A Survey of Neck Pain among Dentists of the Lebanese Community

Results The majority of participants were between the ages of 25 and 35, and the gender distribution of the demographic distribution was comparable. The prevalence of pain was 86.8% (97/342 dentists). NDI analysis showed that 65.7% had mild disability, 12.8% have a moderate disability, and 1% had severe disability. Bivariate analysis showed that pain was affected by age (p=0.013), orthodontist practices (p=0.031), regular exercise (p < 0.001), using vibrating instruments (p < 0.001), cervical flexion for better vision while working (p < 0.001), knowledge, and experience about ergonomic posture (p < 0.005). Multivariate analysis showed four predictors for pain: age (p=0.017), performing stretching exercises after finishing clinical practice (p=0.022), orthodontist specialty (p=0.029), and performing cervical flexion for better vision while working (p=0.004). Conclusion This study showed that through the application of some strategies such as stretching, exercising, and being careful in using vibrating instruments, the dentist may be able to relieve the pain.


Introduction
Te World Health Organization estimates that there are 1.71 billion musculoskeletal disorders worldwide. Multiple sclerosis (MSD), especially neck pain, is a signifcant occupational health hazard in dentistry [1]. Tese problems have been around for a while and are still prevalent now. In a 1990 poll of dentists, 72% said they occasionally or frequently experienced neck, shoulder, or head pain [2]. Dental professionals in Western nations reported 58.5% neck discomfort, 56.4% back pain, 43.1% shoulder pain, and 41.1% back pain in a 2018 poll [3]. Rheumatoid arthritis refers to a group of conditions that afect many components of the nervous system, including the muscles, tendons, cartilage, bones, blood, and appendages such as intervertebral discs [3]. A study in Iran revealed no statistically signifcant diference between the two sexes, in contrast to a study in Germany that found women reported more neck stress than males [4,5]. Unknown gender prevalence exists. However, both male and female younger dentists see rheumatoid arthritis more frequently than older dentists [2]. It must be crucial to comprehend this idea in order to improve periodontal disease diagnosis and management, comprehend its causes, risk factors, and preventive measures, and raise knowledge of ergonomic concerns that impact a dentist's periodontal health and general well-being. Strong motor abilities are essential for dentistry's physically and intellectually demanding practice [3].

A Gap of Knowledge.
Several characteristics and risk variables from our study have been used in other studies throughout the world to defne observation or no glasses and the kind of treatment for neck and back pain. Previous research just sought to identify the frequency of neck and back issues among dentists. Te fnal decision on the optimal conditions for dentists has not yet been made. Our research's objectives are to determine the most efective methods for dentists in Lebanon to utilize in preventing cervical cancer and instruct and interact with dental students.

Objectives.
Several characteristics and risk variables from our study have been used in other studies throughout the world to defne observation or no glasses and the kind of treatment for neck and back pain. Previous research just sought to identify the frequency of neck and back issues among dentists. Te fnal decision on the optimal conditions for dentists has not yet been made. Our research's objectives are to determine the most efective methods for dentists in Lebanon to utilize in preventing cervical cancer and instruct and interact with dental students.

Study Design and Population. Between July 2022 and
November 2022, the study used a cross-sectional survey to examine how neck pain afected a dentist's capacity for work and productivity. Te number of dentists available in each region is the same as the ratio of dentists registered in Lebanon during the aforementioned time to dentists in the specifed region. Although regional variances must be considered, Lebanon is a very small country, and regional distinctions are minimal.

Inclusion Criteria.
Dentists who are currently working in Lebanon and have no history of whiplash injuries, whiplash-related diseases, or recent trauma were the study's participants. By selecting "Agree to accept" on the electronic permission form listed in Google forums, they have consented to take part in the study. Te appendix illustrates the specifcs of the consent (Table 1).

Exclusion Criteria.
Te study did not include retired dentists or dental students, dentists with spinal/ musculoskeletal (MSK) conditions, or dentists who had recently experienced trauma or whiplash injury. In the process of gathering data and evaluating the variables, incomplete questionnaires were disregarded.

