ORIGINAL ARTICLE
MJ Hayes JA Taylor DR Smith
Authors’ affiliations: MJ Hayes, JA Taylor, DR Smith, School of Health Sciences, Faculty of Health, University of Newcastle, Ourimbah, NSW, Australia Correspondence to: M. J. Hayes Department of Oral Health School of Health Sciences Faculty of Health University of Newcastle PO Box 127 Ourimbah, NSW 2258 Australia Tel.: +61 2 4349 4514 Fax: +61 2 4349 4567 E-mail: [email protected]
Introducing loupes to clinical practice: dental hygienists experiences and opinions Abstract: Objectives: Recent literature has identified a number of potential advantages in wearing loupes for dental hygienists, including improved quality of care and ergonomics. The aim of the study was to determine dental hygienists’ opinions about wearing loupes. Methods: A short online survey was distributed to all dental hygienists who had recently participated in a study investigating the efficacy of loupes on musculoskeletal disorders; all had only worn loupes for a 6-month period, and prior to the study had not worn loupes. All of those invited completed the survey (n = 12), achieving a 100% response rate. Results: The majority of respondents noted that the loupes were adaptable to wear; however, only one-quarter of hygienists surveyed were wearing them often following the study. Respondents identified that the biggest advantage to loupes was calculus removal (91.7%), and most indicated that they felt the quality of their work increased when wearing loupes (75%). The biggest disadvantage to wearing loupes was the adjustment period (50%), with limited depth of vision, headache, vertigo and infection control noted by at least one-third of respondents. Conclusions: This study revealed that hygienists identify both benefits and limitations to wearing loupes, and therefore, ongoing support may be required for hygienists adopting their use in clinical practice. Key words: dental hygienists; loupes; musculoskeletal disorders
Introduction
Dates: Accepted 4 December 2014 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12128 Hayes MJ, Taylor JA, Smith DR. Introducing loupes to clinical practice: dental hygienists experiences and opinions. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Wearing dental magnifying loupes is becoming increasingly popular in the dental hygiene profession (1). A number of advantages to wearing loupes have been identified in the literature, chiefly ergonomic benefits and increased visual acuity facilitating improved quality of clinical work (2, 3). The use of magnification promotes a stable and comfortable working distance, limiting neck and trunk forward flexion and improving posture (4). It is postulated that this improved positioning eases muscle load in the neck and back, reducing the risk of musculoskeletal disorders (MSD) (5). While this assumption has not been proven with clinically objective outcomes, analyses of self-reporting surveys have correlated the use of loupes with improved musculoskeletal health among dental professionals (6–8). A recent study identified that dental hygienists using loupes were less likely to report MSD in the neck, shoulder, upper back and wrist/hand than those not using loupes (6). Similarly, dentists’ use of loupes has been correlated with decreasing lower back pain (7). Int J Dent Hygiene |
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Hayes et al. Introducing loupes: experiences and opinions
The use of magnifying loupes increases visual acuity; however, studies have demonstrated noticeable variations depending on age and natural visual acuity (9, 10). One might assume that improvements in visual acuity enhance clinical outcomes in dentistry; however, there are conflicting results in the literature (9). The wearing of dental loupes has been shown to reduce enamel damage during orthodontic bracket debonding procedures (11), as well as improve the quality of cavity preparations and productivity of dental students (12). Conversely, little benefit was found in student’s performance when wearing loupes during paediatric cavity preparations (13). In the field of dental hygiene, there is a dearth of research investigating the use of loupes and improved clinical outcomes (1). It has been suggested, however, that particularly during subgingival debridement, increased visual acuity would be less beneficial than tactile sensitivity and proprioception (2). A number of limitations to the use of loupes have also been identified, including cost, weight and adjustment period, as well as difficulty in observing non-verbal patient prompts (14, 15). Wearing loupes produces a ring of blindness (16) and requires wearers to move between magnified and non-magnified fields, which may trigger symptoms such as vertigo and nausea as well as leading hygienists to feel disengaged with their patients (2). While much of the literature suggests that loupes reduce the risk of MSD through improved posture, it has also been suggested that the limited depth of visual field actually requires increased static positioning and as such may in fact increase neck and back problems (10). Furthermore, poorly fitted or adjusted loupes may promote inferior postures (2). Research examining dental hygienists opinions on wearing loupes is scarce. Two studies have been conducted in the United States of America (US), one focusing on the opinions of a large sample of practising hygienists (15) and another concentrating on the use of loupes in dental hygiene education programmes (1). While these studies provide valuable insight into dental hygienists views on the advantages and disadvantages of magnification loupes, in both studies, a large percentage of respondents were not loupes wearers at the time of the survey (15). An individual case study involving a dental hygiene student detailed his experiences acclimatizing to loupes wear and overall reported satisfaction with their use (17). The opinions of practising hygienists who have recently been introduced to wearing loupes would be useful, as they would be able to reflect on the benefits and challenges during employment, and what impact this may have on future use. The aim of the study therefore was to investigate the experiences and opinions of dental hygienists who had recently commenced using loupes in clinical practice.
