between knowledge, atti-
tude, and practice of the dental students and ergonomics. Most
of the students with positive attitudes (96.6%) had a signifi-
cant good knowledge (p = 0.000), whereas 90.6% of the stu-
dents with bad practice had significant poor knowledge
(p = 0.007). The majority of students with bad practice
(95.8%) had positive attitude, with no significant association
between practice and attitude (p = 0.317).

Table 5 Knowledge, attitude and practices of students according to their sociodemographic characteristics, work duration/day and physical exercise
practice

Sociodemographic Knowledge X2 (p) Attitude X2 (p) Practice X2 (p)

characteristics
No (%) No (%) No (%)

Poor 128 Fair 234 Good 117 Positive 406 Negative 73 Good 22 Bad 457
(26.7) (48.9) (24.4) (84.8) (15.2) (4.6) (95.4)

Age groups
≤22 years 96 (26.7) 171 (47.6) 92 (25.6) 1.28 302 (84.1) 57 (15.9) 0.451 18 (5.0) 341 (95.0) 0.580
>22 years 32 (26.7) 63 (52.5) 25 (20.8) (0.527) 104 (86.7) 16 (13.3) (0.502) 4 (3.3) 116 (96.7) (0.446)
Gender
Males 55 (29.3) 95 (50.5) 38 (20.2) 3.171 154 (81.9) 34 (18.1) 1.939 9 (4.8) 179(95.2) 0.027
Females 73 (25.1) 139 (47.8) 79 (27.1) (0.205) 252 (86.6) 39 (13.4) (0.164) 13 (4.5) 278 (95.5) (0.870)
Residence
Urban 102 (28.4) 170 (47.4) 87 (24.2) 2.211 306 (85.2 53 (14.8) 0.252 18 (5.0) 341 (95.0) 0.580
Rural 26 (21.7) 64 (53.3) 30 (25.0) (0.331) 100 (83.3) 20 (16.7) (0.615) 4 (3.3) 116 (96.7) (0.446)
Academic level
4th year 110 (26.9) 187 (45.7) 112 (27.4) 19.736 348 (85.1) 61 (14.9) 9.077 20 (4.9) 389 (95.1) 1.288
3rd year 15 (33.3) 27 (60.0) 3 (6.7) (0.001)* 33 (73.3) 12 (26.7) (0.011)* 2 (4.4) 43 (95.6) (0.525)
House officer 3(12.0) 20 (80.0) 2 (8.0) 25 (100) 0 (0%) 0 25 (100)
Work duration/day
≥5 h 75 (26.0) 146 (50.7) 67 (23.3) 1.26 242 (84.0) 46 (16.0) 0.300 10 (3.5) 278 (96.5) 2.070
<5 h 53 (27.7) 88 (46.1) 50 (26.2) (0.599) 164 (85.9) 27 (14.1) (0.584) 12 (6.3) 179 (93.7) (0.150)
Physical activities outside the work
Yes 63 (28.4) 113 (50.9) 46 (20.7) 3.106 188 (84.7) 34 (15.3) 0.002 13 (5.9) 209 (94.1) 1.506
No 65 (25.3) 121 (47.1) 71 (27.6) (0.212) 218 (84.8) 39 (15.2) (0.966) 9 (3.5) 248 (96.5) (0.220)

