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J Am Dent Assoc, Vol 132, No 2, 163-170.
© 2001 American Dental Association
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DENTISTRY & MEDICINE

COVER STORY
JADA Continuing Education

Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists



CURT HAMANN, M.D., ROBERT A. WERNER, M.D., ALFRED FRANZBLAU, M.D., PAMELA A. RODGERS, Ph.D., CHAKWAN SIEW, Ph.D. and STEVE GRUNINGER, M.S.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors undertook a study to determine the prevalence in dentists of abnormal sensory nerve conduction and/or symptoms of carpal tunnel syndrome, or CTS, the most common nerve entrapment syndrome.

Methods. In a cross-sectional study, dentists (n = 1,079) were screened during the American Dental Association’s Annual Health Screening Program in 1997 and 1998 by means of standard electrodiagnostic measures in the dominant hand and a self-reported symptom questionnaire. The authors diagnosed a median mononeuropathy from a 0.5- or 0.8-millisecond, or ms, prolongation of the median sensory-evoked peak latency compared to the ulnar latency. They diagnosed CTS if the subject also had accompanying symptoms of numbness, tingling or pain.

Results. Thirteen percent of screened dentists were diagnosed with a median mononeuropathy (using a 0.5-ms prolongation as the criterion), but only 32 percent of these had symptoms consistent with CTS (4.8 percent overall). When the 0.8-ms prolongation was used as the electrodiagnostic criterion, only 2.9 percent (overall) were diagnosed with CTS. People with diabetes, rheumatoid arthritis and obesity were more likely to have a median mononeuropathy.

Conclusions. The prevalence of symptoms consistent with CTS in the dominant hand among dentists was higher than the prevalence in the general population. However, when electrodiagnostic confirmation is added, the prevalence of CTS was nearly the same as that among the general population.

Clinical Implications. Early recognition of CTS can lead to more effective management. Education regarding ergonomic risk factors can be an effective preventive measure.

Carpal tunnel syndrome, or CTS, is one of a number of muscle-, tendon- and nerve-related disorders that affect people performing intensive work with their hands. There has been a tremendous increase during the last 20 years in the numbers of reported cases of CTS.1–3 Both dentists and dental hygienists have been reported to have a high prevalence of upper-extremity musculoskeletal disorders, including CTS.4–8 A 1997 American Dental Association survey reported that 9.2 percent of dentists had been diagnosed by a physician as having some type of repetitive motion disorder.9 The prevalence was higher among female and older dentists. Within this group of dentists who had a diagnosed repetitive-motion disorder, approximately 19 percent required surgery and more than 40 percent shortened their work hours.

This study of carpal tunnel syndrome is the largest in the literature to feature both a clinical symptom survey of and electrodiagnostic testing in dentists.

CTS is characterized by numbness, tingling or pain in the distribution of the median nerve in the hand. The palmar surface of the thumb, index and middle finger are the primary areas involved (FigureGo). The symptoms typically are worse at night and with repetitive activity. Although CTS is a clinical diagnosis based on history and symptoms, tests of median nerve function can be used to confirm injury to the median nerve at the wrist. The use of nerve conduction studies adds objective evidence to what can be a confusing clinical picture. If conduction of the median nerve across the wrist is prolonged as compared with conduction of another nerve in the hand that does not go through the carpal tunnel (for instance, the radial or ulnar nerve), this abnormality is referred to as a median mononeuropathy. Although many people complain of hand pain and tingling, only 20 percent are diagnosed with a concomitant median mononeuropathy.10–12



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  		Figure. The anatomy of the carpal tunnel with the placement of ring electrodes and electrical impulse stimulation site. The electrical signal is transmitted toward the fingers along the median nerve (which passes through the carpal tunnel) and ulnar nerve.

 
Conversely, the presence of a median mononeuropathy at the wrist is not synonymous with the diagnosis of CTS. Up to 15 percent of the population has a median mononeuropathy at the wrist with no symptoms of numbness, tingling, burning or pain in the hand or fingers.10 Similarly, Franzblau and colleagues12 reported that up to 25 percent of active industrial workers in several occupations had a median mononeuropathy in one or both hands. However, only one-half of these workers had symptoms consistent with CTS. Without symptoms, a median mononeuropathy does not represent CTS.

