A Survey of Left-Handed Dental Students

and Interns in Saudi Arabia

Sulieman S. Al-Johany, B.D.S., M.S.D., D.A.B.P., F.A.C.P.
Abstract: The purpose of this study was to survey left-handed (LH) dental students and interns concerning whether they face any
problems in their dental education or in their practice of dentistry. The questionnaires were distributed in four dental colleges in
different regions in Saudi Arabia. The questionnaire was comprised of sixteen questions to assess the following issues: demo-
graphic information, difficulties in dental school or dental practice due to left-handedness, preferred hand in performing different
dental procedures, and musculoskeletal complications. The study found that the percentage of LH dental students was around 7
percent (110 out of 1,660). More than half of these participants (n=56) reported that being LH is not a problem in general, while
when performing the required dental work, around 51 percent (n=56) agreed to having a problem. The majority (68 percent;
n=75) reported that they had a problem with having RH instructors, and 84.5 percent (n=93) responded that their institution is not
properly equipped to accommodate LH students. Only 34 percent (n=37) agreed that using facilities of an RH dentist may cause
musculoskeletal complications to an LH dentist. The results of this study suggest that dental schools should provide LH students
with appropriate equipment and a proper learning environment.
Dr. Al-Johany is Associate Professor, Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University.
Direct correspondence and requests for reprints to Dr. Sulieman Al-Johany, Department of Prosthetic Dental Sciences, College
of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545, Saudi Arabia; saljohany@hotmail.com.
Keywords: dental education, dental students, left-handed students, musculoskeletal complications, Saudi Arabia
Submitted for publication 6/15/11; accepted 3/12/12

D
entistry is a demanding profession requiring
concentration, precision, and skills.1 Suc-
cessful dental treatment depends on such
factors as the anatomy and location of teeth, selection
of a well-adapted instrument, proper angulations of
the instrument, and the proper position of the patient
and the dentist as well as manual skills.2 In dentistry,
as in many other professions, equipment and instru-
ments are manufactured to be used by right-handed
(RH) users.3-8 In the general population, the average
percentage of left-handed (LH) people ranges from 8
to 15 percent.9 About 11 percent of U.S. citizens are
LH (20 percent of men and 8 percent of women).10
The percentage has been found to be slightly less than
10 percent in dentists11 and around 9.3 percent in sur-
geons.12 Henderson et al.11 reported the prevalence of
self-reported sinistrality as 8.6 percent among dental
students and 17.2 percent among orthodontists com-
pared to 7.4 percent among the general population.11,13
In an older survey of dental students, Brown3 found
that one in twelve (8 percent) were LH.
Manual dexterity is defined as the ability to
integrate precision and speed with finely coordinated
movement of the arm, hand, and fingers.14 Brayer
et al. defined skill as proficiency that results from
training and practice.15 In dental schools, dental
procedures, techniques, chairs, and stations are
designed mainly for the RH students.1,2,5,6,16 Some
dental equipment manufacturers design dental chairs
especially for LH dentists or in a way that they can be
used by both RH and LH dentists with minor modi-
fications.3,4 Likewise, some of the dental instrument
manufacturers have started designing dental instru-
ments especially for LH dentists. The effect of being
left-handed on professional practice is a concern not
only in dentistry, but also in other fields of medicine
requiring hand skills like surgery.10,12,17-21
Dentists, and particularly general dentists, are
at high risk for development of musculoskeletal dis-
orders due to the high visual demands that result in
the adoption of a fixed posture.22 To work on a chair
designed for RH students was found uncomfortable
by 85.7 percent of the LH students in a study of forty-
two dental students (twenty-one RH and twenty-one
LH).2 In a study by Tezel et al.1 about musculoskel-
etal disorders in LH and RH Turkish dental students
(ninety-seven RH and twenty-four LH), they found
that LH students experienced more musculoskeletal
symptoms than RH students. LH students especially
suffered from more neck and shoulder pain when
compared with RH students.
Most if not all of the dental techniques and
procedures taught in dental schools are taught to
fit RH students.3-7 Carter and Triplett23 described a
technique for the successful administration of the
inferior alveolar nerve injection by an LH dentist.
There may be other techniques or procedures in
dentistry that also need to be modified to allow LH

