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REVIEW ARTICLE
Year : 2012  |  Volume : 3  |  Issue : 3  |  Page : 138-144

Carpal tunnel syndrome: An occupational hazard


Department of Prosthodontics, SDM College of Dental Sciences, Dharwad, Karnataka, India

Date of Submission09-Oct-2012
Date of Acceptance23-Jan-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Sagar J Abichandani
Department of Prosthodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.111175

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  Abstract 

Background: The authors wanted to evaluate the comprehensive literature on carpal tunnel syndrome and find out if there is any correlation with dentists having a higher prevalence of its occurrence and finding out the scientific literature involving carpal tunnel syndrome among dentists.
Materials and Methods: A review of dental literature involving carpal tunnel syndrome was undertaken. Details appearing in the literature prior to 1995 was reviewed in a comprehensive manner and the literature post 1995 was reviewed electronically.
Results: The prevalence of carpal tunnel syndrome is higher in dental professionals involving various facets of dental specialties.
Conclusions: Abnormal postures, including muscle imbalances, muscle necrosis, trigger points, hypo mobile joints, nerve compression, and spinal disk herniation or degeneration may result in serious detrimental physiological changes in the body. These changes often result in pain, injury, or possible neuro-skeletal disorders.
Clinical Implications: Dentists have an increased risk of carpal tunnel syndrome and precautions and care should be exercised to prevent detrimental irreversible changes to occur in the body.

Keywords: Carpel tunnel, musculoskeletal disorders, tenosynovitis


How to cite this article:
Nadiger R, Shaikh S, Abichandani SJ. Carpal tunnel syndrome: An occupational hazard. Indian J Oral Sci 2012;3:138-44

How to cite this URL:
Nadiger R, Shaikh S, Abichandani SJ. Carpal tunnel syndrome: An occupational hazard. Indian J Oral Sci [serial online] 2012 [cited 2017 May 25];3:138-44. Available from: http://www.indjos.com/text.asp?2012/3/3/138/111175


  Introduction Top


Anatomy: Carpal tunnel

Moore JS [1] stated that the formation of a deep arch anteriorly at the wrist by the carpal bones and the flexor retinaculum is called the carpal tunnel. The pisiform and the hook of the hamate medially form the base of the carpal arch, while laterally by the tubercles of the scaphoid and trapezium. The carpal arch is converted into the carpal tunnel when the flexor retinaculum, which is a thick connective tissue ligament, bridges the space between the medial and lateral sides of the base of the arch. The four tendons of the flexor digitorum profundus, the four tendons of flexor digitorum superficialis, and the tendon of flexor pollicis longus pass through the carpal tunnel, as so does the median nerve. The tendons of the bone plane at the wrist are held by the flexor retinaculum, preventing them from "bowing." Synovial sheaths facilitate free movement of the tendons in the carpal, which surrounds the tendons.

Carpal tunnel syndrome

It is an entrapment syndrome caused by the pressure on the median nerve within the carpal tunnel.


  Materials and Methods Top


A review of the dental literature pertaining to carpal tunnel syndrome was undertaken. Details appearing in the literature prior 1995 were reviewed in a comprehensive manner and the material post 1995 was reviewed electronically. Electronic searches of the literature were performed in MEDLINE using key words - carpal tunnel syndrome, musculoskeletal disorders, tenosynovitis - in various combinations to obtain potential references for review. A total of 245 English language titles were obtained, many of which were duplicates due to multiple searches. The titles were reviewed and selected for closer examination. If the article under review was a study of any type, manual hand searching of the MEDLINE reference list was performed to identify any articles missed in the original search.

Etiology

Kimura J. [2] showed that the complications in symptoms and further healing time can be caused by any previous neck injury or injury to the upper body. A systemic or a biochemical factor could be an additional component, which without any repetitive movement can bring on an inflammatory condition. Risk of a narrow tunnel can increase due to a genetic or anatomical factor, such as race or gender. Curt Hamann et al. [3] stated that repetitiveness of work, forceful exertions, mechanical stress, posture, temperature, and vibration are the ergonomic risk factors associated with CTS. These risk factors are present for "dentists." Contact stress over the carpal tunnel may be caused by dental instruments, and wrists may be held in awkward positions for prolonged periods.

Other Predisposing Factors

Genetic predisposition


The carpal tunnel is smaller in some people as compared to others.