The ergonomic risk factors associated with CTS include repetitiveness of work, forceful exertions, mechanical stress, posture, temperature and vibration.13 These risk factors are present for dentists and dental hygienists: dental instruments may cause contact stress over the carpal tunnel, and wrists may be held in awkward positions for prolonged periods. In a 1998 study of a small cohort of dental hygienists, Bramson and colleagues14 evaluated several potential risk factors using hand-surface goniometry and electromyography. They concluded that hygienists’ exposure to high-risk postures was minimal and that the force they exerted during work was of medium risk (11 to 20 percent maximum voluntary contraction, based on surface electromyography data). In addition to repetitive work and contact stresses, hygienists and dentists may be exposed to other potential risk factors, such as the use of potentially restrictive ambidextrous gloves.15

In addition to ergonomic risk factors, there are several anthropometric factors and medical conditions associated with an increased risk of developing CTS.16 There is a higher prevalence of CTS among women and among people with diabetes, rheumatoid arthritis and thyroid disease.17 Obese people are four times more likely to have an entrapment of the median nerve at the wrist, but the mechanism of injury is not known; other peripheral nerves do not seem to be affected.

In the study described here, we attempted to quantify the prevalence of CTS among dentists using an objective assessment of the health of the median nerve across the wrist, using nerve conduction measures. We attempted to compare these results with the prevalence of CTS in the general population. Additionally, we explored the association of the various known risk factors for CTS within this population.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The data were collected as part of the annual Health Screening Program, or HSP, conducted at two of the American Dental Association’s annual meetings (in Washington in 1997 and in San Francisco in 1998). A total of 2,197 dentists participated in the two HSPs, but only 1,288 dentists chose to be screened for CTS. Of these, 209 dentists participated in both CTS screenings. When we used only the most recent results for repeat subjects, 1,079 dentists were included in the final analysis. The CTS screening consisted of the HSP self-reported symptom questionnaire and standardized electrodiagnostic testing of the median and ulnar nerves.18 Owing to time constraints of the HSP, we did not perform provocative clinical examinations for symptoms of hand pain or numbness produced by certain wrist postures. Subjects provided written consent as required by the American Dental Association’s institutional review board.

Questionnaire. The HSP questionnaire included questions on CTS-related symptoms, medical history, and demographic and anthropometric data—that is, age, sex, hours worked per week and weeks worked per year. Each dentist also was weighed and his or her height was measured; these values were recorded on the questionnaire. Height and weight were converted to body mass index, or BMI (in kilograms per square meter), as a measure of obesity (defined as a BMI > 29).

Electrodiagnostic testing. Certified electrodiagnostic technicians measured median and ulnar sensory-evoked responses in the dominant hand using the techniques described by Kimura.18 Hands were warmed if the midpalmar temperature was below 32 C (lower hand temperatures slow nerve conduction and increase latency values).

The technicians recorded the final hand temperature. They then stimulated both ulnar and median nerves supramaximally at a distance 14 centimeters away from ring-recording electrodes placed around the second and fifth digits (FigureGo), using a standard interelectrode distance of 3 cm. The transcutaneous electrical current depolarizes the median and ulnar nerves, and these depolarization waves travel down the hand to the fingers. The technicians performed all studies using either TECA TD 20 (TECA Inc.) or Viking Compass (Nicolet) electromyographic testing instruments.