MSD among dental hygienists (18). In the intervention study, participants were recruited from the Dental Hygienists’ Association of Australia New South Wales branch; hygienists that were not currently wearing loupes, working at least 24 h per week, and had experienced MSD were eligible to participate. Dental hygienists were issued with 2.5 9 magnification Galilean loupes to wear during all clinical treatment; the declination angle and co-axial alignment were adjustable, and the working distance was measured on an individual basis. None of the participants were given additional education on ergonomics; however, they were all assessed for their working distance based on their most balanced posture and were provided with written instructions from the manufacturer on how to adjust and wear the loupes. All participants in the intervention study provided written consent to undergo physical assessment prior to the intervention and then after 6 months of wearing loupes; they had also consented to be contacted for involvement in future research projects and had supplied their email address. For the follow-up study, these participants were emailed a participant information statement and a link to an online survey, after wearing the loupes for the 6-month intervention period. Informed consent was implied by the voluntary completion of the online survey. The online survey was developed by the researchers and was based on previously used questions identified during the literature review (15, 17, 19). The survey was based online (SurveyMonkey.com, California, USA) and consisted of ten questions, all with a numerical answer or tick-box response required. It collected demographic data including the participant’s age, years working and hours worked per week, as well as questions about their experience and opinions of magnification loupes. Participants were asked about whether they continued to wear loupes following their involvement in the research project, whether they found them easy to wear, the advantages and disadvantages of wearing loupes, the perceived impact on quality of work and posture, and whether they would have been beneficial as a student. Data were entered into a spreadsheet program, and percentages and means for all items were explored.
8.3%
0% 25%
Always Often Sometimes
33.3%
Rarely Never
Methods This exploratory and descriptive study was approved by the Human Research and Ethics Committee at the University of Newcastle in 2012 and was a follow-up from an intervention study investigating the effect of loupes on upper extremity 2
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33.3% Fig. 1. How often participants wore loupes after completing the research project.
Hayes et al. Introducing loupes: experiences and opinions
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Ergonomics/posture Caries detection Periodontal probe readings Restoration detection Quality of care Radiographic evaluations Calculus removal Soft tissue evaluation Fig. 2. Participants perceived advantages of loupes wear.
Increased sharpening accuracy
Results All dental hygienists who had participated in the broader research project (n = 12) agreed to participate, achieving a 100% response rate. The subjects had a mean age of 32.7 (SD 7.9) years, had been practising for an average of 4.8 (SD 6.6) years and worked an average of 31.5 (SD 7.8) hours at the time of the survey. None of the hygienists reported ‘always’ wearing loupes following their requirements for the research project; the distribution of responses is displayed in Fig. 1, with most wearing them only sometimes or rarely. When prompted to list the main procedures where loupes were worn, half of the participants indicated it was during scaling and debridement, while one participant indicated that she was still ‘getting used to them’. When asked about ease of use, most found them adaptable (75%), while two respondents indicated that they found them hard to wear. The participants identified a number of advantages and disadvantages of wearing loupes. All but one hygienist (91.7%) indicated that loupes were a benefit to the identification of calculus during removal, while at least half identified ergonomics/posture and periodontal probe readings as other advantages. The results for all perceived advantages are displayed in Fig. 2. The
most commonly reported drawbacks to loupes wear were the adjustment period (50%) and limited depth of vision (41.7%); the results for all identified disadvantages are presented in Fig. 3. None of the participants felt that the use of loupes impeded their quality of work, and the majority (75%) perceived that the quality of their work had actually improved. Only half of respondents indicated that there was a positive change in their posture while wearing loupes; of those remaining, 41.7% felt there was no noticeable change in their posture, while one dental hygienist indicated that her posture had been negatively impacted by wearing loupes. Participants were asked whether they felt loupes would have been beneficial if introduced during dental hygiene education and training. Half of the respondents felt that this would be beneficial (50%), while the most of the remaining were unsure (41.7%); only one participant felt that they should not be introduced during their education. A summary of these results is displayed in Table 1.
