Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel

Deepika Chenna; Medhini Madi; Mathangi Kumar; Vijay Kumar; Sitaram Chopperla; Abhinav Tadikonda; Kalyana Pentapati

doi:10.12688/f1000research.131659.1

Home Browse Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among...

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

Systematic Review

Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel

[version 1; peer review: 2 approved with reservations]

Deepika Chenna¹^*, Medhini Madi²^*, Mathangi Kumar², [...] Vijay Kumar³, Sitaram Chopperla⁴, Abhinav Tadikonda⁵, Kalyana Pentapati ⁶

Deepika Chenna¹^*, Medhini Madi²^*, [...] Mathangi Kumar², Vijay Kumar³, Sitaram Chopperla⁴, Abhinav Tadikonda⁵, Kalyana Pentapati ⁶

^* Equal contributors

PUBLISHED 08 Mar 2023

Author details Author details

¹ Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
² Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
³ Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidhyapeetham, Kochi, Kerala, India
⁴ Department of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
⁵ Public Health Dentistry, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
⁶ Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India

Deepika Chenna
Roles: Conceptualization, Methodology, Resources, Software, Validation, Writing – Review & Editing

Medhini Madi
Roles: Conceptualization, Methodology, Resources, Validation, Writing – Original Draft Preparation

Mathangi Kumar
Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation

Vijay Kumar
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Original Draft Preparation

Sitaram Chopperla
Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation

Abhinav Tadikonda
Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Original Draft Preparation

Kalyana Pentapati
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Software, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Health Services gateway.

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background: Carpal Tunnel Syndrome (CTS) is one such common disorder among dental health care personnel caused due to the entrapment neuropathy of the median nerve in the carpal tunnel. We aimed to evaluate the pooled estimates of the CTS among dental healthcare personnel.
Methods: We systematically reviewed the existing literature from six databases till January 1^st, 2022. Studies reported in English along with the prevalence of CTS or where prevalence could be calculated were included. Independent screening of title and abstracts, and the full text was done by two examiners. Information collected was authors, year of publication, geographic location, type of dental healthcare personnel, sample size, distribution of age, sex, CTS, method of diagnosis, and risk of bias. The random effect model was used to estimate the pooled estimates.
Results: Thirty-seven studies yielded 38 estimates. A total of 17,152 dental health care personnel were included of which 2717 had CTS. The overall pooled prevalence of CTS among the included studies was 15%, with a high heterogeneity. Meta-analysis showed no significant difference in the pooled estimates of CTS between male and female dental healthcare personnel (OR: 0.73; 95% CI: 0.52 -1.02; I²= 69.71). The pooled estimates among the dentist and dental auxiliaries were 20% and 10%, respectively. The pooled prevalence of CTS with self-reported measures, clinical examination and NCS were 21%, 13% and 8% respectively. Meta-regression showed that the prevalence estimates were significantly associated with publication year (coefficient: 0.006; 95% CI= 0.002-0.01).
Conclusion: One out of seven dental health care personnel may be affected by CTS. No significant difference was seen in the prevalence of CTS between male and female dental healthcare personnel.

Keywords

Carpal Tunnel, Pain, Dentist, Dentist, Dental students, Dental auxiliaries

Corresponding author: Kalyana Pentapati

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Chenna D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Chenna D, Madi M, Kumar M et al. Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:251 (https://doi.org/10.12688/f1000research.131659.1) First published: 08 Mar 2023, 12:251 (https://doi.org/10.12688/f1000research.131659.1) Latest published: 20 Jul 2023, 12:251 (https://doi.org/10.12688/f1000research.131659.2)

Introduction

Dentistry involves complex procedures with repetitive movements, firm grasp, and fine tactile movements with prolonged static postures often with poor illumination and access. Due to this dental healthcare personnel are prone to various musculoskeletal disorders.¹^–⁷

Carpal Tunnel Syndrome (CTS) is one such common disorder among dental health care personnel caused due to the entrapment neuropathy of the median nerve in the carpal tunnel. It can cause sensorimotor symptoms like pain, numbness, tingling, and weakness in the hand leading to loss of grip strength and dexterity. CTS can have negative effects on the individual quality of life, functional disability, limitation of daily living, poor sleep quality, decreased productivity, and the discontinuation of the profession. It can have a significant impact on the individual’s family and the community.

Numerous risk factors like repetitive actions,⁸ use of vibrating instruments,⁸^,⁹ pregnancy, diabetes,¹⁰ obesity,¹⁰ trauma, smoking,¹¹ increasing age,⁸^,¹² female sex,⁹^,¹⁰^,¹³^–¹⁶ wrist diameter ratio,⁹ clinical experience¹² and the number of working hours per day¹⁴ have been linked to the development of CTS. Studies have used different modalities for the assessment of CTS. Self-reported measures (for ex: Boston carpal tunnel questionnaire, Nordic questionnaire, hand diagram, Clinical questionnaire by Kamath and Stothard) are the most used methods of assessment. This was followed by nerve conduction studies (NCS) and clinical examination using variety of tests (Tinel’s test, Phalen’s test, or Durkan compression test) and a combination of any of the above methods.

The prevalence of CTS among dental healthcare personnel was reported to be high akin to musculoskeletal disorders when compared to the general population. However, no attempt was made to consolidate the estimates of CTS among dental healthcare personnel. Considering this, our goal was to compile the estimates of the CTS among dental healthcare professionals reported from the literature.

Methods

We systematically reviewed the existing literature to evaluate the prevalence of CTS among dental healthcare personnel. The protocol for this study was registered with “International Platform of Registered Systematic Review and Meta-analysis Protocols” (INPLASY202210084)¹⁷ and was reported as per the “PRISMA” guidelines.

Search strategy

A methodical search of six databases (“PubMed, Embase, Dentistry and Oral Sciences Source, CINAHL, Web of Science, and Scopus”) was conducted without any date restrictions till January 1^st, 2022. The keywords used were “dentist” OR “dental student” OR “dental auxiliary” OR “dental hygienist” OR “dental personnel” AND “carpal tunnel syndrome” or “carpal tunnel” or “medial nerve entrapment” or “CTS.”

Inclusion and exclusion criteria

Studies written in English that reported the prevalence of CTS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Screening

Studies obtained from various databases were added to “Rayyan – a web-based application” for duplicate removal and title and abstract screening. This was followed by full-text screening and data extraction. Two review authors did the screening independently, and the disagreements, if any, were resolved by a third review author.

Data extraction

Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel, age and sex distribution, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.

Risk of bias assessments

Two review authors independently evaluated the risk of bias using a nine-item questionnaire developed by Hoy et al.¹⁸ The total score was obtained based on which the studies were graded as low (0-3), moderate (4-6), or high risk of bias (7-9).

Statistical analysis

All the analysis was done using OpenMeta software (Metafor Package 1.4, 1999). The random effect model (Restricted maximum likelihood method) was used to estimate the pooled estimates. Subgroup analysis was performed for the type of dental personnel, geographic location, and type of diagnosis. The distribution of the prevalence of CTS between males and females was evaluated using the Binary Random effect model, and the Odds ratio was calculated. Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach. Meta-regression was done with publication year to evaluate time trends in the prevalence estimates. Sensitivity analysis was performed using the Leave one out method. Heterogeneity among the studies was assessed using I² statistics. Underlying data for this review is available at Mendeley datasets.¹⁹

Results

The search of six databases (Embase (n=77), Scopus (n=54), PubMed (n=120), CINAHL (n=465), DOSS (n=570), and Web of Science (n=95)) yielded 1381 studies, of which 249 were duplicates. A total of 1131 studies were subjected to title, and abstract screening out of which 43 studies were eligible for full-text screening. Another nine studies were obtained from manual searching of reference lists at the end of publications resulting in a total of 52 studies for full-text screening. After screening full-text, 15 studies were further excluded due to missing outcome (n=7), the secondary publication (n=3), or inappropriate study design (n=4) and full-text unavailable (n=1).²⁰ Data extraction was performed for 37 studies which yielded 38 estimates (Figure 1, Table 1).⁹^,¹²^–¹⁶^,²¹^–⁵¹

Figure 1. PRISMA flowchart.

Table 1. Characteristics of the included studies.

Author, Year	Continent	Diagnosis	Risk of bias	N	Prevalence (%)	Type of dental health care personnel
Macdonald et al. 1988	NA	SR	L	2464	8.69	DA
Osborn et al. 1990	NA	SR	M	394	6.85	DA
Conrad et al. 1991	NA	V	L	20	0.00	DA
Conrad et al. 1992	NA	V	M	16	0.00	DA
Conrad et al. 1993	NA	V	L	16	0.00	DA
Nakladalova et al. 1995	Eu	NC	M	120	3.33	DA
Liss et al. 1995	NA	SR	M	1058	10.21	DA
Scoggins and Campbell 1995	NA	SR	M	79	5.06	DA
Rice et al. 1996	NA	PE	L	45	11.11	Mixed
Akesson et al. 1999	Eu	PE	L	84	7.14	Mixed
Lalumandier et al. 2000	NA	SR	L	5115	25.45	Mixed
Hamann et al. 2001	NA	NC	L	1079	4.82	D
Anton et al. 2002	NA	NC	L	89	8.99	DA
Werner et al. 2002	NA	NC	L	305	5.57	DA
Mamatha et al. 2005	Asia	SR	L	300	32.00	D
Werner et al. 2005	NA	NC	L	232	0.43	D
Werner et al. 2005b	NA	SR	L	111	0.90	DA
Cherniack et al. 2006	NA	PE	L	160	12.50	DA
Greathouse et al. 2009	NA	NC	L	35	25.71	DA
Shaffer et al. 2012	NA	NC	L	55	10.91	DA
Haghighat et al. 2012	Asia	PE	L	240	16.67	D
Borhan et al. 2013	Asia	NC	L	40	17.50	D
Khan et al. 2014	Asia	SR	L	417	10.31	D
Pai et al. 2014	Asia	SR	L	210	20.00	D
Munirah et al. 2014	Asia	SR	M	99	21.21	D
Hodacova et al. 2015	Eu	SR	M	575	14.61	D
Nor Rasid et al. 2016	Asia	SR	L	95	38.95	DA
Ehsan et al. 2016	Asia	PE	L	103	15.53	D
Prasad et al. 2017	Asia	SR	L	100	86.00	D
Jaoude et al. 2017	Asia	SR	L	314	7.64	D
De JeSUS et al. 2018	SA	SR	L	286	13.29	D
Inbasekharan et al. 2018	Asia	SR	L	120	25.83	D
Alhusain et al. 2019	Asia	SR	L	223	30.49	D
Meisha et al. 2019	Asia	SR	L	234	9.40	D
Al Muraikhi et al. 2020	Asia	SR	L	66	24.24	D
Harris et al. 2020	NA	SR	L	647	18.39	DA
Berdouses et al. 2020	Eu	SR	L	1500	8.27	D
Maghsoudipour et al. 2021	Asia	NC	L	106	17.92	D

Prevalence

A total of 17,152 dental health care personnel were included in 37 studies of which 2717 had CTS. The prevalence ranged from 0 to 86%.²¹^,⁴²^,⁵⁰^,⁵¹ The overall pooled prevalence of CTS was 15%, with a high heterogeneity (I²=99.18) (Figure 2).

Figure 2. Forest plot showing the pooled prevalence of CTS.

Age

Nine studies have not reported the age distribution.¹⁴^,¹⁶^,²⁵^,³⁰^,⁴⁴^–⁴⁶^,⁴⁸^,⁴⁹ The age-specific estimates of CTS lacked uniformity in reporting. The mean age ranged from 21-50 years.

Sex

Eight studies have not reported the sex distribution of the participants.²¹^,²²^,²⁶^,³⁰^,⁴⁸^–⁵¹ Twelve studies reported the prevalence of CTS concerning the sex of which one study had only female participants and was excluded from analysis.¹² Meta-analysis showed no significant difference in the pooled estimates of CTS between male and female dental healthcare personnel (OR: 0.73; 95% CI: 0.52-1.02; P=0.07; I²=69.71) (Figure 3).

Figure 3. Forest plot showing the sex differences in the prevalence of CTS.

Geographic location

Almost half of the studies were reported from North America (n=17)¹²^,¹⁶^,²¹^–²³^,²⁵^,²⁷^–²⁹^,³¹^,³²^,³⁴^,⁴⁶^,⁴⁸^–⁵¹ followed by Asia (n=15)⁹^,¹⁴^,¹⁵^,³⁰^,³³^,³⁵^–³⁹^,⁴¹^–⁴³^,⁴⁵^,⁴⁷ and Europe (n=4).¹³^,²⁴^,²⁶^,⁴⁰ Only one study was reported from South America.⁴⁴ High pooled prevalence was seen among studies that were reported from Asia (25%), followed by North America (9%) and Europe (8%) (Table 2).

Table 2. Subgroup analysis of the pooled estimates of overall MSD.

Characteristic	Estimate (95% CI)	Q	I²	Number of estimates
Overall	0.15 (0.10-0.2)	2073.13	99.18	38
Sex
Male	0.14 (0.09-0.19)	265.61	96.41	11
Female	0.17 (0.11-0.23)	417.15	95.44	12
Dental personnel
Dentists	0.2 (0.12-0.28)	1045.42	99.4	19
Dental auxiliaries	0.1 (0.05-0.14)	182.68	96.6	16
Mixed	0.15 (0.03-0.27)	48.76	93.92	3
Continent
North America	0.09 (0.05-0.12)	1291.72	97.61	18
Europe	0.08 (0.04-0.13)	27.46	90.64	4
Asia	0.25 (0.15-0.35)	546.87	97.96	15
Risk of bias
Low	0.17 (0.11-0.22)	2028.49	99.33	31
Moderate	0.09 (0.05-0.13)	44.53	91.23	7
Method of diagnosis
Self-reported	0.21 (0.13-0.29)	1154.82	99.4	20
Physical examination	0.13 (0.09-0.16)	7.36	47.12	5
Nerve conduction studies	0.08 (0.03-0.12)	85.93	95.49	10

Type of dental personnel

More than half of the included studies were reported among dentists (n=18)⁹^,¹³^–¹⁵^,²⁷^,²⁸^,³⁰^,³³^,³⁵^–⁴⁰^,⁴²^–⁴⁴^,⁴⁷ followed by dental auxiliaries (n=16).¹²^,²¹^–²⁴^,²⁷^,²⁸^,³¹^,³²^,³⁴^,⁴¹^,⁴⁸^–⁵¹ The pooled estimates among the dentist and dental auxiliaries were 20% and 10%, respectively (Table 2).

