Work 42 (2012) 299–306 299

DOI 10.3233/WOR-2012-1354
IOS Press

A unique approach to preventing back pain in

the dental office
Gregory J. Booksa,∗ and Kurt Klemmb
a
Career Extenders Inc., Omro, WI, USA
b
Spine and Sport Physical Therapy, Rhinelander, WI, USA

Received 14 May 2008

Accepted 11 December 2010

Abstract. Back pain has been reported by a majority of dental practitioners for decades. Efforts to relieve pain have focused on
postural modification, exercise, and equipment designed to facilitate “neutral” posture, but there has been no significant reduction
in reported rates of pain. By focusing on static muscle activity and muscle overuse rather than posture, the authors describe the
theory behind an innovative approach for the development of an ergonomic intervention.
Objective: Demonstrate that posture is not the problem.
Participants: none.
Methods: Critical analysis of existing literature in dentistry and in other more advanced fields.
Results: Application of current research outside of dentistry.
Conclusions: Elimination of Static Muscle Activity rather than modification of posture is the critical issue in preventing pain,
fatigue, and injury.

Keywords: Sustained muscle activity, anterior support, trigger point

1. Introduction troduced; these may lead to back dysfunction. Final-

ly, a unique approach for eliminating SMA exposure
Dentistry may not seem to be a profession requiring through the introduction of anterior support is present-
physical effort because it presents no obvious threat ed.
for bodily damage. Dentists do not lift patients as in
other healthcare sectors, or carry concrete blocks like
construction workers. However, the sustained muscle 2. Background
activity required by dentists and other dental personnel
Since the advent of sit-down dentistry, the issue of
can initiate a cascade of muscular microtrauma leading
back dysfunction has received much attention. Low
to muscle dysfunction and fatigue. Regrettably, this
back pain amongst dentists was documented as early as
can lead to chronic pain, lost wages, reduced revenue,
1946 [1] and has been an ongoing issue reported in the
and early retirement.
scientific literature and dental trade publications since
This article explores the current literature regard-
then [2–12,16]. The incidence of low back pain has
ing back pain dysfunction and prevention in the den-
not decreased over the last 60 years. Rates of muscu-
tal profession. Next, the notion of Static Muscle Ac-
loskeletal pain affecting the cervical, thoracic and lum-
tivity (SMA) and the events triggered by SMA are in-
bar areas of the spine in dentists have been as low as
33% [2], however, most report pain affecting more than
∗ Address for correspondence: Gregory J. Books, Career Extenders 50% and up to 80% of dental practitioners [1,3–12,
Inc., 117 W. Main, Omro, WI 54963, USA. Tel.: +1 920 685 0818; 16]. Studies indicate that men and women are equal-
Fax: +1 920 685 3059; E-mail: [email protected]. ly affected and the problem is reported international-

1051-9815/12/$27.50  2012 – IOS Press and the authors. All rights reserved
300 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office

Fig. 1. Illustration showing unsupported forward lean, unsupported vertical, and supported recline. (Colours are visible in the online version of
the article; http://dx.doi.org/10.3233/WOR-2012-1354)

