Mind and Body

With all these factors in play, it's no secret that hygienists can be prone to burnout.¹ If you've ever experienced mental distress or physical pain, you're not alone. To gain insights on much-needed self-care for hygienists, Inside Dental Hygiene asked some of the top experts in mental health and ergonomics to offer specifics about staying both psychologically and physically fit. They've even got ideas on dealing with that difficult-to-position patient who just doesn't want to cooperate.

Let's face it. The job of a dental hygienist, while rewarding in many ways, is also quite tough. "We give a piece of ourselves to every patient that we treat," says Katrina Klein, RDH, CEAS, CPT, a speaker, author, ergonomic consultant, and coach who is certified in ergonomics and personal training and whose company, ErgoFitLife, helps dental professionals improve the longevity of their careers by getting and staying in shape.

"We go through confessions of ‘I haven't been flossing as much as I should,' to the forgiveness and encouragement phase. ‘It's OK, today is a great day to start,'" Klein says. "We are givers. We give encouragement, education, and even support in their personal lives. We become their cheerleaders. We cry with them, we laugh with them, we celebrate with them. We spend every resource we have to give all day long until we're emotionally depleted, mentally fatigued, and physically exhausted."

"The nature of dental hygiene practice is complex and requires precision with multitasking mastery," Klein says. "The mental gymnastics are only met because of an immense joy for giving. We love to serve."

Kari Carter-Cherelus, RDH, DA, an educator, consultant, career coach, and founder of KMC Strategic Solutions, a consulting media platform, says being a hygienist is challenging not only mentally but physically as well. "We don't always exercise proper ergonomics or have the proper ergonomic equipment," Carter-Cherelus says. "Maybe we don't have a saddle stool, or we haven't invested in loupes or a light, or we don't have ergonomic handpieces or instrumentation that can help us. And then we have patients who don't want to turn toward us. A lot of times we contort our bodies to fit our patient, and in our mind we may think, ‘Oh I'm just doing it this one time,' but all throughout the day we're doing it, and those micro movements that we're doing to adjust to our patients to make them more comfortable over time really add problems to us, and we end up having to see chiropractors, physical therapists, and have surgeries and things."

"We're not contortionists," Carter-Cherelus says. "We're not performing in Cirque du Soleil."

For those hygienists who are tired of all the mental and physical gymnastics, there are solutions. First, let's talk about the mind.

In recent years public discourse on the importance of maintaining mental health in the workplace has been heightened, one example of which is the U.S. Surgeon General's "Framework for Workplace Mental Health and Well-Being."² There are many things that dental hygienists, like those working in all occupations, can do to care for their own psychological well-being. Here are some concrete examples:

Conduct a self-assessment

For those who are struggling mentally or emotionally, it can be helpful to do some inner reflection. "I always say the hygienist should self-evaluate themselves and think about what is causing the burnout," Carter-Cherelus says. "We often attribute it to work, but sometimes there's underlying factors. Is it something that's going on within you or something that is annoying you? Can you talk to management? Having an open and honest conversation with employers can help."

Janiece C. Ervin, BSDH, RDH, CWWS, an educator and speaker who founded DEN Smiles, a company that finds employment for traveling dental hygienists, and the DEN Study Club, which provides online CE courses, sees great value in self-assessment. "For me and the hygienists that I've spoken to, that first step is to hone in on why they're feeling that way. Where is that added stress coming from? Is the stress coming strictly from a workplace issue or are there outside factors in their personal life that are adding to the stress? You must assess and pinpoint the origin of the stress to be able to move forward with a solution on how to get out of this pit. For me, it took years to get out of it. I had to struggle and fight through burnout and personal hardships that would intensify workplace dissatisfaction. Once you're able to pinpoint the origin of the stress, then you can move forward with problem solving."

Ervin also stresses the importance of having empathy for others in the workplace who might be dealing with mental health issues of their own.

Find someone to talk to

For anyone dealing with mental health issues, discussing things with others can often do wonders.

"If you are struggling with something, make sure that you're talking about it. Don't hold it in or think that it's going to get better," says Stephanie Botts, BSDH, RDH, CEAS, an educator and certified ergonomics specialist who offers assessments and coaching to dental professionals through her company, Polished Posture. "Find someone, maybe a friend or someone close to you at your job, or your partner, or whoever, but just make sure you're talking about it. There's no shame in struggling with stuff, but if we hold it in and pretend it's not happening, it's just going to fester."

Carter-Cherelus is a proponent of talk therapy, and participating in positive social media groups, where hygienists can discuss challenges and exchange ideas with their peers.

Harness the power of communication

For Ervin, one of the most helpful tools is communication, whether at home or at work. "If you're communicating with your work leader about things that you need in your workspace, then discussion can take place," Ervin says. "Sometimes the outcome can be positive and sometimes it's negative, but at least your concerns or suggestions have been relayed and then both parties can move forward toward a solution. Either way, you're in the driver's seat, because you can now make the decision on whether you want to accept the outcome of the conversation, as opposed to not saying anything and then you just kind of fester in it, and then of course you know that leads to negative situations in the office."