Discussion This study examined the experiences and opinions of dental hygienists recently introduced to wearing loupes during patient 0%
10%
20%
30%
40%
50%
60%
Vision dependency Limited depth of vision Headache Eye soreness Vertigo False sense of security Uncomfortable Adjustment period Fatigue Infection control Cost-to-benefit ratio Fig. 3. Participants perceived disadvantages of loupes wear.
Decreased tactile sensitivity Decreased pt awareness
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Hayes et al. Introducing loupes: experiences and opinions
Table 1. Summary of participants opinions of loupes wear
Comfort Hard to wear Adaptable Easy to wear Quality of work Increases No difference Impeded Impact on posture Positive change No change Negative impact Beneficial during education Yes No Unsure
Percentage
n
16.7 75.0 8.3
2 9 1
75.0 25.0 0.0
9 3 0
50.0 41.7 8.3
6 5 1
50.0 8.3 41.7
6 1 5
treatment. While the majority of participants found the loupes adaptable to wear, none of the hygienists were ‘always’ wearing the loupes following their participation in the research project. These findings are similar to reports from dental hygiene students exposed to loupes, where 59% found them adaptable, yet indicated that even if they were provided at no cost, they would not wear them all of the time (19). Likewise, over two-thirds of another cohort of dental hygiene students exposed to loupes found them adaptable (20). It appears as though the participants found the loupes most useful during debridement and scaling tasks. Furthermore, it can be postulated that they did not use the loupes routinely as they found them less beneficial during specific procedures; a possibility given that very few participants identified loupes wear as advantageous during procedures such as caries and restoration detection. This finding is inconsistent with previous research, whereby dental students using loupes displayed enhanced clinical performance (12). It should also be considered that some of the participants found them uncomfortable due to the reported disadvantages and chose not to wear them for this reason. Perhaps more detailed written instructions and alternative methods of support (such as education sessions on ergonomics) would have fostered their continued use. In the present study, the advantage to wearing loupes that was reported most often was calculus removal. This differs from two US surveys, where ergonomics was the most reported advantage (1, 15); however, both surveys had a much broader participant base and were not restricted to hygienists who actually wore loupes. None of the participants perceived the use of loupes to be advantageous for radiographic evaluations or increased sharpening accuracy; again, this is quite dissimilar from one US study where close to half felt that these items were benefited by loupes wear (15). It should be considered that perhaps this difference lies in the education and training of dental hygienists; in the United States, the use of loupes by students may be more common than in Australia, and as such, instructions in using loupes for a variety of procedures may be better supported.
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The most commonly reported disadvantage to wearing loupes was the adjustment period; this too was the case in the study of US dental hygienists, where almost half reported this as a limitation of loupes wear (15). It has been suggested that this adjustment period may be limited if wearing loupes was mandatory during education and training, allowing students to become comfortable with their use as they learn rather than having to ‘re-learn’ and adapt later during their careers (2). Alternatively, a study of US dental schools reported that the expense was the biggest disadvantage (1); in the current study, ‘expense’ was not an option when questioned about the disadvantages of loupes wear; however, they could have listed it as an ‘other’ if they had felt so inclined. Other commonly reported disadvantages in the current study include limited depth of vision, headaches and vertigo, which have been reported similarly in other studies (15, 19). In the current study, the level of comfort may have been influenced by noncoaxial alignment, or individual participants re-adjusting the declination angle or ocular angulation after first issued, to less than optimal positions. It was surprising that only half of those surveyed felt that their posture had improved, as studies observing hygienists have demonstrated a distinct improvement in posture when wearing loupes, compared to their usual working position (19, 20). However, the 2.59 magnification used by all the hygienists surveyed has a generous depth of vision, and as such, changes in position and posture are more likely than if the magnification had been higher; that is, hygienists are still able to flex their neck or trunk into awkward positions, while continuing to maintain visual clarity. One of the studies investigating posture change before and while wearing loupes found that a small number actually had worse posture when wearing loupes; it was proposed that these students had good posture prior to wearing loupes, so there was little scope for improvement (19). These findings clarify that the use of loupes should not be considered a panacea for optimal posture or prevention of MSD. The use of loupes should in fact complement in understanding the principles of neutral positioning, and the use of other ergonomically sound equipment, such as adjustable operator and patient chairs. The question of when is the best time to introduce loupes remains unclear, as the evidence to support improved clinical outcomes or improved health of hygienists is weak (4, 9). A survey of US dental hygienists found that there was inadequate support for the use loupes to be a requirement during education and training, even among those that indicated they always wore loupes (15). Despite this, some dentistry and oral health programmes have introduced the compulsory purchase and use of loupes during undergraduate education (1, 2). It has been suggested that the use of loupes in preclinic may support ideal positioning and posture before bad habits can be learned (19). If the use of loupes is mandated, it should be ensured that adequate and continued education on their use is included in the curriculum, as well as adequate training for faculty and clinical tutors.