January 2013  ■  Journal of Dental Education 105

 dental students to improve the quality of their work.
A literature review found no published data focusing
on the problems facing LH dental students in their
education in dental schools. The purpose of this study
was thus to survey LH dental students and interns
in Saudi Arabia concerning whether they face any
problems in their dental education or in their practice
of dentistry.
Methods
This study was registered as non-funded re-
search and approved by the College of Dentistry
Research Center in King Saud University (Registra-
tion No. NF2269). A paper-and-pencil questionnaire
was designed based on interviews with LH dentists
and review of the available literature on this topic.
The LH dentists interviewed were two students,
two interns, and two specialists with an age range
of twenty-three to thirty-six years; all of them were
still in practice. The interview was unstructured, and
no focus groups were used. Suggestions were taken
also from academic colleagues who have performed
survey studies but are not expert methodologists. The
questionnaire was developed based on all these com-
ments and suggestions. The questionnaire was then
pilot-tested with five LH dental students and interns
to ensure clarity and face validity and was finalized.
Face validity is a method used to estimate
whether a test appears to measure a certain criterion.
A test is considered to have face validity if it appears
to measure what it is supposed to measure. It could
be used to refer to the validity of observers who are
not expert in testing methodologies as was done in
this study. Face validity differs from content validity
but is closely related. Content validity depends on a
theoretical basis for assuming if a test is assessing all
domains of a certain criterion, and it requires more
extensive statistical tests than face validity, which
only requires an intuitive judgment and relates to
whether a test appears to be a good measure or not.24
The final questionnaire consisted of sixteen
questions that assessed the following: demographic
information (age, gender, institution, educational
level); any perceived difficulties due to being left-
handed in dental school and practice; preferred
hand in performing various dental procedures and
other activities; musculoskeletal complications; and
parents’ manual habits and any efforts to change the
use of the left hand. At the end, the participants were
asked for any additional comments.
106
The questionnaires were distributed to dental
students and interns in one private and three public
dental colleges in different regions in Saudi Arabia.
These dental schools were the College of Dentistry
in King Saud University (two campuses) and the
Riyadh Colleges for Dentistry and Pharmacy, both
in Riyadh (Central Region); the College of Dentistry
at the King Abdulaziz University in Jeddah (Western
Region); and the College of Dentistry at the Uni-
versity of Dammam in Dammam (Eastern Region).
The students and interns were asked to indicate their
preferred hand in performing dental procedures (self-
reporting), and questionnaires were given to the LH
students and interns only. Class and group leaders
helped to distribute the questionnaires to their LH
peers. The total number of students and interns was
recorded to determine the percentage of LH students
in each class and out of the total number. Only stu-
dents in their third year and above who were involved
in clinical dentistry courses were surveyed because
most of the survey questions were clinically oriented.
The collected data were analyzed with the
Statistical Package for the Social Sciences (SPSS
Inc., Chicago, IL; version 16.0). Descriptive sta-
tistics were used to summarize the responses, and
chi-square and independent proportional t-test were
used to compare differences. A p-value <0.05 was
accepted as significant.
Results
Of the 1,660 undergraduate dental students
and interns at the four dental schools in academic
year 2010-11, only 110 (6.6 percent) were found to
be LH. There was no significant difference in the
percentages of the LH respondents between the two
genders: 6.8 percent for male and 6.4 percent for
female (p=0.724). Of the 110 reported to be LH,
there were sixty-three male (57 percent) and forty-
seven female (43 percent). They ranged in age from
twenty-one to twenty-seven years and were on aver-
age twenty-four years of age (mean=23.7, standard
deviation=1.56). There was no significant difference
among the percentages of LH students and interns
at the four schools (p=0.236). There was at least
one LH student in all the schools and in all the class
levels. The highest percentage of LH students (14.3
percent) was found to be five in a class of thirty-five
students, while the lowest percentage (5.56 percent)
was found with only one student in a class of eighteen
students (Table 1).
Journal of Dental Education  ■  Volume 77, Number 1
 Table 2 shows the results of the participants’
responses to part of the questionnaire and the cor-
responding p-values. Of those respondents who re-
ported having musculoskeletal complications due to
the use of facilities of RH dentists, the most common
area with pain was the shoulder and neck. Figure 1
shows the percentage of the answers concerning the
area afflicted with pain among the participants. No
significant gender differences in the responses to this
question were found. Only 34.5 percent (n=38) were
purely LH, while 65.5 percent (n=72) were mixed
(using both right and/or left hand in performing some
dental procedures). Figure 2 shows the percentage of
the hand used in performing these dental procedures.
The majority of the subjects (74.5 percent; n=82)
used only their left hand in writing, 50.9 percent
(n=56) in sports, and 9.1 percent (n=10) only in
eating. The rest used either the right hand or both.
Table 3 shows the manual habits of the par-
ticipants’ parents. There were more LH mothers
compared to LH fathers, which was significant
(p=0.004). Around 61.8 percent (n=68) reported that
their parents tried to modify their habit to be RH when
they were young. It partially succeeded in 72 percent
(n=49) and failed with the rest, 28 percent (n=19).
Comments from respondents to the open-ended
questions showed that many of them had asked for
LH equipment not only in the clinic and laboratory,
but also in classrooms. Some participants stated the
need of LH teachers to teach them special techniques
for being left-handed. Other comments noted the
participants’ appreciation that this study was being
conducted.
Discussion
Surveys are procedures used to investigate
opinions, and a paper-and-pencil questionnaire can
be used to improve the response rate and the accuracy
of responses.25 Only a few data regarding LH dental
students were found in the literature.1,2,11,13,15,16,23 In
this study, the LH dental students and interns were
asked to express their opinions about various aspects
of learning and practicing dentistry.
The results of the survey showed that the
percentage of the LH students is 6.6 percent of the
total number of the students approached. This is
slightly less than the percentage reported by Brown3
and Henderson et al.11 among dental students; those
researchers reported 8 percent and 8.6 percent, re-
spectively, and 17.2 percent among orthodontists.
In the general population, the percentages ranged
from 8 to 15 percent.9 However, no information is