The technicians recorded the peak latency and the amplitude (baseline to peak) of the median and ulnar sensory-evoked responses. Latency (in milliseconds, or ms) is defined as the time required for the impulse to travel the 14-cm distance. To control for the influences of age, disease state and limb temperature, the latency of the ulnar sensory-evoked response is subtracted from that of the median sensory-evoked response.19 This difference between median and ulnar peak latencies (median-ulnar latency) is used in the diagnosis of a median mononeuropathy. Therefore, when median nerve conduction slows, its peak latency increases, resulting in a larger median-ulnar latency value. We diagnosed CTS-screened dentists as having a median mononeuropathy if the following three criteria were met:

– their absolute median sensory peak latency was greater than 3.7 ms;
– their absolute ulnar peak latency was less than 3.6 ms;
– their median-ulnar latency equaled or exceeded 0.5 ms.

Although it is common to use a 0.5-ms cutoff to evaluate median ulnar latency, a more stringent criterion of 0.8 ms also has been used.19–21 Therefore, of the CTS-screened dentists who met the above criteria, we diagnosed a subset that also met the more stringent requirement of a median-ulnar latency that equaled or exceeded 0.8 ms. Finally, we diagnosed the CTS-screened dentists who had a median mononeuropathy (according to either the 0.5-ms or 0.8-ms cutoff) as having CTS if they also had symptoms of numbness, tingling or pain in the fingers or hand (not limited to the median distribution).

Statistics. We analyzed the data using statistical software (STATA Statistical Software, Release 4.0, Stata Corp.); the data consisted of descriptive statistics of the demographic, medical history, work history and electrophysiological variables. For comparisons of these results to those reported in the general population, we used {chi}2 statistics for proportional variable and the Student t test for comparison of continuous variables. We used these same statistics for comparisons within the sample and stratified by presence or absence of a median mononeuropathy or the diagnosis of CTS.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Questionnaire-based demographics for the CTS study population (n = 1,079) and the HSP population (n = 2,197) are presented in Table 1Go. In general, the CTS-screened dentists were predominantly male (84 percent) and somewhat older than the national average of 39 years,9 and they had practiced dentistry for 1 to 58 years. Significantly fewer of the CTS-screened dentists than of the HSP participants reported symptoms of hand or finger pain.


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  		TABLE 1 DEMOGRAPHICS OF DENTISTS PARTICIPATING IN THE 1997 AND 1998 CARPAL TUNNEL SYNDROME SCREENING AND ANNUAL HEALTH SCREENING PROGRAM OF THE AMERICAN DENTAL ASSOCIATION.

 
As shown in Table 2Go, no significant differences in amplitude or latency values were observed for either median or ulnar sensory-evoked responses of CTS-screened dentists as compared with expected mean values for the general population.18 Thirteen percent of CTS-screened dentists were diagnosed with a median mononeuropathy based on a median-ulnar latency cutoff of 0.5 ms (Table 3Go). By comparison, when the 0.8-ms cutoff was applied to CTS-screened dentists, only 6.7 percent met the criteria for a median mononeuropathy and only 2.9 percent were diagnosed with CTS. Self-reported pain symptoms, self-reported history of CTS and the presence of a median mononeuropathy were not associated with a diagnosis of CTS in this population (Tables 1Go and 3Go). Of the CTS-screened dentists, only 17 percent with hand and finger pain symptoms also had a median mononeuropathy as confirmed by electrodiagnostic testing (using the 0.5-ms median-ulnar latency cutoff). Of the 89 dentists with a self-reported history of CTS, only 34 percent had a prolonged median-ulnar latency, and less than 20 percent also had evidence of median nerve slowing and persistent symptoms. Conversely, there also were dentists who had no complaints of symptoms but had an abnormality of the median nerve across the wrist. Only 45 (32 percent) of the 140 dentists with a median mononeuropathy (according to the 0.5-ms cutoff) also reported the symptoms of numbness, tingling or pain in the hand or fingers needed for a clinical diagnosis of carpal tunnel syndrome.


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  		TABLE 2 MAGNITUDE OF MEDIAN AND ULNAR SENSORY-EVOKED RESPONSES IN THE DOMINANT HAND OF 1,079 CTS*-SCREENED DENTISTS.dagger;

 

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  		TABLE 3 PERCENTAGE OF 1,079 CTS*-SCREENED DENTISTS WITH MEDIAN MONONEUROPATHY AND DEFINITE CTS IN THE DOMINANT HAND.