ly. Low back pain is considered “the leading cause of The authors also measured a decrease in disc pressure
occupational disability in dentistry” [12]. and muscle activity when the test subject was writing as
Those who experienced pain reported that symptoms opposed to typing. In a writing position, an individual is
occurred from 65 to 125 days per year. The average supported at the forearm orwrist while a typist benefits
dentist lost one day per year to pain, and 17% reported from no upper extremity weight bearing. . . This finding
reducing daily patient load, taking additional breaks, suggests that anterior support of the trunk can reduce
and alternating other practice procedures. In 1984 in disk pressure and muscle activity as well as posterior
the USA the financial impact was estimated as a reduc- support. Andersson et al noted the support provided by
tion of $315 per day in billings, totaling more than $41 an arm leaning against a desk while writing provided a
million dollars of lost revenue [3]. Current American measurable decrease in both indices. In addition, both
Dental Association (ADA) statistics suggest that aver- forms of support were introduced above the pelvis; not
from beneath (Fig. 1).
age dentists’ billings in 2007 were ten times the figure
used in 1984.
3. Solutions to back pain
2.1. “Pain” in the seated work position: Role of
muscle forces Publications that cater to the working dentist typi-
cally advocate one of two solutions to lower back prob-
lems: postural modification and exercise, or selection
While there are many studies that report subjective of the proper stool to enhance postural modification.
pain experiences, there have been few attempts to es- The assumption is instruction in proper posture im-
tablish objective measurement of the physical process- proves position and removes risk. There are more than
es that produce pain. One of the most often referenced 80 articles on PubMed that address back pain in den-
studies of back stress was conducted by Andersson et tists and resources conclude better posture will prevent
al. [13]. In this study, measurements of disc pressure symptoms. Margolis [14] advocates the use of a surgi-
and myoelectric activity were recorded across a variety cal scope to modify posture. The scope allows the prac-
of positions in a small sample of test subjects. Positions titioner to assume a “neutral balanced posture, which
included several variations of unsupported sitting, and has been shown to help prevent ergonomic problems
sitting against a backrest. Key findings included: that seem to be an occupational hazard” [14, p. 1]. The
surgical scope uses a camera to project the image of the
1. Both myoelectric activity and disc pressure de- patient’s oral cavity onto a monitor directly in front of
crease when the back is supported. the practitioner. However, the literature does not pro-
2. Optimal results are achieved at a backward incli- vide evidence that postural modification prevents mus-
nation of 15–20 degrees. culoskeletal problems. Lalumandier et al. note “den-
3. Unsupported sitting increased both disc pressure tal professionals can reduce their risk of developing
and myoelectric activity. musculoskeletal injuries and pain by using proper body
 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office 301

posture and positioning during dental procedures, in-

corporating regular rest periods, maintaining good gen-
eral health, and performing exercises for affected body
areas” [8, p. 162]. The authors suggest an exercise rou-
tine to reduce injury risk but offer no documentation
for effectiveness.
When Shugars [15] examined the 15 most frequently
used forms of intervention to relieve musculoskeletal
pain in dentists, little effectiveness was found in overall
pain reduction using most modalities. For instance; on-
ly 16% reported exercise brought complete relief, and
only 9% found a change of treatment position to be
effective. The highest success rate (20%) for complete
relief was using a whirlpool. More frequent breaks
benefited only 5%, while fewer practice hours benefited
11%. Shugars also states, “the dentists in this survey
reported having tried over 35 different treatments for Fig. 2. Balanced neutral seating, unsupported above Center of Rota-
relief. The results show on the average, no treatment tion (CR).
was more than marginally effective. Complete relief
was elusive, even the most effective treatments offered were spent in isometric positions” [17, p. 668]. While
relief to only one out of every five respondents who the angular deviation was not great (90% of the mea-
tried them” [15, p. 274]. Marshall et al. concluded, sured deviation was less than approximately 10 degrees
“modification of work practices does not appear to have forward), any departure from neutral 0 degrees created
decreased the prevalence of symptoms. Neither, it ap- a sustained isometric contraction of the back muscles.
pears, does taking short pauses throughout the day” [6, “It turned out that the preliminary posture specific risk
p. 245]. factor could be the continuous phases of the isometric
Recent advice from Valachi [16] also advocates im- spine and trunk position” (p. 669).
proved posture, proper stool selection, and use of mag- Balance can be defined as center of gravity (CG)
nification devices. Both the stool and the magnifica- over center of rotation (CR). In a sitting position, the
tion devices are intended to facilitate improved pos- hips function as a CR. If the CG of the upper body is in
ture, which is claimed to significantly reduce injury. front of the CR, it can only be supported by one of two
Valachi indicates reports of back pain range from 54% means: from behind (muscle effort) or in front (sup-
to 93%. The suggestions for prevention, which all fo- port). Posterior support requires constant muscle ten-
cus upon achieving neutral posture of the practitioner, sion to maintain. Balance (CG over CR) of an unstable
have been recommended by numerous sources during mass requires equal and continuous tension in oppos-
the 60 year time span covered by the studies included ing muscle groups (anterior and posterior), which clear-
here. However, the current rates of injury are similar ly does not describe a position of rest. Thus, a “bal-
to those reported in earlier studies. anced, neutral” posture describes a vertical position,
held in place through static muscle contraction. This
3.1. The concept of neutral posture revisited is precisely what Andersson et al. [13] described as the
unsupported sitting that created measurable increases
Although “neutral and balanced” posture is consid- in muscle activity and disc pressure. Thus, the verti-
ered to be the key to proper sitting posture [14], this cal unsupported posture is itself a major contributor to
posture is not free of ergonomic hazards. First, a “neu- back pain because it requires static muscle activity to
tral” position is one which is entirely vertical, with no be maintained. In addition, the need for visualization
departure from the zero degree mark. This does not of the oral cavity shifts the CG forward, which places
describe using the back rest to support the upper body. all of the constant stress on the posterior muscle group
For instance, Wunderlich et al. [17] used an inclinome- (Fig. 2).
ter to measure the amplitude and duration of angular In summary, the literature on musculoskeletal dis-
deviations from 0 degrees during periodontal proce- orders in dentistry has documented over 60 years of
dures. They found that “up to 85% of the working days consistent percentages of those reporting pain. Table 1
302 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office