Table 1. Demographic data of participants in study

Left-Handed Participants

N % p-value

Age 21 8 7.3%
(left-handed n=110) 22 13 11.8%
23 19 17.3%
24 21 19.1%
25 17 15.5%
26 9 8.2%
27 3 2.7%
Did not indicate 20 18.2%
Gender Male (n=924) 63 6.8% 0.724
(total n=1660) Female (n=736) 47 6.4%
Institution King Saud University (n=452) 26 5.8% 0.236
(total n=1660) Riyadh Colleges of Dentistry and Pharmacy (n=613) 51 8.3%
King Abdulaziz University (n=469) 25 5.3%
University of Dammam (n=126) 8 6.3%
Educational level Undergraduate 81 73.6%
(left-handed n=110) Third year 25 22.7%
Fourth year 29 26.4%
Fifth year 27 24.5%
Intern 29 26.4%

January 2013  ■  Journal of Dental Education 107

 Table 2. Selected survey questions and participants’ responses with p-values
p-value
Question Agree Don’t Know Disagree Agree/Disagree

It is difficult for you to be left-handed. 41 (37.3%) 13 (11.8%) 56 (50.9%) 0.040

You have a problem in being left-handed to do the required
dental work. 56 (50.9%) 3 (2.7%) 51 (46.4%) 0.500
You have a problem with your instructors or supervisors in 75 (68.2%) 10 (9.1%) 25 (22.7%) 0.000
being left-handed and they are right-handed.
Your institution is properly equipped to accommodate you 9 (8.2%) 8 (7.3%) 93 (84.5%) 0.000
as left-handed.
You prefer to use a dental chair, unit, or station designed 93 (84.5%) 8 (7.3%) 9 (8.2%) 0.000
especially for a left-handed dentist.
You can use the devices manufactured to be used by 88 (80.0%) 11 (10.0%) 11 (10.0%) 0.000
right-hand dentists.
Being a left-handed dentist will affect your dental assistant’s 63 (57.0%) 19 (17.3%) 28 (25.5%) 0.000
ability or convenience to work.
Patient feels discomfort being treated by a left-handed dentist. 32 (29.1%) 42 (38.2%) 36 (32.7%) 0.559
You should write being a left-handed dentist in your CV. 37 (33.6%) 43 (39.1%) 30 (27.3%) 0.304
You will correct the habit of your children in the future if 34 (30.9%) 13 (11.8%) 63 (57.3%) 0.000
they show the habit of using their left hand.
A left-handed dentist using the facilities of a right-handed 37 (33.6%) 28 (25.5%) 45 (40.9%) 0.263
dentist can cause some musculoskeletal medical
complications.
Note: p-value <0.05 was considered significant.