Method of diagnosis

The majority of the included studies (n=21) had used only self-reported measures for estimating the prevalence of CTS.¹³^–¹⁶^,²²^,²³^,²⁹^,³⁰^,³⁷^–⁴⁹ Nine studies have used nerve conduction studies⁹^,¹²^,²⁴^,²⁷^–²⁹^,³²^,³⁴^,³⁶ out of which four studies used clinical examination along with NCS.⁹^,³²^–³⁴ Only five studies have used clinical examination.²⁵^,²⁶^,³¹^,³³^,³⁵ Three studies conducted have used Vibrometry and have reported nil prevalence.²¹^,⁵⁰^,⁵¹ The pooled prevalence of CTS with self-reported measures, clinical examination and NCS were 21%, 13% and 8% respectively (Table 2).

Risk of bias

Majority of the studies (n=30) were in the low-risk category with a pooled prevalence of 17% (Tables 1 and 2).⁹^,¹²^–¹⁶^,²⁵^–³⁶^,³⁸^,³⁹^,⁴¹^–⁴⁸^,⁵⁰^,⁵¹

Publication bias

The funnel plot showed publication bias (Fail safe N=26129; P-value<0.001) (Figure 4).

Figure 4. Funnel plot for publication bias.

Sensitivity analysis

There was no change in the overall pooled estimate of CTS using the Leave-one out method.

Meta-regression

A meta-regression was performed to evaluate the pooled estimates of CTS with publication year. The prevalence estimates were significantly associated with publication year (coefficient: 0.006; 95% CI=0.002-0.01; P=0.002) (Figure 5).

Figure 5. Meta-regression showing the time trends in the prevalence of CTS.

Discussion

We conducted a systematic review of the prevalence of CTS among dental healthcare personnel. Many systematic reviews reported a high prevalence of musculoskeletal disorders among these professionals¹^–⁷ without emphasizing the CTS.

High heterogeneity was observed among the studies that were included in this review. The overall pooled prevalence of CTS was 15% obtained from 38 estimates. It was higher among dentists than dental auxiliaries. The prevalence was higher than the reported studies among other professionals (9.6%).⁵²^,⁵³ The age-standardised prevalence rates of confirmed clinical and NCS were 2.1 and 3% among males and females, respectively.⁵⁴ A study among Danish office workers reported a confirmed CTS prevalence of 5%.⁵⁵ It was reported that repetitive activity and firm gripping could be a major risk factor for the development of CTS.⁵² This suggests that dental healthcare personnel have a higher risk of CTS than the general population. In our analysis, only six studies reported a prevalence of less than 5%.²¹^,²⁴^,²⁷^,²⁹^,⁵⁰^,⁵¹ More than half of the studies showed higher than 10% prevalence.⁹^,¹⁴^,¹⁶^,²³^,²⁵^,³⁰^–⁴⁴^,⁴⁶^,⁴⁷ There was substantial variation in the estimates of CTS with geographic location. Studies reported from Asia showed a high pooled prevalence of CTS.

The pooled prevalence among male and female dental healthcare personnel was 14 and 17%, respectively. Few studies have reported female predilection to CTS among dental healthcare personnel⁹^,¹³^–¹⁶ and the general population.⁵⁶ However, we found no significant difference between male and female dental healthcare personnel.

There were substantial variations in the assessment of CTS among the included studies. Methods like self-reported measures, clinical examination (Tinels test, Phalen’s test, or compression test), Vibrometry and NCS were used for the assessment of CTS. Studies that used self-reported measures showed higher pooled prevalence than those studies that used clinical examination and NCS for the diagnosis of CTS. NCS is a useful tool and can be used as complimentary methods with clinical examination in the assessment of CTS. It is not recommended to be used as a sole method of diagnosis as it has limitations like difficulty in the assessment of nerve injuries that are very distal or proximal to the extremity, timing of the test, expertise of the examiner, multi-level injury along the course of nerve or systemic polyneuropathy. Also, the nerve latency is mainly due to the available myelinated fibers than the affected fibers. Due to the above reasons, a thorough physical examination of hand is a prerequisite for the diagnosis of CTS.

Our review included studies over four decades and it was seen that there was an increasing trend in the prevalence estimates of CTS. This could be attributed to many factors like increasing workload, increasing awareness about CTS, comorbidities etc.

Further high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. High heterogeneity among the included studies, inclusion of only studies that were reported in English, lack of age specific estimates, variations in the assessment of CTS are some of the limitations.

Conclusion

One out of seven dental health care personnel may be affected by CTS. There was no difference in the prevalence of CTS between male and female dental healthcare personnel. Dentists more than dental auxiliaries are affected by CTS.

Data availability

Underlying data

Mendeley Data: Pooled prevalence of Carpal Tunnel syndrome among dental health care providers, https://doi.org/10.17632/m2tytmjdzf.2.¹⁹

This project contains the following underlying data:

- Data CTS mendeley.xlsx

Reporting guidelines

Mendeley Data: PRISMA checklist ‘Pooled prevalence of Carpal Tunnel syndrome among dental health care providers’, https://doi.org/10.17632/m2tytmjdzf.2.¹⁹

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. ZakerJafari HR, YektaKooshali MH: Work-Related Musculoskeletal Disorders in Iranian Dentists: A Systematic Review and Meta-analysis. Saf. Health Work. 2018; 9(1): 1–9. PubMed Abstract | Publisher Full Text | Free Full Text
2. Leggat PA, Kedjarune U, Smith DR: Occupational health problems in modern dentistry: A review. Ind. Health. 2007; 45(5): 611–621. PubMed Abstract | Publisher Full Text
3. Puriene A, Janulyte V, Musteikyte M, et al.: General health of dentists. Literature review. Stomatologija. 2007; 9(1): 10–20. PubMed Abstract
4. Hayes MJ, Cockrell D, Smith DR: A systematic review of musculoskeletal disorders among dental professionals. Int. J. Dent. Hyg. 2009; 7(3): 159–165. Publisher Full Text
5. Shams-Hosseini NS, Vahdati T, Mohammadzadeh Z, et al.: Prevalence of Musculoskeletal Disorders among Dentists in Iran: A Systematic Review. Mater. Sociomed. 2017; 29(4): 257–262. PubMed Abstract | Publisher Full Text | Free Full Text
6. Chenna D, Pentapati KC, Kumar M, et al.: Prevalence of musculoskeletal disorders among dental healthcare providers: A systematic review and meta-analysis. F1000Res. 2022; 11: 1062. Publisher Full Text
7. Lietz J, Kozak A, Nienhaus A: Prevalence and occupational risk factors of musculoskeletal diseases and pain among dental professionals in Western countries: A systematic literature review and meta-analysis. PLoS One. 2018; 13(12): e0208628. PubMed Abstract | Publisher Full Text | Free Full Text
8. Spahn G, Wollny J, Hartmann B, et al.: Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part II. Occupational risk factors. Z. Orthop. Unfall. 2012; 150(5): 516–524. PubMed Abstract | Publisher Full Text
9. Maghsoudipour M, Hosseini F, Coh P, et al.: Evaluation of occupational and non-occupational risk factors associated with carpal tunnel syndrome in dentists. Work. 2021; 69(1): 181–186. PubMed Abstract | Publisher Full Text
10. Becker J, Nora DB, Gomes I, et al.: An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Clin. Neurophysiol. 2002; 113(9): 1429–1434. PubMed Abstract | Publisher Full Text
11. Pourmemari MH, Viikari-Juntura E, Shiri R: Smoking and carpal tunnel syndrome: a meta-analysis. Muscle Nerve. 2014; 49(3): 345–350. PubMed Abstract | Publisher Full Text
12. Anton D, Rosecrance J, Merlino L, et al.: Prevalence of musculoskeletal symptoms and carpal tunnel syndrome among dental hygienists. Am. J. Ind. Med. 2002; 42(3): 248–257. PubMed Abstract | Publisher Full Text
13. Berdouses E, Katsantoni A, Andrikoula T, et al.: Work-Related Musculoskeletal Disorders among Greek Dentists - A Nationwide Survey. Dent. Res. Oral Heal. 2020; 03(04): 169–181. Publisher Full Text
14. Alhusain FA, Almohrij M, Althukeir F, et al.: Prevalence of carpal tunnel syndrome symptoms among dentists working in Riyadh. Ann. Saudi Med. 2019; 39(2): 104–111. PubMed Abstract | Publisher Full Text | Free Full Text
15. Bou Jaoude S, Naaman N, Nehme E, et al.: Work-Related musculoskeletal pain among lebanese dentists: An epidemiological study. Niger. J. Clin. Pract. 2017; 20(8): 1002–1009. PubMed Abstract | Publisher Full Text
16. Lalumandier JA, McPhee SD, Riddle S, et al.: Carpal tunnel syndrome: Effect on Army dental personnel. Mil. Med. 2000; 165(5): 372–378. PubMed Abstract | Publisher Full Text
17. Pentapati K, Chenna D, Kumar M, et al.: Prevalence of Carpal Tunnel Syndrome among Dental Health Care Providers-Systematic Review Protocol.2022. Publisher Full Text
18. Hoy D, Brooks P, Woolf A, et al.: Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J. Clin. Epidemiol. 2012; 65(9): 934–939. PubMed Abstract | Publisher Full Text
19. Pentapati K, Chenna D: Pooled prevalence of Carpal Tunnel syndrome among dental health care providers. [Dataset]. Mendeley Data. 2023; V2. Publisher Full Text
20. Ravisankar A, Thenmozhi MS: Awareness, knowledge, and prevalence of carpal tunnel syndrome among dental students in Saveetha Dental College. Drug Invent. Today. 2020; 14(3): 151–154.
21. Conrad JC, Conrad KJ, Osborn JB: A short-term, three-year epidemiological study of median nerve sensitivity in practicing dental hygienists. J. Dent. Hyg. 1993; 67(5): 268–272. PubMed Abstract
22. Scoggins KM, Campbell RM: Impact of carpal tunnel education on changing dental hygienists knowledge, risk behaviors, symptoms and functional performance. Work. 1995; 5(4): 243–254. PubMed Abstract | Publisher Full Text
23. Liss GM, Jesin E, Kusiak RA, et al.: Musculoskeletal problems among Ontario dental hygienists. Am. J. Ind. Med. 1995; 28(4): 521–540. PubMed Abstract | Publisher Full Text
24. Nakladalova M, Fialova J, Korycanova H, et al.: State of health in dental technicians with regard to vibration exposure and overload of upper extremities. Cent. Eur. J. Public Health. 1995; 3 Suppl: 129–131. PubMed Abstract
25. Rice VJ, Nindl B, Pentikis JS: Dental workers, musculoskeletal cumulativetrauma, and carpal tunnel syndrome: Who is at risk? a pilot study. Int. J. Occup. Saf. Ergon. 1996; 2(3): 218–233. Publisher Full Text
26. Åkesson I, Johnsson B, Rylander L, et al.: Musculoskeletal disorders among female dental personnel--clinical examination and a 5-year follow-up study of symptoms. Int. Arch. Occup. Environ. Health. 1999; 72(6): 395–403. PubMed Abstract | Publisher Full Text
27. Hamann C, Werner RA, Franzblau A, et al.: Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J. Am. Dent. Assoc. 2001; 132(2): 163–170. PubMed Abstract | Publisher Full Text
28. Werner RA, Hamann C, Franzblau A, et al.: Prevalence of carpal tunnel syndrome and upper extremity tendinitis among dental hygienists. J. Dent. Hyg. 2002; 76(2): 126–132. PubMed Abstract
29. Werner RA, Franzblau A, Gell N, et al.: Prevalence of upper extremity symptoms and disorders among dental and dental hygiene students. J. Calif. Dent. Assoc. 2005; 33(2): 123–131. PubMed Abstract
30. Mamatha Y, Gopikrishna V, Kandaswamy D: Carpal tunnel syndrome: survey of an occupational hazard. Indian J. Dent. Res. 2005; 16(3): 109–113.
31. Cherniack M, Brammer AJ, Nilsson T, et al.: Nerve conduction and sensorineural function in dental hygienists using high frequency ultrasound handpieces. Am. J. Ind. Med. 2006; 49(5): 313–326. PubMed Abstract | Publisher Full Text
32. Greathouse DG, Root TM, Carrillo CR, et al.: Clinical and electrodiagnostic abnormalities of the median nerve in dental assistants. J. Orthop. Sports Phys. Ther. 2009; 39(9): 693–701. PubMed Abstract | Publisher Full Text
33. Haghighat A, Khosrawi S, Kelishadi A, et al.: Prevalence of clinical findings of carpal tunnel syndrome in Isfahanian dentists. Adv. Biomed. Res. 2012; 1(1): 13. PubMed Abstract | Publisher Full Text | Free Full Text
34. Shaffer SW, Moore R, Foo S, et al.: Clinical and electrodiagnostic abnormalities of the median nerve in US Army Dental Assistants at the onset of training. U.S. Army Med. Dep. J. 2012; 72–81. PubMed Abstract
35. Ehsan MA, Ehsan S, Arshad HS: Frequency of Carpal Tunnel Syndrome in Dentists Working in Government Hospitals of Lahore. Int. J. Sci. Res. 2016; 5(5): 1672–1675.
36. Borhan Haghighi A, Khosropanah H, Vahidnia F, et al.: Association of dental practice as a risk factor in the development of carpal tunnel syndrome. J. Dent. (Shiraz, Iran). 2013; 14(1): 37–40.
37. Munirah M, Normastura A, Azizah Y, et al.: Prevalence of Probable Carpal Tunnel Syndrome and itsAssociated Factors among Dentists in Kelantan. Int. J. Collab. Res. Intern. Med. Public Heal. 2014; 6(8): 247–259.
38. Pai MB, Shenoy R, Rao A, et al.: Symptoms of Carpal Tunnel Syndrome in a dental work force of a developing country. Int. J. Adv. Res. 2014; 2(2): 87–94.
39. Ahmed KA, Siddiqui AZ, Ahmed MR, et al.: Prevalence of carpel tunnel syndrome in the dentists working in Karachi. Pakistan Oral Dent J. 2014; 34(4): 588–591.
40. Hodacova L, Sustova Z, Cermakova E, et al.: Self-reported risk factors related to the most frequent musculoskeletal complaints among Czech dentists. Ind. Health. 2015; 53(1): 48–55. PubMed Abstract | Publisher Full Text | Free Full Text
41. Nurfarah Wahidah MN, Nurul SN, Munirah MANAR, et al.: Probable carpal tunnel syndrome and its coping Hospital Universiti Sains Malaysia. J. Sch. Dent. Sci. USM. 2016; 11(2): 31–38.
42. Prasad DA, Appachu D, Kamath V, et al.: Prevalence of low back pain and carpal tunnel syndrome among dental practitioners in Dakshina Kannada and Coorg District. Indian J. Dent. Res. 2017; 28(2): 126–132. PubMed Abstract | Publisher Full Text
43. Inbasekaran D, Sankari M, Nambi G: Prevalence of carpal tunnel syndrome among dentists in Chennai, India. Drug Invent. Today. 2018; 10(3): 3262–3265.
44. De JeSUS LC, Tedesco TK, MaceDo MC, et al.: A self-report joint damage and musculoskeletal disorders data among dentists: a cross-sectional study. Minerva Stomatol. 2018; 67(2): 62–67. PubMed Abstract | Publisher Full Text
45. Meisha DE, Alsharqawi NS, Samarah AA, et al.: Prevalence of work-related musculoskeletal disorders and ergonomic practice among dentists in Jeddah, Saudi Arabia. Clin. Cosmet. Investig. Dent. 2019; Volume 11: 171–179. PubMed Abstract | Publisher Full Text | Free Full Text
46. Harris ML, Sentner SM, Doucette HJ, et al.: Musculoskeletal disorders among dental hygienists in Canada. Can. J. Dent. Hyg. 2020; 54(2): 61–67.
47. Al Muraikhi SSHS, Rahimi KEME, Shetty AC: Prevalence of clinical signs of carpel tunnel syndrome among dentist in Qatar. Eur. J. Mol. Clin. Med. 2020; 7(7): 450–456.
48. Macdonald G, Robertson MM, Erickson JA: Carpal tunnel syndrome among California dental hygienists. Dent. Hyg (Chic). 1988; 62(7): 322–327. PubMed Abstract
49. Osborn JB, Newell KJ, Rudney JD, et al.: Carpal tunnel syndrome among Minnesota dental hygienists. J. Dent. Hyg. 1990; 64(2): 79–85. PubMed Abstract
50. Conrad JC, Conrad KJ, Osborn JS: Median nerve dysfunction evaluated during dental hygiene education and practice (1986-1989). J. Dent. Hyg. 1991; 65(6): 283–288. PubMed Abstract
51. Conrad JC, Conrad KJ, Osborn JB: A short-term epidemiological study of median nerve dysfunction in practicing dental hygienists. J. Dent. Hyg. 1992; 66(2): 76–80. PubMed Abstract
52. Feng B, Chen K, Zhu X, et al.: Prevalence and risk factors of self-reported wrist and hand symptoms and clinically confirmed carpal tunnel syndrome among office workers in China: a cross-sectional study. BMC Public Health. 2021; 21(1): 57. PubMed Abstract | Publisher Full Text | Free Full Text
53. Hagberg M, Morgenstern H, Kelsh M: Impact of occupations and job tasks on the prevalence of carpal tunnel syndrome. Scand. J. Work Environ. Health. 1992; 18(6): 337–345. PubMed Abstract | Publisher Full Text
54. Atroshi I: Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA. 1999; 282(2): 153. Publisher Full Text
55. Andersen JH, Thomsen JF, Overgaard E, et al.: Computer use and carpal tunnel syndrome: a 1-year follow-up study. JAMA. 2003; 289(22): 2963–2969. Publisher Full Text
56. Lee IH, Kim YK, Kang DM, et al.: Distribution of age, gender, and occupation among individuals with carpal tunnel syndrome based on the National Health Insurance data and National Employment Insurance data. Ann. Occup. Environ. Med. 2019; 31(1): e31. PubMed Abstract | Publisher Full Text | Free Full Text