Repetitive movements

Franklin GM et al.[4] stated that people who repeatedly do the same movements with their wrists and hands over and over may be more likely to develop CTS. People with certain types of jobs are more likely to have CTS, including dentists manufacturing and assembly line workers, grocery store checkers, violinists, and carpenters. CTS can also be caused due to some hobbies and sports that use repetitive hand movements, such as golfing, knitting, and gardening.

Injury or trauma

Mary Sesto et al.[5] stated that swelling and pressure on the nerve can be caused by a sprain or a fracture of the wrist, increasing the risk of CTS. Strong vibrations caused by heavy machinery or power tools along with forceful and stressful movements of the hand and wrist can also cause trauma.

Pregnancy

Atroshi I et al.[6] stated that pregnant women, especially during the last few months, are at greater risk of getting CTS due to hormonal changes during pregnancy and build up of fluid. Most doctors treat CTS in pregnant women with wrist splits or rest, rather than surgery, as CTS almost always goes away following childbirth.

Menopause

During menopause, hormonal changes can put women at greater risk of getting CTS. Also, the wrist structures become enlarged, in some postmenopausal women, which can press on the wrist nerve.

Breast cancer

Some women who have a mastectomy get lymph edema, the build-up of fluids that go beyond the lymph system's ability to drain it. In mastectomy patients, this causes pain and swelling of the arm.

Medical conditions

People suffering from diabetes, hypothyroidism, lupus, obesity, and rheumatoid arthritis are more likely to get CTS. In some of these patients, the normal structures in the wrist can become enlarged and lead to CTS.

Also, smokers with CTS usually have worse symptoms and recover more slowly than nonsmokers.

Nancy Carter [7] described that carpal tunnel syndrome is particularly associated with dentists involved in certain tasks including:

  • Repetitive hand motion
  • Awkward hand position
  • Strong gripping
  • Mechanical stress on the palm
  • Vibration
Stockstill JW et al.[8] stated that Symptoms of carpal tunnel syndrome may include the following:

Patients typically report pain and pin-and-needles in the distribution of the median nerve.

  • Loss of sense of touch
  • Tingling and numbness in hand and fingers
  • Pain in shoulder at night, pain in elbow, or swelling in wrist area
  • Loss of grip strength in hand
  • Pain in wrist when you have it stretched in an extreme position, such as bending wrist, pointing the fingers to the floor
  • Dropping objects more often than usual
  • A burning sensation in your wrist and hand area
  • Being unable to unscrew a jar lid
  • Tenderness in the wrist area
  • More difficult to do tasks such as brushing your hair
Stevens JC et al.[9] showed that the Findings on physical examination (signs) are frequently absent or non-specific. Tinel's sign (tapping on the wrist or over the median nerve) and Phelan's signs (forced flexion of the wrist) are frequently described. Electromyogram can also be used to check for muscle damage when a needle is inserted into the muscle for recording electrical activity in that muscle at rest and when contracted. Generally, symptoms can be better examined when not working and on holidays when the worker has been removed from the workplace exposure. When examined, wasting of muscles of the thenar eminence, absence of abduction of thumb at metacarpophalangeal joint, and absence of opposition of the thumb were the symptoms. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenaratrophy), causing difficulty with pinch. Relatively high number of dentists has a prolonged median-ulnar latency.

Lam N and Thurston A [10] stated that higher rate of hand and finger pain symptoms are seen amongst dentists as compared to the general population. This higher rate of pain is associated with dentists who reportedly work longer hours.

Examination

Physical examination of the patient's hands, arms, shoulders, and neck can help determine if the complaints are related to daily activities or to an underlying disorder, following which other painful conditions that mimic carpal tunnel syndrome can be ruled out. The wrist is examined for:

  • Tenderness
  • Swelling
  • Warmth
  • Discoloration
The muscles at the base of the hand should be examined for strength and signs of atrophy, along with each finger being tested for sensation. Routine laboratory tests and X-rays can reveal:

  • Diabetes
  • Arthritis
  • Fractures
If one or more symptoms, such as tingling or increasing numbness, are felt in the fingers within 1 minute, the presence of carpal tunnel syndrome is suggested. Doctors may also ask patients to try and repeat the movements that bring on symptoms.

Tests

Electrodiagnostic tests are often used to confirm the diagnosis. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied to measure the speed with which nerves transmit impulses.