Hayes et al. Introducing loupes: experiences and opinions
Limitations
The small sample size limited our ability to perform any complex statistical analysis and also the generalizability of the results to the wider profession. However, this information may be valuable in exploring the acceptability of loupes among practising hygienists. This study extended on from a larger study investigating whether wearing loupes limited or prevented the progression for MSD; even if the findings of the larger study are positive, the use of loupes as an MSD intervention may be limited if hygienists find them hard to wear, or perceive too many disadvantages. Furthermore, the level of support provided to the hygienists in using and adjusting the loupes may have been inadequate as suggested by the symptoms experienced by participants; while the manufacturers’ written instructions were provided, perhaps more details were required, or alternative methods of support or specific ergonomic education provided, to support using the loupes and maintaining balanced positions.
Conclusion Overall, this study provided an insight into the experiences and opinions of dental hygienists who had recently been introduced to loupes wear. Despite the reported advantages, there were also numerous disadvantages identified, and as such, further support may be required for dental hygienists adopting their use, including strategies for troubleshooting any barriers encountered.
Clinical Relevance Scientific rationale for study
Wearing dental loupes is being promoted as one method for improving ergonomics and treatment outcomes. However, the opinions of hygienists recently introduced to wearing loupes have not been explored; their experience and views would be valuable for those considering loupes. Principal findings
Most dental hygienists surveyed indicated that they felt the quality of their work increased while wearing loupes and that they were adaptable to use in clinical practice. However, the adjustment period was the most reported limitation. Practical implications
Both advantages and disadvantages to wearing loupes were identified, and as such, dental hygienists may require further support in adopting their use.
References 1 McHaney Congdon L, Tolle SL, Darby S. Magnification loupes in U.S. entry-level dental hygiene programs – occupational health and safety. J Dent Hyg 2012; 86: 215–222. 2 Sunell S, Rucker L. Surgical magnification in dental hygiene practice. Int J Dent Hyg 2004; 2: 26–35. 3 Syme SE, Fried JL, Strassler HE. Enhanced visualization using magnification systems. J Dent Hyg 1997; 71: 202–206. 4 James T, Gilmour ASM. Magnifying loupes in modern dental practice: an update. Dent Update 2010; 37: 633–636. 5 Smith CA, Sommerich CM, Mirka GA, George MC. An investigation of ergonomic interventions in dental hygiene work. Int J Dent Hyg 2002; 33: 175–184. 6 Hayes MJ, Taylor JA, Smith DR. Predictors of work-related musculoskeletal disorders among dental hygienists. Int J Dent Hyg 2012; 10: 265–269. 7 Rucker L, Sunell S. Ergonomic risk factors associated with clinical dentistry. J Calif Dent Assoc 2002; 30: 139–148. 8 Sunell S, Rucker LM. Ergonomic risk factors associated with clinical dental hygiene practice. Probe 2003; 37: 159–166. 9 Eichenberger M, Perrin P, Neuhaus NW, Bringolf U, Lussi A. Influence of loupes and age on the near visual acuity of practicing dentists. J Biomed Opt 2011; 16 [DOI: 10.1117/ 1.3555190]. 10 Burton JF, Bridgman GF. Presbyopia and the dentist: the effect of age on clinical vision. Int Dent J 1990; 40: 303–312. 11 Baumann DF, Brauchli L, van Waes H. The influence of dental loupes on the quality of adhesive removal in orthodontic debonding. J Orofac Orthop 2011; 72: 125–132. 12 Maggio PM, Villega H, Blatz MB. The effect of magnification loupes on the performance of preclinical dental students. Quintessence Int 2011; 42: 45–55. 13 Donaldson ME, Knight GW, Guenzel PJ. The effect of magnification on student performance in pediatric operative dentistry. J Dent Educ 1998; 62: 905–910. 14 Sunell S, Maschak L. Positioning for dental hygiene care: preventing back, neck and shoulder pain. Probe 1996; 30: 216–221. 15 Thomas J, Thomas F. Dental hygienists’ opinion about loupes in education. J Dent Hyg 2007; 81: 1–12. 16 Baker JM, Meals RA. A practical guide to surgical loupes. J Hand Surg Am 1997; 22A: 967–974. 17 Branson BG, Black MA, Simmer-Beck M. Changes in posture: a case study of a dental hygienist’s use of magnification loupes. Work 2010; 35: 467–476. 18 Hayes MJ, Osmotherly PG, Taylor JA, Smith DR, Ho A. The effect of wearing loupes on upper extremity musculoskeletal disorders among dental hygienists. Int J Dent Hyg 2014; 12: 174– 179. 19 Maillet JP, Millar AM, Burke JM, Maillet MA, Maillet WA, Neish NR. Effect of magnification loupes on dental hygiene student posture. J Dent Educ 2008; 72: 33–44. 20 Branson BG, Bray KK, Gadbury-Amyot C et al. Effect of magnification lenses on student operator posture. J Dent Educ 2004; 68: 384–389.