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 08 Mar 2023

Author details Author details

Deepika Chenna
Roles: Conceptualization, Methodology, Resources, Software, Validation, Writing – Review & Editing

Medhini Madi
Roles: Conceptualization, Methodology, Resources, Validation, Writing – Original Draft Preparation

Mathangi Kumar
Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation

Vijay Kumar
Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Original Draft Preparation

Sitaram Chopperla
Roles: Conceptualization, Methodology, Resources, Writing – Original Draft Preparation

Abhinav Tadikonda
Roles: Conceptualization, Methodology, Resources, Supervision, Writing – Original Draft Preparation

Kalyana Pentapati
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Software, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 20 Jul 2023, 12:251

https://doi.org/10.12688/f1000research.131659.2

version 1

Published: 08 Mar 2023, 12:251

https://doi.org/10.12688/f1000research.131659.1

© 2023 Chenna D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

SEE MORE DETAILS

CITE

how to cite this article

Chenna D, Madi M, Kumar M et al. Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:251 (https://doi.org/10.12688/f1000research.131659.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 1

VERSION 1

PUBLISHED 08 Mar 2023

Views

Reviewer Report 19 Jun 2023

Y. Ravi shankar Reddy, Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Aseer Province, Saudi Arabia

Approved with Reservations

https://doi.org/10.5256/f1000research.144521.r178238

Title: Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel.

Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to

Title: Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel.

Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Musculosketal Rehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

20 Jul 2023

Author Response

We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in ... Continue reading We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Response: We added the following information: Data pertaining to the pooled prevalence of CTS and associated risk factors is lacking among dental healthcare personnel.

Query: Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Response: we have revised as follows: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Query: Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Response: Revised the information as below:
Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel (Dentist, dental auxiliary or Mixed population), age and sex distribution, age, sex and clinical experience distribution with respect to the distribution of CTS, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.
The first four questions (representative target population and sampling frame, random selection and non-response bias) assessed the external validity and the later five questions (participant or proxy data collection, acceptable case definition, validity and reliability of the instrument, similar data collection for all participants and specifying the numerators and denominators) assessed the internal validity of the study. All the questions were rated as low or high risk.

Query: Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Response: We attempted to explore the reasons for heterogeneity using sub-group analysis. The nature of the study design was same for all the studies. With respect to participant characteristics, we analysed based on the type of dental health care personnel which also showed high heterogeneity. Similar, was the case with geographic location. With respect to type of diagnosis, clinical examination showed lower levels of heterogeneity (<50%) than other modalities of diagnosis. However, the number of studies that used clinical examination were less (n=5).

Query: Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Response: Added the following information: Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standard could have caused considerable heterogeneity.

Query: Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Response: Added the following information: Implications of CTS can be at an individual, family or workplace level. Symptoms like pain, numbness, tingling and weakness in the hand and fingers can lead to significant functional disability to the dental personnel while performing the dental procedures. There by substantially affecting the individuals’ quality of life in performing daily activities and decreased productivity at workplace leading to loss of work, work place absenteeism along with financial losses. Indirectly, employers can face decreased productivity and loss of time in hiring new professionals. This can affect the overall productivity. Moreover, CTS can have a profound impact on the outside of the work, affecting simple tasks like writing, typing and grasping objects which may become challenging and be a limitation in their professional and personal activities alike.

Query: Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Response: We agree with reviewers about the role of potential confounders. We have included the data specific to age and clinical experience with respect to CTS. However, data on other factors like type of dental procedures and use of ergonomic interventions have not been reported in relation to the CTS prevalence among the included studies. It is crucial for further research to account for these confounding factors and assess their relationship between CTS and dental healthcare personnel.

Query: Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Response: Added information as below:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of dental profession as risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.

Query: Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
During training years, emphasis should be on the potential role of dental profession in the development of CTS and other musculoskeletal disorders. There is need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimise the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Query: Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Response: Future studies should explore the relationship between various potential risk factors and CTS. There is a need to develop and incorporate guidelines for the prevention of work-related musculoskeletal disorders into the training curriculum. Continuing dental education programs for the prevention of musculoskeletal disorders need to be conducted for the benefit of dental health care personnel.

Query: Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Response: Findings of this review highlight the potential impact of CTS among dental healthcare personnel. Policymakers need to ensure the development and implementation of the guidelines for the prevention of work-related musculoskeletal disorders and the incorporation of the same into the curriculum. Occupational Safety and Health Administration guidelines on the prevention of work-related musculoskeletal disorders have elements like management support, involvement of staff, training, identification of problems, early reporting, solutions to control hazards and evaluation. It should also emphasize the importance of the number of patients seen and attended, periodic breaks, task rotation, workflow and workload in the prevention of musculoskeletal disorders.

Query: Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.
Response: The information below was added:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of the dental profession as a risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.
High heterogeneity among the included studies, inclusion of only studies that were reported in English, publication bias, lack of age specific estimates, and variations in the assessment of CTS are some of the limitations. Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to the inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standards could have caused considerable heterogeneity.
We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Response: We added the following information: Data pertaining to the pooled prevalence of CTS and associated risk factors is lacking among dental healthcare personnel.

Query: Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Response: we have revised as follows: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Query: Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Response: Revised the information as below:
Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel (Dentist, dental auxiliary or Mixed population), age and sex distribution, age, sex and clinical experience distribution with respect to the distribution of CTS, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.
The first four questions (representative target population and sampling frame, random selection and non-response bias) assessed the external validity and the later five questions (participant or proxy data collection, acceptable case definition, validity and reliability of the instrument, similar data collection for all participants and specifying the numerators and denominators) assessed the internal validity of the study. All the questions were rated as low or high risk.

Query: Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Response: We attempted to explore the reasons for heterogeneity using sub-group analysis. The nature of the study design was same for all the studies. With respect to participant characteristics, we analysed based on the type of dental health care personnel which also showed high heterogeneity. Similar, was the case with geographic location. With respect to type of diagnosis, clinical examination showed lower levels of heterogeneity (<50%) than other modalities of diagnosis. However, the number of studies that used clinical examination were less (n=5).

Query: Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Response: Added the following information: Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standard could have caused considerable heterogeneity.

Query: Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Response: Added the following information: Implications of CTS can be at an individual, family or workplace level. Symptoms like pain, numbness, tingling and weakness in the hand and fingers can lead to significant functional disability to the dental personnel while performing the dental procedures. There by substantially affecting the individuals’ quality of life in performing daily activities and decreased productivity at workplace leading to loss of work, work place absenteeism along with financial losses. Indirectly, employers can face decreased productivity and loss of time in hiring new professionals. This can affect the overall productivity. Moreover, CTS can have a profound impact on the outside of the work, affecting simple tasks like writing, typing and grasping objects which may become challenging and be a limitation in their professional and personal activities alike.

Query: Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Response: We agree with reviewers about the role of potential confounders. We have included the data specific to age and clinical experience with respect to CTS. However, data on other factors like type of dental procedures and use of ergonomic interventions have not been reported in relation to the CTS prevalence among the included studies. It is crucial for further research to account for these confounding factors and assess their relationship between CTS and dental healthcare personnel.

Query: Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Response: Added information as below:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of dental profession as risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.

Query: Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
During training years, emphasis should be on the potential role of dental profession in the development of CTS and other musculoskeletal disorders. There is need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimise the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Query: Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Response: Future studies should explore the relationship between various potential risk factors and CTS. There is a need to develop and incorporate guidelines for the prevention of work-related musculoskeletal disorders into the training curriculum. Continuing dental education programs for the prevention of musculoskeletal disorders need to be conducted for the benefit of dental health care personnel.

Query: Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Response: Findings of this review highlight the potential impact of CTS among dental healthcare personnel. Policymakers need to ensure the development and implementation of the guidelines for the prevention of work-related musculoskeletal disorders and the incorporation of the same into the curriculum. Occupational Safety and Health Administration guidelines on the prevention of work-related musculoskeletal disorders have elements like management support, involvement of staff, training, identification of problems, early reporting, solutions to control hazards and evaluation. It should also emphasize the importance of the number of patients seen and attended, periodic breaks, task rotation, workflow and workload in the prevention of musculoskeletal disorders.

Query: Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.
Response: The information below was added:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of the dental profession as a risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.
High heterogeneity among the included studies, inclusion of only studies that were reported in English, publication bias, lack of age specific estimates, and variations in the assessment of CTS are some of the limitations. Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to the inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standards could have caused considerable heterogeneity.
Competing Interests: Nil Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

20 Jul 2023

Author Response

We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in ... Continue reading We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Response: We added the following information: Data pertaining to the pooled prevalence of CTS and associated risk factors is lacking among dental healthcare personnel.

Query: Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Response: we have revised as follows: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Query: Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Response: Revised the information as below:
Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel (Dentist, dental auxiliary or Mixed population), age and sex distribution, age, sex and clinical experience distribution with respect to the distribution of CTS, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.
The first four questions (representative target population and sampling frame, random selection and non-response bias) assessed the external validity and the later five questions (participant or proxy data collection, acceptable case definition, validity and reliability of the instrument, similar data collection for all participants and specifying the numerators and denominators) assessed the internal validity of the study. All the questions were rated as low or high risk.

Query: Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Response: We attempted to explore the reasons for heterogeneity using sub-group analysis. The nature of the study design was same for all the studies. With respect to participant characteristics, we analysed based on the type of dental health care personnel which also showed high heterogeneity. Similar, was the case with geographic location. With respect to type of diagnosis, clinical examination showed lower levels of heterogeneity (<50%) than other modalities of diagnosis. However, the number of studies that used clinical examination were less (n=5).

