Ergonomic Excellence: Positioning Strategies for Dentists and Patients

The static load in an awkward posture are the number one factors in risk injury. So what we want to avoid are things like trunk twisting, reaching out repeatedly under load. You know, you're pinching your fingers together to hold on to that handpiece. And so you're doing that. That's pressure. That's compression of your joints, cutting off oxygen, innervation, blood flow, all the things. And then you're doing it bent over. Welcome to the Phil Klein Dental Podcast. I think all of us who are listening to this podcast who work in a dental office and treat patients chairside can agree that what we do for a living is a physically demanding profession. I mean, there's just no doubt about it. We're performing extremely detailed tasks that require high precision. We need really good visibility. And doing this over and over again throughout the course of the day can be traumatic to our bodies. So that's why it's so imperative that we are aware of our body position and also the patient's position in the dental chair. The objective is to minimize the wear and tear on our musculoskeletal system. Now, what does that mean? It means that we need to develop and maintain good ergonomic habits. And we need to maintain this throughout our entire career in order to work comfortably and enjoy our profession. So based on this topic, we thought the best person to talk to would be Katrina Klein. And she truly is an expert in ergonomics. She's a registered dental hygienist for about 16 years now. She's a national speaker, author, competitive bodybuilder. and she's a certified personal trainer. She's the founder of ErgoFitLife, where ergonomics and fitness are a lifestyle to prevent, reduce, or eliminate pain. Katrina will be joining us in a second, but first... 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Katrina, thanks for coming back on our show. Thank you for having me. This is a lot of fun. I love the environment that you created here. Yeah, it's really good to get you on the show, especially with your specialty being ergonomics, very important to dentistry. And we have a lot of stuff to talk about today. So when it comes to dentistry, there's no question that clear visibility is an essential part of performing almost every procedure. We need to see what we're doing. So as clinicians, we certainly have different ways of increasing our ability to see things. So from your perspective, what tool do you think is the most underutilized for visibility inside the mouth? And why do you think it's so important to take advantage of this tool? Well, most importantly is our eyes. So using ergonomic loops allows us to keep our head up, but our eyes are dependent upon what we can actually gain access to in our sight of vision. And so I would say while... ergonomic loops keep our head up, we have got to use indirect vision. That is one of the biggest troubles that I see when I go out and help dentists in practice is we contort ourselves into pretzels in order to see a maxillary tooth. You know, it's the legendary number 15, right? And so not using that indirect vision and feeling comfortable to do our craft in that position is going to be the most underutilized thing. So it's loops and the positioning of yourself in relation to the patient. Yes, with your indirect vision. Okay, so let's focus on that point. And let me ask you this. From the standpoint of ergonomics and increased visibility, it helps us as clinicians to have the patient fully reclined in the dental chair. But some patients, even though they're able to, are somewhat resistant to being fully reclined. So what's the best and easiest way to overcome this and get them to lay back all the way without coming across as too demanding? Well, the first thing is, you know, when it comes to patient positioning, remember that we need to see into the mouth. We're not doing, you know, a chest exam. We're doing an oral cavity. And so having their head rest back before they ever sit in the chair so that when they lie back, the body doesn't have to be quite as far back if the chin is up. And so we bring that occlusal plane, you know, more into our vision when we have their chin up. And especially with those patients that are, say, they're experiencing some of their own kyphosis, you know, their necks are forward. They've got that hunchy appearance to them. Putting your chin up is a whole lot easier than laying your whole upper torso back and flat in a chair. If you imagine, say, a much more senior citizen and they've got that skeletal system that's just hunched over and they cannot physically sit upright, what are you going to do with those people? You got to put their chin up. And so that's the one thing that I tell people routinely is put that headrest back. It's a piece of ergonomic equipment that the chair manufacturers really use. to make it easier for you to do your job. So Katrina, talk to us about the ideal scenario. So if you could just make it happen every single time, what is the best position for the operator to be in? And once that's established, what is the best position for the patient to be in? So visibility is ideal and the operator has the most comfortable ergonomic position while they're working. So ideal is so that their oral cavity is completely flat. And so that you can see directly in with your body in neutral. And when I say neutral, I mean ears over shoulders, over hips. If you're standing, knees and then ankles. If you're sitting, obviously it's just over your hips. And so we want to