available about the prevalence of left-handedness in
the general population of Saudi Arabia that could be
used as a reference figure.
Slightly more than one-third of the LH respon-
dents indicated that it is difficult to be LH in general.
In response to the question about how difficult it is
for LH students to perform the required dental pro-
cedures, the percentage increased to slightly more
than half of the group. This finding is consistent with
the results of Henderson et al.,11 who found that LH
dentists thought that left-handedness was a general
inconvenience. The finding points to the difficulties
LH individuals face, and these difficulties increase
when practicing dentistry.
When working with RH instructors, around
two-thirds of the respondents indicated that they had a
problem. This could be due to the difficulty of the RH
instructors to teach an LH student some techniques
that may require certain modifications or to adjust to
their LH station for the evaluation of their work. The
thoughts of RH instructors or mentors concerning
teaching LH dental students could be for the focus
of a future survey. In their comments, most of the LH
students complained that there were no clear instruc-
tions or materials to read either in the literature or in
dental textbooks that would help them to master the
required dental techniques. Some of them asked if
there is an LH instructor to teach the LH students.
Maybe it would be useful for dental schools to encour-
age qualified LH or mixed-handed specialist dentists
to provide special attention to LH students.
It is not surprising to find that most of the LH
respondents (84.5 percent) said their institution is not
equipped properly to accommodate them as LH den-
tal students. It is probably not easy for dental schools
to provide these needed modifications of the dental
chairs and laboratory stations. However, it could be
done.3,4 The same majority in my study asked for
dental chairs and stations designed especially for
LH dentists. This is in agreement with the results of
Kaya and Orbak that 85.7 percent of LH students felt
uncomfortable using dental chairs designed for RH
providers.2 In addition, a majority of the respondents
(80 percent) in my study agreed that they use devices
designed especially for RH. It is very important
for LH students to be familiar with the equipment
designed for RH. Someone may argue that teaching
a student to work in a comfortable LH environment
does not prepare them for the RH units present in
most dental practices.11 Still this finding should not
be used as a reason not to provide LH students with
convenient LH chairs and stations.

108 Journal of Dental Education  ■  Volume 77, Number 1

Figure 1. Percentage of left-handed participants’ responses regarding the area in which they felt pain

Figure 2. Percentage of left-handed participants’ responses regarding the hand they used in performing dental
procedures

If an LH dentist works on an RH dental chair, found convenient at the left of the chair.3 Kaya and
some modifications were found to be convenient Orbak2 reported that “the care their patients received
such as over-the-patient delivery (which may be could be improved by providing the opportunity for
unpopular with patients) and also the spittoon was LH dentists to work from the left side of the patient.”

January 2013  ■  Journal of Dental Education 109

 Table 3. The manual habits of participants’ parents
Father Mother

Number Percentage Number Percentage

Right-handed 94 88.7% 82 77.4%

Left-handed 8 7.5% 15 14.2%
Both hands 3 2.8% 8 7.5%
Don’t know 1 0.9% 1 0.9%
Did not indicate 4 3.6% 4 3.6%
p=0.004