* indicates sinificant difference

Environ Sci Pollut Res
Table 6 The relationship between knowledge, attitude, and practice
Attitude
Positive Negative
No (%) No (%)
Knowledge
Poor 92 (71.9) 36 (28.1)
Fair 201 (85.9) 33 (14.1)
Good 113 (96.6) 4 (3.4)
Attitude
Positive
Negative
Discussion
Ergonomics has been always neglected, from both knowl-
edge and practice point of view during clinical work. In
addition, ergonomics may not be a part of the syllabus of
dental course both undergraduate and postgraduate levels.
Musculoskeletal ache is a foremost problem recognized
between dental staff affecting their competence and job
fulfillment; the main cause for this may be attributed to
unsuitable workplace ergonomics. This enhances the as-
sessment of knowledge, attitude, and practices towards
ergonomic principles during routine dental procedures
among dental students (Kalghatgi et al. 2014). In dentist-
ry, ergonomics plays a crucial role throughout a profes-
sional’s life which makes it mandatory to inculcate it right
from the inception of the course, given the pressures of
university education and the physical burden of the clin-
ical training (Ayma 2011).
This study revealed that nearly half of the students had
fair knowledge. This was in agreement with other studies
done by Garbin et al. (2011), Bârlean et al. (2012), and
Madaan and Chaudhari (2012). In the current study, most
of the studied students (85%) had positive attitudes to-
wards ergonomics. Unfortunately, this did not result in
good practice where only 4.6% of the studied students
had good practice. This is also found by another study
done by Mailoa and Rovani (2011) where the level of
attitude found is 75%, which is a good reflection of ac-
ceptability and willingness to adopt the ergonomic princi-
ples in routine dental practice by the study subjects
(Mailoa and Rovani 2011). Compared to the attitude
scores, the practice scores in the current study were low.
There were a significant association between knowledge
and attitude, and also knowledge and practice, but no
association did occur between attitude and practice. This
was in agreement with another study done by Karibasappa
et al. (2014).They observed that students had sufficient
knowledge, attitude regarding the importance of proper
Significance X2 (p) Practice Significance X2 (p)
Good Bad
No (%) No (%)
29.343 (.000)* 12 (9.4) 116 (90.6) 9.929 (.007)*
5 (2.1) 229 (97.9)
5 (4.3) 112 (95.7)
17 (4.2) 389 (95.8) 1.001 (.317)
5 (6.8) 68 (93.2)
working postures, and position during providing treatment
but did not result in the desired behavior. This indicates
that knowledge had not motivated sufficiently to adapt
ergonomic principles (Karibasappa et al. 2014). This is
also found in another study done by Kalghatgi et al.
(2014); they reported that Pearson’s correlation analysis
was conducted and showed a positive significant correla-
tion of knowledge with attitude and negative significant
correlation with practices. Correlation of attitude with
practices was not statistically significant (Kalghatgi et al.
2014). The current study did not explain the reasons be-
hind the noncompliance of ergonomic principles among
Tanta dental students in their daily practice. This demands
further studies to recognize the gap between fair knowl-
edge and positive attitude not being translated to a good
practice.
In this study, there was no significant association between
gender of the students, their age, or residence and their level of
knowledge or attitude and practice. This was in agreement
with another study done by Kritika et al. (2014) except that
they found significant association between knowledge and
gender with female predominance. They explained that fe-
males are more liable for musculoskeletal disorders than males
so they were more interested to obtain more knowledge re-
garding ergonomics.
In the present study, there was a significant association
between academic level of the studied students and their
knowledge and attitudes towards ergonomics. This was in
agreement with another study done by Kalghatgi et al.
(2014) who reported that a significant difference for knowl-
edge, attitude, and practices was observed between the studied
subjects with increasing their academic level. Pairwise com-
parison using Scheffe’s post hoc test revealed that the differ-
ence between participants was significant for knowledge and
practices only.
In this study, 53.7% of the dental students did not practice
physical exercises outside their work and 60% of them
worked for 6 h/day or more. The physical inactivity among

dentist seems to put them at risk for the occurrence of work
musculoskeletal disorders (WMSDs) especially without adop-
tion of ergonomic principles in their routine dental work.
WMSDs are the major reasons leading for loss of work effi-
ciency as well as early ill-health retirement among dentists
(Brown et al. 2010).
Good positioning of the feet and legs broadens the
holdup base of the body, avoiding potential changes in the
circulatory system such as varicose veins, edema, pain, and
inflammation because of muscle compression on the
lower extremities impeding the venous return. The lower
limbs are the second most likely body region to experience
pain because of poor positioning during sitting, with
reported pain occurring within the lower limbs and 81%
with the neck and back (Munaga et al. 2013).Therefore, it
was highly recommended that students must continuously
practice ergonomic principles and correct their whole
body posture during clinical works (Mohammed and Al-
Zain 2009). In the current study, more than half of the
students (54.3%) never work with the legs separated and
the feet flat on the floor. Also half of the students (50.3%)
reported that they worked in the upright position and the
spine resting on the back of the stool. Only 24.2% of the
students always orient the operating field to the elbow level
of the working hand. What’s more, only 8.6% of the
participants always made an effort to maintain neutral pos-
ture while working compared to 37.8% of them who never
did that. Only 12.1% of the participants always orient beam
of light perpendicular to the observational direction com-
pared to 27.8% of them who never did that. All students
under this study never use loops for magnification during
work. This was in agreement with another study done by
Mohammed and Al-Zain (2009) in King Abdul-Aziz
University (KAU) during clinical procedures. Their results
showed that 43% of the students placed their patients’
chair within normal limits (almost supine), 50% of the
students’ backs were bent, 33% of students’ elbows
were below the level of the quadrant treated, 50% of the
students approached the maxillary arch directly, and
only three male students used magnifiers. The dental
students should be skilled during their clinical trainning in
their universty before graduation on dental ergonomic prin-
ciples. The acquisition of ergonomic knowledge can occur
at any time; however, early assimilation of knowledge and
internalization of dental ergonomic principles might
prevent their suffering from work-related musculoskeletal
disorders (Karibasappa et al. 2014).
Conclusion and recommendations
Only 48.9% of the studied students had fair knowledge re-
garding ergonomics. Only 5% of students had good practice.
Environ Sci Pollut Res
But 84.8% of students have a positive attitude towards study-
ing ergonomics. Ergonomic working principles should be
taught to the budding dental graduates at the dental colleges
and should be incorporated into their curriculum. Oral health
professionals need to emphasize on practicing ergonomics in
their routine dental practice to avoid major ergonomics-related
health problems and various guidelines followed.
Compliance with ethical standards
Administrative consideration Written approval to implement the
study in the dental hospital was obtained from the head of the institution
to ensure maximum cooperation.
Ethical consideration Subjects were informed about the purpose and
procedures of the study and benefits of sharing it. Oral consent and ap-
proval were obtained from each subject to participate in the study and
those who refused participation were excluded. Confidentiality and pri-
vacy were guaranteed during the whole period of the study. Approval of
the ethical committee of Faculty of Medicine, Tanta University, was ob-
tained before starting the study.
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