lists the most commonly referenced studies from 1946 in skeletal muscle [18]. Simons, Travell, and Simons
to the present day, and shows reported rates of back and state, “the activation of a trigger point is usually as-
upper extremity pain have consistently been reported sociated with some degree of mechanical abuse of the
at rates between 57% and 81%. When solutions are of- muscle in the form of muscle overload, which may be
fered, they focus upon postural modification, exercise, acute, sustained, and/or repetitive” (p. 19). For exam-
and equipment selection to enhance “better” posture; ple, laborers who exercise their muscles heavily on a
however, those suggestions have either been ignored daily basis show significantly less back pain than those
by practicing dentists or the suggestions have not been in jobs requiring sustained static positions. This is be-
effective. cause laborers have the benefit of varied muscle activi-
ty, which increases circulation, and ultimately enhances
tissue health (p. 21).
4. Position versus sustained muscle activity The practice of dentistry demands sustaining con-
stant unsupported positions for extended periods, if the
One aspect of early studies that has been largely practitioner assumes the “balanced, neutral posture.”
overlooked is the notion of muscle overuse. Earlier The consequences of working in static unsupported
writers assumed fatigue and pain were the result of postures can be understood by following the develop-
the position of the practitioner. The notion of muscle ment of trigger points. Over the last few decades, trig-
overuse suggests the pain is the result of muscle overuse ger point research has illuminated several possibilities
from the effort required to hold a static position, rather for the etiology of the problem in dentistry and other
than the position itself. Lalumandier et al. reported, occupations that require sustained muscle contraction.
“. . . muscle contraction is required to maintain the In 1988 Hägg [19] proposed the Cinderella Hypoth-
posture that dental professionals use when treating esis to explain occupational myalgia. According to the
patients. If any position, even a neutral one, is held hypothesis, “muscular force generated at sub-maximal
too long, the muscles may fatigue and develop a levels during sustained muscle contractions engages
tightness or spasm in response to the overworking only a fraction of the motor units available without the
of the muscle” [8, p. 163]. normally occurring substitution of motor units during
Fatigue resulting from extended static muscle con- higher force contractions” (pp. 260–262). This results
traction is recognized in many earlier studies [e.g. in overloaded motor units, followed by activation of
Lehto, Lake,Valachi, Lalumandier]. Lehto stated, “the autogenic destructive processes, and muscle pain.
concept of a single correct work posture may be phys- More recently, the Integrated Theory has been pro-
iologically invalid; it may be that the human body is posed, which introduces the measurement of damage
made for movement and ever changing postures” [5, from sustained submaximal contractions. In the grow-
p. 43]. ing body of evidence to support the Integrated Hypoth-
esis Theory [20–22], research shows further damage to
the cell membrane and mitochondria with sub-maximal
5. Sustained muscle activity and trigger points sustained muscle activity. Multiple researchers have
found evidence of ragged red fibers and moth-eaten
Lake [7] introduces the concept of a Static Muscle fibers in subjects with myalgia – further indication of
Activity (SMA) and describes it as the starting point of structural damage of the cell itself [23].
muscle events leading to pain. Unlike dynamic activ- Dommerholt et al. [24] include low level muscle con-
ities, which include alternating contraction and relax- tractions as one of several possible causes of trigger
ation of muscles, a Static Muscle Activity is one which points. They include dentists in the occupational group
involves a sustained contraction of the muscle tissue. where myofascial trigger points are common [24]. In
Prolonged contraction compresses capillaries, causing a study of experienced typists, Treasters et al. report,
blood pressure to rise, which results in reduced nutrient “that sustained low level muscle contractions for as lit-
and oxygen supply. Lactic acid builds up, leading to tle as 30 minutes commonly resulted in the formation of
muscular pain and fatigue. Lake notes that “A static trigger points” [25, p.112A Uni]. This is supported by
muscular effort can only be maintained for a short time Chen et al. [26] who suggest low level muscle exertions
before pain and tissue injury ensue” [7, p. 7]. can lead to sensitization and development of myofas-
Repeated exposures to SMA over time can lead to cial trigger points. Overall there is a growing body of
the development of trigger points, a hyper-irritable spot evidence that supports the concept that low-level static
 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office 303