stay neutral, shoulders back, chest up, chin straight forward so that you're in a natural gaze. And as you're looking down through your deflective loops, that oral cavity is right open in front of you. Having access with your indirect division, the chin is up. If the patient can lay supine and it's more comfortable for them, great. If they cannot lay completely supine, say they have vertigo or whatever, and they need to have their chest in a more vertical position, then great. But their chin even more so needs to be up so that their oral cavity is completely parallel with the ground. Okay, so that's the ideal position. And you did cover this, but I wanted to ask you, when we're encountering patients, that simply cannot lean back, like you mentioned, or so they say. In other words, they claim to have physical issues impeding them from doing so. How do we manage those patients? And you talked about it just now by having them tip their chin back to make sure that the plane of occlusion is parallel to the floor. Is that what you're looking to accomplish? Yes, yes. And we also want to avoid limiting their ability to move their head to the left and right. So often I see, say, the old dog bone pillow that we all know and love and has been around in dentistry forever. It supports their neck, but then prevents them from turning their chin to the left or the right so that you can gain either direct vision or a better indirect vision positioning. And so they're just stuck in this position where their chin is down. onto their chest and they can't move and now you can't move and now we become contortionist. So I would say making sure that we don't limit that and make sure that we have, say, a tube type of a pillow and like in a microbead, beanie baby type material so that it conforms and supports their exact neck without limiting their range of motion. So when a patient is fidgety in the chair and you finally get them in a good position and you're working and you and you. Everything's just going swimmingly. And then they start moving and tossing and then they kind of sit up and then they don't get back in the right position again. That kind of breaks the workflow. You know, it's somewhat disruptive to the flow of everything, especially at a critical point in the procedure. How do you propose a dentist handle that where the patient is just can't get comfortable, even though you have a good dental chair? How do you manage that? The first thing I would do is look at where the patient is sitting in the chair. It's too often that I'll see a patient in the chair who is of average height and they're sitting so far down and their head is not even all the way up in the headrest. Because remember, these chairs are meant to accommodate a six foot tall person. And so if you're five foot six, you need to have that patient scooch up in the chair all the way to the top. And so what I do in practice is I let people know. go ahead and scoot all the way up to the top here. And it's going to better support your head and neck because patients are going to do things that are going to make them feel better. You know, it's what's in it for me. That's the question they all ask. So if they know it's going to better support their back and neck, they're much more apt to do it rather than I need you here. It's going to make my job easier. They care, but they don't care. And so. if you evaluate where is that position of the patient in the chair that's much more likely causing their discomfort than anything else and then you can offer some lumbar you know pillows and also an under the knee pillow oftentimes is helpful you'll notice that they put their feet up on the chair with a bent knee With all of the disc issues that normal population people have these days, it's common. So offering them a way to change their spinal position by putting a pillow under the knee can be very helpful as well. So it's important, in your opinion, from the standpoint of ergonomics, is to have that conversation prior to starting the procedure and making sure they're in a position where they're comfortable so they can maintain that position throughout the procedure. That's worth putting in that extra time. Absolutely, 100%. Because the problem with having a patient in the wrong position to begin with is that you're spending all of that time fatiguing yourself unnecessarily and making that procedure less comfortable for the patient without meaning to. You know, if we have them in the right position, our instruments are made to be adapted to the mouth in a certain way. And so we have to... do things. I mean, as a hygienist, I'm opening up my blade the wrong way. It's going to cause more tissue trauma, which is going to cause more discomfort for the patient anyway, rather than just positioning them correctly in the first place. It goes smoother for them. It goes smoother for me. So it is worth spending the time having them scooch all the way to the top. And I'll always ask them once I get them up there, does that feel better on your back? And it's every time without fail. Oh yeah, that feels much better. And so they're convinced already that they're in a better position. So we talked about body positioning for the operator. We talked about patient positioning in the chair. What about the patient that just doesn't open their mouth very wide? I know we can use a bite block. We can use various techniques. But how do we manage those patients where visibility is just so restricted? Access is very restricted as well. That takes a toll emotionally and physically on us as an