 
Dentists diagnosed with a median mononeuropathy tended to be older (55.2 vs. 49.4 years, P < .001) and more likely to have practiced longer (27.5 vs. 21.8 years, P < .001) than CTS-screened dentists who did not receive this diagnosis. Dentists diagnosed with CTS also tended to be older than CTS-screened dentists who did not receive this diagnosis (52.4 vs. 49.7 years), but the difference was not significant (P = .17). The prevalence of CTS in dentists younger than 40 years of age was 1.9 percent vs. 2.9 percent among dentists between 40 and 60 years of age. Dentists older than 60 years of age had a CTS prevalence rate of 3.4 percent. In addition, while dentists who worked longer hours during the year were more likely to report hand and finger pain symptoms, they were not more likely to have a median mononeuropathy. Female dentists in the study were younger on average than the male dentists (43 vs. 51 years of age) and were less likely to have a median mononeuropathy (8.7 percent vs. 13.7 percent).

Of the medical conditions surveyed, rheumatoid arthritis, diabetes and obesity were additional risk factors in the CTS-screened dentists. Among the 12 dentists who had a history of rheumatoid arthritis, we found an increased likelihood of finding a median mononeuropathy compared with those who did not have the disorder (42 percent vs. 12 percent). Of the 22 dentists who had diabetes, 36 percent had a median mononeuropathy compared with 13 percent who did not have diabetes. Dentists with a median mononeuropathy were more likely to be overweight—that is, they had a higher BMI (27.5 vs. 26.0 Kg/m2, P = .001).

The type of gloves (ambidextrous vs. surgical or left/right specific) the dentists usually wore did not significantly influence the presence of a median mononeuropathy, but the vast majority of dentists used ambidextrous gloves (87 percent). However, dentists using surgical gloves (less than 4 percent of CTS-screened dentists) had slightly fewer hand and finger pain symptoms. Glove material (latex, vinyl, nitrile, neoprene or thermoplastic elastomer) also did not influence the presence of a median mononeuropathy.

Seventy-nine dentists (7.8 percent) had a prolongation of both the median and ulnar sensory latencies that would be consistent with a mild peripheral polyneuropathy. This group was older than the dentists who had no evidence of a polyneuropathy (57 vs. 49 years, P < .001), and 5 percent of this group had a history of diabetes. Symptoms of a peripheral neuropathy, sometimes confused with those of CTS, can include numbness of the hands and feet. Peripheral neuropathy often is associated with diabetes, thyroid disorders, exposure to heavy metals and nutritional disorders.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
CTS is diagnosed clinically on the basis of numbness, tingling and pain in the distribution of the median nerve in the hand. It typically is worse at night and with repetitive activity. The best estimates of the prevalence in the general population is 0.5 to 5 percent, depending on whether the definition of CTS included confirmation of a median mononeuropathy with electrodiagnostic testing.20–22 The most common cutoff criterion is a median-ulnar latency greater than or equal to 0.5 ms.19,20 However, a more stringent criterion, which has been used in other studies of CTS prevalence10,22 to apply to on-the-job workers, is a median-ulnar latency of 0.8 ms or greater.

The most recent population-based study of the prevalence of CTS in a general population was conducted in Sweden in 1997.10 This study examined the prevalence (rather than incidence) of CTS based on both electrodiagnostic and clinical criteria. Although the Swedish study also included provocative clinical examinations to further identify symptoms of hand pain and numbness, its results are directly comparable with those of our cross-sectional study of dentists (Table 4Go). Based on the 0.8-ms median-ulnar latency cutoff, the prevalence of CTS among the screened dentists and that among the general population of Sweden are not remarkably different. Furthermore, the two populations were similar in age and history of diabetes or rheumatoid arthritis, which minimizes differences that could be attributed to these confounding factors. Results from the Swedish population are directly comparable with those of our cross-sectional study of dentists. Although our study population was somewhat smaller and disproportionately male, the prevalence of CTS, age and history of diabetes and rheumatoid arthritis was not significantly different in the two populations. The researchers who conducted the Swedish study used the same electrodiagnostic criteria as ours, but their clinical diagnosis included a symptom survey as well as a physical examination. In addition, their dental screening relied on both symptoms and electrodiagnostic measures, but it did not include a physical examination.10