In electromyography, a fine needle is inserted into a muscle; the severity of damage to the median nerve can be determined by electrical activity viewed on a screen. Impaired movement of the median nerve can be seen by ultrasound imaging. Magnetic resonance imaging can show the anatomy of the wrist, but till now has not been especially useful in diagnosing carpal tunnel syndrome.

Dental Implications and Clinical Features

B. Valachi [11],[12] stated that the work carried on certain specialties in dentistry has increased incidence of carpal tunnel syndrome.

Endodontics

Biomechanical shaping of the root canals over long hours requires repeated usage of hand-files that can predispose a dentist to CTS.

Periodontics

Constant use of ultrasonic scalers can predispose a dentist to CTS not only due to increased vibrations and repetitive movements, but also due to awkward positioning over prolonged periods.

Prosthodontics

Constant prolonged static position during tooth preparation using an aerator hand piece can predispose to CTS.

Oral surgery

During tooth extraction carried out by dentists, extraction of maxillary premolars involves jerky, repetitive movements with awkward positioning of the musculoskeletal system for prolonged periods that can predispose to CTS.

Muscles, tendons, ligaments, and nerves in the hands and forearms are repeatedly overworked and stressed due to older, low-speed hand pieces that were designed with very heavy motors at one end, thus requiring unnecessary leverage just to control the unbalanced weight during each dental procedure.

Modern hand pieces are better to handle and use as they are shorter, made with lighter-weight durable materials, and often weigh about three ounces, two-thirds less than older models. Owing to modern designs, the weight is evenly distributed over the entire length of the handpiece rather than concentrated at the hose-end connection, making it easier to handle. They also come with a variety of swivel mechanisms that reduce unnecessary torque on the hand, wrist, forearm, and elbow.

Straight, cylindrical, or tapered-wider at the hose-end connection-are different types of handpiece silhouettes. Overall pinch/grip can be reduced by flared or tapered handpieces. The back end of the handpiece is supported and balanced by the soft tissue between the thumb and index finger. Pinch/grip is affected by the texture on the handpiece shaft. Texture equals traction; the clinician's ability to grasp the handpiece lightly while still maintaining control, especially in a moisture-laden environment, is improved by any texture or ribbing. To stabilize the prophy angle, make sure your current handpiece is in good running order, maintained regularly, and has a proper locking mechanism. Also, it never hurts to regularly check the availability of more ergonomically sound handpieces.

Conrad JC et al.[13] stated a design that necessitates more wrist flexion and extension for reaching tooth surfaces, also where majority both metal and single-use prophy angles are right-angled. Similar to the bend of a high-speed handpiece, contra-angled prophy angles have a small 4-mm bend in the shaft. The clinician can keep his or her wrist in a neutral position as this reduces stress on the wrist and forearm. An adjustable contra-angled DPA is ideal for use with a non-swiveling handpiece.

Osborn JB et al.[14] stated that hand comfort is directly affected by cup stability. Spinning screw or latch-mounted cups remain concentrically stable during polishing, contrasting to the wobble created by snap-on cups. Unnecessary hand stress for the clinician is created by an unstable snap-on cup.

Formulation of Rotary instruments, due to advancements in endodontics results not only in decreasing the perception of vibrations, but also makes it more durable by reducing the needs for hand-filing for biomechanical shaping of root canals.

Many a times, dentists assume static postures, which require more than 50 percent of the body's muscles to contract to hold the body motionless while resisting gravity. The static forces resulting from these postures have been shown to be much more taxing than dynamic (moving) forces. [15]

Powell BJ et al.[16] presented a series of events that may result in pain, injury, or a career-ending MSD can be initiated when the human body is subjected repeatedly to PSPs. Some of the physiological consequences of PSPs are muscle imbalances, ischemia, trigger points, joint hypomobility, and spinal disk degeneration.

To recover from even very low-level exertion, human muscles require rest periods as they are not adapted for continuous long-lasting contractions. During a sustained, static muscle contraction, the tendon stretches and compresses the vascular supply to the muscle and surrounding tissues, thereby depleting nutrient and oxygen supply. Lactic acid and other metabolites accumulate in the muscle tissues. [13] This process can result in damaged muscle tissue and a painful sensation.

Damaged tissues are repaired during rest periods, under normal conditions. Due to insufficient rest periods, in dentistry, however, the damage often exceeds the rate of repair. It can result in Muscle necrosis. The body uses another part of the damaged muscle to maintain the body position to protect the stressed area from further injury. The body recruits different muscle groups to perform the needed task as over long periods, entire muscles become compromised. This is known as muscle substitution, and muscles are required to perform a task for which they are not ideally designed. An abnormal "compensatory" motion then develops and predisposes the person to joint hypomobility (stiffness), nerve compression.