Query: Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Response: Added the following information: Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standard could have caused considerable heterogeneity.

Query: Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Response: Added the following information: Implications of CTS can be at an individual, family or workplace level. Symptoms like pain, numbness, tingling and weakness in the hand and fingers can lead to significant functional disability to the dental personnel while performing the dental procedures. There by substantially affecting the individuals’ quality of life in performing daily activities and decreased productivity at workplace leading to loss of work, work place absenteeism along with financial losses. Indirectly, employers can face decreased productivity and loss of time in hiring new professionals. This can affect the overall productivity. Moreover, CTS can have a profound impact on the outside of the work, affecting simple tasks like writing, typing and grasping objects which may become challenging and be a limitation in their professional and personal activities alike.

Query: Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Response: We agree with reviewers about the role of potential confounders. We have included the data specific to age and clinical experience with respect to CTS. However, data on other factors like type of dental procedures and use of ergonomic interventions have not been reported in relation to the CTS prevalence among the included studies. It is crucial for further research to account for these confounding factors and assess their relationship between CTS and dental healthcare personnel.

Query: Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Response: Added information as below:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of dental profession as risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.

Query: Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
During training years, emphasis should be on the potential role of dental profession in the development of CTS and other musculoskeletal disorders. There is need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimise the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Query: Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Response: Future studies should explore the relationship between various potential risk factors and CTS. There is a need to develop and incorporate guidelines for the prevention of work-related musculoskeletal disorders into the training curriculum. Continuing dental education programs for the prevention of musculoskeletal disorders need to be conducted for the benefit of dental health care personnel.

Query: Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Response: Findings of this review highlight the potential impact of CTS among dental healthcare personnel. Policymakers need to ensure the development and implementation of the guidelines for the prevention of work-related musculoskeletal disorders and the incorporation of the same into the curriculum. Occupational Safety and Health Administration guidelines on the prevention of work-related musculoskeletal disorders have elements like management support, involvement of staff, training, identification of problems, early reporting, solutions to control hazards and evaluation. It should also emphasize the importance of the number of patients seen and attended, periodic breaks, task rotation, workflow and workload in the prevention of musculoskeletal disorders.

Query: Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.
Response: The information below was added:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of the dental profession as a risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.
High heterogeneity among the included studies, inclusion of only studies that were reported in English, publication bias, lack of age specific estimates, and variations in the assessment of CTS are some of the limitations. Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to the inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standards could have caused considerable heterogeneity.
We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Response: We added the following information: Data pertaining to the pooled prevalence of CTS and associated risk factors is lacking among dental healthcare personnel.

Query: Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Response: we have revised as follows: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Query: Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Response: Revised the information as below:
Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel (Dentist, dental auxiliary or Mixed population), age and sex distribution, age, sex and clinical experience distribution with respect to the distribution of CTS, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.
The first four questions (representative target population and sampling frame, random selection and non-response bias) assessed the external validity and the later five questions (participant or proxy data collection, acceptable case definition, validity and reliability of the instrument, similar data collection for all participants and specifying the numerators and denominators) assessed the internal validity of the study. All the questions were rated as low or high risk.

Query: Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Response: We attempted to explore the reasons for heterogeneity using sub-group analysis. The nature of the study design was same for all the studies. With respect to participant characteristics, we analysed based on the type of dental health care personnel which also showed high heterogeneity. Similar, was the case with geographic location. With respect to type of diagnosis, clinical examination showed lower levels of heterogeneity (<50%) than other modalities of diagnosis. However, the number of studies that used clinical examination were less (n=5).

Query: Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Response: Added the following information: Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standard could have caused considerable heterogeneity.

Query: Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Response: Added the following information: Implications of CTS can be at an individual, family or workplace level. Symptoms like pain, numbness, tingling and weakness in the hand and fingers can lead to significant functional disability to the dental personnel while performing the dental procedures. There by substantially affecting the individuals’ quality of life in performing daily activities and decreased productivity at workplace leading to loss of work, work place absenteeism along with financial losses. Indirectly, employers can face decreased productivity and loss of time in hiring new professionals. This can affect the overall productivity. Moreover, CTS can have a profound impact on the outside of the work, affecting simple tasks like writing, typing and grasping objects which may become challenging and be a limitation in their professional and personal activities alike.

Query: Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Response: We agree with reviewers about the role of potential confounders. We have included the data specific to age and clinical experience with respect to CTS. However, data on other factors like type of dental procedures and use of ergonomic interventions have not been reported in relation to the CTS prevalence among the included studies. It is crucial for further research to account for these confounding factors and assess their relationship between CTS and dental healthcare personnel.

Query: Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Response: Added information as below:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of dental profession as risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.

Query: Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
During training years, emphasis should be on the potential role of dental profession in the development of CTS and other musculoskeletal disorders. There is need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimise the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Query: Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Response: Future studies should explore the relationship between various potential risk factors and CTS. There is a need to develop and incorporate guidelines for the prevention of work-related musculoskeletal disorders into the training curriculum. Continuing dental education programs for the prevention of musculoskeletal disorders need to be conducted for the benefit of dental health care personnel.

Query: Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Response: Findings of this review highlight the potential impact of CTS among dental healthcare personnel. Policymakers need to ensure the development and implementation of the guidelines for the prevention of work-related musculoskeletal disorders and the incorporation of the same into the curriculum. Occupational Safety and Health Administration guidelines on the prevention of work-related musculoskeletal disorders have elements like management support, involvement of staff, training, identification of problems, early reporting, solutions to control hazards and evaluation. It should also emphasize the importance of the number of patients seen and attended, periodic breaks, task rotation, workflow and workload in the prevention of musculoskeletal disorders.

Query: Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.
Response: The information below was added:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of the dental profession as a risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.
High heterogeneity among the included studies, inclusion of only studies that were reported in English, publication bias, lack of age specific estimates, and variations in the assessment of CTS are some of the limitations. Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to the inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standards could have caused considerable heterogeneity.
Competing Interests: Nil Close
Report a concern

Views

Reviewer Report 24 Mar 2023

Dileep Nag Vinnakota, Department of Prosthodontics, Narayana Dental College, Nellore, Andhra Pradesh, India

Rekhalakshmi Kamatham, Department of Paedodontics and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh, India

Approved with Reservations

https://doi.org/10.5256/f1000research.144521.r165926

I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Methodology: Many sections are poorly written.

The authors can mention the keywords separately as MeSH words and alternate words employed for the search.
The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practised in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.
Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?

Results:

It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female, so that the readers can easily depict the side which is favoured.
Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs explanation regarding the precision of individual studies.
Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after removal of studies with high prevalence like Prasad et al (2017).

Discussion: Discussion is not enough. Authors can discuss the importance of case control studies to know whether dentists are really more prone for this condition compared to normal population. Authors can discuss about the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, management of this condition (non-surgical and exercises) needs mentioning.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly

References

1. MacDermid JC, Wessel J: Clinical diagnosis of carpal tunnel syndrome: a systematic review.J Hand Ther. 2004; 17 (2): 309-19 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Implantology, Full mouth rehabilitation

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

CITE

Report a concern

Author Response 20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

20 Jul 2023

Author Response

Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for ... Continue reading Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Response: We will edit the same in our manuscript “Worldwide prevalence of carpal tunnel syndrome among dental health care personnel - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Response: Thank you for your valuable insight. We had gone through MacDermid and Wessel to understand the value-added points. They concluded that the primary limitation of establishing a gold standard diagnosis for CTS. This difficulty, combined with methodologic flaws, made interpretation difficult. Also, there was no guarantee that these choices increased the validity of our results. It was also stated that we should not consider the findings of this review to be conclusive concerning the value of clinical tests in the diagnosis of CTS. Furthermore, a systematic review requires that issues be addressed using specific and documented methods. Therefore, discussions on why certain tests may be better in specific situations or relevant in different stages of CTS are beyond the scope of this review.
Our review focussed on the burden of disease (CTS) among dental health professionals which was by pooling the estimates that have been reported from the literature. Various methods are available in the literature for the diagnosis of CTS which are broadly categorized as self-reported, clinical, and nerve conduction studies. All these tests have their own advantages and limitations that are discussed by the authors of these primary studies.

Methodology: Many sections are poorly written.
Query: The authors can mention the keywords separately as MeSH words and alternate words employed for the search.

Response: MeSH words are only specific for Pubmed. We have used All fields option for all the databases and have not restricted our search to title, abstract and keywords search. Based on our previous review experience on musculoskeletal disorders, we noticed that few studies that reported prevalence estimates of musculoskeletal disorders have reported carpal tunnel syndrome. If we restrict our search to title, abstract and keywords, these studies would be missed during the first stage of screening. We will reframe the sentence as search terms instead of keywords in the manuscript.

Query: The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.

Response: There is no consensus or gold standard for the diagnosis of carpal tunnel syndrome. Nerve conduction studies are a useful tool and can be used as complementary methods with clinical examination in the assessment of CTS. Use of such methods in epidemiological surveys is quite challenging as it is costly, requires trained personnel to perform and interpret and cannot be used alone for the diagnosis of CTS. Hence, there were many attempts to develop self-reported measures and clinical examination for the diagnosis of CTS. Self-reported measures like boston carpal tunnel questionnaire has been used widely and was shown to have acceptable validity and reliability in many previous studies. We agree that there were will be bias, hence we reported the estimates of CTS as per the diagnostic method used in the primary studies.

We have revised the sentence: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

We agree with reviewers that there are many factors (years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel) on the prevalence estimates. The main aim of this review was to quantify the prevalence estimates obtained from the published literature. To look at these factors that may have the effect of confounding, it is imperative that published literature reports that prevalence estimates as per age groups, work experience, level of ergonomics, etc. We have reviewed the included studies and extracted data on age, clinical experience, and gender distribution as per the CTS distribution.

Response: We will include the information below in the manuscript.

Based on the data from the included studies, age estimates with respect to CTS and No CTS was reported by only six studies. Studies that reported age as categorical data could not be analysed as there was no similarity in the categories used (Table 2). Three studies reported age as continuous variable. Meta-analysis showed that there was no significant difference in the age between CTS and No CTS groups (SMD: 0.1; 95%CI: -0.17 – 0.38) (figure 3).

Image 1; Image 2

A total of seven studies reported clinical experience which was either continuous (n=3) or categorical (n=4). Meta-analysis showed that there was no significant difference in the mean clinical experience between the groups (SMD: -0.03; 95%CI: -0.31 – 0.24) (Figure 5). Categorical data on clinical experience was categorized as < 10 years and > 10 years for analysis. Meta-analysis showed no significant difference in the pooled estimates between different levels of clinical experience (OR: 0.76; 95%CI: 0.39-1.47) (Figure 6).

Image 3; Image 4

Query: Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Response: Yes. We have collected the information on country. However, country wise estimates were not feasible. Hence, we pooled the estimates as per the continent.

Query: Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine-item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Response: Thank you for your comments. We will incorporate the item-wise scores for individual studies. The questionnaire used for quality assessment was validated and primarily developed for the assessment of risk of bias for systematic reviews on prevalence studies. STROBE guidelines are primarily intended as a checklist for reporting cross-sectional studies. The valid overall risk of bias scores cannot be computed so that studies can be rated as high or low risk of bias from STROBE guidelines. Hence, it was not used in this study.

Image 5

Query: Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?
Response: We have used Fail-Safe N analysis using the Rosenthal approach. We will add this information also in the manuscript.
Statistical analysis: Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach and Egger regression test.
Publication bias: Egger Regression Test for Funnel Plot Asymmetry showed asymmetry (Z=2.187; P=0.029).

Query: It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Response: Yes, we agree with the reviewer that self-reported measures have yielded higher estimates and we have reported the estimates as per the diagnostic criteria used in the studies. We also agree with the fact that type of dental health care personnel cannot be combined as all have different range of work but all these personnel do activities that requires repetitive movements, firm grasp, and fine tactile movements with prolonged static postures. Many studies which were included in this review have included all types of dental health personnel. Studies that reported prevalence separately were captured separately. In our review, we have mentioned the estimates as per the type of healthcare personnel. We understand that all these factors along with age and clinical experience have potential influence. This review is focussed on the burden of CTS among these dental health care personnel.

Query: Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female so that the readers can easily depict the side which is favoured.
Response: We will edit the figure in the manuscript as per your recommendation.

Image 6

Query: Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs an explanation regarding the precision of individual studies.
Response: We will add the following details to the manuscript.
Inverse standard error in the y-axis depicts the precision of the studies. It helps in identifying the studies with lower precision which will be distributed at the bottom. Inverse standard error was selected as there was no inversion required when compared to plots that use standard error in the y-axis where studies with large sample sizes and lower standard error are placed at the top of the graph. The plot showed asymmetry where in large studies showed higher precision and lower prevalence estimates whereas smaller studies had lower precision and higher prevalence estimates.

Query: Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after the removal of studies with high prevalence like Prasad et al (2017).
Response: We performed a sensitivity analysis using Leave -one out method. The prevalence estimate marginally decreased to 13% after the removal of Prasad et al. We will add this information in the manuscript.