Don't internalize your patient's trauma

Debi Rubino, RDH, BS, CEAS, CYT, a self-described "industry disruptor" and inventor of CordEze, an ergonomic device designed to reduce the risk of musculoskeletal injuries, says that providing hygiene care can be draining-but it doesn't have to be.

"We are working inside someone's mouth. We're in their personal space, and we're exchanging energy with them. There's no question about that," Rubino says. "If you have a very negative patient in the chair, you might need to take a moment during or after the appointment to release their energy and realign yourself."

Rubino says that she'll sometimes step into another room and just breathe and collect herself. "You can still be a pleasant and kind person and a good oral health care provider without getting into the deep and personal details of a patient's life with each appointment," she says. "It's not our responsibility to take somebody who's in a bad mood and put them in a good mood. If your patient comes across as being unhappy, closed off, or quiet, maybe it's not the best time to engage in oral hygiene instruction. You've got to learn how to read the room, so to speak."

Botts puts in this way: "Hygienists are empathetic as people and as clinicians, so if we've got an anxious patient or a patient who is struggling with some stuff, we tend to absorb that energy. I used to do that, but we just need to realize that we can empathize with people and understand what they're going through, but we don't have to take that on ourselves."

"It's not our fault that they're anxious. It's not our fault that their home care might be bad and that they need all this dental work," Botts says. "That's on them, and I think we need to be clear on what we absorb and what we take on and what we don't."

Deal with stress—or release it

When you experience stress, Ervin says, it must be managed or released. "If you're the kind of person who sits in stress, then you need to figure out how to release it, and you know as well as the whole entire world the number one thing to do is exercise," she says.

Meditation or even simply taking a breath without reacting emotionally can also be helpful tools for dealing with stress proactively, Carter-Cherelus says.

The basics like eating right, drinking plenty of water, and getting enough sleep are also key.

"Our bodies don't really acknowledge the difference between mental stress and physical stress, and they treat both the same on a cellular level," says Rubino, who practices yoga, meditation, and breathing exercises.

Klein is a strong proponent of strength training, not only as a stress reducer but also to promote overall physical well-being. "Muscle is truly the longevity organ of our body," she says. "We need to develop and maintain it to the best of our ability." Klein is also keen on stretching, which she does throughout the day, in between patients, or even with some of her patients.

When she offers her workplace wellness lecture, Ervin offers five tips on how to increase "happy chemicals" to reduce stress: get plenty of exercise; practice mindfulness, such as meditation and quiet time; keep a daily journal; connect with friends and family; and seek therapy.

To help decrease physical strain, ergonomics plays a crucial role for hygienists. "Ergonomics by definition is to have the environment work for you versus you adapting to the environment," Rubino says.

Here are some of the key ergonomic principles to keep in mind:

Keep your body in a neutral posture

"Neutral posture is the result of proper ergonomics," Rubino says.

A neutral body posture means maintaining an upright position without straining or having to work super hard.

Botts says that means "stacking your bones."

"We want to see the ear vertically stacked on top of the shoulder so there should be a straight line from the ear down to the shoulder, and that should be aligned with the hip, and then if you're standing that should be aligned with the foot," Botts says. "If you're standing up and neutral, I should be able to put a yardstick up next to you and it would hit your ear, shoulder, hip, and foot, all at the same time."

Rubino says that hygienists will from time to time get in awkward positions out of necessity, but the trick is to not stay there long.

Don't reach

Botts advises hygienists to organize their workspace, so they don't have to reach far for equipment during a procedure. "We obviously have to reach for things when we're chairside, but we want to avoid a full arm extended reach, where your shoulder and your elbow are engaged and your arm is straight out in front of you," Botts says.

"To be reaching far for instruments, reaching far for suction, it's not efficient," Botts says. "It's a waste of energy, and it can really hurt the elbow and shoulder over time."

Standing might be better

Some hygienists find that standing is better for them than sitting. Others alternate between sitting and standing. Botts says she recommends alternating between sitting and standing, because standing uses different muscles than used for sitting, increases blood flow, and can improve posture in certain situations. We want to keep moving during the day. She says standing can be especially useful when treating patients who are physically incapable or being reclined. "If we have a patient who can't lean back, standing helps us have a somewhat healthier posture," Botts says. "That way we can move around a bit better."

Your handheld mirror is your friend

Rubino strongly advocates that hygienists use indirect vision, despite what they might have been taught in school. "You need to get super comfortable with indirect vision, so much so that you instinctively use it more than direct vision," she says. "Using your mirror will allow you to reduce the amount of bending at your hips or your neck to try and get direct vision, and it will also minimize your movement around the patient."

To care for their patients, hygienists use a great deal of equipment, and ergonomically correct tools are vitally important to preserving the user's musculoskeletal health. Poorly designed products, on the other hand, can cause physical harm over time. Let's consider some of the most important tools used by hygienists:

Ergonomic Loupes

Magnification is the number one most impactful ergonomic tool, Klein says. But not all loupes are created equal. Finding the right set of ergonomic loupes is crucial. The key, Botts says, is to find a pair that provide magnification without having to tilt your head down or forward.