Sample
Size. Based on the Slovin formula n � N/ (1 + N.e 2 ), where n is the "number of samples," N is the "total population," and e is the "error tolerance (level)," 340 participants are representative of the dentist population in Lebanon. "N" represents the number of dentists registered in the dentist syndicate in 2019 (2774 dentists). "e" represents the p value � 0.05. 353 dentists who practice in Lebanon as a whole took part in the survey, which is about the same size as the bare minimum, sample required (350 participants). Tere were 342 full surveys. Due to lacking data, 11 incomplete surveys were deleted and excluded.

Data
Collection. An online validated survey was designed to be used in the data collection process. Its link was shared by social media and messages. Direct calls were also made with many dentists from all around Lebanon, and the link was sent after the call.
Tere will be three key sections to the questionnaire. Demographic information (gender, age) and the nature and duration of the dental practice-represented by the number of hours worked each week, general health status, and exercise habits-were all included in the frst part. Te work of Diaz-Caballero et al., which the authors validated, served as the basis for the second portion [6]. It asked questions based on Nordic questionnaires for the investigation of musculoskeletal symptoms [7] concerning ergonomic practices and the location of musculoskeletal pain. Additionally, a numeric pain rating scale from 0 (no pain) to 10 was used to gauge the degree of pain (worst pain possible). Te Neck Disability Index (NDI), which is intended to determine how neck pain impacts the ability to handle daily tasks, was added in the third segment. Te Likert scale has a 0-5 range, while the NDI has 10 items [8]. Table 2 shows the specifcs of the questionnaire and the scoring methodology.

Ethical Considerations.
Tis study was based on a crosssectional survey. Te RHUH IRB committee received the study proposal and the data collecting form (Rafc Hariri University Hospital). Te IRB was approved, and a form seeking IRB approval was retrieved. Te doctors' names were not requested, and top confdentiality was maintained. Everyone who took part got a study code. Each participant was told of the study's purpose, and an internet survey asked for his or her informed permission. All of the participants had been guaranteed that the data would stay private and that just the statistical elements would be looked at.

Data Management.
A well-known technique for evaluating neck pain-related self-rated disability is the NDI. Tere are ten items in it. For each of the 10 items, scores are given between 0 and 5. Tus, the best possible score is 50. Te reliability test found strong associations among the 10 components that make up the score NDI. Te Alpha for Cronbach was 0.845. Te score NDI was broken into 5 categories after item computation: No disability: NDI between 0 and 4; the NDI ranges from 5 to 14 for mild disability, 15 to 24 for moderate disability, and 25 to 34 for signifcant disability. Disability level 20: NDI of 34 or higher ( Table 2).

Data
Analysis. IBM SPSS version 25 was used for all statistical analyses. Te variables were reported according to their kind in a descriptive analysis that was conducted. Te frequency and percentage were used to present the categorical variables (for example, gender and specialty). For the continuous variables, the frequency, mean, median, and standard deviation were shown (for example, Pain Score and NDI). Te Chi-square test and Fisher exact test were used in bivariate analysis to examine the connection between two nominal variables (for example, pain and gender). Te odds ratio is denoted by "OR." Te correlation between one continuous variable (not normally distributed) and one nominal variable was examined using the Student's t-test (for example, pain and NDI). To forecast the likelihood that dentists would experience work-related musculoskeletal pain, multiple logistic regression models were used. All hypotheses were tested at a signifcance level of 0.05 (using an alpha error of 5%).

Data Bias.
Dentists were approached one-on-one to talk about questions of misinterpretation of either of the questionnaire's options and to consider any potential bias. Te authors walked dentists with a French education through the questionnaire to make sure they understood their options. After trying unsuccessfully to reach the subject, missing information or incomplete questionnaires were eliminated.