Query: Discussion is not enough. Authors can discuss the importance of case-control studies to know whether dentists are really more prone to this condition compared to the normal population. Authors can discuss the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, the management of this condition (non-surgical and exercises) needs mentioning.
Response: The below information will be added in the manuscript.
Further case-control studies are required to understand the role of the dentistry profession as a risk factor for the development of CTS are needed.
During training years, emphasis should be on the potential role of the dental profession in the development of CTS and other musculoskeletal disorders. There is a need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimize the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier, and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS.
Many conditions like systemic neurologic disorders (motor neuron disease, multiple sclerosis, and hereditary neuropathy), cervical spine disorders (cervical spondylotic myelopathy, cervical radiculopathy, and syringomyelia), tumors (Pancoast tumors, benign peripheral nerve tumors, malignant peripheral nerve sheath tumors, intraneural ganglia), inflammatory and autoimmune disorders.
The management of CTS includes conservative methods like wrist splinting in the neutral position at night, analgesics, corticosteroid injections, and nerve and tendon gliding exercises with varying degrees of results. Also, the carpal tunnel can be surgically decompressed to relieve the symptoms when there is a lack of response to the above. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Response: We will edit the same in our manuscript “Worldwide prevalence of carpal tunnel syndrome among dental health care personnel - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Response: Thank you for your valuable insight. We had gone through MacDermid and Wessel to understand the value-added points. They concluded that the primary limitation of establishing a gold standard diagnosis for CTS. This difficulty, combined with methodologic flaws, made interpretation difficult. Also, there was no guarantee that these choices increased the validity of our results. It was also stated that we should not consider the findings of this review to be conclusive concerning the value of clinical tests in the diagnosis of CTS. Furthermore, a systematic review requires that issues be addressed using specific and documented methods. Therefore, discussions on why certain tests may be better in specific situations or relevant in different stages of CTS are beyond the scope of this review.
Our review focussed on the burden of disease (CTS) among dental health professionals which was by pooling the estimates that have been reported from the literature. Various methods are available in the literature for the diagnosis of CTS which are broadly categorized as self-reported, clinical, and nerve conduction studies. All these tests have their own advantages and limitations that are discussed by the authors of these primary studies.

Methodology: Many sections are poorly written.
Query: The authors can mention the keywords separately as MeSH words and alternate words employed for the search.

Response: MeSH words are only specific for Pubmed. We have used All fields option for all the databases and have not restricted our search to title, abstract and keywords search. Based on our previous review experience on musculoskeletal disorders, we noticed that few studies that reported prevalence estimates of musculoskeletal disorders have reported carpal tunnel syndrome. If we restrict our search to title, abstract and keywords, these studies would be missed during the first stage of screening. We will reframe the sentence as search terms instead of keywords in the manuscript.

Query: The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.

Response: There is no consensus or gold standard for the diagnosis of carpal tunnel syndrome. Nerve conduction studies are a useful tool and can be used as complementary methods with clinical examination in the assessment of CTS. Use of such methods in epidemiological surveys is quite challenging as it is costly, requires trained personnel to perform and interpret and cannot be used alone for the diagnosis of CTS. Hence, there were many attempts to develop self-reported measures and clinical examination for the diagnosis of CTS. Self-reported measures like boston carpal tunnel questionnaire has been used widely and was shown to have acceptable validity and reliability in many previous studies. We agree that there were will be bias, hence we reported the estimates of CTS as per the diagnostic method used in the primary studies.

We have revised the sentence: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

We agree with reviewers that there are many factors (years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel) on the prevalence estimates. The main aim of this review was to quantify the prevalence estimates obtained from the published literature. To look at these factors that may have the effect of confounding, it is imperative that published literature reports that prevalence estimates as per age groups, work experience, level of ergonomics, etc. We have reviewed the included studies and extracted data on age, clinical experience, and gender distribution as per the CTS distribution.

Response: We will include the information below in the manuscript.

Based on the data from the included studies, age estimates with respect to CTS and No CTS was reported by only six studies. Studies that reported age as categorical data could not be analysed as there was no similarity in the categories used (Table 2). Three studies reported age as continuous variable. Meta-analysis showed that there was no significant difference in the age between CTS and No CTS groups (SMD: 0.1; 95%CI: -0.17 – 0.38) (figure 3).

Image 1; Image 2

A total of seven studies reported clinical experience which was either continuous (n=3) or categorical (n=4). Meta-analysis showed that there was no significant difference in the mean clinical experience between the groups (SMD: -0.03; 95%CI: -0.31 – 0.24) (Figure 5). Categorical data on clinical experience was categorized as < 10 years and > 10 years for analysis. Meta-analysis showed no significant difference in the pooled estimates between different levels of clinical experience (OR: 0.76; 95%CI: 0.39-1.47) (Figure 6).

Image 3; Image 4

Query: Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Response: Yes. We have collected the information on country. However, country wise estimates were not feasible. Hence, we pooled the estimates as per the continent.

Query: Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine-item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Response: Thank you for your comments. We will incorporate the item-wise scores for individual studies. The questionnaire used for quality assessment was validated and primarily developed for the assessment of risk of bias for systematic reviews on prevalence studies. STROBE guidelines are primarily intended as a checklist for reporting cross-sectional studies. The valid overall risk of bias scores cannot be computed so that studies can be rated as high or low risk of bias from STROBE guidelines. Hence, it was not used in this study.

Image 5

Query: Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?
Response: We have used Fail-Safe N analysis using the Rosenthal approach. We will add this information also in the manuscript.
Statistical analysis: Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach and Egger regression test.
Publication bias: Egger Regression Test for Funnel Plot Asymmetry showed asymmetry (Z=2.187; P=0.029).

Query: It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Response: Yes, we agree with the reviewer that self-reported measures have yielded higher estimates and we have reported the estimates as per the diagnostic criteria used in the studies. We also agree with the fact that type of dental health care personnel cannot be combined as all have different range of work but all these personnel do activities that requires repetitive movements, firm grasp, and fine tactile movements with prolonged static postures. Many studies which were included in this review have included all types of dental health personnel. Studies that reported prevalence separately were captured separately. In our review, we have mentioned the estimates as per the type of healthcare personnel. We understand that all these factors along with age and clinical experience have potential influence. This review is focussed on the burden of CTS among these dental health care personnel.

Query: Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female so that the readers can easily depict the side which is favoured.
Response: We will edit the figure in the manuscript as per your recommendation.

Image 6

Query: Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs an explanation regarding the precision of individual studies.
Response: We will add the following details to the manuscript.
Inverse standard error in the y-axis depicts the precision of the studies. It helps in identifying the studies with lower precision which will be distributed at the bottom. Inverse standard error was selected as there was no inversion required when compared to plots that use standard error in the y-axis where studies with large sample sizes and lower standard error are placed at the top of the graph. The plot showed asymmetry where in large studies showed higher precision and lower prevalence estimates whereas smaller studies had lower precision and higher prevalence estimates.

Query: Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after the removal of studies with high prevalence like Prasad et al (2017).
Response: We performed a sensitivity analysis using Leave -one out method. The prevalence estimate marginally decreased to 13% after the removal of Prasad et al. We will add this information in the manuscript.

Query: Discussion is not enough. Authors can discuss the importance of case-control studies to know whether dentists are really more prone to this condition compared to the normal population. Authors can discuss the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, the management of this condition (non-surgical and exercises) needs mentioning.
Response: The below information will be added in the manuscript.
Further case-control studies are required to understand the role of the dentistry profession as a risk factor for the development of CTS are needed.
During training years, emphasis should be on the potential role of the dental profession in the development of CTS and other musculoskeletal disorders. There is a need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimize the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier, and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS.
Many conditions like systemic neurologic disorders (motor neuron disease, multiple sclerosis, and hereditary neuropathy), cervical spine disorders (cervical spondylotic myelopathy, cervical radiculopathy, and syringomyelia), tumors (Pancoast tumors, benign peripheral nerve tumors, malignant peripheral nerve sheath tumors, intraneural ganglia), inflammatory and autoimmune disorders.
The management of CTS includes conservative methods like wrist splinting in the neutral position at night, analgesics, corticosteroid injections, and nerve and tendon gliding exercises with varying degrees of results. Also, the carpal tunnel can be surgically decompressed to relieve the symptoms when there is a lack of response to the above. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Competing Interests: Nil Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

20 Jul 2023

Author Response

Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for ... Continue reading Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Response: We will edit the same in our manuscript “Worldwide prevalence of carpal tunnel syndrome among dental health care personnel - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Response: Thank you for your valuable insight. We had gone through MacDermid and Wessel to understand the value-added points. They concluded that the primary limitation of establishing a gold standard diagnosis for CTS. This difficulty, combined with methodologic flaws, made interpretation difficult. Also, there was no guarantee that these choices increased the validity of our results. It was also stated that we should not consider the findings of this review to be conclusive concerning the value of clinical tests in the diagnosis of CTS. Furthermore, a systematic review requires that issues be addressed using specific and documented methods. Therefore, discussions on why certain tests may be better in specific situations or relevant in different stages of CTS are beyond the scope of this review.
Our review focussed on the burden of disease (CTS) among dental health professionals which was by pooling the estimates that have been reported from the literature. Various methods are available in the literature for the diagnosis of CTS which are broadly categorized as self-reported, clinical, and nerve conduction studies. All these tests have their own advantages and limitations that are discussed by the authors of these primary studies.

Methodology: Many sections are poorly written.
Query: The authors can mention the keywords separately as MeSH words and alternate words employed for the search.

Response: MeSH words are only specific for Pubmed. We have used All fields option for all the databases and have not restricted our search to title, abstract and keywords search. Based on our previous review experience on musculoskeletal disorders, we noticed that few studies that reported prevalence estimates of musculoskeletal disorders have reported carpal tunnel syndrome. If we restrict our search to title, abstract and keywords, these studies would be missed during the first stage of screening. We will reframe the sentence as search terms instead of keywords in the manuscript.

Query: The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.

Response: There is no consensus or gold standard for the diagnosis of carpal tunnel syndrome. Nerve conduction studies are a useful tool and can be used as complementary methods with clinical examination in the assessment of CTS. Use of such methods in epidemiological surveys is quite challenging as it is costly, requires trained personnel to perform and interpret and cannot be used alone for the diagnosis of CTS. Hence, there were many attempts to develop self-reported measures and clinical examination for the diagnosis of CTS. Self-reported measures like boston carpal tunnel questionnaire has been used widely and was shown to have acceptable validity and reliability in many previous studies. We agree that there were will be bias, hence we reported the estimates of CTS as per the diagnostic method used in the primary studies.

We have revised the sentence: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

We agree with reviewers that there are many factors (years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel) on the prevalence estimates. The main aim of this review was to quantify the prevalence estimates obtained from the published literature. To look at these factors that may have the effect of confounding, it is imperative that published literature reports that prevalence estimates as per age groups, work experience, level of ergonomics, etc. We have reviewed the included studies and extracted data on age, clinical experience, and gender distribution as per the CTS distribution.

Response: We will include the information below in the manuscript.

Based on the data from the included studies, age estimates with respect to CTS and No CTS was reported by only six studies. Studies that reported age as categorical data could not be analysed as there was no similarity in the categories used (Table 2). Three studies reported age as continuous variable. Meta-analysis showed that there was no significant difference in the age between CTS and No CTS groups (SMD: 0.1; 95%CI: -0.17 – 0.38) (figure 3).

Image 1; Image 2

A total of seven studies reported clinical experience which was either continuous (n=3) or categorical (n=4). Meta-analysis showed that there was no significant difference in the mean clinical experience between the groups (SMD: -0.03; 95%CI: -0.31 – 0.24) (Figure 5). Categorical data on clinical experience was categorized as < 10 years and > 10 years for analysis. Meta-analysis showed no significant difference in the pooled estimates between different levels of clinical experience (OR: 0.76; 95%CI: 0.39-1.47) (Figure 6).

Image 3; Image 4

Query: Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Response: Yes. We have collected the information on country. However, country wise estimates were not feasible. Hence, we pooled the estimates as per the continent.

Query: Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine-item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Response: Thank you for your comments. We will incorporate the item-wise scores for individual studies. The questionnaire used for quality assessment was validated and primarily developed for the assessment of risk of bias for systematic reviews on prevalence studies. STROBE guidelines are primarily intended as a checklist for reporting cross-sectional studies. The valid overall risk of bias scores cannot be computed so that studies can be rated as high or low risk of bias from STROBE guidelines. Hence, it was not used in this study.

Image 5

Query: Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?
Response: We have used Fail-Safe N analysis using the Rosenthal approach. We will add this information also in the manuscript.
Statistical analysis: Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach and Egger regression test.
Publication bias: Egger Regression Test for Funnel Plot Asymmetry showed asymmetry (Z=2.187; P=0.029).

Query: It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Response: Yes, we agree with the reviewer that self-reported measures have yielded higher estimates and we have reported the estimates as per the diagnostic criteria used in the studies. We also agree with the fact that type of dental health care personnel cannot be combined as all have different range of work but all these personnel do activities that requires repetitive movements, firm grasp, and fine tactile movements with prolonged static postures. Many studies which were included in this review have included all types of dental health personnel. Studies that reported prevalence separately were captured separately. In our review, we have mentioned the estimates as per the type of healthcare personnel. We understand that all these factors along with age and clinical experience have potential influence. This review is focussed on the burden of CTS among these dental health care personnel.

Query: Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female so that the readers can easily depict the side which is favoured.
Response: We will edit the figure in the manuscript as per your recommendation.

Image 6

Query: Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs an explanation regarding the precision of individual studies.
Response: We will add the following details to the manuscript.
Inverse standard error in the y-axis depicts the precision of the studies. It helps in identifying the studies with lower precision which will be distributed at the bottom. Inverse standard error was selected as there was no inversion required when compared to plots that use standard error in the y-axis where studies with large sample sizes and lower standard error are placed at the top of the graph. The plot showed asymmetry where in large studies showed higher precision and lower prevalence estimates whereas smaller studies had lower precision and higher prevalence estimates.

Query: Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after the removal of studies with high prevalence like Prasad et al (2017).
Response: We performed a sensitivity analysis using Leave -one out method. The prevalence estimate marginally decreased to 13% after the removal of Prasad et al. We will add this information in the manuscript.