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  		TABLE 4 COMPARISON OF THE PREVALENCE OF CLINICALLY AND ELECTRODIAGNOSTICALLY CONFIRMED CTS*{dagger} AMONG 1997–1998 CTS-SCREENED DENTISTS VS. GENERAL POPULATION SAMPLE IN SWEDEN.{ddagger}

 
The meaning of an abnormality of the median nerve at the wrist in a subject without symptoms is critical to our understanding of these results. In a previous study, Werner and colleagues23 demonstrated that even after 18 months, people with a prolonged median sensory nerve conduction across the wrist were at no greater risk of developing CTS symptoms than age-and sex-matched workers with normal median nerve findings. Our current findings are consistent with this. However, a recent study by Nathan and colleagues24 with an 11-year follow-up demonstrated that 25 percent of people with an abnormal median nerve finding went on to develop symptoms of CTS, as compared with 10 percent of the subjects whose initial nerve findings were normal. Thus, up to one-quarter of the dentists with an abnormal median nerve latency may go on to develop CTS within the next decade.

Women have an increased risk of the development of CTS and hand or finger pain symptoms. Because female workers have been shown to have smaller wrists and potentially smaller carpal canal volumes, they may be at greater risk of developing CTS.26 In the study by Atroshi and colleagues10 of clinical and electrodiagnostically confirmed cases of CTS in the general population in Sweden, the prevalence rate among women was 3.0 percent vs. 2.1 percent among men. Stevens and colleagues22 found the incidence rate to be three times higher among women, especially in the 50- to 70-year-old age group. Because the female dentists in our study were younger and fewer in number than the male dentists, our estimate of the prevalence among dentists may underrepresent women.

More CTS-screened dentists reported CTS-consistent hand and finger pain symptoms (28 percent) than did the Swedish population in the study by Atroshi and colleagues10 (14 percent), but less than did industrial workers in a study by Franzblau and colleagues12 (30 percent). Because CTS-screened dentists reported fewer total symptoms than did dentists who participated in the HSP, the prevalence of CTS reported in our study may be underestimated.

As we do here, earlier studies have identified several medical conditions and related prescription drug use associated with an increased risk of developing CTS and hand or finger pain symptoms: obesity, oral contraceptive use, pregnancy, diabetes, rheumatoid arthritis, thyroid disease and certain connective-tissue disorders.13 Obesity also may be associated with decreased carpal canal volumes and has been correlated with an increased prevalence of CTS.13,25 Also consistent with our observations, previous studies13,25 have associated age with the development of CTS, based on years of exposure to repetitive and forceful work. However, CTS-screened dentists were older than the national average, as reported by the ADA.9 Therefore, our findings would tend to overestimate the true prevalence of CTS in dentists overall.

A relatively high number of dentists have a prolonged median-ulnar latency, yet two-thirds of the dentists affected are asymptomatic.

Electrodiagnostic evaluation was performed only on the dominant hand and without the use of hand diagrams. It is possible that some dentists had CTS in only the nondominant hand, and thus our sample population may underestimate the condition’s true prevalence. The symptom questionnaire did not include a hand diagram or any other scheme for localizing symptoms to the distribution of the median nerve. While hand diagrams may be more specific than questionnaires for identifying symptoms related to CTS, they are less sensitive than the posing of direct questions about (nonlocalizing) symptoms in the hands and fingers, as was done in this study.12