Adusumilli et al.17 made many suggestions based on
their findings with LH surgeons that could also be
applied to LH dentists. These include having basic
sets of LH instruments available in the teaching
hospitals for medical students to minimize the incon-
venience associated with learning, the provision of
LH mentors, and other environmental modifications,
a simple website, a chapter in surgical textbooks, or a
pocket manual outlining the guidelines in performing
invasive and surgical procedures specifically for LH
medical students and surgery residents.
The convenience of dental assistants to assist
an LH dentist is an area of interest. The participants
in this survey were dental students who usually
work without the help of a dental assistant to do
four-handed dentistry in dental school. However, the
majority of them (57 percent) said being LH may af-
fect the ability or convenience of the dental assistant
to work. Dental assistant training programs should
include training to assist LH dentists.3 The opinions
of dental assistants about assisting LH dentists could
be obtained in future survey.
Surprisingly, one-third (31 percent) of the par-
ticipants said that they will change the habit of their
children in the future if they show LH preference.
This could be because of the difficulties facing being
left-handed, which they do not want their children
to face. This attitude can be expected in a dominant
RH world. It adds some responsibility for dental
educators to accommodate LH students without any
kind of differentiation than RH. Simply, it is not a
disability that needs correction.
The results of this survey showed that one-third
(33.5 percent) of the participants have musculoskel-
etal symptoms mainly in the neck and shoulder. This
finding is consistent with the results of Tezel et al.1
when they compared the musculoskeletal symptoms
of RH and LH dental students. The purpose of that
study was to find out the musculoskeletal disorders
between LH and RH dental students and concentrated
only on the position, location, and severity of the pain
without any other aspects of being LH in dentistry.
In my study, the questionnaire focused on being LH
in dentistry and the problems associated with being
LH in dental education and dental practice in general.
My findings were also in agreement with the
results by Henderson et al.,11 who found that fixed RH
units seemed to generate minor irritation to LH den-
tists. This could be explained by the inconvenience in
using RH dental chairs and stations. Canakci et al.16
reported that the average negative scaling and root
planing forces were significantly greater in LH den-
tists than in RH dentists. It could be that LH dentists
exert more efforts than RH dentists due to working
on an RH dental chair. This poor working condition
may cause musculoskeletal symptoms. The present
study results are consistent with this consideration.1
As stated by Tezel et al.,1 “The best ergonomic work-
ing principles should be taught to the students, and
dental schools should provide a comfortable working
environment. LH students should work on an LH de-
signed chair, and further study is required to identify
factors that will reduce the prevalence of symptoms
amongst those practicing general dentistry.”
Most of the participants reported being able to
use both hands in performing dental procedures. This
could be an advantage for them. This result was in
agreement with the findings by Henderson et al.11 that
there are many more mixed-handers than LH only
among dental students. Schmauder et al.26 found that
the strength of the sub-dominant hand-arm system is
inferior in RH subjects. Contrary to this, the differ-
ence in strength between the arms of an LH person
was hardly noticeable. In treatment of dental calculus,
Orbak et al.13 reported that the LH students were bet-
ter than the RH students when using reverse chairs.
The finding that 51 percent of the respondents
used their left hand in sports was consistent with

110 Journal of Dental Education  ■  Volume 77, Number 1

the results of studies in other professions, which
showed that around 45 percent of LH persons are left-
footed.27 Very few subjects (9 percent) used their left
hand when eating. This could be due to religious and
cultural reasons. In Saudi Arabia where the survey
was conducted, it is generally not acceptable to eat
with the left hand especially in public events.
The results of this study did not find significant
correlations between the parents’ preferred hand and
the students’ LH habit. There were more LH moth-
ers compared to LH fathers, which was significant,
but most of the parents were RH. LH mothers may
have more effect on their children to be LH than LH
fathers, but the explanation for this is beyond this
study’s purpose and author’s experience. However,
this could explain why many students (62 percent)
reported that their parents tried when they were
young to modify their habit to be RH.
Conclusions
This article has attempted to bring the attention
of the profession to this important issue as many LH
dental students face challenges. This problem seems
to be an issue in dental education worldwide. It raises
serious questions such as whether applicants for
admission to dental schools should be asked about
their preferred hand to allow the school to prepare
ahead of time the equipment needed for LH students.
Should it be mandatory for dental schools to provide
LH dental educators or mentors to teach LH dental
students? Shall this be included as part of the aca-
demic accreditation requirements? More research is
needed to answer these and related questions.
This study found that the prevalence of LH
students in this dental school population was around
7 percent. Dental schools should provide LH stu-
dents with needed equipment and a proper learning
environment. Expert senior LH dentists should help
junior LH dental students to learn techniques and
procedures used by left-handers. This could be done
by involving LH educators in dental education or
by publishing articles and reading materials for LH
dental students.
Acknowledgments
The author would like to thank Drs. Was-
seem Alzemei and Ahmad Farghal, King Abdulaziz
University, for distributing the questionnaire in
Jeddah; Dr. Aws AlRejay, Dammam University, for
distributing the questionnaire in Dammam; Drs.
January 2013  ■  Journal of Dental Education
Faleh AlShahrany and Abdulaziz AlHilal, King Saud
University, and Dr. Hadi Alamri, Riyadh Colleges of
Dentistry and Pharmacy, for distributing the question-
naire in Riyadh. Appreciation is also extended to
Mr. Nassr AlMaflehi for his help with the statistical
analysis as well as all the students and interns for
responding to the survey.
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Journal of Dental Education  ■  Volume 77, Number 1