Query: Discussion is not enough. Authors can discuss the importance of case-control studies to know whether dentists are really more prone to this condition compared to the normal population. Authors can discuss the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, the management of this condition (non-surgical and exercises) needs mentioning.
Response: The below information will be added in the manuscript.
Further case-control studies are required to understand the role of the dentistry profession as a risk factor for the development of CTS are needed.
During training years, emphasis should be on the potential role of the dental profession in the development of CTS and other musculoskeletal disorders. There is a need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimize the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier, and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS.
Many conditions like systemic neurologic disorders (motor neuron disease, multiple sclerosis, and hereditary neuropathy), cervical spine disorders (cervical spondylotic myelopathy, cervical radiculopathy, and syringomyelia), tumors (Pancoast tumors, benign peripheral nerve tumors, malignant peripheral nerve sheath tumors, intraneural ganglia), inflammatory and autoimmune disorders.
The management of CTS includes conservative methods like wrist splinting in the neutral position at night, analgesics, corticosteroid injections, and nerve and tendon gliding exercises with varying degrees of results. Also, the carpal tunnel can be surgically decompressed to relieve the symptoms when there is a lack of response to the above. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Response: We will edit the same in our manuscript “Worldwide prevalence of carpal tunnel syndrome among dental health care personnel - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Response: Thank you for your valuable insight. We had gone through MacDermid and Wessel to understand the value-added points. They concluded that the primary limitation of establishing a gold standard diagnosis for CTS. This difficulty, combined with methodologic flaws, made interpretation difficult. Also, there was no guarantee that these choices increased the validity of our results. It was also stated that we should not consider the findings of this review to be conclusive concerning the value of clinical tests in the diagnosis of CTS. Furthermore, a systematic review requires that issues be addressed using specific and documented methods. Therefore, discussions on why certain tests may be better in specific situations or relevant in different stages of CTS are beyond the scope of this review.
Our review focussed on the burden of disease (CTS) among dental health professionals which was by pooling the estimates that have been reported from the literature. Various methods are available in the literature for the diagnosis of CTS which are broadly categorized as self-reported, clinical, and nerve conduction studies. All these tests have their own advantages and limitations that are discussed by the authors of these primary studies.

Methodology: Many sections are poorly written.
Query: The authors can mention the keywords separately as MeSH words and alternate words employed for the search.

Response: MeSH words are only specific for Pubmed. We have used All fields option for all the databases and have not restricted our search to title, abstract and keywords search. Based on our previous review experience on musculoskeletal disorders, we noticed that few studies that reported prevalence estimates of musculoskeletal disorders have reported carpal tunnel syndrome. If we restrict our search to title, abstract and keywords, these studies would be missed during the first stage of screening. We will reframe the sentence as search terms instead of keywords in the manuscript.

Query: The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.

Response: There is no consensus or gold standard for the diagnosis of carpal tunnel syndrome. Nerve conduction studies are a useful tool and can be used as complementary methods with clinical examination in the assessment of CTS. Use of such methods in epidemiological surveys is quite challenging as it is costly, requires trained personnel to perform and interpret and cannot be used alone for the diagnosis of CTS. Hence, there were many attempts to develop self-reported measures and clinical examination for the diagnosis of CTS. Self-reported measures like boston carpal tunnel questionnaire has been used widely and was shown to have acceptable validity and reliability in many previous studies. We agree that there were will be bias, hence we reported the estimates of CTS as per the diagnostic method used in the primary studies.

We have revised the sentence: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

We agree with reviewers that there are many factors (years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel) on the prevalence estimates. The main aim of this review was to quantify the prevalence estimates obtained from the published literature. To look at these factors that may have the effect of confounding, it is imperative that published literature reports that prevalence estimates as per age groups, work experience, level of ergonomics, etc. We have reviewed the included studies and extracted data on age, clinical experience, and gender distribution as per the CTS distribution.

Response: We will include the information below in the manuscript.

Based on the data from the included studies, age estimates with respect to CTS and No CTS was reported by only six studies. Studies that reported age as categorical data could not be analysed as there was no similarity in the categories used (Table 2). Three studies reported age as continuous variable. Meta-analysis showed that there was no significant difference in the age between CTS and No CTS groups (SMD: 0.1; 95%CI: -0.17 – 0.38) (figure 3).

Image 1; Image 2

A total of seven studies reported clinical experience which was either continuous (n=3) or categorical (n=4). Meta-analysis showed that there was no significant difference in the mean clinical experience between the groups (SMD: -0.03; 95%CI: -0.31 – 0.24) (Figure 5). Categorical data on clinical experience was categorized as < 10 years and > 10 years for analysis. Meta-analysis showed no significant difference in the pooled estimates between different levels of clinical experience (OR: 0.76; 95%CI: 0.39-1.47) (Figure 6).

Image 3; Image 4

Query: Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Response: Yes. We have collected the information on country. However, country wise estimates were not feasible. Hence, we pooled the estimates as per the continent.

Query: Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine-item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Response: Thank you for your comments. We will incorporate the item-wise scores for individual studies. The questionnaire used for quality assessment was validated and primarily developed for the assessment of risk of bias for systematic reviews on prevalence studies. STROBE guidelines are primarily intended as a checklist for reporting cross-sectional studies. The valid overall risk of bias scores cannot be computed so that studies can be rated as high or low risk of bias from STROBE guidelines. Hence, it was not used in this study.

Image 5

Query: Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?
Response: We have used Fail-Safe N analysis using the Rosenthal approach. We will add this information also in the manuscript.
Statistical analysis: Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach and Egger regression test.
Publication bias: Egger Regression Test for Funnel Plot Asymmetry showed asymmetry (Z=2.187; P=0.029).

Query: It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Response: Yes, we agree with the reviewer that self-reported measures have yielded higher estimates and we have reported the estimates as per the diagnostic criteria used in the studies. We also agree with the fact that type of dental health care personnel cannot be combined as all have different range of work but all these personnel do activities that requires repetitive movements, firm grasp, and fine tactile movements with prolonged static postures. Many studies which were included in this review have included all types of dental health personnel. Studies that reported prevalence separately were captured separately. In our review, we have mentioned the estimates as per the type of healthcare personnel. We understand that all these factors along with age and clinical experience have potential influence. This review is focussed on the burden of CTS among these dental health care personnel.

Query: Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female so that the readers can easily depict the side which is favoured.
Response: We will edit the figure in the manuscript as per your recommendation.

Image 6

Query: Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs an explanation regarding the precision of individual studies.
Response: We will add the following details to the manuscript.
Inverse standard error in the y-axis depicts the precision of the studies. It helps in identifying the studies with lower precision which will be distributed at the bottom. Inverse standard error was selected as there was no inversion required when compared to plots that use standard error in the y-axis where studies with large sample sizes and lower standard error are placed at the top of the graph. The plot showed asymmetry where in large studies showed higher precision and lower prevalence estimates whereas smaller studies had lower precision and higher prevalence estimates.

Query: Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after the removal of studies with high prevalence like Prasad et al (2017).
Response: We performed a sensitivity analysis using Leave -one out method. The prevalence estimate marginally decreased to 13% after the removal of Prasad et al. We will add this information in the manuscript.

Query: Discussion is not enough. Authors can discuss the importance of case-control studies to know whether dentists are really more prone to this condition compared to the normal population. Authors can discuss the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, the management of this condition (non-surgical and exercises) needs mentioning.
Response: The below information will be added in the manuscript.
Further case-control studies are required to understand the role of the dentistry profession as a risk factor for the development of CTS are needed.
During training years, emphasis should be on the potential role of the dental profession in the development of CTS and other musculoskeletal disorders. There is a need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimize the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier, and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS.
Many conditions like systemic neurologic disorders (motor neuron disease, multiple sclerosis, and hereditary neuropathy), cervical spine disorders (cervical spondylotic myelopathy, cervical radiculopathy, and syringomyelia), tumors (Pancoast tumors, benign peripheral nerve tumors, malignant peripheral nerve sheath tumors, intraneural ganglia), inflammatory and autoimmune disorders.
The management of CTS includes conservative methods like wrist splinting in the neutral position at night, analgesics, corticosteroid injections, and nerve and tendon gliding exercises with varying degrees of results. Also, the carpal tunnel can be surgically decompressed to relieve the symptoms when there is a lack of response to the above. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Competing Interests: Nil Close
Report a concern

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 08 Mar 2023

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 20 Jul 23	read	read
Version 1 08 Mar 23	read	read

Dileep Nag Vinnakota, Narayana Dental College, Nellore, India

Rekhalakshmi Kamatham, Narayana Dental College, Nellore, India
Y. Ravi shankar Reddy, King Khalid University, Abha, Saudi Arabia

Comments on this article

All Comments(0)

Add a comment

Browse by related subjects

Back to all reports

Reviewer Report

9 Views

26 Jul 2023 | for Version 2

Dileep Nag Vinnakota, Department of Prosthodontics, Narayana Dental College, Nellore, Andhra Pradesh, India

Rekhalakshmi Kamatham, Department of Paedodontics and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh, India

9 Views Cite this report Responses(0)

Approved

The revisions made by the authors satisfactorily address our comments, and based on their efforts, I recommend approving the article for indexing.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Implantology, Full mouth rehabilitation

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

7 Views

20 Jul 2023 | for Version 2

Y. Ravi shankar Reddy, Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Aseer Province, Saudi Arabia

7 Views Cite this report Responses(0)

Approved

I believe the authors have effectively responded to the reviewers' comments in the revised manuscript, so I have no additional remarks to add.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Musculosketal Rehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

8 Views

19 Jun 2023 | for Version 1

Y. Ravi shankar Reddy, Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Aseer Province, Saudi Arabia

8 Views Cite this report Responses(1)

Approved With Reservations

Title: Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel.

Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Musculosketal Rehabilitation

Respond to this report

Responses (1)

Author Response

20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

We thank your efforts in reviewing the manuscript. Below are the responses for your comments.

Query: Provide a clear rationale for conducting the study and highlight the gap in the existing literature that the study aims to address.
Response: We added the following information: Data pertaining to the pooled prevalence of CTS and associated risk factors is lacking among dental healthcare personnel.

Query: Clearly define the inclusion and exclusion criteria for the selection of studies to ensure transparency and reproducibility.
Response: we have revised as follows: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

Query: Discuss the methods used for data extraction and risk of bias assessment in more detail, including the specific items evaluated in the risk of bias assessment tool.
Response: Revised the information as below:
Two review authors independently performed the data extraction. Information that was collected was authors, year of publication, country, type of dental personnel (Dentist, dental auxiliary or Mixed population), age and sex distribution, age, sex and clinical experience distribution with respect to the distribution of CTS, sample size, number of participants with CTS, method of diagnosis used (self-reported, clinical examination, or NCS), the sex distribution of CTS and risk of bias.
The first four questions (representative target population and sampling frame, random selection and non-response bias) assessed the external validity and the later five questions (participant or proxy data collection, acceptable case definition, validity and reliability of the instrument, similar data collection for all participants and specifying the numerators and denominators) assessed the internal validity of the study. All the questions were rated as low or high risk.

Query: Address the high level of heterogeneity among the included studies and discuss potential reasons for this heterogeneity. Explore possible sources of variation, such as differences in study design, participant characteristics, diagnostic methods, or geographic location.
Response: We attempted to explore the reasons for heterogeneity using sub-group analysis. The nature of the study design was same for all the studies. With respect to participant characteristics, we analysed based on the type of dental health care personnel which also showed high heterogeneity. Similar, was the case with geographic location. With respect to type of diagnosis, clinical examination showed lower levels of heterogeneity (<50%) than other modalities of diagnosis. However, the number of studies that used clinical examination were less (n=5).

Query: Provide a more comprehensive discussion of the limitations of the study, including the potential impact of publication bias, language restriction, and the quality of the included studies.
Response: Added the following information: Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standard could have caused considerable heterogeneity.

Query: Discuss the implications of the findings in more depth, including the potential impact of CTS on the quality of life, functional disability, and productivity of dental healthcare personnel.
Response: Added the following information: Implications of CTS can be at an individual, family or workplace level. Symptoms like pain, numbness, tingling and weakness in the hand and fingers can lead to significant functional disability to the dental personnel while performing the dental procedures. There by substantially affecting the individuals’ quality of life in performing daily activities and decreased productivity at workplace leading to loss of work, work place absenteeism along with financial losses. Indirectly, employers can face decreased productivity and loss of time in hiring new professionals. This can affect the overall productivity. Moreover, CTS can have a profound impact on the outside of the work, affecting simple tasks like writing, typing and grasping objects which may become challenging and be a limitation in their professional and personal activities alike.

Query: Consider the potential confounding factors or interactions that could influence the relationship between CTS and dental healthcare personnel, such as the duration of practice, specific dental procedures performed, or the use of ergonomic interventions.
Response: We agree with reviewers about the role of potential confounders. We have included the data specific to age and clinical experience with respect to CTS. However, data on other factors like type of dental procedures and use of ergonomic interventions have not been reported in relation to the CTS prevalence among the included studies. It is crucial for further research to account for these confounding factors and assess their relationship between CTS and dental healthcare personnel.

Query: Provide recommendations for future research based on the identified limitations and gaps in knowledge. Discuss the need for studies with larger sample sizes, more rigorous study designs, and standardized diagnostic criteria.
Response: Added information as below:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of dental profession as risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.

Query: Discuss the practical implications of the findings and potential interventions that can be implemented to reduce the risk of CTS among dental healthcare personnel. Consider the development of guidelines for ergonomic practices, workload management, and education on early detection and prevention of CTS.
During training years, emphasis should be on the potential role of dental profession in the development of CTS and other musculoskeletal disorders. There is need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimise the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.
Query: Ensure that the conclusion aligns with the findings of the study and emphasizes the key takeaways for researchers, clinicians, and policymakers.
Response: Future studies should explore the relationship between various potential risk factors and CTS. There is a need to develop and incorporate guidelines for the prevention of work-related musculoskeletal disorders into the training curriculum. Continuing dental education programs for the prevention of musculoskeletal disorders need to be conducted for the benefit of dental health care personnel.

Query: Consider the broader implications of the study findings, such as the potential impact on healthcare policy, occupational health and safety regulations, and professional training programs for dental healthcare personnel.
Response: Findings of this review highlight the potential impact of CTS among dental healthcare personnel. Policymakers need to ensure the development and implementation of the guidelines for the prevention of work-related musculoskeletal disorders and the incorporation of the same into the curriculum. Occupational Safety and Health Administration guidelines on the prevention of work-related musculoskeletal disorders have elements like management support, involvement of staff, training, identification of problems, early reporting, solutions to control hazards and evaluation. It should also emphasize the importance of the number of patients seen and attended, periodic breaks, task rotation, workflow and workload in the prevention of musculoskeletal disorders.

