Stress perception among dentists in Croatia

Introduction

Stress and burnout definitions

Stress is currently ubiquitous in the modern world and dentists are very susceptible to stress. In fact, dentistry is widely considered to be one of the most stressful of all health professions. Some studies suggest that dentists find their profession more stressful than other work, and that suicide, chemical addiction, burnout, and musculoskeletal problems may be the manifestations of this perception. Certain stressors can pose a serious threat to physical and mental well-being. One of the possible consequences of chronic work stress is occupational burnout [1]. In dentistry, chronic work stress and burnout have been identified as potential dangers to professional and private life of dentists [2, 3]. In most studies, burnout is measured using Maslach burnout inventory (MBI) [4], which recognizes three aspects of burnout, including emotional exhaustion (EE), depersonalization (D), and personal performance (PA). Burnout is defined as the syndrome of emotional exhaustion (EE) and cynicism that is common in people working with other people [4]. A systematic review by Amoafo et al. [5] examined significant factors associated with physicians’ burnout. General medicine and dentistry are similar in terms of practice and patients’ participation, and it is believed that dentists can experience a burnout due to many of the same factors.

Factors contributing to increased stress

Burnout seems to be associated with a shortfall in executive function or cognitive control [4], including working memory, planning, problem solving, and execution. Burnout by physicians and surgeons can affect the quality and safety of patient care, such as frequency of medical errors [5, 6], which are thought to be caused by effects on executive function. A recent study [9] of primary care dentists found that an increased PA sensation, and EE and DP levels were associated with higher level of anxiety in clinical situations reported by themselves, suggesting that reduced burnout may lead to improved decision-making and therefore, patients’ better outcomes. Dentists are heavily affected by burnout syndrome (BOS), and factors such as time and organizational problems related to existing activity requirements as well as interpersonal roles and their ambiguity, create and/ or encourage, among other things, an emotional exhaustion [10]. It has been documented that a dental office is perceived as a health profession, which generates the most anxiety [11]. Various other health risks are associated with dealing with dentistry, such as chronic musculoskeletal problems [13], transmission of infectious diseases [14-16], or injuries that increase overall stress level. In a study by Pozos Radillo [12], no correlation was found between variables, including male gender, age, weight, height, number of children, marital status, socio-economic level, length of service, work with an assistant, daily working hours, etc., employment, family interaction time, and housework. The association of females with high chronic stress has been accepted [12]. Main causes of stress were identified as time pressure [17-19], fear of unforeseen results, fear of patient dissatisfaction, and financial problems [20-22].

Coping mechanisms

Various unhealthy stress management mechanisms have been observed, and their frequency in the dental population is also a problem. In recent years, there has been a growing importance of problems related to the use of alcohol and illegal drugs by dentists [29-34]. Drinking and consumption of drugs by dentists and doctors is of concern not only for their health and well-being, but also for the safety of the patients they care for. Normal coping mechanisms, such as physical exercise, are known to positively correlate with the reduction of stress and long-term health problems [26, 35]. A significant proportion of dentistry graduates have been shown to question their original career choices [36] because the field is demanding, and occupational diseases have a significant impact on health. Musculoskeletal disorders, vision, and skin problems are among the most commonly reported health problems [37]. Students enrolling in dental programs are relatively unaware of health-related hazards of the dental profession [38]. The aim of the study was to investigate the subjective perception of stress in dentists, confirm known correlations between stress and various factors, such as gender, age, socioeconomic level, work seniority, and specialization as well as to examine the influence of various coping mechanisms in its manifestation.

Material and methods

The survey was taken by 432 respondents (female, 62.5%; male, 37.5%) (Table 1). The response rate among participants was 54%. The research was conducted through an electronic survey, which was sent via email to 800 addresses of actively working dentists in the Republic of Croatia. Participation in the survey was anonymous and voluntary, and all respondents had been working as dental professionals for at least one year. The questionnaire consisted of two parts; the first part was demographics and included gender, age, length of service, and specialization. The second part was about the dentists’ awareness of stress in dental profession. The study was approved by an ethics committee of the School of Dental Medicine in Zagreb. The statistical analysis was performed with SPSS Statistics computer program as a combination of descriptive and correlational analysis, with the relations being presented as non-parametric chi square analyses due to a reduced, nominal measurement.

Results

The largest age group was between 31 and 40 years of age (33.1%) (Figure 1). The greatest percentage of respondents (36.8%) presented between 11 and 20 years of working experience (Figure 2). Most of the respondents were general dentists (70.1%) (Figure 3).

Subjective perception of stress in dentists

91.9% of participants considered dentistry to be a stressful occupation, 4.7% did not consider stressful, while 3.4% of respondents were not sure (Figure 4). 46.1% of participants believed that practicing dentistry may cause problems in mental health, 36.5% considered that it cannot, and 17.4% of answers showed „not sure “. Furthermore, 93% of participants thought that practicing dentistry can endanger their general health, 5.5% believed it cannot, and 1.4% of respondents were not sure. 89.6% of participants assumed they should pay greater attention to their health, 8% thought they should not, and 2.4% were not sure. The greatest percentage of participants has identified time pressure as a significant source of stress (62.3%). The fear of patient dissatisfaction was identified by 54.2% of participants. The fear of unsuccessful outcomes was recognized by 52.5% of respondents, while 39.1% identified financial problems and 6.7% chose „other“ as their answer.

Stress and gender correlations

The difference in subjective stress evaluation regarding participants’ gender did not reveal a statistically significant difference (χ = 0.620 (2), p > 0.05). The evaluation was consistent in both genders. The difference in perceiving fear of unsuccessful outcomes as a source of stress, depending on gender did not show a statistically significant difference (χ = 0.327 (1), p > 0.05). The difference in perceiving fear of patient dissatisfaction as a source of stress, depending on gender did not demonstrate a statistically significant difference (χ = 0.022 (1), p > 0.05). The difference in perceiving time pressure as a source of stress, depending on gender did not show a statistically significant difference (χ = 1.577 (1), p > 0.05). The difference in perceiving financial pressure as a source of stress, depending on gender did not demonstrate a statistically significant difference (χ = 0.286 (1), p > 0.05).

Stress and working experience correlations

The difference in subjective perception of stress in dentist in relation to years of experience did not show a statistical significance (χ = 7.669 (6), p > 0.05). Dentists with more or less years of experience equally perceived their profession as stressful. The difference in fear of unsuccessful outcomes in relation to years of experience showed to be statistically significant (χ = 8.552 (3), p < 0.05) (Table 2). The participants’ group of less than 10 years of experience identified fear of unsuccessful outcomes more frequently compared to the normal distribution, while the participants’ group of 21-30 years of experience found this fear less frequently than the normal distribution. The difference in perceiving fear of patient dissatisfaction as a source of stress, depending on years of working experience did not show a statistically significant difference (χ = 5.219 (3), p > 0.05). The difference in perceiving time pressure as a source of stress, depending on years of experience did not reveal a statistically significant difference (χ = 3,929 (3), p > 0.05). The difference in perceiving financial pressure as a source of stress, depending on years of experience did not show a statistically significant difference (χ = 3.802 (3), p > 0.05). The number of participants that in their own opinion should pay greater attention to their health in relation to years of working experience did not yield a statistically significant difference (χ = 9.079 (6), p > 0.05).

Stress and dental specialty correlations

The difference in subjective perception of stress in specialists and general dentists was not statistically significant (χ = 1.169 (2), p > 0.05). The difference in subjective evaluation of health risks in specialists in relation to general dentists showed a statistically significant difference (χ = 7.716 (2), p < 0.05) (Table 3). General dentists perceived health risks as greater than the expected normal distribution, while specialists perceived their health risks as lesser than expected. The difference in alcohol consumption between specialists and general dentists demonstrated a statistically significant difference (χ = 11.347 (4), p < 0.05) (Table 4). Specialists reported consuming strong alcoholic beverages more than expected compared to the normal distribution, while general dentists reported consuming less of strong alcohol. However, it must be noted that most specialists in this survey were men, who also reported more alcohol consumption than women in this survey. The difference in frequency of consumption of strong alcoholic beverages between men and women was also statistically significant (χ = 45.992 (4), p < 0.01).

Stress and substances abuse and/or other coping mechanisms

77.1% of participants reported as smokers, while 22.9% denied smoking. 42.1% of participants reported consumption of strong alcoholic beverages once a month, 38.7% stated no consumption at all, 13.1% reported their consumption as 1-2 times per week, while 5.4% reported 3-4 times per week. The difference in stress perception in regard to reported consumption of strong alcoholic beverages did not show a statistically significant difference (χ = 3.759 (8), p > 0.05). The difference in subjective stress perception between smokers and non-smokers did not reveal a statistically significant difference (χ = 3.759 (8), p > 0.05). The difference in frequency of consumption of strong alcoholic beverages in regard to gender was statistically significant (χ = 45.992 (4), p < 0.01). Male participants reported a much greater frequency of consumption than female participants (Table 5).

Stress and engagement in sports activities correlations

The greatest percentage of respondents was engaged in sports activities 1-2 times per week (42%), while 33.3% did not engage themself in sports at all. 19.7% of participants participated in sports activities 3-4 times per week and 5% was engaged every day. The largest percentage of respondents traveled by a car (63.7%), while 25.6% walked to work, 6.7% used a public transport, 2.7% traveled by a bicycle, and 1.2% by a motorcycle. The difference in subjective stress perception in relation to the frequency of engaging in sports did not show as statistically significant. (χ = 10.727 (6), p > 0.05). The difference in subjective stress perception in relation to the mode of transport to work did not demonstrate as statistically significant (χ = 10.727 (6), p > 0.05).

Discussion

General perceptions

When measuring the subjective perception of stress in dental professionals, our results showed that 91.9% of participants considered dentistry a stressful occupation, while 4.7% did not consider. This perception is in line with the existing conclusions about dentistry being thought as one of the most stressful of all healthcare professions [1, 10, 11]. Furthermore, 46.1% of respondents believed that practicing dentistry may cause problems in mental health. This is also in line with existing research that recognizes professional burnout as one of the possible consequences of chronic professional stress [1-6, 9, 10]. We found that 93% of participants thought that practicing dentistry could endanger their general health, showing that a greater proportion of dentists are concerned about their general health, rather than mental health, in terms of professional risks. Indeed, there are significant health risk factors associated with dentistry, ranging from chronic disease risks to acute states or infection risks [13-16]. Following this, we also found that 89.6% of participants believed they should pay greater attention to their health.

Stress factors perception

In this survey, the participants identified time pressure as the greatest stress factor (62.3%), followed by patient dissatisfaction (54.2%), and the fear of unsuccessful outcomes was identified by 52.5% of respondents. In another study by Myers, time pressure was also identified as the greatest stress factor in 64.4% of participants [17].

Correlations with external factors

We found that the difference in subjective stress evaluation in regard to participant gender did not show a statistically significant difference. The opposite has been shown by a research by Pozos Radillo, where an association of the female gender with high level of chronic stress was accepted [12]. Furthermore, we tested various correlations and found that the difference in perceiving fear of unsuccessful outcomes as a source of stress, depending on gender did not prove to be a statistically significant difference. There was also no difference in perceiving fear of patient dissatisfaction, time pressure, or financial pressure as sources of stress, depending on gender. In regards to working experience, we found that dentists with more or less years of experience equally perceived their profession as stressful, however, the participants’ group of less than 10 years of experience identified fear of unsuccessful outcomes more frequently compared to their colleagues with more experience, which is in line with existing conclusions about stress amongst young dentists and dental students [3, 23]. In some papers, there was no such correlation [12]. Furthermore, there was no significant difference in the perception of other tested stressors (fear of patient dissatisfaction, time pressure, or financial pressure) regarding working experience. Considering dental specialization, we found that the difference in subjective perception of stress in specialists and general dentists was not statistically significant, however, it was found that general dentists perceived health risks as greater than the expected normal distribution, while specialists perceived their health risks as lesser than expected.

Coping mechanisms

The connection between stress and substance abuse was also investigated. In this survey, we found that 77.1% of participants reported as smokers, while 22.9% denied smoking, and 42.1% of respondents reported consumption of strong alcoholic beverages once a month, 38.7% stated no consumption at all, 13.1% reported consumption as 1-2 times per week, while 5.4% stated 3-4 times per week. There was no significant difference in stress perception in terms of reported consumption of strong alcoholic beverages, nor between smokers and non-smokers. Various research found that substance dependency is not prevalent among dentists than in the general population [24], while in some cases, it has been proven that smoking is more prevalent in comparison to the general population [25]. The difference in frequency of consumption of strong alcoholic beverages in gender was statistically significant. The male participants reported a much greater frequency of consumption than female participants. Also, specialists reported consuming strong alcoholic beverages more than expected compared to the normal distribution, while general dentists reported consuming less. However, it must be noted that most specialists in this survey were men, who reported more alcohol consumption. The greatest percentage of respondents were engaged in sports activities 1-2 times per week (42%), while 33.3% were not involved in sports at all. 19.7% of participants engaged in sports activities 3-4 times per week, and 5% were engaged every day. The difference in subjective stress perception in relation to the frequency of engaging in sports or walking to work has not been shown to be statistically significant. However, in other papers, a direct link has been established between engaging in everyday sports activities and a reduction in musculoskeletal chronic problems [26, 27].

Conclusions

Chronic stress stands as one of the main factors contributing to the decline in overall health and mental health in dental professionals. Most of the participants in our research reported feeling stressed, and identified major stressors in their workplace, which is in line with existing research on the subject. These were primarily time pressure, patient dissatisfaction, and fear of unsuccessful outcomes. Most participants believed they should pay more attention to their health, and prevent its deterioration. No association was found between gender and stress or stressor perceptions. Regarding working experience, we found that younger dentists with up to 10 years of experience presented more fear from unsuccessful outcomes. It was also found that general dentists perceived health risks as greater in contrast to specialists. There was no significant difference in stress perception regarding reported consumption of strong alcoholic beverages, nor between smokers and non-smokers. However, 77.1% of participants were smokers, which is significantly above the national average (33%) [28]. The male participants reported a much greater frequency of consumption than female participants. Also, specialists revealed consuming strong alcoholic beverages more than expected.
The difference in subjective stress perception in relation to the frequency of engaging in sports or walking to work did not prove to be significant. The conclusions here can be used to further confirm the correlations between chronic stress and negative long-term health outcomes, such as BOS and professional outcomes. Also, the investigated associations may be further analyzed to assess the relation between various factors, such as gender, age, weight, height, number of children, marital status, socioeconomic level, work seniority, working with an assistant, hours worked daily, other employment, substance abuse, sports etc., and chronic stress. Furthermore, it can be used to validate future surveys and improve measurement parameters in relevant correlations.

CONFLICT OF INTEREST

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.