Early intervention could be important for people who have symptoms of CTS or are at an increased risk of developing the condition. When recognized early, CTS can be managed effectively with conservative and noninvasive treatment, such as the following (as stated by Corks I. [17] ):

  • The highest risk of injury occurs at the median nerve due to the extremes of wrist flexion and extension position; however, the most common intervention is the use of a night time wrist splint. This device helps the patient avoid wrist flexion and extension extremes during sleep and thus decreases the pressure on the median nerve.
  • As extended wrist flexion or extension can place the median nerve at risk, pacing of work activity can be helpful to reduce the pressure on the nerve and prevent injury.
  • Large-handled instruments that distribute pressure over a larger surface area can help reduce direct instrument pressure over the carpal tunnel.
  • Bramson JB et al.[18] stated that management of ergonomic stressors could include the use of fitted gloves that reduce hand tension.
  • Avoidance of awkward wrist posture during procedures reduces the stress on the median nerve.
Early recognition of symptoms and education regarding ergonomic risk factors is important in the successful management of CTS.

Treatment

Fish DR and Morris-Allen [19] stated that symptoms may often be relieved without surgery. Some ways to reduce pressure on the nerve are identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. Swelling around the nerve can relieve the symptoms by a steroid injection into the carpal tunnel. Surgery may be needed to make more room for the nerve, when symptoms are severe or do not improve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand. Incisions for this surgery may vary, although the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Soreness around the incision may last for several weeks or months, following surgery. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

Guay AH [15] stated that some precautions would be: keep the wrist at relaxed, middle position without bending it completely up or down. Use a relaxed grip, use less hand and finger force when performing tasks. Strive for good posture, so that neck and shoulder muscles do not compress nerves in the neck, which affects the wrist and hands.

Wrist splint

Field T et al. [20] stated that one's wrist can be supported and braced by wearing a splint in a neutral position, so that the nerves and tendons can recover. A splint can be worn 24 hours a day or only at night. Sometimes, wearing a splint at night helps to reduce the pain. Splinting can work the best when done within three months of having any symptoms of CTS.

Rest

Stopping or doing less of a repetitive movement may be all that is needed, for people with mild CTS. Your doctor will advice you about the steps that should be taken to prevent CTS from coming back. Rest, stretch, and bend the hand and wrists in an interval of 20 minutes, alternate tasks, change work position frequently. Watch for headaches, fatigue, and muscle pain, if they come, and activities. Non-steroidal anti-inflammatory drugs (NSAIDS) may be helpful.

Find assistance

Stress and pain can be reduced by relaxation techniques such as those found in yoga. Water therapy, heat, and massage might be useful in relieving symptoms.

Ergonomics

B. Valachi and Keith Valachi [11],[12] stated that effective and efficient needs can be met by the design of the workplace. Huge variety of equipment is available to ensure correct posture and good wrist position, wrist and forearm supports, sprints and braces, work surfaces, chairs, and other innovative devices. Werner RA and Armstrong TJ [21] stated that it is imperative to take care to adjust equipment to avoid stress from awkward body positioning and wrist angles.

Medication

Patient leaflets from the BMJ group states that for controlling CTS pain, the short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) may be helpful. NSAIDs include aspirin, ibuprofen, and other non-prescription pain relievers. In severe cases, swelling may be reduced with the help of an injection of cortisone. Your doctor may also give you corticosteroids in a pill form. But, these treatments only relieve symptoms temporarily. If CTS is caused by another health problem, your doctor will probably treat that problem first. If you have diabetes, it is important to know that long-term corticosteroid use can make it hard to control insulin levels.

Physical therapy

Nigel Ashworth [22] stated that to make your wrist and hand stronger, a physical therapist can help you do special exercises. Massage, yoga, ultrasound, chiropractic manipulation, and acupuncture are just a few such options that have been found to be helpful, that can make CTS better and help relieve symptoms.

The massage treatment consists of moderate stroking techniques from the fingertip to elbow region. The technique was described as "…stroking the wrist up to the elbow and back down on both sides of the forearm." After that, another technique was described as "…a wringing motion applied to the same area." This was most likely describing petrissage-type techniques. Two more techniques were described as part of the massage process. The first was stroking using the thumb and forefinger in a circular back-and-forth motion, covering the entire forearm and hand. The final technique described was rolling the skin between the thumb and forefinger across the hand and up both sides of the forearm. Before trying these alternative treatments, you must consult your doctor first.