Query: Finally, acknowledge any limitations of the study not previously discussed and provide suggestions for further research in the field of CTS among dental healthcare personnel.
Response: The information below was added:
Further large high-quality studies using clinical examination for the identification of CTS among a representative sample of dental health care personnel using STROBE guidelines are required for calculating robust prevalence estimates. A larger sample would allow for a more representative distribution of demographic and professional characteristics, enabling researchers to explore potential subgroups that may be more susceptible to CTS. Also, a larger sample size would provide more statistical power to detect significant associations and to examine the effects of potential confounding factors. Case control studies are required to understand the role of the dental profession as a risk factor for the development of CTS. Studies can use self-reported questionnaires to screen potential participants following which a clinical examination using various tests need to be adopted to diagnose CTS. Furthermore, adapting standardized, validated diagnostic criteria for CTS across studies would facilitate more apt comparisons of different studies and enhance the reliability of the study findings.
High heterogeneity among the included studies, inclusion of only studies that were reported in English, publication bias, lack of age specific estimates, and variations in the assessment of CTS are some of the limitations. Publication bias was due to less precise studies with high prevalence estimates which could have distorted the overall estimates. Language bias due to the inclusion of studies that were reported in English could have over or under-estimated the overall pooled estimates. Although, most of the studies had low risk of bias, the lack of acceptable diagnostic standards could have caused considerable heterogeneity.

View more View less

Competing Interests

Nil

Back to all reports

Reviewer Report

27 Views

24 Mar 2023 | for Version 1

Dileep Nag Vinnakota, Department of Prosthodontics, Narayana Dental College, Nellore, Andhra Pradesh, India

Rekhalakshmi Kamatham, Department of Paedodontics and Preventive Dentistry, Narayana Dental College, Nellore, Andhra Pradesh, India

27 Views Cite this report Responses(1)

Approved With Reservations

The authors can mention the keywords separately as MeSH words and alternate words employed for the search.
The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practised in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.
Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?

Results:

It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female, so that the readers can easily depict the side which is favoured.
Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs explanation regarding the precision of individual studies.
Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after removal of studies with high prevalence like Prasad et al (2017).

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly

References

1. MacDermid JC, Wessel J: Clinical diagnosis of carpal tunnel syndrome: a systematic review.J Hand Ther. 2004; 17 (2): 309-19 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Implantology, Full mouth rehabilitation

Respond to this report

Responses (1)

Author Response

20 Jul 2023

Kalyana Pentapati, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India

Thank you for the effort and time take in reviewing this manuscript. Below are our responses to your comments.

Reviewer 1:
I have gone through the meta-analysis sent for peer review. The topic seems interesting, but there are lot of flaws which are of concern. I have mentioned the possibilities of changing the manuscript section wise.

Title: The authors have mentioned the title as “Meta-analysis of the prevalence of carpal tunnel syndrome among dental health care personnel”. I feel the title can be improved as “Prevalence of carpal tunnel syndrome among dental health care personnel worldwide - A systematic review and meta-analysis”

Response: We will edit the same in our manuscript “Worldwide prevalence of carpal tunnel syndrome among dental health care personnel - A systematic review and meta-analysis”

Introduction: The need for the study has been focused by the authors properly. However, can elaborate on the clinical diagnosis of the condition (including the sensitivity and specificity of the tests), and a note on the differential diagnosis. A systematic review is also published on the diagnosis of this condition. This part is important as it has a link with the way the authors can mold the quality of the present systematic review.

Response: Thank you for your valuable insight. We had gone through MacDermid and Wessel to understand the value-added points. They concluded that the primary limitation of establishing a gold standard diagnosis for CTS. This difficulty, combined with methodologic flaws, made interpretation difficult. Also, there was no guarantee that these choices increased the validity of our results. It was also stated that we should not consider the findings of this review to be conclusive concerning the value of clinical tests in the diagnosis of CTS. Furthermore, a systematic review requires that issues be addressed using specific and documented methods. Therefore, discussions on why certain tests may be better in specific situations or relevant in different stages of CTS are beyond the scope of this review.
Our review focussed on the burden of disease (CTS) among dental health professionals which was by pooling the estimates that have been reported from the literature. Various methods are available in the literature for the diagnosis of CTS which are broadly categorized as self-reported, clinical, and nerve conduction studies. All these tests have their own advantages and limitations that are discussed by the authors of these primary studies.

Methodology: Many sections are poorly written.
Query: The authors can mention the keywords separately as MeSH words and alternate words employed for the search.

Response: MeSH words are only specific for Pubmed. We have used All fields option for all the databases and have not restricted our search to title, abstract and keywords search. Based on our previous review experience on musculoskeletal disorders, we noticed that few studies that reported prevalence estimates of musculoskeletal disorders have reported carpal tunnel syndrome. If we restrict our search to title, abstract and keywords, these studies would be missed during the first stage of screening. We will reframe the sentence as search terms instead of keywords in the manuscript.

Query: The inclusion and exclusion criteria are not proper. The authors can consider only those studies that have employed nerve conduction tests, instead of considering those with self-report. There are definite chances of bias, if the self-reported measures are considered for diagnosis. Also many factors like number of years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel all play a key role on prevalence. The authors did not take any step to cut down the effect of confounding factors in their criteria for inclusion.

Response: There is no consensus or gold standard for the diagnosis of carpal tunnel syndrome. Nerve conduction studies are a useful tool and can be used as complementary methods with clinical examination in the assessment of CTS. Use of such methods in epidemiological surveys is quite challenging as it is costly, requires trained personnel to perform and interpret and cannot be used alone for the diagnosis of CTS. Hence, there were many attempts to develop self-reported measures and clinical examination for the diagnosis of CTS. Self-reported measures like boston carpal tunnel questionnaire has been used widely and was shown to have acceptable validity and reliability in many previous studies. We agree that there were will be bias, hence we reported the estimates of CTS as per the diagnostic method used in the primary studies.

We have revised the sentence: Studies written in English that reported the prevalence of CTS using self-reported or clinical tests or NCS or where the prevalence could be determined were included. Studies reported as letters, commentaries, and short communications were excluded.

We agree with reviewers that there are many factors (years practiced in dentistry, number of working hours, the knowledge of ergonomics, and age of the dental personnel) on the prevalence estimates. The main aim of this review was to quantify the prevalence estimates obtained from the published literature. To look at these factors that may have the effect of confounding, it is imperative that published literature reports that prevalence estimates as per age groups, work experience, level of ergonomics, etc. We have reviewed the included studies and extracted data on age, clinical experience, and gender distribution as per the CTS distribution.

Response: We will include the information below in the manuscript.

Based on the data from the included studies, age estimates with respect to CTS and No CTS was reported by only six studies. Studies that reported age as categorical data could not be analysed as there was no similarity in the categories used (Table 2). Three studies reported age as continuous variable. Meta-analysis showed that there was no significant difference in the age between CTS and No CTS groups (SMD: 0.1; 95%CI: -0.17 – 0.38) (figure 3).

Image 1; Image 2

A total of seven studies reported clinical experience which was either continuous (n=3) or categorical (n=4). Meta-analysis showed that there was no significant difference in the mean clinical experience between the groups (SMD: -0.03; 95%CI: -0.31 – 0.24) (Figure 5). Categorical data on clinical experience was categorized as < 10 years and > 10 years for analysis. Meta-analysis showed no significant difference in the pooled estimates between different levels of clinical experience (OR: 0.76; 95%CI: 0.39-1.47) (Figure 6).

Image 3; Image 4

Query: Under extraction of data, in text, the authors have mentioned that ‘information regarding country of study’, but in the table the authors have considered only continent.
Response: Yes. We have collected the information on country. However, country wise estimates were not feasible. Hence, we pooled the estimates as per the continent.

Query: Under risk of bias assessment, the authors have mentioned that risk was evaluated using a nine-item questionnaire. The authors have to elaborate the items in a tabular form along with the total scores obtained by individual studies. Need to mention the reason for not considering the STROBE guidelines for evaluation? I think they can add this part also.
Response: Thank you for your comments. We will incorporate the item-wise scores for individual studies. The questionnaire used for quality assessment was validated and primarily developed for the assessment of risk of bias for systematic reviews on prevalence studies. STROBE guidelines are primarily intended as a checklist for reporting cross-sectional studies. The valid overall risk of bias scores cannot be computed so that studies can be rated as high or low risk of bias from STROBE guidelines. Hence, it was not used in this study.

Image 5

Query: Under statistical analysis, the authors did not mention the test employed for the publication bias. Is it Begg and Egger test?
Response: We have used Fail-Safe N analysis using the Rosenthal approach. We will add this information also in the manuscript.
Statistical analysis: Publication bias was assessed using a funnel plot and Fail-Safe N analysis using the Rosenthal approach and Egger regression test.
Publication bias: Egger Regression Test for Funnel Plot Asymmetry showed asymmetry (Z=2.187; P=0.029).

Query: It is clearly evident from Table 1 that the prevalence is more in studies that have diagnosed the condition using self-reported measures. The type of dental health care personnel also cannot be combined; the work done by dentists is different from dental assistants. The mean age as mentioned in the review is in the range of 21-50 years, which is too long. All these have an influence on the overall estimate mentioned.
Response: Yes, we agree with the reviewer that self-reported measures have yielded higher estimates and we have reported the estimates as per the diagnostic criteria used in the studies. We also agree with the fact that type of dental health care personnel cannot be combined as all have different range of work but all these personnel do activities that requires repetitive movements, firm grasp, and fine tactile movements with prolonged static postures. Many studies which were included in this review have included all types of dental health personnel. Studies that reported prevalence separately were captured separately. In our review, we have mentioned the estimates as per the type of healthcare personnel. We understand that all these factors along with age and clinical experience have potential influence. This review is focussed on the burden of CTS among these dental health care personnel.

Query: Clarity of the forest plot showing gender differences is not clear. The authors need to mention the sides as male and female so that the readers can easily depict the side which is favoured.
Response: We will edit the figure in the manuscript as per your recommendation.

Image 6

Query: Under publication bias, the authors did not explain about the symmetry of the funnel plot. What is inverse standard error? Also, the reason for selecting the inverse standard error needs mentioning. The scatter plot needs an explanation regarding the precision of individual studies.
Response: We will add the following details to the manuscript.
Inverse standard error in the y-axis depicts the precision of the studies. It helps in identifying the studies with lower precision which will be distributed at the bottom. Inverse standard error was selected as there was no inversion required when compared to plots that use standard error in the y-axis where studies with large sample sizes and lower standard error are placed at the top of the graph. The plot showed asymmetry where in large studies showed higher precision and lower prevalence estimates whereas smaller studies had lower precision and higher prevalence estimates.

Query: Under sensitivity analysis, the authors need to mention the outliers and the explanation of difference in the overall estimate after the removal of studies with high prevalence like Prasad et al (2017).
Response: We performed a sensitivity analysis using Leave -one out method. The prevalence estimate marginally decreased to 13% after the removal of Prasad et al. We will add this information in the manuscript.

Query: Discussion is not enough. Authors can discuss the importance of case-control studies to know whether dentists are really more prone to this condition compared to the normal population. Authors can discuss the ergonomics to prevent these conditions. Can discuss about differential diagnosis of this condition and discuss about other neurologic, musculoskeletal and vascular conditions that have similar symptoms as carpal tunnel syndrome. Also, the management of this condition (non-surgical and exercises) needs mentioning.
Response: The below information will be added in the manuscript.
Further case-control studies are required to understand the role of the dentistry profession as a risk factor for the development of CTS are needed.
During training years, emphasis should be on the potential role of the dental profession in the development of CTS and other musculoskeletal disorders. There is a need for the development and implementation of preventive strategies for early detection and prevention of CTS. Comprehensive preventive strategies like workplace postural requirements and adoption of ergonomic postures, use of ergonomically designed instruments and equipment to reduce strain on the hand and wrist, the importance of intermittent breaks between patients, an alternation between the activities, keeping wrists in a neutral position, strengthening and stretching daily which aid in alleviating the muscular tension and promote blood circulation, minimize repetitive movements and management of patient flow can be incorporated into the curriculum during training years to prevent or minimize the onset of musculoskeletal disorders. Regular monitoring and evaluation of musculoskeletal disorders need to be mandated for high-risk individuals. Workplace-associated CTS must be identified earlier, and care should be exercised on the prevention and progression of the development of CTS. Active referral should be initiated by the employer who is at risk of development of CTS. It is important for the dental health care professional to be aware of the symptoms of CTS.
Many conditions like systemic neurologic disorders (motor neuron disease, multiple sclerosis, and hereditary neuropathy), cervical spine disorders (cervical spondylotic myelopathy, cervical radiculopathy, and syringomyelia), tumors (Pancoast tumors, benign peripheral nerve tumors, malignant peripheral nerve sheath tumors, intraneural ganglia), inflammatory and autoimmune disorders.
The management of CTS includes conservative methods like wrist splinting in the neutral position at night, analgesics, corticosteroid injections, and nerve and tendon gliding exercises with varying degrees of results. Also, the carpal tunnel can be surgically decompressed to relieve the symptoms when there is a lack of response to the above. Early diagnosis will help in initiating early interventions like medication, splinting, and changes in daily activities and can be relieved without surgical interventions. Therefore, a multi-pronged approach with ergonomic guidelines, workload management strategies, and health education and prevention can significantly reduce the risk of CTS among dental personnel and enhance their occupational well-being.