Demographic
Characteristics. 201 (58.8%) of the 342 dentists were men and 141 (41.2%) were women. 51.2% of participants were between the ages of 25 and 35, 30.4% were between the ages of 36 and 45, 10.5% were between the ages of 46 and 56, and 7.9% were over the age of 56 (Table 3).
Among the 342 dentists, 145 (42%) engaged in regular exercise, while 197 (58%) did not. During dental practice, out of 342 dentists, 85.4% were able to change their posture, whether they were sitting or standing; 64.9% frequently changed positions; 32.7% stretched after fnishing clinical practice; 47.4% were handling instruments within hand reach without making strenuous movements; 91.2% performed torsions or cervical fexions to improve vision when working in the oral cavity; and 26.0% crossed their legs (Table 3).

Pain-Related Characteristics.
Out of 342 dentists, 297 (86.8%) confrmed having muscular pain due to dental practice, whereas only 45 (13.2%) did not approve of having any pain. Out of 342 dentists, 153 (44.7%) experienced pain using vibrating instruments, 297 (86.8%) performed cervical fexion for better vision while working, and 254 (74.3%) were familiar with the ergonomic posture to perform clinical procedures in your dental practice. Te most frequent activity causing muscular discomfort was related to endodontics (69.4%) out of 297 dentists who verifed having pain, followed by surgery (41.4%), restorative surgery (30.6%), and the activities related to endodontics (15.5%). Out of 297 dentists who admitted to experiencing pain, the neck (75.8%), lumbar zone (43.4%), shoulders (41.4%), and dorsal zone (20.5%) were the top fve pain zones ( Figure 1). A pain score, from 0 to 10, was used to assess the level of pain in dentists. Te correlation between the presence of pain and the pain score was statistically diferent (p 0.001). When compared to dentists who confrmed they were pain-free (mean pain score � 1.64), dentists who confrmed they were in pain had a higher mean score (5.54) ( Figure 2).

Neck Disability Index.
To measure the degree of neck pain in dentists, the Neck Disability Index was utilized. Table 3 displays the outcomes for the 10 questions. Te fndings indicated minimal levels of pain severity, and Table 3 lists the 10 items' most frequent outcomes. Te Neck Disability Index has four categories. Out of 297 dentists, 61 (20.5%) were handicapped, 195 (65.7%) had a light impairment, 38 (12.8%) had a moderate impairment, and only three (1%) had a severe impairment. Te relationship between the NDI and the occurrence of pain was statistically Table 1: Details of the electronic consent.
Confrmation statements I confrm that I have read and understood all the information related to the above study I had the opportunity to ask questions, which have been answered fully I understand that my participation in this study is voluntary and I have the right to withdraw from the above study at any point without giving any reason, and without my medical care or legal rights being afected I acknowledge that my name will not be used at any point in the above study Declaration of consent to participate I agree to participate Yes No    My sleep is moderately disturbed for up to 2-3 hours Pain Research and Management diferent (p < 0.001). When compared to dentists who afrmed they were pain-free (mean NDI � 2.69), dentists who confrmed they were in pain had a higher mean score (mean NDI � 8.6) ( Table 4).