operator. What do you recommend for those kinds of cases? So the first thing that I do with patients that have a difficult time opening up and making that range of opening bigger is I actually start with a little TMJ massage. I just kind of give them a little massage. I have them do some deep breathing. I will actually put my palms on the side of their masseter to create a little bit of warmth and then have them do some deep breathing so that they can get that. And then, of course, using a bite block if you need to. If it's a patient that can't open or is it a patient that won't open. and understanding, you know, really reading that patient. If you know it's somebody that, you know, they've got chronic TMD and, you know, you're going to have to use the bite block and then indirect vision becomes essential. Recruiting an assistant is going to be a major asset and sometimes we need that. We'll be getting back to Katrina in a second, but first, when it comes to digital workflow equipment, it's important to partner with companies that provide premium products with unparalleled service, all at an affordable price. That's why you should check out Shining 3D Dental, a company that offers a complete and integrated suite of high-quality and easy-to-use digital dental equipment. Their local offices are based in California and Florida, so you get in-time comprehensive support. In fact, Shining 3D Dental can furnish your office with an entire suite of digital equipment for under $27,000. This includes their AoralScan 3 wireless intraoral scanner, Metasmile 3D facial scanner, and the AccuFab 3D printer with its post-processing equipment. Plus, the Shining 3D Dental digital workflow solution includes cloud storage, synchronization, and software for consultation, analysis, and design. So whether you're taking your... You work with a lot of dental practices and a big part of what you do is to evaluate how the team members are working in the office. And you're looking at all of this in large part from the ergonomic perspective. What are the most glaring, common mistakes that you see? when you are doing your ergonomic assessments? I love this one because it is pretty classic. You've got the telltale chicken arm. Everyone wants to put their arm out away from their side, which causes all of the upper body, neck, shoulder issues. And then you've got the leaners. People don't want to get up close to their patient. This is a very personal space. And we recognize that it is a very personal space and we don't want to impede on people. But at the same time, if we're leaning 30 or 60 degrees forward perched at the end of our chairs, that's hurting us and it makes it much more fatiguing for them. So the leaning forward, leaning to the side, the chicken arm, the head being leaned forward. And then the worst of all worst is when we're just completely going upside down. And, you know, we're balancing on one foot. So we become a contortionist acrobat all at the same time while holding a high-speed drill. Yeah, so there's a lot there. Now, are you seeing more dentists standing up and practicing dentistry? I know you mentioned on a previous podcast that dentists are exploring the idea of hybridizing their position where they sit and practice, but also stand and practice. What's the terminology for that when a dentist stands and practices versus sitting? It is just sitting or standing. Okay. Nothing more sophisticated than that. Okay. Keep it simple. Keep it simple. Okay. Yeah. I am seeing a few more people standing now, which is great. It does give us a variation in posture, which is fantastic for less fatigue and because we're able to move from one position to the next. not being afraid to get onto the opposite clock side of the patient, that is perfectly okay. It's whatever you got to do to keep yourself in neutral, it's fine. So yeah, that is really the crux of it is we need to give ourselves a variation in posture. And if we can get more people standing, great. And when I introduce it as I'm doing an ergonomic coaching session or training with a team, it's... It's fantastic when they put that arm down or they start standing and the expression is always the same. It's always, whoa, that feels so much better. Oh, my back feels so much better. And it works. And so I recommend the hygienist doing it every other patient. And I have the doctors doing it on all hygiene checks and any quick appointments that you have. And then if you have an extended. long procedure, for example, in endo, you know, you do part of it standing, part of it sitting, give yourself some variation. Everybody loves that. It feels better. What considerations go into purchasing a chair that accommodates both sitting and standing or, or do all chairs go up high enough? I'm six foot five and I was an endodontist. So if I was to stand, you're shaking your head. No, I know the audience can't see you, but it ain't going to work for someone six foot five. So that's what I'm asking. How do we get the right chair for this all to happen? you know that is a thing um we're we're getting there in dentistry there there is you know a manufacturer out there um i don't know if i'm allowed to say it or not but sure say whatever you want we're open open forum here okay good so dental ease actually has a chair now that elevates to 35 inches high and so as a six foot five person that might actually make it so that you can stand because without a chair that goes up to you know At least 30 inches high, you know, you're leaning forward. So then you're back out of neutral and you have to sit all