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MJ Hayes JA Taylor DR Smith
Authors’ affiliations: MJ Hayes, JA Taylor, DR Smith, School of Health Sciences, Faculty of Health, University of Newcastle, Ourimbah, NSW, Australia Correspondence to: M. J. Hayes Department of Oral Health School of Health Sciences Faculty of Health University of Newcastle PO Box 127 Ourimbah, NSW 2258 Australia Tel.: +61 2 4349 4514 Fax: +61 2 4349 4567 E-mail: [email protected]
Introducing loupes to clinical practice: dental hygienists experiences and opinions Abstract: Objectives: Recent literature has identified a number of potential advantages in wearing loupes for dental hygienists, including improved quality of care and ergonomics. The aim of the study was to determine dental hygienists’ opinions about wearing loupes. Methods: A short online survey was distributed to all dental hygienists who had recently participated in a study investigating the efficacy of loupes on musculoskeletal disorders; all had only worn loupes for a 6-month period, and prior to the study had not worn loupes. All of those invited completed the survey (n = 12), achieving a 100% response rate. Results: The majority of respondents noted that the loupes were adaptable to wear; however, only one-quarter of hygienists surveyed were wearing them often following the study. Respondents identified that the biggest advantage to loupes was calculus removal (91.7%), and most indicated that they felt the quality of their work increased when wearing loupes (75%). The biggest disadvantage to wearing loupes was the adjustment period (50%), with limited depth of vision, headache, vertigo and infection control noted by at least one-third of respondents. Conclusions: This study revealed that hygienists identify both benefits and limitations to wearing loupes, and therefore, ongoing support may be required for hygienists adopting their use in clinical practice. Key words: dental hygienists; loupes; musculoskeletal disorders
Introduction
Dates: Accepted 4 December 2014 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12128 Hayes MJ, Taylor JA, Smith DR. Introducing loupes to clinical practice: dental hygienists experiences and opinions. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Wearing dental magnifying loupes is becoming increasingly popular in the dental hygiene profession (1). A number of advantages to wearing loupes have been identified in the literature, chiefly ergonomic benefits and increased visual acuity facilitating improved quality of clinical work (2, 3). The use of magnification promotes a stable and comfortable working distance, limiting neck and trunk forward flexion and improving posture (4). It is postulated that this improved positioning eases muscle load in the neck and back, reducing the risk of musculoskeletal disorders (MSD) (5). While this assumption has not been proven with clinically objective outcomes, analyses of self-reporting surveys have correlated the use of loupes with improved musculoskeletal health among dental professionals (6–8). A recent study identified that dental hygienists using loupes were less likely to report MSD in the neck, shoulder, upper back and wrist/hand than those not using loupes (6). Similarly, dentists’ use of loupes has been correlated with decreasing lower back pain (7). Int J Dent Hygiene |
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Hayes et al. Introducing loupes: experiences and opinions
The use of magnifying loupes increases visual acuity; however, studies have demonstrated noticeable variations depending on age and natural visual acuity (9, 10). One might assume that improvements in visual acuity enhance clinical outcomes in dentistry; however, there are conflicting results in the literature (9). The wearing of dental loupes has been shown to reduce enamel damage during orthodontic bracket debonding procedures (11), as well as improve the quality of cavity preparations and productivity of dental students (12). Conversely, little benefit was found in student’s performance when wearing loupes during paediatric cavity preparations (13). In the field of dental hygiene, there is a dearth of research investigating the use of loupes and improved clinical outcomes (1). It has been suggested, however, that particularly during subgingival debridement, increased visual acuity would be