Table 1
Most commonly referenced dental studies
Study Pub date MSD rate
Biller [1] 1946 65%
Fauchard Academy [2] 1965 33%
Shugars, Williams, Cline and Fishburne [4] 1984 57%
Shugars, Miller, Williams, Fishburne and Strickland [15] 1987 60%
Lehto [5] 1991 71–81%
Marshall, Duncombe, Robinson and Kilbreath [6] 1997 59%
Lake [7] 1996 60%
Hedge [10] 2005 59%
Murray and Broering [11] 2004 66%
JADA 2005 70%
Valachi [16] 2008 54–93%

muscle contraction can cause pain and damage muscle or when they maintain end positions for any length of
fibers. time. . .” [31, p. 81]. This would be the case in the
Recent research on muscle pain and dysfunction has spine if full flexion was maintained for extended peri-
culminated in an expansion of Simon’s Integrated Trig- ods. If one was to maintain a full forward bent, shoe-
ger Point Hypothesis [27–29]. It is based on cumulated tying position for extended periods stress would be ap-
hystopathological and electrodiagnostic evidence [24] plied to the tissues and pain would result. According to
suggesting motor, sensory, and autonomic components. McKenzie’s approach, this is not the problem in den-
Motor effects may include decreased range of motion, tistry because the practitioner assumes only a limited
stiffness, and weakness due to muscle inhibition. Sen- amount of forward lean with minimal actual spine flex-
sory effects include local tenderness, referral of pain to ion, thereby clearly avoiding end range posture. Pre-
a distant site as well as peripheral and central sensitiza- vious efforts to reduce the onset of pain in dentistry
tion [25]. Peripheral and central sensitization include have failed, because the balanced, neutral position is
allodynia (pain due to a stimulus that does not normally largely unsupported. As the Andersson et al. study [13]
provoke pain), and hyperalgesia (an increased response suggests, unsupported sitting increases myoelectric ac-
to a normally painful stimulus) [30]. Many of these tivity and disc pressure. The static nature of the myo-
effects are common in the dental arena. electric activity, coupled with the compression of blood
When a trigger point is properly located and treated, vessels, reduces oxygen to the tissue. Ultimately, any
the decreased tissue tension and increased blood flow unsupported position produces the very problems it is
results in an immediate improvement of local as well as thought to prevent.
referred symptoms with near or complete resolution of Maintaining any posture, even a neutral one, can
symptoms over time. Fundamentally, the decreased cir- lead to muscle overuse, decreased circulation and the
culation associated with trigger points can be avoided, resulting symptoms. All tissues of the body, including
allowing muscle relaxation, by identifying and elimi- the spine and muscles, depend on adequate circulation
nating the sustained activity. Constant muscle tension for optimal health. Intermittent muscle contraction or
is the heart of the problem and must be alleviated to muscle relaxation can enhance blood flow to local tissue
achieve pain relief. improving and restoring tissue health. The spine is a
structure that is made to move in all planes. Spinal
discs and other soft tissues depend on this movement
6. The current fallacy for good health. Tissue health is enhanced through
movement or relaxation. Attempting to sustain a single
Dental practitioners are encouraged to maintain an work position through muscle effort is a problem.
ideal posture because of an assumption that pain will
not develop if posture is correct. The concept as pre-
sented in dentistry is contrary to the McKenzie philos- 7. The case for anterior support
ophy. McKenzie suggests that postural problems may
occur as a result of two problems, “. . . when a person The goal of eliminating Static Muscle Contractions
performs activities which keep the lumbar spine in a and hypoxiais maximizing adequate blood flow by re-
relatively static position (as in vacuuming, gardening) laxing muscles and preventing muscle overuse. One
304 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office

