Edward A. Alvarez, DDS, CaC

According to the Journal of Physical Therapy Science, 70 percent of dentists suffer from back pain.

From the first day we sat in clinical, or even preclinical classes in dental school, we had someone telling us, “Sit up straight, or you’re going to hurt your back!”

As dentists, we are always navigating the difficulties of getting a line of sight to that pesky second molar when doing a root canal or trying to prep the distal of that upper molar that is just a little rotated. We bend, we twist, and sometimes it even seems like we are standing on our heads.

Unfortunately, this past June, I also befell one of our greatest risks as dentists. I suffered one of the scariest injuries I have ever had. I couldn’t walk, I couldn’t put my socks on, I couldn’t lie down, I couldn’t sit, and I couldn’t stand. Everything caused pain. Even scarier than that, I had numbness that ran from my lower back, across my buttock, down my leg, and my foot was completely numb. Unfortunately, this is a common occurrence in our profession, but it is something that we can hopefully prevent.

According to statistics from the NIH, 80 percent of people will experience back pain in their lifetime. Back pain is the most common cause of job-related disability, and it is the second leading cause of visits to a doctor’s office after upper respiratory infections.

The New England Journal of Medicine says that at any given time, more than 30 million Americans are experiencing lower back pain, which can range anywhere from a general dull soreness to a constant ache to a sharp and debilitating pain. Acute pain can come on suddenly and will usually last a few days. Back pain that is dull and chronic can last for three months or more.

A study in the Journal of Physical Therapy Science found that 70 percent of the dentists in their study suffered from back pain. Lower back pain predominated with over 47 percent of the subjects reporting symptoms, while almost 30 percent demonstrated pain in multiple sites, including upper back and cervical regions.

Why are dentists at such greater risk to suffer a back injury and pain? 

First, we must examine what back pain is. As we studied in anatomy, our back is a system of vertebrae, joints, ligaments, and muscles. At any point, we may sustain an injury by tearing a ligament, tearing or straining a muscle, or worse, bulging or rupturing a disc.

 Unfortunately, we do not have to be fighting in a UFC ring, doing extreme sports, or jumping out of an airplane to hurt our backs. Many times, simple things such as bending over to tie our shoes, giving someone a hug, or picking up our child will cause our backs to give out. Back pain may also be caused by organic diseases such as kidney stones, infections, bone loss, cancer, and more. For the purpose of this discussion, we are not addressing those causes.

Typically, back pain is as the result of a herniation of the disc between L4-L5, commonly known as sciatica. Discs between our vertebrae serve as a shock absorber and consist of a tough outer band known as the annulus fibrosus which encases a softer, jelly-like substance called the nucleus pulposus. Disc herniation occurs when the annulus fibrosus breaks open or cracks, allowing the soft nucleus to “leak out” and compress the nerves of the spinal cord. Once the nerve is compressed, it will cause everything from numbness to mild pain to debilitating pain. If left untreated, the pain can possibly become permanent (chronic) and lead to permanent numbness and weakness.

What are our risk factors? What can we do to help ourselves? 

Unfortunately, as dentists, we are prime candidates for back injuries. Some of the biggest factors include lifestyle choices because as dentists, we tend to neglect ourselves. Lack of regular exercise, poor nutrition, and insufficient hydration will all lead to back problems. Our discs need water to remain hydrated and flexible.

Many times, we are so concerned with production, running the office, and all the other responsibilities that we face, that we forget to drink enough water. In the same way, we also forget to eat, or many times, when we do eat, we don’t make healthy choices. When we add pounds onto our midsections and hips, it places an incredible amount of stress on our spinal column. Excess weight can easily cause us to sit in poor positions, thereby pulling our lower back muscles and putting strain on the vertebra. We must also exercise to strengthen the muscles that help stabilize our cores, and thereby help stabilize our spines, keeping it in the correct position.

Poor posture is a huge factor in our profession and something that we need to be very mindful about. The use of loupes has become more prevalent with newer dentists and hygienists coming out of school. Maintaining a direct line of sight while sitting with proper alignment will help us prevent the additional strain placed on our backs by bending or twisting. As any user of loupes knows, they force us to maintain a certain focal distance, and that will then prevent us from bending forward to see.