less beneficial than tactile sensitivity and proprioception (2). A number of limitations to the use of loupes have also been identified, including cost, weight and adjustment period, as well as difficulty in observing non-verbal patient prompts (14, 15). Wearing loupes produces a ring of blindness (16) and requires wearers to move between magnified and non-magnified fields, which may trigger symptoms such as vertigo and nausea as well as leading hygienists to feel disengaged with their patients (2). While much of the literature suggests that loupes reduce the risk of MSD through improved posture, it has also been suggested that the limited depth of visual field actually requires increased static positioning and as such may in fact increase neck and back problems (10). Furthermore, poorly fitted or adjusted loupes may promote inferior postures (2). Research examining dental hygienists opinions on wearing loupes is scarce. Two studies have been conducted in the United States of America (US), one focusing on the opinions of a large sample of practising hygienists (15) and another concentrating on the use of loupes in dental hygiene education programmes (1). While these studies provide valuable insight into dental hygienists views on the advantages and disadvantages of magnification loupes, in both studies, a large percentage of respondents were not loupes wearers at the time of the survey (15). An individual case study involving a dental hygiene student detailed his experiences acclimatizing to loupes wear and overall reported satisfaction with their use (17). The opinions of practising hygienists who have recently been introduced to wearing loupes would be useful, as they would be able to reflect on the benefits and challenges during employment, and what impact this may have on future use. The aim of the study therefore was to investigate the experiences and opinions of dental hygienists who had recently commenced using loupes in clinical practice.
MSD among dental hygienists (18). In the intervention study, participants were recruited from the Dental Hygienists’ Association of Australia New South Wales branch; hygienists that were not currently wearing loupes, working at least 24 h per week, and had experienced MSD were eligible to participate. Dental hygienists were issued with 2.5 9 magnification Galilean loupes to wear during all clinical treatment; the declination angle and co-axial alignment were adjustable, and the working distance was measured on an individual basis. None of the participants were given additional education on ergonomics; however, they were all assessed for their working distance based on their most balanced posture and were provided with written instructions from the manufacturer on how to adjust and wear the loupes. All participants in the intervention study provided written consent to undergo physical assessment prior to the intervention and then after 6 months of wearing loupes; they had also consented to be contacted for involvement in future research projects and had supplied their email address. For the follow-up study, these participants were emailed a participant information statement and a link to an online survey, after wearing the loupes for the 6-month intervention period. Informed consent was implied by the voluntary completion of the online survey. The online survey was developed by the researchers and was based on previously used questions identified during the literature review (15, 17, 19). The survey was based online (SurveyMonkey.com, California, USA) and consisted of ten questions, all with a numerical answer or tick-box response required. It collected demographic data including the participant’s age, years working and hours worked per week, as well as questions about their experience and opinions of magnification loupes. Participants were asked about whether they continued to wear loupes following their involvement in the research project, whether they found them easy to wear, the advantages and disadvantages of wearing loupes, the perceived impact on quality of work and posture, and whether they would have been beneficial as a student. Data were entered into a spreadsheet program, and percentages and means for all items were explored.
8.3%
0% 25%
Always Often Sometimes
33.3%
Rarely Never
Methods This exploratory and descriptive study was approved by the Human Research and Ethics Committee at the University of Newcastle in 2012 and was a follow-up from an intervention study investigating the effect of loupes on upper extremity 2
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33.3% Fig. 1. How often participants wore loupes after completing the research project.