Fig. 3. Extreme forward lean, supported above Center of Rotation

(CR). Fig. 4. Dentist in supported forward lean with anterior support.

would need to support the trunk in the desired working forward incline position avoids the muscle overload
position to accomplish this goal in a relatively seden- problem and the resulting symptoms (Fig. 4).
tary occupation such as dentistry. The resulting muscle Attempts have been made to provide anterior sup-
relaxation avoids the cascade of negative events, and port as part of the operator’s stool (Fig. 5). While the
can prevent fatigue and other symptoms. The solution concept of anterior support is good, the stability and
in dentistry is not support from behind the practition- adjustability of the platform itself is limited and does
er because it is difficult to perform dental procedures not allow for the necessary support in the variety of
when leaning back at the 10–20 degree incline that An- positions encountered during patient treatment. Varia-
dersson et al. [13] found to be effective. Support ante- tions to the operator’s stool inevitably make the stool
riorly is the more practical solution, allowing a forward cumbersome and ingress and egress difficult.
inclination for direct visualization of the work area.
This type of support is a natural, intuitive activity we all
perform on a regular basis. For example, individuals 8. Development of front support using the
have the tendency to lean forward on a table surface AnterioRest prototype
and support the upper trunk with forearms on the desk
to rest if reading or studying intently. We actually are The authors tested the anterior support approach by
able to rest in this position (posture) because we are designing and fabricating a small supporting cushion
supported and no muscle effort is required (Fig. 3). attached to the patient chairs of two dentists treated in
Postural modification has not reduced back pain and a Wisconsin spine therapy practice. The device perma-
has taken the dental practitioner away from direct vi- nently attaches to the back of the patient chair and is
sualization of the worksite. While tilting seat pans fully adjustable in all planes via a single release knob.
and saddle seat designs can help by facilitating a bet- Release of the knob affords movement of two ball-
ter position of the hips and lumbar spine, they cannot joints and one scissor joint. The practitioner is not only
provide the kind of support that Andersson et al. [13] allowed but is encouraged to fully lean on the device to
found to be effective. This type of support is located avoid static muscle contraction and thereby avoid mus-
below the CR; therefore it cannot provide benefit for cle pain and dysfunction. One of the early testers was
anything located above the CR. Addressing the muscle treated for chronic back pain, and the other had expe-
overload problem with a postural change has had no rienced regular back fatigue. The results were promis-
positive statistical impact. Anterior support intuitively ing. The dentist who was being treated for chronic back
and practically has been shown to alleviate and reverse pain considered retirement inevitable within one year
symptoms. Support of the body in the natural, desired, due to his chronic pain condition. Within one month of
 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office 305