day. And that's going to be the biggest factor is does your chair go up high enough to stand? Does your operatory delivery system allow you to get to 12 o'clock? And is the chair back narrow enough that you can marry the side of your hip with that shoulder area? or back of the chair, depending on how much space your patient takes up in that chair, is it narrow enough that you can get to the midline? And those are all major considerations. I see too often we have these lazy boy-sized chairs for our patients, and that does not help us at all. So how dangerous is reaching for things ergonomically for the operator? You know, because I know that when I was an endodontist and I practiced, I didn't have an assistant next to me all the time. And I had over the patient delivery system that was attached to the, I think the light post, I don't know, different chairs we had. But I was, you know, reaching for instruments quite a bit. There was a mobile cart to my right. There was a counter behind me. And I couldn't fit everything on the over the patient tray, of course. You know, I didn't think much of it at the time because I thought, okay, this isn't so bad. I'm just kind of moving my muscles around, reaching for things. But is that something that's dangerous or what's your preference on doing these kinds of things? It's definitely dangerous. You know, the static load in an awkward posture are the... the number one factors in risk injury, if you look at the OSHA website. So what we want to avoid are things like trunk twisting, reaching out repeatedly under load. You know, you're pinching your fingers together to hold onto that handpiece. And so you're doing that. That's pressure, that's compression of your joints, cutting off oxygen, innervation, blood flow, all the things. And then you're doing it bent over or you're reaching. just sitting here holding your arm out. You can do it while we're sitting here talking. You put your arm out away from your side and eventually you get the electrophysiological effects of having your fingers start to tingle. It's because you're cutting off the oxygen innervation blood flow. So that's very dangerous to us and that's what causes the musculoskeletal disorders that we're experiencing. Today's episode is sponsored by Sunstar, makers of gum products. Gum's premium line of interdental cleaners, soft picks, and toothbrushes offers innovative, easy-to-use solutions for better oral care. Introduce your patients to gum, the tools they need to maintain healthier smiles. Learn more today by visiting sunstargum.com. The herniation of the disc in the lower back, the lumbar region, very common for dentists and dental team members because I remember I had a family doctor because I had a herniated disc. When I was practicing endo, I didn't have a microscope. I can tell you how old I am. It had just come out, the endodontic microscope. And I want to ask you about that too, how that's certainly had been a great help to endodontists as far as ergonomic problems with that microscope. But I didn't have one. So I did have to use direct vision to see things. And I was leaning over. And this primary care physician that I had many years ago in Philadelphia said that you could pick up a paperclip with bad posture and herniate your disc. But then you could lift weights with the right support of your musculoskeletal system by lining everything up and you'll be fine. So it's really, everything's based on physics. And you need to, you can't be leaning over lifting something up because a paperclip could actually cause a problem. Now I know you're a bodybuilder. So talk to us about lifting weights. And I want to hear. before we end this podcast, how your bodybuilding career has kind of catapulted you into a career of teaching dentists and dental team members how to extend their career by good ergonomics. It's all tied together. It is. And the biomechanics of it all is exactly what you're talking about right there. It's, you know, if I could get a dime for every time I got a message or an email saying L4, L5, L4, L5, it's always L4, L5, L6. And it's because we perch at the end of our chairs and then we lean over and we sit there contracted for hours with a tiny instrument in our hands and do micro movements. I mean, it's it's a musculoskeletal disaster waiting to happen, which so many of us experience. Right. That's why 90 percent of dental professionals, dental clinicians, I should say, report body pain. And so. So biomechanically, it's a nightmare. We need to not be doing that. Hence the introduction of other things like saddle stools and ergonomic deflective loops and things like that. So definitely we want to do things in proper form, which is where staying in neutral helps and which is how bodybuilding got me kind of into this. I didn't get into bodybuilding until I was 35 and I've always been active and I've always exercised, but I didn't get into the gym until I was 35. I just started working out and I felt stronger. And all of a sudden I went for my first competition and I was half an inch taller. Okay, nobody grows half an inch after the age of 35. And I know for a fact that I was taller because when you go on the day of the show, they measure how high you are. And so that's because my posture was reinforced and strengthened and I was standing literally taller. And that kind of pivoted me into realizing that, Not only A, is a dental clinician's career temporary, it doesn't have to be that way. We can work as long as we want to if we do these things. And B, how do I get this message out there? And