"We have true ergonomic loupes now that will allow people to have a completely neutral head position, and those are relatively new," Botts says. "I think these are a no-brainer for anyone in dentistry. I tell practitioners to do a simple test: Put on your loupes next time you're in the operatory with a patient. Are you having to tip your head down and forward? If so, that's not an ergonomic loupe. You don't want to be tilting your head down and forward."

Custom-Fit Seating

Properly fitted seating-preferably a saddle stool or an ergonomic chair that is custom-fit from a good company-is among the key considerations for hygienists.

"We want to be fit for our saddle stools the way that we are fit for our loupes," Klein says. "You need to sit on it, you need to try it, you need to make sure that seat pan is tilted the right way for your pelvic bone."

"I tell people a stool is like a pair of pants, and the one that fits me probably isn't going to fit you and we really need to look at stools like a customized piece of equipment, almost like loupes," Botts says.

Hand instrumentation

When it comes to hand instruments, there are several factors to consider. First is handle size. "As hygienists, the number one musculoskeletal disorder we're at risk for is carpal tunnel syndrome, and that can be because of excessive pinch force," Botts says. "We're gripping things way too tightly and fighting against things like the cord, so using a cordless polisher is also a good idea."

"I'll probably be buried with my cordless polisher," Botts says. She advises looking for instruments with a fat handle, wide, light, and textured, nothing skinny or heavy, and that goes for the mirror, too.

Carter-Cherelus recommends any device designed to reduce strain. She looks for hand instruments with proper grip.

"I also 100% believe in the CordEze tube management bracelet," Klein says. "I will not work without mine. It saves your wrist and your fingers and prevents hand strain 10 times over."

OK, so the hygienist is all set up with the correct ergonomic strategy and the proper equipment, but now the patient simply won't play nice. Now what?

"The first thing I do is I set my myself up for success," Klein says. "I position the chair just back a little bit before they enter the room so that when they sit down, they're in a relaxed position and the journey from sitting down to supine is not as far or as emotionally or mentally daunting for them."

"Ultimately this is their appointment, and this is their mouth," Klein says. "I'll say things like, ‘Are you comfortable enough for me to treat you safely?' Klein says. "‘Enough' is the key word here. I want them to be comfortable, but this isn't a day spa. They're not getting a mani-pedi. This is a healthcare facility, and I need to be able to treat my patients safely while they are comfortable enough."

Klein also asks her patients to scoot all the way up in the chair, so their back and neck are better supported.

"If we do a few of these things like moving the headrest back and having them scoot to the top of the chair, it will expedite the rest of the things that we do so that we can work efficiently and do our procedures, all with less wear and tear on our own bodies," Klein says. "If we do these things, not only can we do our job quicker and with more efficacy, but we are also going to be physically less taxed because we're not going to be holding our body in an awkward position. Remember, we were not designed to lean over all day long. We were designed to stand upright, and so if we can stay in that neutral posture by design we won't be as exhausted when we leave at the end of the day."

Provided it's not a patient with a physical malady that prevents them from reclining, Botts will use a polite but firm approach with patients who resist.

"I recommend compromising with them and saying, ‘I can partially recline you for the lower arch, so we will start there, but I need to lean you back more for the upper arch, but it's only going to be a few more inches more and only for 10 minutes,' and usually they say, ‘OK I can do that for 10 minutes,' and most patients when they tip back realize it's not as bad as they think."

"I think we need to become the authority in the operatory and not let our patients dictate things for us," Botts says. "We really just need to be firm and take charge, and using some of those compromising techniques can help."

Botts also swears by using positioning cushions to help get her patients comfortable in her chair.

In summary, the rewards of practicing dental hygiene can be greatly fulfilling, but to be truly effective as caregivers, hygienists must first master mind and body wellness for themselves.

"As healthcare professionals we know that we treat the whole patient, so if we consider ourselves to be the patient then we want to make sure that we are taking care of ourselves," Carter-Cherelus says. "It's important for us to take care of our physical selves, making sure that we are investing in ourselves as far as ergonomic equipment, as far as getting massages or chiropractic treatment or going to our own medical professionals to make sure that we're OK in all aspects as well as making sure that our mental health is good. If we have any different symptoms that are related to mental discomfort or stress, we want to make sure that we get that checked out and we don't wait like our patients sometimes do and then require more expensive treatment or work to be done."

"To be your best in terms of being able to help your patients, you really have to take care of yourself first, and that includes ergonomics and mental health," Botts says.

"Remember to give yourself grace," Klein says. "We are not going to be 100% all the time, so give yourself permission to be human. Even if you haven't worked out in five years, even if you haven't stretched or done yoga or done any meditation or done anything that you're supposed to do, it's OK. If a patient hasn't flossed in five years, what do we tell them? Start today. It's the same for us. Start with something simple like going for a 10-minute walk around the block. It will change your life."