Fig. 5. Examples of stool-based anterior support. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/WOR-
2012-1354)

tioner was experiencing debilitating discomfort. Iron-

ically, clinical assessment of her work posture showed
she used exactly the posture advocated by proponents
of postural modification. By August of 2007, the prac-
titioner was ready to leave dentistry. She agreed to test
the support device installed in her operatory in October
2007. In late January of 2008, she re-opened the dis-
cussion thread to report she was pain-free, and she has
remained so until the present.
The initial design has been refined into a support de-
vice that can be added to any dental operatory. The
AnterioRestTM is a front support that minimizes mus-
cle overload and provides stable, comfortable, and ad-
Fig. 6. AnterioRest attached to typical patient chair. (Colours are
visible in the online version of the article; http://dx.doi.org/10.3233/
justable support of the trunk. It attaches to the most
WOR-2012-1354) stable platform in the dental operatory, the back of the
patient chair. It is fully adjustable to infinite positions.
placing the support device on his dental chair, the den- It adapts to various body types and practice positions.
tist changed his plans and continued to practice for a Full adjustability of the device allows the practitioner
further six years. The second dentist, who sought occa- to be supported in all positions throughout the work-
sional treatment for back fatigue and soreness, reported day. The natural support of the trunk while in the work-
a significant reduction in fatigue and muscle effort. The ing position provided by the AnterioRest, allows mus-
initial prototype was refined into a more aesthetically cle relaxation and maintains adequate circulation for
pleasing design and has been used by practitioners in optimal tissue health. Predictably, following restora-
over 70 dental practices. (Fig. 6) tion of adequate circulation the body can resolve the
A practitioner seeking advice from fellow hygienists inflammatory reaction and restore tissue health.
through an online dental professional community came
to the authors’ attention. The practitioner had been 8.1. Future research needed
practising for 61/2 years and experienced severe pain in
her upper right scapular area. She received no benefit While the early success of anterior support is promis-
from neck and back therapy and strength training. The ing, further studies to document the effectiveness of
pain spread to her middle back, lower back, and left this approach need to be conducted. Studies are needed
side after spending more time working. Despite contin- to measure myoelectric activity and ideally disc pres-
uing strength training and massage therapy, the practi- sure with the addition of the AnterioRest for the ante-
306 G.J. Books and K. Klemm / A unique approach to preventing back pain in the dental office