Hayes et al. Introducing loupes: experiences and opinions
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Ergonomics/posture Caries detection Periodontal probe readings Restoration detection Quality of care Radiographic evaluations Calculus removal Soft tissue evaluation Fig. 2. Participants perceived advantages of loupes wear.
Increased sharpening accuracy
Results All dental hygienists who had participated in the broader research project (n = 12) agreed to participate, achieving a 100% response rate. The subjects had a mean age of 32.7 (SD 7.9) years, had been practising for an average of 4.8 (SD 6.6) years and worked an average of 31.5 (SD 7.8) hours at the time of the survey. None of the hygienists reported ‘always’ wearing loupes following their requirements for the research project; the distribution of responses is displayed in Fig. 1, with most wearing them only sometimes or rarely. When prompted to list the main procedures where loupes were worn, half of the participants indicated it was during scaling and debridement, while one participant indicated that she was still ‘getting used to them’. When asked about ease of use, most found them adaptable (75%), while two respondents indicated that they found them hard to wear. The participants identified a number of advantages and disadvantages of wearing loupes. All but one hygienist (91.7%) indicated that loupes were a benefit to the identification of calculus during removal, while at least half identified ergonomics/posture and periodontal probe readings as other advantages. The results for all perceived advantages are displayed in Fig. 2. The
most commonly reported drawbacks to loupes wear were the adjustment period (50%) and limited depth of vision (41.7%); the results for all identified disadvantages are presented in Fig. 3. None of the participants felt that the use of loupes impeded their quality of work, and the majority (75%) perceived that the quality of their work had actually improved. Only half of respondents indicated that there was a positive change in their posture while wearing loupes; of those remaining, 41.7% felt there was no noticeable change in their posture, while one dental hygienist indicated that her posture had been negatively impacted by wearing loupes. Participants were asked whether they felt loupes would have been beneficial if introduced during dental hygiene education and training. Half of the respondents felt that this would be beneficial (50%), while the most of the remaining were unsure (41.7%); only one participant felt that they should not be introduced during their education. A summary of these results is displayed in Table 1.
Discussion This study examined the experiences and opinions of dental hygienists recently introduced to wearing loupes during patient 0%
10%
20%
30%
40%
50%
60%
Vision dependency Limited depth of vision Headache Eye soreness Vertigo False sense of security Uncomfortable Adjustment period Fatigue Infection control Cost-to-benefit ratio Fig. 3. Participants perceived disadvantages of loupes wear.
Decreased tactile sensitivity Decreased pt awareness
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Hayes et al. Introducing loupes: experiences and opinions
Table 1. Summary of participants opinions of loupes wear
Comfort Hard to wear Adaptable Easy to wear Quality of work Increases No difference Impeded Impact on posture Positive change No change Negative impact Beneficial during education Yes No Unsure
Percentage
n
16.7 75.0 8.3
2 9 1
75.0 25.0 0.0
9 3 0
50.0 41.7 8.3
6 5 1
50.0 8.3 41.7
6 1 5
treatment. While the majority of participants found the loupes adaptable to wear, none of the hygienists were ‘always’ wearing the loupes following their participation in the research project. These findings are similar to reports from dental hygiene students exposed to loupes, where 59% found them adaptable, yet indicated that even if they were provided at no cost, they would not wear them all of the time (19). Likewise, over two-thirds of another cohort of dental hygiene students exposed to loupes found them adaptable (20). It appears as though the participants found the loupes most useful during debridement and scaling tasks. Furthermore, it can be postulated that they did not use the loupes routinely as they found them less beneficial during specific procedures; a possibility given that very few participants identified loupes wear as advantageous during procedures such as caries and restoration detection. This finding is inconsistent with previous research, whereby dental students using loupes displayed enhanced clinical performance (12). It should also be considered that some of the participants found them uncomfortable due to the reported disadvantages and chose not to wear them for this reason. Perhaps more detailed written instructions and alternative methods of support (such as education sessions on ergonomics) would have fostered their continued use. In the present study, the advantage to wearing loupes that was reported most often was calculus removal. This differs from two US surveys, where ergonomics was the most reported advantage (1, 15); however, both surveys had a much broader participant base and were not restricted to hygienists who actually wore loupes. None of the participants perceived the use of loupes to be advantageous for radiographic evaluations or increased sharpening accuracy; again, this is quite dissimilar from one US study where close to half felt that these items were benefited by loupes wear (15). It should be considered that perhaps this difference lies in the education and training of dental hygienists; in the United States, the use of loupes by students may be more common than in Australia, and as such, instructions in using loupes for a variety of procedures may be better supported.