Surgery

CTS surgery is one of the most common surgeries done in the U.S. Generally, surgery is only an option for severe cases of CTS and/or after other treatments has failed for a period of at least six months. A common approach to CTS surgery and that involves making a small incision in the wrist or palm and cutting the ligament to enlarge the carpal tunnel is an open release surgery. This surgery is done under a local anesthetic to numb the wrist and hand area and is an outpatient procedure

Overview of the Treatment Modalities as given by the Medical Treatment Guidelines by the Washington State Department of Labor and Industries [23]

Conservative


  • Corticosteroids (Local Injection/Systemic)
  • Diuretics
  • NSAIDS
  • Pyridoxine
  • Large doses of Vitamin B6
  • Acupuncture
  • Massage
  • Nerve and/or tendon exercise
  • Therapeutic ultrasound
  • Wrist Splints
Curt Hamann et al. [3] stated that whether the patient can remain at work is primarily depended by the duration of conservative treatment. Whether or not specific treatment is rendered, most patients will improve when they are off work. In some cases, worsening of OCTS can be prevented and symptoms may be improved by job modification, along with conservative treatment. If job modification is not possible, or if the claimant cannot continue working with conservative treatment, then surgery should be considered as a treatment option.

Surgery (as given by the American Society for the surgery of hand [24] )

  • Endoscopic carpal tunnel release and open carpel tunnel release
  • Internal neurolysis in conjunction with open carpal tunnel release
For OCTS, the surgical procedure of choice is decompression of the transverse carpal ligament.

In general, the following criteria should have been met for authorization of surgery to occur:

  • The clinical history should be consistent with OCTS;
  • Nerve Conduction testing (NCV) should have demonstrated a conduction slowing of the median motor or sensory fibers across the carpal tunnel; and
  • A course of conservative management must have been tried.
According to various studies, it is suggested that in 60 to 90% of the post-surgical cases, the burning pain associated with OCTS will be alleviated. The patient's ability to return to the same job is not clear. If pain persists or recurs, NCVs can help sort out whether nerve entrapment continues to be a problem.

Acupressure

Acupressure is based on the same principles as acupuncture. Pressure is applied instead of needles to acupuncture points, which is thought to stimulate blood flow to the wrists and hands and ease numbness and swelling in the area.

Acupressure points for carpal tunnel syndrome are typically on the wrists, forearms, and hands.

Instructions

  • Matthew C. Kiernan et al.[25] stated that with your thumb or middle finger at a 90 degree angle to the skin, apply gradually increasing the pressure. Hold for 2 to 3 minutes. Each point will feel different; it may be achy, sore, or tense;
  • The pressure should not be painful or uncomfortable - do not try to bore a hole into your arm!
  • The points do not have to be used together to be effective, so choose the most tense points if you do not have time for the whole routine.
Post surgery (as given by the university of pittsburgh medical center information for patients section)

Medicine

Be sure to take the prescribed pain medication and an antibiotic as directed by your doctor.

Elevation

It is important to keep your hand raised above the level of your heart as much as possible for the first 48 hours following surgery. This helps to reduce swelling and pain.

Dressing

Keep the dressing over your incision clean and dry until your follow-up appointment with your doctor, unless instructed otherwise. The stitches under the dressing will be removed by your doctor.

Activity

Do not lift anything with the hand you had surgery on until your doctor says it is OK. Be sure to move your fingers regularly. This will keep them from getting stiff and help lessen the swelling.

What is the prognosis?

By changing the way they do repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods when they perform the movements, majority recover completely, and can avoid re-injury.


  Conclusion Top


Abnormal postures, including muscle imbalances, muscle necrosis, trigger points, hypo mobile joints, nerve compression, and spinal disk herniation or degeneration, may result in serious detrimental physiological changes in the body. These changes often result in pain, injury, or MSDs.

Clinical work habits, including proper use of ergonomic equipment, frequent short stretch breaks, and regular strengthening exercise, may require a paradigm shift within the profession of dentistry to prevent chronic pain.