Our study is limited by its cross-sectional design and its nonrandom sample. Selection bias cannot be excluded, even though HSP-participating dentists were not drawn to the screening solely owing to hand symptoms but participated in other screening procedures as well. Our expectation was that more dentists with hand symptoms would participate in the CTS screening and lead to an overestimation of prevalence. However, when we compared the CTS screening group with the HSP group as a whole, the prevalence of hand and finger symptoms was significantly lower among CTS-screened dentists. While a random sample and longitudinal study of dentists would be ideal to assess true prevalence and incidence, this study is the largest in the literature to feature both a clinical symptom survey of and electrodiagnostic testing in dentists. Another potential factor that could bias the sample is avocational hand activity. Within our sample, dentists with the diagnosis of CTS were twice as likely to report pain symptoms (not limited to the hand) during hobby and gardening activities but not with sports activities. We did not assess this potential risk factor in enough detail to define any additional risk or protective role these activities may have had in this study.


   CONCLUSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
This cross-sectional study demonstrates that a relatively high number of dentists have a prolonged median-ulnar latency, yet two-thirds of the dentists affected are asymptomatic. There also is a higher rate of hand and finger pain symptoms among dentists than among the general population. This higher rate of pain is associated with dentists who reportedly work longer hours. However, there appears to be no significant difference between the prevalence of clinically and electrodiagnostically definite CTS among dentists and the rate among the general population. As in the general population, there are many dentists with slowing of the median nerve who are asymptomatic but may be at an increased risk of experiencing CTS in the future.

For people who have symptoms of CTS or are at an increased risk of developing the condition, early intervention can be important. When recognized early, CTS can be managed effectively with conservative and noninvasive treatment, such as the following:

– Since the extremes of wrist flexion and extension are the positions that place the median nerve at the highest risk of injury, the use of a nighttime wrist splint is the most common intervention. This device helps the patient avoid wrist flexion and extension extremes during sleep and thus decreases the pressure on the median nerve.
– Pacing of work activity can be helpful, as extended wrist flexion or extension can place the median nerve at risk. A short break from activity can reduce the pressure on the nerve and prevent injury.
– Direct instrument pressure over the carpal tunnel can be reduced by the use of large-handled instruments that distribute pressure over a larger surface area.
– 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.

There are many unproven interventions, including vitamin B6 supplements, nonsteroidal anti-inflammatory drugs and diuretics. More aggressive and invasive treatments that have been shown to be successful include steroid injections into the carpal tunnel and surgery. However, surgical management should be reserved for people with whom other treatment modalities and therapies have failed.

Early recognition of symptoms and education regarding ergonomic risk factors is important in the successful management of CTS. And although the prevalence of CTS appears no different in dentists than in the general population, implementation of some of the strategies listed here no doubt would be useful in alleviating the hand fatigue and pain reported by dentists in this study. Furthermore, because the relationship of symptoms to CTS still is not fully understood, proactive management of people at risk of developing CTS or experiencing pain is a reasonable approach to reducing the risk of future development of CTS.


   FOOTNOTES
 

Dr. Hamann is medical director, SmartPractice, 3400 E. McDowell, Phoenix, Ariz. 85008, e-mail "Hamann{at}SmartPractice.com". Address reprint requests to Dr. Hamann.


Dr. Werner is an associate professor and the chief of physical medicine and rehabilitation, Physical Medicine and Rehabilitation Service, Veterans Affairs Medical Center, Ann Arbor, Mich.; Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center, Ann Arbor; and Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor.


Dr. Franzblau is an associate professor, Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor.


Dr. Rodgers is a clinical research scientist, SmartPractice, Phoenix.


Dr. Siew is director, Department of Toxicology, Research Institute, American Dental Association, Chicago.


Mr. Gruninger is an assistant director, Safety and Biocompatibility, Division of Science, American Dental Association, Chicago.


Support for this research is provided, in part, by the National Institute of Disability and Rehabilitation Research of the U.S. Department of Education, grant H133E980007. The opinions contained in this publication are those of the grantee and do not necessarily reflect those of the U.S. Department of Education.


The authors gratefully acknowledge the assistance of the ADA Health Foundation and Kim Sullivan in the conduct of this study and review of the manuscript.


   REFERENCES
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 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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A. Vinik, A. Mehrabyan, L. Colen, and A. Boulton
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