View more View less

Competing Interests

Nil

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. ZakerJafari HR, YektaKooshali MH: Work-Related Musculoskeletal Disorders in Iranian Dentists: A Systematic Review and Meta-analysis. Saf. Health Work. 2018; 9(1): 1–9. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. Leggat PA, Kedjarune U, Smith DR: Occupational health problems in modern dentistry: A review. Ind. Health. 2007; 45(5): 611–621. PubMed Abstract | Publisher Full Text

[3] 3. Puriene A, Janulyte V, Musteikyte M, et al.: General health of dentists. Literature review. Stomatologija. 2007; 9(1): 10–20. PubMed Abstract

[4] 4. Hayes MJ, Cockrell D, Smith DR: A systematic review of musculoskeletal disorders among dental professionals. Int. J. Dent. Hyg. 2009; 7(3): 159–165. Publisher Full Text

[5] 5. Shams-Hosseini NS, Vahdati T, Mohammadzadeh Z, et al.: Prevalence of Musculoskeletal Disorders among Dentists in Iran: A Systematic Review. Mater. Sociomed. 2017; 29(4): 257–262. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Chenna D, Pentapati KC, Kumar M, et al.: Prevalence of musculoskeletal disorders among dental healthcare providers: A systematic review and meta-analysis. F1000Res. 2022; 11: 1062. Publisher Full Text

[7] 7. Lietz J, Kozak A, Nienhaus A: Prevalence and occupational risk factors of musculoskeletal diseases and pain among dental professionals in Western countries: A systematic literature review and meta-analysis. PLoS One. 2018; 13(12): e0208628. PubMed Abstract | Publisher Full Text | Free Full Text

[8] 8. Spahn G, Wollny J, Hartmann B, et al.: Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part II. Occupational risk factors. Z. Orthop. Unfall. 2012; 150(5): 516–524. PubMed Abstract | Publisher Full Text

[9] 9. Maghsoudipour M, Hosseini F, Coh P, et al.: Evaluation of occupational and non-occupational risk factors associated with carpal tunnel syndrome in dentists. Work. 2021; 69(1): 181–186. PubMed Abstract | Publisher Full Text

[10] 10. Becker J, Nora DB, Gomes I, et al.: An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Clin. Neurophysiol. 2002; 113(9): 1429–1434. PubMed Abstract | Publisher Full Text

[11] 11. Pourmemari MH, Viikari-Juntura E, Shiri R: Smoking and carpal tunnel syndrome: a meta-analysis. Muscle Nerve. 2014; 49(3): 345–350. PubMed Abstract | Publisher Full Text

[12] 12. Anton D, Rosecrance J, Merlino L, et al.: Prevalence of musculoskeletal symptoms and carpal tunnel syndrome among dental hygienists. Am. J. Ind. Med. 2002; 42(3): 248–257. PubMed Abstract | Publisher Full Text

[13] 13. Berdouses E, Katsantoni A, Andrikoula T, et al.: Work-Related Musculoskeletal Disorders among Greek Dentists - A Nationwide Survey. Dent. Res. Oral Heal. 2020; 03(04): 169–181. Publisher Full Text

[14] 14. Alhusain FA, Almohrij M, Althukeir F, et al.: Prevalence of carpal tunnel syndrome symptoms among dentists working in Riyadh. Ann. Saudi Med. 2019; 39(2): 104–111. PubMed Abstract | Publisher Full Text | Free Full Text

[15] 15. Bou Jaoude S, Naaman N, Nehme E, et al.: Work-Related musculoskeletal pain among lebanese dentists: An epidemiological study. Niger. J. Clin. Pract. 2017; 20(8): 1002–1009. PubMed Abstract | Publisher Full Text

[16] 16. Lalumandier JA, McPhee SD, Riddle S, et al.: Carpal tunnel syndrome: Effect on Army dental personnel. Mil. Med. 2000; 165(5): 372–378. PubMed Abstract | Publisher Full Text

[17] 17. Pentapati K, Chenna D, Kumar M, et al.: Prevalence of Carpal Tunnel Syndrome among Dental Health Care Providers-Systematic Review Protocol.2022. Publisher Full Text

[18] 18. Hoy D, Brooks P, Woolf A, et al.: Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J. Clin. Epidemiol. 2012; 65(9): 934–939. PubMed Abstract | Publisher Full Text

[19] 19. Pentapati K, Chenna D: Pooled prevalence of Carpal Tunnel syndrome among dental health care providers. [Dataset]. Mendeley Data. 2023; V2. Publisher Full Text

[20] 20. Ravisankar A, Thenmozhi MS: Awareness, knowledge, and prevalence of carpal tunnel syndrome among dental students in Saveetha Dental College. Drug Invent. Today. 2020; 14(3): 151–154.

[21] 21. Conrad JC, Conrad KJ, Osborn JB: A short-term, three-year epidemiological study of median nerve sensitivity in practicing dental hygienists. J. Dent. Hyg. 1993; 67(5): 268–272. PubMed Abstract

[22] 22. Scoggins KM, Campbell RM: Impact of carpal tunnel education on changing dental hygienists knowledge, risk behaviors, symptoms and functional performance. Work. 1995; 5(4): 243–254. PubMed Abstract | Publisher Full Text

[23] 23. Liss GM, Jesin E, Kusiak RA, et al.: Musculoskeletal problems among Ontario dental hygienists. Am. J. Ind. Med. 1995; 28(4): 521–540. PubMed Abstract | Publisher Full Text

[24] 24. Nakladalova M, Fialova J, Korycanova H, et al.: State of health in dental technicians with regard to vibration exposure and overload of upper extremities. Cent. Eur. J. Public Health. 1995; 3 Suppl: 129–131. PubMed Abstract

[25] 25. Rice VJ, Nindl B, Pentikis JS: Dental workers, musculoskeletal cumulativetrauma, and carpal tunnel syndrome: Who is at risk? a pilot study. Int. J. Occup. Saf. Ergon. 1996; 2(3): 218–233. Publisher Full Text

[26] 26. Åkesson I, Johnsson B, Rylander L, et al.: Musculoskeletal disorders among female dental personnel--clinical examination and a 5-year follow-up study of symptoms. Int. Arch. Occup. Environ. Health. 1999; 72(6): 395–403. PubMed Abstract | Publisher Full Text

[27] 27. Hamann C, Werner RA, Franzblau A, et al.: Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J. Am. Dent. Assoc. 2001; 132(2): 163–170. PubMed Abstract | Publisher Full Text

[28] 28. Werner RA, Hamann C, Franzblau A, et al.: Prevalence of carpal tunnel syndrome and upper extremity tendinitis among dental hygienists. J. Dent. Hyg. 2002; 76(2): 126–132. PubMed Abstract

[29] 29. Werner RA, Franzblau A, Gell N, et al.: Prevalence of upper extremity symptoms and disorders among dental and dental hygiene students. J. Calif. Dent. Assoc. 2005; 33(2): 123–131. PubMed Abstract

[30] 30. Mamatha Y, Gopikrishna V, Kandaswamy D: Carpal tunnel syndrome: survey of an occupational hazard. Indian J. Dent. Res. 2005; 16(3): 109–113.

[31] 31. Cherniack M, Brammer AJ, Nilsson T, et al.: Nerve conduction and sensorineural function in dental hygienists using high frequency ultrasound handpieces. Am. J. Ind. Med. 2006; 49(5): 313–326. PubMed Abstract | Publisher Full Text

[32] 32. Greathouse DG, Root TM, Carrillo CR, et al.: Clinical and electrodiagnostic abnormalities of the median nerve in dental assistants. J. Orthop. Sports Phys. Ther. 2009; 39(9): 693–701. PubMed Abstract | Publisher Full Text

[33] 33. Haghighat A, Khosrawi S, Kelishadi A, et al.: Prevalence of clinical findings of carpal tunnel syndrome in Isfahanian dentists. Adv. Biomed. Res. 2012; 1(1): 13. PubMed Abstract | Publisher Full Text | Free Full Text

[34] 34. Shaffer SW, Moore R, Foo S, et al.: Clinical and electrodiagnostic abnormalities of the median nerve in US Army Dental Assistants at the onset of training. U.S. Army Med. Dep. J. 2012; 72–81. PubMed Abstract

[35] 35. Ehsan MA, Ehsan S, Arshad HS: Frequency of Carpal Tunnel Syndrome in Dentists Working in Government Hospitals of Lahore. Int. J. Sci. Res. 2016; 5(5): 1672–1675.

[36] 36. Borhan Haghighi A, Khosropanah H, Vahidnia F, et al.: Association of dental practice as a risk factor in the development of carpal tunnel syndrome. J. Dent. (Shiraz, Iran). 2013; 14(1): 37–40.

[37] 37. Munirah M, Normastura A, Azizah Y, et al.: Prevalence of Probable Carpal Tunnel Syndrome and itsAssociated Factors among Dentists in Kelantan. Int. J. Collab. Res. Intern. Med. Public Heal. 2014; 6(8): 247–259.

[38] 38. Pai MB, Shenoy R, Rao A, et al.: Symptoms of Carpal Tunnel Syndrome in a dental work force of a developing country. Int. J. Adv. Res. 2014; 2(2): 87–94.

[39] 39. Ahmed KA, Siddiqui AZ, Ahmed MR, et al.: Prevalence of carpel tunnel syndrome in the dentists working in Karachi. Pakistan Oral Dent J. 2014; 34(4): 588–591.

[40] 40. Hodacova L, Sustova Z, Cermakova E, et al.: Self-reported risk factors related to the most frequent musculoskeletal complaints among Czech dentists. Ind. Health. 2015; 53(1): 48–55. PubMed Abstract | Publisher Full Text | Free Full Text

[41] 41. Nurfarah Wahidah MN, Nurul SN, Munirah MANAR, et al.: Probable carpal tunnel syndrome and its coping Hospital Universiti Sains Malaysia. J. Sch. Dent. Sci. USM. 2016; 11(2): 31–38.

[42] 42. Prasad DA, Appachu D, Kamath V, et al.: Prevalence of low back pain and carpal tunnel syndrome among dental practitioners in Dakshina Kannada and Coorg District. Indian J. Dent. Res. 2017; 28(2): 126–132. PubMed Abstract | Publisher Full Text

[43] 43. Inbasekaran D, Sankari M, Nambi G: Prevalence of carpal tunnel syndrome among dentists in Chennai, India. Drug Invent. Today. 2018; 10(3): 3262–3265.

[44] 44. De JeSUS LC, Tedesco TK, MaceDo MC, et al.: A self-report joint damage and musculoskeletal disorders data among dentists: a cross-sectional study. Minerva Stomatol. 2018; 67(2): 62–67. PubMed Abstract | Publisher Full Text

[45] 45. Meisha DE, Alsharqawi NS, Samarah AA, et al.: Prevalence of work-related musculoskeletal disorders and ergonomic practice among dentists in Jeddah, Saudi Arabia. Clin. Cosmet. Investig. Dent. 2019; Volume 11: 171–179. PubMed Abstract | Publisher Full Text | Free Full Text

[46] 46. Harris ML, Sentner SM, Doucette HJ, et al.: Musculoskeletal disorders among dental hygienists in Canada. Can. J. Dent. Hyg. 2020; 54(2): 61–67.

[47] 47. Al Muraikhi SSHS, Rahimi KEME, Shetty AC: Prevalence of clinical signs of carpel tunnel syndrome among dentist in Qatar. Eur. J. Mol. Clin. Med. 2020; 7(7): 450–456.

[48] 48. Macdonald G, Robertson MM, Erickson JA: Carpal tunnel syndrome among California dental hygienists. Dent. Hyg (Chic). 1988; 62(7): 322–327. PubMed Abstract

[49] 49. Osborn JB, Newell KJ, Rudney JD, et al.: Carpal tunnel syndrome among Minnesota dental hygienists. J. Dent. Hyg. 1990; 64(2): 79–85. PubMed Abstract

[50] 50. Conrad JC, Conrad KJ, Osborn JS: Median nerve dysfunction evaluated during dental hygiene education and practice (1986-1989). J. Dent. Hyg. 1991; 65(6): 283–288. PubMed Abstract

[51] 51. Conrad JC, Conrad KJ, Osborn JB: A short-term epidemiological study of median nerve dysfunction in practicing dental hygienists. J. Dent. Hyg. 1992; 66(2): 76–80. PubMed Abstract

[52] 52. Feng B, Chen K, Zhu X, et al.: Prevalence and risk factors of self-reported wrist and hand symptoms and clinically confirmed carpal tunnel syndrome among office workers in China: a cross-sectional study. BMC Public Health. 2021; 21(1): 57. PubMed Abstract | Publisher Full Text | Free Full Text

[53] 53. Hagberg M, Morgenstern H, Kelsh M: Impact of occupations and job tasks on the prevalence of carpal tunnel syndrome. Scand. J. Work Environ. Health. 1992; 18(6): 337–345. PubMed Abstract | Publisher Full Text

[54] 54. Atroshi I: Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA. 1999; 282(2): 153. Publisher Full Text

[55] 55. Andersen JH, Thomsen JF, Overgaard E, et al.: Computer use and carpal tunnel syndrome: a 1-year follow-up study. JAMA. 2003; 289(22): 2963–2969. Publisher Full Text

[56] 56. Lee IH, Kim YK, Kang DM, et al.: Distribution of age, gender, and occupation among individuals with carpal tunnel syndrome based on the National Health Insurance data and National Employment Insurance data. Ann. Occup. Environ. Med. 2019; 31(1): e31. PubMed Abstract | Publisher Full Text | Free Full Text

Meta-analysis of the prevalence of Carpal Tunnel Syndrome (CTS) among dental health care personnel

Abstract

Keywords

Introduction

Methods

Search strategy

Inclusion and exclusion criteria

Screening

Data extraction

Risk of bias assessments

Statistical analysis

Results

Figure 1. PRISMA flowchart.

Table 1. Characteristics of the included studies.

Prevalence

Figure 2. Forest plot showing the pooled prevalence of CTS.

Age

Sex

Figure 3. Forest plot showing the sex differences in the prevalence of CTS.

Geographic location

Table 2. Subgroup analysis of the pooled estimates of overall MSD.

Type of dental personnel

Method of diagnosis

Risk of bias

Publication bias

Figure 4. Funnel plot for publication bias.

Sensitivity analysis

Meta-regression

Figure 5. Meta-regression showing the time trends in the prevalence of CTS.

Discussion

Conclusion

Data availability

Underlying data

Reporting guidelines

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated