# Hand Joint Hypermobility among Dental Students--A Cross-Sectional Study
## 4 Discussion
### Strength and Limitations  
This study highlighted the worrisome prevalence of young individuals with hand joint hypermobility among a cohort of first-year dental students. It adopted a grading system specifically designed for dental professionals and was able to identify the severity of the participants' hypermobility, in contrast to the dichotomous pattern of other validated criteria [10; 57]. It also reinforced the need for multidisciplinary assessments, followed by appropriate interventions, conducted by occupational therapy and/or hand specialists. This study also had some important limitations. First, its cross-sectional nature reflected only one time point, and nothing can be ascertained on the progression of hand joint hypermobility. Studies in the literature have suggested a progressive decrease in hypermobility and hyperlaxity over time. As such, the current investigation can only be generalized to young individuals belonging to the same age group (i.e., the range between 21 and 27 years). To overcome the limitations derived from our cross-sectional design, we plan to conduct a standardized assessment of hand joint hypermobility on incoming classes of first-year dental students over an extended period. By implementing this repeated longitudinal assessment, possible trends and patterns of hypermobility may emerge over time and will contribute to more robust and generalizable findings. Furthermore, repeating the assessment on the same subjects over time will provide valuable insights into the natural progression of hypermobility, particularly within this specific population. Longitudinal studies also have the potential to identify risk factors that contribute to the development or progression of hand joint hypermobility among dental students. Factors such as ergonomics, workload, and specific dental procedures can be examined to understand their potential influence on the severity of hypermobility. Moreover, the relatively small sample size of the study (\(n=140\)) limits the generalizability and external validity of our findings. However, this assessment has now been incorporated in the dental curriculum for first-year dental students. Consequently, future studies employing a longitudinal design and standardized assessment tool will be able to validate these findings. In addition, our study relied on self-reported data on the participants' dominant hand, which limits the reliability of the findings. To enhance future study designs, it is recommended to validate self-reported data through means such as medical records or a clinical assessment, in which the students' actual performance on a manikin is observed. Next, the results of this study can only report the extent of hypermobility with no speculation on pain symptomatology. Future studies are needed to investigate pain and discomfort in individuals with peripheral joint hypermobility while performing functional dental tasks. Moreover, the present investigation utilized a hand screening assessment developed by an OT to assess dental students. As such, comparisons with other available studies in the literature that used different scoring systems (e.g., the Beighton score, Brighton criteria, or Horan Joint Mobility Index) may not be accurate. The hand screening assessment was adopted in our study because it was considered more pertinent for our cohort of dental students, as the finger joints, rather than elbow, knee, and trunk, are particularly crucial for daily performance tasks. In addition, even by adopting a standardized scoring system, the results would have been difficult to compare across the studies, due to the several recommended cut-off scores [58]. Moreover, the aim of this study was to assess the prevalence of joint hypermobility limited to the hand; therefore, a more comprehensive assessment was not needed. This study did not assess the contribution of ethnicity to the presence of hand joint hypermobility, which is known to represent a non-modifiable risk factor [4; 7].