Factors Afecting Pain.
Te gender of the dentists did not statistically difer from the frequency of discomfort (p � 0.614). 58.2% of the 297 dentists who admitted to experiencing discomfort were men, and 41.8% were women (Table 5). Te dentists' age and the occurrence of discomfort difered statistically signifcantly (p � 0.013). Dentists who reported experiencing pain are older than dentists who reported experiencing no discomfort. 52.2% of the 297 dentists who reported experiencing discomfort were older than 35, compared to 73.3% of dentists who reported experiencing no pain (Table 5).
Among the 6 specialties, only 1 specialty, orthodontist, was shown a statistical diference in the function of the pain occurrence (Table 6). Only 5.1% of dentists who confrmed having pain were orthodontists compared to 13.3% (OR: 0.346; CI: 0.127-2.991) of those who confrmed having no pain. Te fact of being a dentist and not practicing orthodontics increase the risk of pain by 0.346 times.
Te relationship between the frequency of pain and the number of working hours was not statistically diferent (p � 0.168). Of the 297 dentists who admitted to experiencing pain, 34% worked 15-30 hours per week, 53.2% worked 31-40 hours per week, and 12.8% worked 41-50 hours per week (Table 6). Te presence of pain and the history of spine disease did not difer statistically signifcantly (p � 0.654). 4 (1.3%) of the 297 dentists who reported pain had a congenital spinal disease, 9 (3%) had had spine surgery, and 284 (95.6%) had no prior history of spine disease (Table 6).
Physical activity and the occurrence of pain difered statistically signifcantly (p < 0.001). According to the fndings, 64.3% of dentists who admitted to experiencing discomfort did not engage in physical exercise, as opposed to 13.3% of dentists who admitted to experiencing no pain. Not Physical exercise increases the likelihood of pain by 0.085 times ( Table 6). Te diference between experiencing pain and doing so while utilizing vibrating instruments was statistically signifcant (p < 0.001). According to the fndings, vibrating devices were utilized by 50.8% of dentists who acknowledged feeling discomfort, as opposed to 4.4% of dentists who acknowledged feeling no pain. Te probability of experiencing pain is increased by 22.236 times by utilizing vibrating equipment (Table 6).
Between experiencing pain and fexing the neck for better working-related vision, there was a statistically signifcant diference (p < 0.001). According to the fndings, 89.2% of dentists who admitted to experiencing pain engaged in cervical fexion for improved eyesight while working, as opposed to 71.1% of dentists who admitted to experiencing no pain. Cervical fexion for enhanced    (Table 7). Knowing the ergonomic posture to use when doing clinical operations in a dental ofce and the occurrence of pain were statistically diferent (p � 0.002). Te fndings revealed that 71.4% of dentists who admitted to experiencing discomfort were conversant in ergonomic posture, as opposed to 93.3% of dentists who admitted to experiencing no pain. Utilizing an ergonomic posture when doing clinical tasks in a dental ofce reduces the chance of pain by 0.178 times (Table 7). During dental practice, there was a statistically signifcant diference between experiencing discomfort and being able to adjust posture, seating, or standing (p � 0.023). Te fndings revealed that 83.8% of dentists who admitted to experiencing discomfort during dental practice were able to adjust their work position, as opposed to 95.6% of dentists who admitted to experiencing no pain. Te likelihood of pain is reduced by altering work posture (Table 8). Changing positions during clinical practice (p � 0.108), stretching after clinical practice (p � 0.073), handling instruments within hand reach without making strenuous movements (p � 0.133), performing torsions or cervical fexions to improve vision when working in the oral cavity (p � 0.246), and crossing leg over leg did not statistically difer from the occurrence of pain (p > 0.05) ( Table 8).
Among the 342 dentists who reported pain, 83.8% were able to adjust their posture while sitting or standing, 63.3% frequently switched positions, 31% stretched after fnishing clinical practice, 47.4% handled instruments within easy reach without making strenuous motions, 91.9% performed torsions or cervical fexions to improve vision when working in the oral cavity, and 26.9% crossed their legs (Table 8).
Finally, a multivariate analysis was enrolled to test the factors afecting pain in dentists. 4 factors afecting pain: age (p � 0.017), performing stretching exercises after fnishing clinical practice (p � 0.022), orthodontist specialty (p � 0.029), and performing cervical fexion for better vision while working (p � 0.004) ( Table 9). Te risk of pain increased with age (OR � 1.765), when not performing stretching exercises after fnishing clinical practice (OR � 0.451), when practicing dental activities other than orthodentistry (OR � 0.284), and when performing cervical fexion for better vision while working (OR � 3.185).