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The most commonly reported disadvantage to wearing loupes was the adjustment period; this too was the case in the study of US dental hygienists, where almost half reported this as a limitation of loupes wear (15). It has been suggested that this adjustment period may be limited if wearing loupes was mandatory during education and training, allowing students to become comfortable with their use as they learn rather than having to ‘re-learn’ and adapt later during their careers (2). Alternatively, a study of US dental schools reported that the expense was the biggest disadvantage (1); in the current study, ‘expense’ was not an option when questioned about the disadvantages of loupes wear; however, they could have listed it as an ‘other’ if they had felt so inclined. Other commonly reported disadvantages in the current study include limited depth of vision, headaches and vertigo, which have been reported similarly in other studies (15, 19). In the current study, the level of comfort may have been influenced by noncoaxial alignment, or individual participants re-adjusting the declination angle or ocular angulation after first issued, to less than optimal positions. It was surprising that only half of those surveyed felt that their posture had improved, as studies observing hygienists have demonstrated a distinct improvement in posture when wearing loupes, compared to their usual working position (19, 20). However, the 2.59 magnification used by all the hygienists surveyed has a generous depth of vision, and as such, changes in position and posture are more likely than if the magnification had been higher; that is, hygienists are still able to flex their neck or trunk into awkward positions, while continuing to maintain visual clarity. One of the studies investigating posture change before and while wearing loupes found that a small number actually had worse posture when wearing loupes; it was proposed that these students had good posture prior to wearing loupes, so there was little scope for improvement (19). These findings clarify that the use of loupes should not be considered a panacea for optimal posture or prevention of MSD. The use of loupes should in fact complement in understanding the principles of neutral positioning, and the use of other ergonomically sound equipment, such as adjustable operator and patient chairs. The question of when is the best time to introduce loupes remains unclear, as the evidence to support improved clinical outcomes or improved health of hygienists is weak (4, 9). A survey of US dental hygienists found that there was inadequate support for the use loupes to be a requirement during education and training, even among those that indicated they always wore loupes (15). Despite this, some dentistry and oral health programmes have introduced the compulsory purchase and use of loupes during undergraduate education (1, 2). It has been suggested that the use of loupes in preclinic may support ideal positioning and posture before bad habits can be learned (19). If the use of loupes is mandated, it should be ensured that adequate and continued education on their use is included in the curriculum, as well as adequate training for faculty and clinical tutors.
Hayes et al. Introducing loupes: experiences and opinions
Limitations
The small sample size limited our ability to perform any complex statistical analysis and also the generalizability of the results to the wider profession. However, this information may be valuable in exploring the acceptability of loupes among practising hygienists. This study extended on from a larger study investigating whether wearing loupes limited or prevented the progression for MSD; even if the findings of the larger study are positive, the use of loupes as an MSD intervention may be limited if hygienists find them hard to wear, or perceive too many disadvantages. Furthermore, the level of support provided to the hygienists in using and adjusting the loupes may have been inadequate as suggested by the symptoms experienced by participants; while the manufacturers’ written instructions were provided, perhaps more details were required, or alternative methods of support or specific ergonomic education provided, to support using the loupes and maintaining balanced positions.
Conclusion Overall, this study provided an insight into the experiences and opinions of dental hygienists who had recently been introduced to loupes wear. Despite the reported advantages, there were also numerous disadvantages identified, and as such, further support may be required for dental hygienists adopting their use, including strategies for troubleshooting any barriers encountered.
Clinical Relevance Scientific rationale for study
Wearing dental loupes is being promoted as one method for improving ergonomics and treatment outcomes. However, the opinions of hygienists recently introduced to wearing loupes have not been explored; their experience and views would be valuable for those considering loupes. Principal findings
Most dental hygienists surveyed indicated that they felt the quality of their work increased while wearing loupes and that they were adaptable to use in clinical practice. However, the adjustment period was the most reported limitation. Practical implications
Both advantages and disadvantages to wearing loupes were identified, and as such, dental hygienists may require further support in adopting their use.
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