one of my fellow hygienists was brand new, brand new baby hygienist, two years in, seeing the chiropractor upwards of two times a week in pain, didn't think she was going to be able to practice for... for another three years and said, Katrina, what am I going to do? I took her to the gym. I did a lot of posture strengthening workouts with her. I helped her in the operatory. This was before I ever got certified as an ergonomics specialist. And within six weeks, she said, you've saved my career. I can do this as long as I want. And if you don't share this with people, that's a tragedy. And here I am. Great information you've shared with us. And we have more podcasts coming down the road. And we're really blessed and privileged to have you on the show. to have the opportunity to disseminate this information to our... large audience, which by the way, continues to grow. We're getting over 30,000 listens per month now, which is very exciting to see the program grow as fast as it is. So there are several options for dental professionals to get recommendations from someone like you, like an ergonomic consultant. One is for the consultant like you to go into the office, but for every dentist in the world to have you come in and assess their practice and make recommendations, of course, is not practical. So in addition to you doing assessments, in the office itself, which is part of the business that you have, where else can our audience get information where they can start this process of learning how to improve their ergonomic habits? And I assume that's online. I do go to dental offices and I do team trainings where I work one-on-one with the clinicians, the dentists, the assistants, the hygienists, everybody collectively with patients in the chairs and nobody loses production. You're still getting things done and you get real live experience. practicing in neutral with your patient in the chair and the patients love it the staff loves it i'll do a lecture over a lunch hour so that you get the back information and things like that and that's really really successful that's that's the best you can get you know is one-on-one training because there's these are things i don't teach you in school and then if you can't do that I would encourage someone to follow me on social media. I have a Facebook group. I have an Instagram, all these things. I post daily things either for ergonomics, posture workouts, different stretches, you know, all of these things. It's completely free. So you can get that information and you can follow it, try it. I also have done consults over the phone, you know, when doctors are doing build outs, for example, in their practice and they want to make the practice ergonomic for their team. I've done over the phone consults. There's all kinds of ways. And I would just say, reach me, talk to me. And I'm happy to talk to people because I genuinely want dentistry to not be a job that people automatically correlate with body pain. And that's what we do now. So I'm here to change that. I want to be the statistic. Yeah, no, I think it's fantastic and a great service to the dental community. What's the best way to reach you, Katrina? So a direct email is ergofitlifeatgmail.com. And if you want to follow me on Instagram, it's ErgoFitLife underscore Katrina. On Facebook, it's ErgoFitLife. This is going to get repetitive, so you'll never hear me. You'll never not hear me saying this. I have a Facebook page, ErgoFitLife. Hang out with me. Friend me. I don't care. Let's hang out. I mean, I'm wanting to be friends with everybody and help anybody that needs me. I cannot tell you how many messages that I answer daily just with random questions. Hey, I saw this. thing this posture brace what do you think about that and i'm happy to answer i'm just here to help do you still uh compete in bodybuilding um i retired from competing in when i turned 40 but i still train i transitioned into spartan racing and obstacle course racing because i could still train like a bodybuilder but i got to run fast and jump high and do epic things so i kind of reached my potential in bodybuilding and now i do that and i uh i get to do all the things and i also like food so there's that Yeah. I used to work out way more than I do now. But when I did work out a lot, I remember one of the trainers said, one of the best things about working out is that you can eat whatever you want. And that, and literally you can metabolize. I mean, you're not supposed to eat a lot of sugar, of course, but we all love chocolate layer cake once in a while. At least I do. So the benefit and the reward of eating whatever you want and feeling great is, that's what he said is all worth it. But everybody has. reasons why they like to work out. But the feeling of well-being, to me, supersedes everything when you're fit. So exercising is so important. And I really encourage all of our listeners to check out Katrina Klein because she's really enthusiastic about what she does. She's passionate, has incredible information about things you can do to prolong your career and mitigate the risk of being hurt where you're uncomfortable. and in pain while you're working, because there's nothing worse than that, is to be working in pain. And there's no reason to be subjected to that if you take the advice of people that know what they're doing through the expertise of people like Katrina Klein with ergonomics. Katrina, thank you very much for joining us. We really appreciate your input. Thank you so much for having me. This was a pleasure. I can't wait for the next one.