Discussion
342 dentists in Lebanon were interviewed for this study; 58.8% of them were men and 41.2% were women. Te respondents' occupational characteristics were diverse. As would be predicted, more dentists (86.8% vs. 13.2%) reported experiencing muscle soreness than those who did not. Many studies have been conducted to determine the primary pain regions in dentists. Tis study found that neck pain is the most prevalent (75.8%), followed by lumbar pain (43.4%), cervical pain (40.4%), and shoulder pain (40.4%).
With 236 dentists reporting varying degrees of a neck  disability, we discovered a substantial association (p < 0.001) between the presence of discomfort and the Neck Disability Index (NDI) in this study. Te study by Aghahi, Darabi, and Hashemipour found a connection between discomfort and musculoskeletal diseases and sitting position, work environment, and dental chair [10]. Ajwa et al.'s research also revealed that age, academic success, and exercise were risk factors for musculoskeletal issues [11]. Age but not gender were linked with MSDs in our study (p � 0.614). Regarding specialty, the fndings showed that when a dentist's area of expertise was something other than orthodontics, the incidence of pain increased by 0.346. Working hours had no correlation with musculoskeletal pain (p � 0.168). Also, there was no danger associated with the spinal posture (p � 0.654). p values are connected to MSDs for each of the following factors: physical activity, vibrating machinery, the fexibility of the neck for better visibility at work, and knowledge of the ergonomic position to carry out clinical operations in dental practices. Our current study demonstrated no correlation between working hours per week and musculoskeletal pain (p � 0.168), despite the fact that dentists routinely put in between 41 and 50 hours per week. Te number of hours worked each day and hand stifness, however, were found to be signifcantly correlated by Sheikh et al. (2011) (p � 0.018) [6]. Our second aim leads us to the conclusion that, while working hours do not appear to have an impact, the ergonomic position is associated with the presence or absence of muscle difculties.
Finding out how stretching exercises improve human performance was the third goal of this study. Te results show that less than half of the sample size, or 31% of dentists in Lebanon, conducted these exercises following a clinical practice. Four characteristics were shown to have an impact on oral musculoskeletal discomfort in the fnal multivariate analysis of these results: age (p � 0.017), stretching exercises  Parallel to this, other research looked for variables that might afect dental pain. In one study, the number of patients treated daily and the dentist's weight were linked to muscular discomfort, although age did not appear to have any bearing [6].
Tese fndings suggest that musculoskeletal pain is a signifcant burden for dentists, who must move their hands and wrists correctly while working and sitting in particular positions, which might be challenging if they have musculoskeletal problems. It might be unpleasant. Te risk factors that contribute to the development of musculoskeletal pain and MSD, as well as pain-reduction techniques such as stretching and exercise, are better understood.
Working unpleasant or long hours was the risk factor that was most clear [11]. Te primary causes of neck pain are time spent working and studying, workload, and physical circumstances at work [12]. Signifcant risk factors were workplace characteristics, perceived job demands, the harmony between efort and reward, and colleague support.
Psychological factors and neck and back issues are strongly correlated [13,14]. According to research from the Chinese Mental Health Survey [15], people with various forms of mental illness are more likely to experience persistent back or neck pain and mood disorders. A prospective study has revealed that psychological factors are connected to the incidence and severity of disease (e.g., acute, subacute, and chronic). Neck pain has been demonstrated to be signifcantly infuenced by stress, depressive symptoms, anxiety, mood, and emotional states, as well as by behaviors that are associated with pain. Tere is not much proof of personality, though. In general, pain processing in the spinal cord, brainstem, or cerebral cortex can be afected by stress, pain results, depressive symptoms, lack of sleep, and alcohol, leading to telekinetic hyperalgesia. More study is required to comprehend how lifestyle factors afect central pain processes in nontraumatic neck pain due to these cognitive, emotional, and behavioral components. An overview of how sickness afects the four psychological domains of cognition, emotions, social interactions, and conduct is provided. Te cognitive element is the frst and consists of attitudes, beliefs, and perceptions about the disease, incapacity, and perceived health. Te three main elements of the emotional dimension, which is the second theme, are sadness, anxiety, and depression. Finally, there is a social element. Although the data are sketchy, back and neck pain seem to be linked to issues at both work and home. Lastly, a behavioral domain has also been identifed [13,[16][17][18][19], which mainly consists of activity patterns, pain behavior, and adaptation. Vulnerability and stress are closely associated [13,14]. While under a lot of stress, neck pain is more likely to develop [17,20]. Adolescents with neck pain had signifcantly greater stress indices than adolescents without neck pain, according to at least two studies of medium methodological quality. Moreover, chronic or persistent internal stress is linked to an increased risk of reporting neck pain [21]. Stress may have an impact on altered central pain processing at the spinal cord, brainstem, or cortex levels. Pain sensitivity is higher in people who have distal hyperalgesia [22,23]. Stress also plays a role in mediating the link between pain and impairment [24,25].
Disability and anxiety are linked to a variety of chronic disorders, including neck discomfort [13,14,26,27]. Tere is evidence that oral discomfort and anxiety can coexist [27][28][29]. Researchers measured trait and state anxiety in teenagers with and without neck pain using two distinct assessment techniques, and they discovered that adolescents with neck pain had greater trait and state anxiety levels than adolescents without neck pain. Also, it was discovered that anxiety disorders and neck pain were the second most frequent comorbidities, with specifc phobias being the main issue among patients with these diseases.
Lower pressure pain thresholds are linked to higher levels of anxiety (PPT). PPTs have been linked in studies to neck pain severity, duration, recurrence, and disability [30]. Anxiety has been linked to increased levels of anxiety in people with neck pain [28], and anxiety worsens to pain and impairment [24]. Te results are inconsistent in certain ways, though. Anxiety, for instance, does not mediate pain and impairment, according to studies on psychological distress variables (such as stress, anxiety, and depression) [25]. A thorough examination of the neck and other characteristics utilized to treat MSK discomfort is given by Kazeminasab et al. in their study from [31].