When we are forced to sit upright and not bend forward, it prevents our spine from curving into a C shape, which creates a tremendous amount of pressure on our lumbar region. Microscopes, typically used by endodontists, are becoming more commonplace in the offices of general dentists. Using a microscope will allow us to maintain proper ergonomics, much like loupes, while we can perform our procedures at greater magnification. Another modification we can adopt in our office is the use of a saddle chair. Gaining their name from a similarity to a horse saddle, saddle chairs are tilted forward, creating a slope that opens the angle between the spine and hips to approximately 45 degrees. The change in angle from 90 degrees in a traditional chair to 45 degrees in a saddle allows the spine to maintain a more natural S curve, and relieves stress from the lumbar vertebrae. In addition, saddle chairs have a cut-out that removes all pressure from your coccyx bone, which would otherwise increase the strain on your lower back.

Hopefully, we have taken all the steps necessary to avoid injury, but sometimes, injuries will still happen. The first thing that we must do is have our backs examined by a physician familiar with back pain. Either a physiatrist, an orthopedist, or an orthopedic surgeon should be your ideal choices to evaluate you.

Many will seek the treatment of a chiropractor, but, if you have a true herniation of a disc, and may require further treatment, you will need to see an MD or DO. An MRI will be the definitive test to determine if you have a herniation, or if you are just suffering from something such as a muscle strain. Immediate non-surgical treatment will include the use of hot or cold therapy, as well as non-steroidal anti-inflammatory drugs. If your pain is severe, you might require a narcotic, which poses a problem for us, as we cannot be under the influence of a narcotic while providing care to a patient. Electrical Stimulation, or Transcutaneous Electrical Nerve Stimulation (TENS), is an adjunct to NSAIDs. The use of TENS may help relax muscles that may be strained or help mitigate pain.

Much of the pain or numbness in back pain is caused by inflammation compressing the spinal column. If NSAID’s have failed to work, an epidural steroid injection may provide temporary relief. Physical therapy is another option in treating your back pain prior to surgery. Physical therapy will include a combination of exercise, stretching, TENS, and massage to help decrease pain, increase flexibility, and strengthen core muscles which stabilize our spinal columns.

One of the more controversial non-surgical treatments for treating back pain and herniated discs is the use of an inversion table. An inversion table works by allowing you to invert your body, using your own body weight to create separation in your vertebrae. This is otherwise known as spinal traction. By decompressing and creating traction, the theory is that you are taking strain off the compressed discs and nerves, thereby relieving pain and other symptoms. The use of an inversion table also increases blood flow to muscles, stretches muscles, and may help rehydrate spinal discs. Some theorize that with inversion, negative pressure is created in your spinal column, which may cause a disc that has herniated to be sucked back into position. The literature differs as to whether inversion is a permanent solution to back pain, and it is often a treatment cited to only provide temporary relief. A study from Newcastle University Hospital in the UK showed that 70 percent of patients scheduled for back surgery avoided surgery altogether with the use of an inversion table. The use of an inversion table is something that must be discussed with your physician, as conditions such as pregnancy, hypertension, glaucoma, inner ear problems, and others may preclude you from using one.

Unfortunately, sometimes surgery may be your only option. If you are experiencing constant pain, leg weakness — or worse, loss of function — you will require surgical intervention. Left untreated, weakness, numbness, and loss of function may become permanent. Continued degeneration of the spine can sometimes lead to loss of bowel and bladder control. When surgery is indicated, you must discuss your options with your spinal surgeon. Typically, there will be two procedures to be undertaken.

The first procedure is a discectomy. A discectomy involves removal of a part, or in some cases, the entire disc. Once the disc is removed, the pressure on the nerve will be relieved, and symptoms will subside. The second procedure is a laminotomy/laminectomy. A laminotomy is where a portion of the lamina, the thin, bony layer that covers and protects the spinal canal and spinal cord, is removed. Laminectomy is the complete removal of the bony lamina. Laminectomy and laminotomy are many times called spinal decompression surgery because their purpose is to relieve the pressure placed on a nerve due to a herniated disc pushing the nerve against the bony process. Fortunately, surgery is typically now done as minimally invasive, with only a one- to two-inch incision.

As dentists, we are always looking to do what is best for our patients, many times at the price of hurting ourselves. With more attention to what we eat, what we drink, how we sit, and how much we go to the gym, we may be able to extend our careers and avoid the surgeon’s scalpel. Thankfully, I was able to recuperate with all the non-surgical methods included in this article, and hopefully, along with all of you, I will be able to avoid having back pain be the bane of my existence.

Articles

Dentists have one of the highest rates of back pain and injury in the medical industry, but many fail to take preventative measures until it's too late. After a frightening experience that left him in pain and unable to function, Dr. Edward Alvarez is determined to help himself and his peers counteract one of the biggest risks of working in the dental profession. Continue below to find out more. 