After many studies, dentists are proven to be one of the most stressful health careers

(Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 8). This does not start when they
begin their career but when they begin dental school. Dental students report higher levels of
anxiety, depression, obsessive-compulsive disorders, and interpersonal sensitivity than the
general population and age-matched students in other fields of study. (Basudan, Binanzan, &
Alhassan, 2017, P. 182). Dental students have been a major concern for dental educators in
recent decades, and This stress phenomenon amongst dental students has been reported in
different curricula since the 1970s (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P.
8). Farrelly reported that Dentist have one of the highest rates of suicide of any profession
(Farrelly, Oral, Sun, & Mack, 2013, P. 486). This is caused by the effects of stress dentist suffer
from since their first day in dental school. This paper will analyze the cause and effects of stress
dental students have and how they can better cope with stress.

Stress as defined by Cox (1978) as a stimulus, a response or the result of an interaction

between the two, with the interaction described in terms of some imbalance between the person
and the environment(Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 8). Dental
educators measure the stress of dental students using the DES (dental environment stress)
questionnaire which is a close-ended questionnaire, containing 38 questions pertaining to
potential stressor factors like living accommodation, interpersonal relationship, academic
performance, clinical skills and miscellaneous factors. [18] This questionnaire has been modified
and used in several studies across the world (Harikiran, A., Srinagesh, J., Nagesh, K., &
Sajudeen, N., 2012, P. 332). Through this questionnaire dental educators could find the causes of
stress.

The causes of stress in dental students vary greatly. Some students can be stressed about
grades and exams, vacations and breaks, failing or disappointing parents, post-graduation life,
perfectionism requirements from teachers, and peer competition (Harikiran, A., Srinagesh, J.,
Nagesh, K., & Sajudeen, N., 2012, P. 331). Alzahem agrees with Harikiran, adding that he
considered that these [M]ajor five groups of stressors appeared in most studies: (i) living
accommodation factors, (ii) personal factors, (iii) educational environment factors, (iv) academic
factors and (v) clinical factors ( Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P.11).
Although these five major stressors are found in everyones daily lives, they have proven to be
the largest stressors for dental students. In addressing these five major stressors, this paper will
go into further detail about how where dental students live contributes to their overall levels of
stress.

Of the five stressors, living accommodations is the first concern for dental students. Of
the studies Alzahem researched, he found that where dental students were supported financially
by the government or by family, it became a major factor resulting in stress with their living
accommodations (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P.11). Two
different studies show ... [T]hat students living at home were less stressed than those living
away (33), whilst another study reported that students living with their parents had higher stress
scores than students living away from home (Alzahem, Van, Alaujan, Schmidt, &
Zamakhshary, 2011, P. 11). Harikiran found a recent October 2010 study, using the DES
questionnaire, conducted in Bangalore, India where the type of living accommodation was
assessed with 5 questions ( Harikiran, Srinagesh, Nagesh, & Sajudeen, 2012, P. 333). It states
that the lack of home atmosphere was reported to be stressful by 75.8% of the students followed
by the lack of recreation (72.7%). Hostelites were significantly more stressed by these factors
than those students staying at home (P < 0.04). Staying with roommates was least stressful
(66.7%) (Harikiran, Srinagesh, Nagesh, & Sajudeen, 2012, P. 333). Through this study it is
shown that the living atmosphere is a factor in the stress of dental students. By living in an area
that lacks the recreational opportunity pools that a student needs, stress is compounded.
According to Alzahem, Lack of recreation facilities within the accommodation also appeared as
a source of stress for some (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 11).
Students tend to experience stress when there are no facilities for them to destress and participate
in other activities other than their dental work.

Dental students usually need to spend more than 40 hours weekly attending lectures,
homework and training, leaving very little time for personal time (Alzahem, Van, Alaujan,
Schmidt, & Zamakhshary, 2011, P. 11). Harikiran stated from the study done in 2010 that
having reduced holidays and an inadequate time for relaxation (76%) was stressful, while
financial problems, personal physical health, necessity to delay personal milestones like
marriage, children, dependencies on alcohol, drugs etc. were reported to be least stressful
(Harikiran, Srinagesh, Nagesh, & Sajudeen, 2012, P. 333). Although in India financial problems
were reported to be less stressful, Alzahem wrote that in countries such as Canada and the USA,
where students had to financially support themselves, financial problems was a frequently
mentioned personal stress factor, but agrees with Harikiran later stating that students need time
for self-study activities and to satisfy practical requirements but states that this time can be used
inefficiently creating lack of time for social activity, lack of time for relationships, and reduced
holidays. (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 11). Without any leisure
personal time students were reported more stressful.

Regardless of the location, dental students have always felt their school environment to
be demanding (Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P.67).
After a study done, Freeman reported that Study Obligations, Patient-Related Aspects and
Study Pressure, respectively, showed highest mean scores in the dental school environment
(Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P.66) It was found by
Alzahem that the pressures of academics, working hours, and clinical events are more stressful
than personal problems (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 9). This
could be because the pressures of academic achievement are more demanding than issues outside
of the classroom. These stresses mainly come from the need to meet clinical requirements,
passing academic assessments, and dealing with clinical and supporting staff. (Alzahem, Van,
Alaujan, Schmidt, & Zamakhshary, 2011, P. 9). Issues have been found between students and
faculty such as the lack approachable staff and prolonged strikes by faculty resulting in a delay in
graduation (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 12). When students
don't have the necessary support from teachers that they need, they struggle to find that help
elsewhere. Without a supportive educational environment, the expectations of academic
achievement become stressful for dental students.

