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Carpal Tunnel Syndrome: A Growing Epidemic Among Dental Professionals?

The carpal tunnel region - bounded by the carpal bones of the wrist along the floor and the flexor retinaculum along the roof and sides - can become afflicted with a focal peripheral neuropathy known as carpal tunnel syndrome. This disease process involves peripheral nerve dysfunction of the median nerve as it passes through the carpal tunnel region of the wrist. The median nerve is surrounded by nine finger flexor tendons, which also travel through the tunnel (Figure 1). Once the median nerve exits the carpal tunnel, it innervates the thenar muscles of the thumb and the skin covering the thumb, second, third, and the radial half of the fourth digit (Figure 2). Nerve dysfunction in carpal tunnel syndrome is generally due to either chronic pressure-induced loss of the myelin sheath covering (demyelination) and/or acute focal block in the ability of the nerve to conduct impulses beyond a certain site (conduction block) (Figure 3). In severe conditions, these processes can result in the death of nerve fibers (axon loss).

 

Symptoms

Symptoms of carpal tunnel syndrome include paresthesias, incoordination of the fingers, the rapid onset of hand fatigue and, in severe cases, overt weakness of the hands. Nocturnal symptom exacerbation - as well as temporary symptom relief with vigorous shaking of the hands (ie, "flick sign") are additional pathognomic signs. Although symptom onset is generally insidious, it can be acute and precipitated by vigorous or prolonged use of the hands. The symptoms are, therefore, potentially intensified by the performance of dental procedures and can significantly inhibit these activities.

 

Etiology

Although carpal tunnel syndrome has been attributed to numerous etiological factors,1-12 the buildup of pressure within the tunnel and its subsequent transmission to the median nerve is a common denominator. Several medical conditions associated with carpal tunnel syndrome include diabetes mellitus, situations related to fluid overload, tenosynovitis, and connective tissue diseases. Due to the swelling of the nine finger flexor tendon sheaths (flexor tenosynovitis) as they pass through the tunnel, this pressure can significantly increase. Swelling occurs as a result of diseases that directly affect the tendon sheath or from repetitive activities that result in an overuse form of flexor tenosynovitis. Intratunnel pressure can also escalate due to poor ergonomic wrist positions (eg, extension).13,14 Dental procedures have the potential to cause carpal tunnel syndrome via the combined effects of flexor tenosynovitis and repetitive hand movements; pressure increases from the occasional assumption of awkward hand positions. In addition, the use of vibrating handheld instruments has been identified as an independent risk factor for carpal tunnel syndrome.15,16 Dental hygienists are believed to be particularly at risk for this condition.15,17-21

 

Incidence in the Dental Profession

Although the performance of dental procedures is a potential precipitant of carpal tunnel syndrome, relatively few studies have attempted to quantitate the incidence in dental professionals. For example, although a survey from a population of clinicians in Nebraska estimated a 29% incidence of "upper limb or neck peripheral neuropathy" in general, it did not specifically address the incidence of carpal tunnel syndrome.22 Since carpal tunnel syndrome is a frequent upper extremity entrapment neuropathy, however, this study does suggest that it potentially affects a large number of dental professionals. Using vibration threshold testing,17 one study of 58 hygienists determined a 25.9% symptom rate and a 12% actual disease rate for this condition.

 

Diagnosis

The diagnosis of carpal tunnel syndrome is established through the analysis of patient symptoms, as well as objective findings determined by physical examinations and electrodiagnostic testing. Since physical examinations are often insufficient, electrodiagnostic testing is frequently utilized to confirm the diagnosis and determine disease severity.23,24 Various upper extremity conditions can mimic the symptoms of carpal tunnel syndrome, and therefore must be excluded in order to confirm that a patient suffers from carpal tunnel syndrome.

 

Treatment

Carpal tunnel syndrome can be overwhelmingly disabling and difficult to treat in dental professionals, since the practice of dentistry is essentially incompatible with first-line treatment, (eg, wrist splints and rest). Specifically, the dental professional is often unable to comfortably wear wrist splints beneath gloves during the performance of job-related activities. In addition, it is difficult for affected individuals to rest their hands. Although medications that include nonsteroidal anti-inflammatory drugs and corticosteroid injections into the carpal tunnel can be administered, these measures often provide incomplete and transient symptom relief. A definitive cure - surgical transection of the carpal ligament that forms the roof of the tunnel - can be performed, but this procedure necessitates an extended absence from work, and has been associated with potentially severe complications.25 The latter is particularly true when the procedure is performed endoscopically rather than via the traditional open surgical approach.26

 

Prevention

Although prevention of the condition is an ideal strategy, it is difficult to modify the practice of dentistry to the point where its practitioners are no longer at risk for carpal tunnel syndrome. While contemporary literature on ergonomics has focused on back pain and dentistry rather than carpal tunnel syndrome and dentistry,27-30 several relevant preventive strategies have been suggested.31 As additional information on this condition and its effects on dental-related activities are accumulated, the efficacy of prevention strategies can be improved.

 

Conclusion

Carpal tunnel syndrome is caused by a focal upper extremity entrapment neuropathy. Although its exact incidence in dentistry is not known with certainty, it is a potentially prevalent condition due to work-related factors that result in abnormally high pressure on the median nerve as it passes through the carpal tunnel. This condition can be recognized by certain signs and symptoms, and its diagnosis can be confirmed by electrodiagnostic testing. Treatment of dental professionals afflicted with carpal tunnel syndrome is a challenge, as is prevention of the condition. It is an important issue since it can prove to be quite disabling due to the deterioration of technical skills.

 

*Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey.

† Private practices, Union City, New Jersey; New York, New York.

 

References

 

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