 
  References Top

1.Moore JS. Carpal tunnel syndrome. Occup Med 1992:7:741-63.  Back to cited text no. 1
    
2.Kimura J. Electrodiagnosis in diseases of nerve and muscle: Principles and practice. Philadelphia: F.A. Davis; 1983. p. 106-11.  Back to cited text no. 2
    
3.Hamann C, Werner RA, Franzblau A, Rodgers PA, Siew C, Gruninger S. Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J Am Dent Assoc 2001;132:163-70.  Back to cited text no. 3
    
4.Franklin GM, Haug J, Heyer N, Checkoway H, Peck N. Occupational carpal tunnel syndrome in Washington State, 1984-1988. Am J Public Health 1991;81:741-6.  Back to cited text no. 4
    
5.Sesto ME, Radwin RG, Salvi FJ. Functional deficits in carpal tunnel syndrome. Am J Ind Med 2003;44:133-40.  Back to cited text no. 5
    
6.Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999;282:153-8.  Back to cited text no. 6
    
7.Carter NB. Carpal tunnel syndrome. Post Polio Health Spring 2007;23:3-5.  Back to cited text no. 7
    
8.Stockstill JW, Harn SD, Strickland D, Hruska R. Prevalence of upper extremity neuropathy in a clinical dentist population. J Am Dent Assoc 1993;124:67-72.  Back to cited text no. 8
    
9.Stevens JC, Sun S, Beard CM, O'Fallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology 1988;38:134-8.  Back to cited text no. 9
    
10.Lam N, Thurston A. Association of obesity, gender, age and occupation with carpal tunnel syndrome. Aust N Z J Surg 1998;68:190-3.  Back to cited text no. 10
    
11.Valachi B, Valachi K. Mechanisms leading to musculoskeletal disorders in dentistry: Bethany. J Am Dent Assoc 2003;134:1344-50.  Back to cited text no. 11
    
12.Valachi B. Musculoskeletal health of the woman dentist: Distinctive interventions for a growing population. J Calif Dent Assoc 2008;36:127-32.  Back to cited text no. 12
    
13.Conrad JC, Conrad KJ, Osborn JB. A short-term, three-year epidemiological study of median nerve sensitivity in practicing dental hygienists. J Dent Hyg 1993;67:268-72.  Back to cited text no. 13
    
14.Osborn JB, Newell KJ, Rudney JD, Stoltenberg JL. Carpal tunnel syndrome among Minnesota dental hygienists. J Dent Hyg 1990;64:79-85.  Back to cited text no. 14
    
15.Guay AH. Commentary: Ergonomically related disorders in dental practice. J Am Dent Assoc 1998;129:184-6.  Back to cited text no. 15
    
16.Powell BJ, Winkley GP, Brown JO, Etersque S. Evaluating the fit of ambidextrous and fitted gloves: Implications for hand discomfort. J Am Dent Assoc 1994;125:1235-42.  Back to cited text no. 16
    
17.Corks I. Occupational health hazards in dentistry: Musculoskeletal disorders. Ont Dent 1997;74:27-30.  Back to cited text no. 17
    
18.Bramson JB, Smith S, Romagnoli G. Evaluating dental office ergonomics: Risk factors and hazards. J Am Dent Assoc 1998;129:174-83.  Back to cited text no. 18
    
19.Fish DR, Morris-Allen DM. Musculoskeletal disorders in dentists. N Y State Dent J 1998;64:44-8.  Back to cited text no. 19
    
20.Field T, Miguel D, Christy C, Kristin H, Alan G, Maria HR, et al. Carpal tunnel syndrome symptoms are lessened following massage therapy. J Bodyw Mov Ther 2004;8:9-14.  Back to cited text no. 20
    
21.Werner RA, Armstrong TJ. Carpal tunnel syndrome: Ergonomic risk factors and intracarpal canal pressure. Phys Med Rehabil Clin N Am 1997;8:555-69.  Back to cited text no. 21
    
22.Ashworth N. Carpal tunnel syndrome. Clin Evid 2010;3:1114-42.  Back to cited text no. 22
    
23.Diagnoses and treatment of work-related carpal tunnel syndrome (OCTS); Medical Treatment Guidelines Washington State Department of Labor and Industries: Provider Bulletin 95-10. 1995.  Back to cited text no. 23
    
24.Carpal tunnel syndrome, American Society for Surgery of the Hand.  Back to cited text no. 24
    
25.Kiernan MC, Mogyoros I, Burke D. Conduction block in carpal tunnel syndrome. Brain 1999;122:933-41. Oxford: Oxford University Press; 1999.  Back to cited text no. 25
    




 

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