rior supported position. In addition, studies could ex- [13] Andersson BJ, Ortengren R, Nachemson A L, Ellstrom G,
plore prevention with an introduction of anterior sup- Broman, H (1975) The sitting posture: an electromyographic
and discometric study. Orthop Clin North Am 6, 105-120.
port prior to the development of pain in dental student [14] Margolis F (2008) Seeing, feeling, treating better, Dental Prod-
populations. ucts Report May, 84-90.
In summary, postural modification has had no mea- [15] Shugars DA, Miller D, Williams M, Fishburne C, Strickland D
surable results in alleviating pain and dysfunction in (1987) (Muscoloskeletal pain among general dentists. General
Dentistry 35, 272-276.
dentistry. Research suggests little overall effect from [16] Valachi B (2008) Ergonomics and injury in the dental office.
alteration of work practices and frequent rest breaks. Pennwell Publising, Tulsa.
The health of soft tissue depends on adequate circula- [17] Wunderlich Max, Thomas Eger, Thomas Ruther, Andreas
tion, achieved only through the avoidance of static mus- Meyer-Falcke, Dieter Leyk, Analysis of spine loads in denti-
stry-impact of an altered sitting position of the dentist. (2010)
cle activity. The spine positions required in dentistry J Biomedical Science and Engineering 3, 664-671.
are not harmful; however, sustained positions cause [18] Simons, David G and Travell, Janet G, Simons, Lois (1999)
problems. Providing anterior support for the dental Pain and Dysfunction The Trigger Point Manual Volume 1,
Williams and Wilkins, Baltimore.
practitioner in the natural, desired working position has
[19] Hägg GM (1988) Ny förklaringsmodell för muskelskador vid
shown great potential to reverse the pain, inflammation statisk belastning i skuldra och nacke. Arbete Människa Miljö
and work disruption that is rampant in dentistry. Po- 4, 260-262.
tentially, at-risk professionals working in environments [20] Hostens I, Ramon H (2005) Assessment of muscle fatigue in
low level monotonous task performance during car driving. J
such as surgery, lab, and office areas as well as other
Electromyogr Kinesiol 15(3), 266-74.
industries can benefit. [21] Kadefors R, Forsman M, Zoega B, Herberts P (1999) Recruit-
ment of low threshold motor-units in the trapezius muscle in
different static arm positions. Ergonomics 42(2), 359-75.
[22] Zennaro D, Laubli T, Krebs D, Klipstein A, Krueger H (2003)
References Continuous, intermittent and sporadic motor unit activity in
the trapezius muscle during prolonged computer work. J Elec-
[1] Biller, FE (1946) The occupational hazard in dental practice. tromyogr Kinesiol 13(2), 113-24.
Oral Hyg 36, 1194-1201. [23] Hägg GM (2003)The Cinderella Hypothesis. In Chronic Work-
[2] Fauchard Academy Poll (1965) One of every three practition- Related Myalgia Johansson H, et al, eds, University Press,
ers afflicted with back trouble. Dent Surv 41, 69-70. Gävle, Sweden, pp. 127-132.
[3] Schlossberg M (2005) Stop the pain. Dental Practice Report: [24] Dommerholt J, Bron C, and Franssen J (2006) Myofascial
January. Trigger Points: An Evidence-Informed Review. The Journal
[4] Shugars DA, Williams D, Cline SJ, Fishburne C Jr (1984) of Manual and Manipulative Therapy Vol. 14, (4), 203-221.
Musculoskeletal back pain among dentists. Gen Dent 32, 481- [25] Treaster D, Marras WS, Burr D, Sheedy JE, Hart D. (2006)
485. Myofascial trigger point development from visual and postural
[5] Lehto TU (1991) Musculoskeletal symptoms of dentists as- stressors during computer work. J Electromyogr Kinesiol 16,
sessed by a multidisciplinary approach. Community Dental 115-124.
Oral Epidemiology 19, 38-44. [26] Chen S-M, Chen J-T, Kuan T-S, Hong J, Hong C-Z (1995)
[6] Marshall ED, Duncombe L, Robinson R, Kilbreath S (1997) Decrease in pressure pain thresholds of latent myofascial trig-
Musculoskeletal symptoms in new south Wales dentists. Aus- ger points in the middle finger extensors immediately after
tralian Dental Journal 42, 240-246. continuous piano practice. J Musculoskeletal Pain 3 (Suppl 1),
[7] Lake J (1997) Musculoskeletal dysfunction associated with the 57.
practice of dentistry-proposed mechanisms and management: [27] Gerwin, RD, Dommerholt, J and Shah, J (2004) An expansion
literature review. University of Toronto Dental Journal 9, 7-11. of simons’ integrated hypothesis of trigger point formation.
[8] Lalumandier J, McPhee S, Parrot C (2001) Musculoskeletal Current Pain and Headache Reports 8, 468-475.
pain: prevalence, prevention, and differences among dental [28] McPartland JM, Travell (2004) Trigger points–molecular and
office personnel. General Dentistry March/April, 160-166. osteopathic perspectives. J Am Osteopath Assoc 104(6), 244-
[9] Rising D, Bennett B, Hursh K, Plesh O (2005) Reports of 9.
body pain in a dental school population. J Am Dent Assoc [29] McPartland JM, Simons DG (2006) Myofascial trigger points:
136, 81-86. translating molecular theory into manual therapy. J Man Ma-
[10] Hedge A (2000) Back care for dentists and surgeons. http:// nipulative Ther 14(4), 232-239.
www.spineuniverse.com, Posted 23 August 2000, Updated 10 [30] Ge HY, Fernández de las Peñas C, Arendt-Nielsen L (2006)
December 2009. Sympathetic facilitation of hyperalgesia evoked from myofas-
[11] Murray D, Broering L (2004) Ergonomics. Sidekick/Sullivan cial tender and trigger points in patients with unilateral shoul-
Schein Winter, 28-30. der pain. Clin Neurophysiol 117(7), 1545-50.
[12] Ahearn, David. The eight keys to selecting great seating [31] McKenzie, Robin, The Lumbar Spine: Mechanical Diagnosis
for long-term health. Http//www.Dentistrytoday.net, Posted and Therapy (1988) Spinal Publications LTD, Wellington New
1September 2005. Zealand.