Impact of the Study.
In the long-term, dentists are seriously at risk from musculoskeletal conditions. Tis study contributes to the corpus of literature by providing comprehensive knowledge about musculoskeletal pain, its effects, risk factors, treatment, and preventative strategies. According to our research, a number of factors may contribute to increased musculoskeletal pain, and a number of techniques may be efective in preventing or lessening it. Tis study ofers a chance to look into the causes of musculoskeletal disorders and give dentists the proper training to understand how ergonomic factors afect their health.

Study Limitations.
Tis study had certain restrictions. Te sample size was quite small, to begin with, when compared to the total number of dentists in Lebanon who are licensed to practice, which, according to records maintained by the Lebanese Dental Association, is 2774 dentists. Tis could have reduced the study's statistical power and prevented the identifcation of several key risk factors for musculoskeletal illnesses. Second, the percentages between the dentists' specialties were highly diferent from one another, which could have tampered with the results. Last but not the least, this study focuses on self-reporting, which could add some confounding factors and bias due to language.

Study Perspectives.
Future studies should consider conducting broad polls to learn more about the risk factors related to dentists developing musculoskeletal pain, especially in view of the fact that several studies seem to yield conficting fndings. As a result, a larger sample size should be considered. Besides ergonomics and sociodemographic characteristics, other factors that may afect the development of sickness and physical discomfort include psychological factors. Finally, observational studies should be taken into account to reduce the bias caused by self-reporting.

Conclusion
Tis study's main goal was to fnd out how neck pain afected the productivity and efciency of dental ofces. It additionally aimed to comprehend the reasons and remedies for musculoskeletal pain. Te impact of extending work capacity as well as the infuence of duration-represented by the number of hours worked each week and the position adopted during clinical practice-were both heavily emphasized. In this study, 342 dentists who practice in Lebanon were analyzed. According to our research, dentists can lessen the discomfort by using certain procedures including stretching, exercise, and judicious vibration machine use. Large-scale investigations are required in addition to dental monitoring (if possible) and research on treatment and preventative strategies. Studying the answer is crucial after comprehending the nature of the issue. Otherwise, all you do would be in vain.