Alzahem wrote examinations and grades appear to be the most stressful elements
(Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P.13) Harikiran agrees with Alzahem
when he wrote, Among academic concerns (12 questions), 11 queries were reported to be
stressful by >70% of the students. Examinations topped the list with 97% of the students
reporting it as stressful followed by amount and difficulty of coursework (85% and 86%)
(Harikiran, Srinagesh, Nagesh, & Sajudeen, 2012, P. 333). When dental students first enter into
dental school their academic excellence is already the norm, and an adjustment in self-concept
is required (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 9) while a new way of
competitiveness emerges. Student performance becomes a new form of stress. This introduces
the fears of failing students begin to have with the pressure and amount of assigned work while
their student performance expectation arises. (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary,
2011, P.). Alzahem organizes the fears into six fears students have in their academic
performance; first being the fear of failing, the second being able to catch up on late work, third
the fear of employment after graduation, fourth fear of failing their parents in stated countries,
and finally doubting their capacities to get into postgraduate programme. (Alzahem, Van,
Alaujan, Schmidt, & Zamakhshary, 2011, P. ) When students hit clinical years, expectations and
stress begin to rise.

Alzahem wrote clinical factors of stress mostly related to requirements, patients and
staff (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 14). Clinical years have been
proven to be more stressful than the preclinical years and the instructors often create more stress
than the patients treatment (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 9).
From the study that Harikiran reported on he wrote that Clinical requirements (9 questions)
were reported to be stressful by >70% of the participants (Harikiran, Srinagesh, Nagesh, &
Sajudeen, 2012, P. 333). One of the main stressors in these years are clinical training and
meeting clinical requirements. Students fear of failing the clinical requirements and this caused
students level of stress to rise (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 14).
For the students in their clinical years the main stress point was clinical training with the fear of
not completing clinical requirements (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011,
P. 9) Patient contact, patient tardiness or no-show of patient was shown as a major source of
stress. (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 12). Harikiran wrote from
the study, difficulty in managing difficult cases, lack of co-operation by the patient
(88%)(Harikiran, Srinagesh, Nagesh, & Sajudeen, 2012, P. 333). Over time, the stress and
expectations begin to take a toll on the students and will have effects in their mental and physical
health.

Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, (2008), reported on a

study done questioning first year dental students and fifth year dental students to compare and
analyze the effect stress has on dental students over a period of time to predict the outcome it
might have in their professional careers. The questionnaire had two sections, one part with
questions pertaining to demographics and personal details while the other part consisted of the
DES, Likert scales on burnout, psychological distress and general health. (Gorter, Freeman,
Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 62). The hypothesis was that, the
prolonged stress from training would exacerbate burnout and affect self-reported health (Gorter,
Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 65). Over a long period of time
of being stressed through training dental students go through can affect the mental health of the
student through burnout.

(Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P.67)

The study reported that in the first years, one-fifth of dental students reported high levels
of EE (emotional exhaustion), and in their fifth year, EE scores were labelled very high for more
than one-third of the students (Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris,
2008, P. 66) Comparing with the first year scores, this was a huge increase and this can conclude
that students suffered from a demanding study environment throughout the years and accounts
for a serious burnout risk, and potential mental and physical health problems (Gorter, Freeman,
Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 66). They found that stress played a role
on burnout, and Burnout levels may translate stress into mental health problems (Gorter,
Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P.66). This can have huge mental
and physical effects on the dental students.

Divaris describes burnout as the experience of long-term work-related exhaustion and

diminished interest (Divaris, Polychronopoulou, Taoufik, Katsaros, & Eliades, 2012, P.35).
Freeman wrote that one of the possible long term effects of occupational stress is a professional
burnout and adds that Becoming emotionally exhausted is the key characteristic of burnout
(Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 62). Becoming
emotionally exhausted can cause a professional burnout. In another study reported by Freeman,
Over a third of the participants reported significant psychological distress. Furthermore, more
than one-fifth of the participants reported high scores on Emotional Exhaustion (EE), the core
burnout dimension (Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P.
62). This is found and detected among dental students causing major effects when students are in
their professional career (Divaris, Polychronopoulou, Taoufik, Katsaros, & Eliades, 2012, P. 35).
Other effects were found such as student drop-outs causing less manpower in dentistry
(Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P. 9). Also Personality characteristics
can develop while in their professional career such as a negative, cynical attitude towards ones
patients, and the tendency to evaluate oneself and ones accomplishments negatively (Gorter,
Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, (2008, P. ). Alzahem wrote that not
only can persistent stress result in mental problems, but physical problems, it was noted that
stress-related illnesses, together with musculoskeletal disorders, were the main factors
influencing dentists to retire early (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011, P.
8) This raises concern to help students manage and cope stress to prevent these outcomes in
dentistry.

Although not all stress cannot be prevented, there are many ways that can help students
prevent, cope and manage their stress. Alzahem wrote that stress could be detected early by
looking at the signs and symptoms and the students performance, and by using instruments of
stress early detection could be made to address stress issues immediately. (Alzahem, Van,
Alaujan, Schmidt, & Zamakhshary, 2011, P. 15). While Freeman wrote most attention should
be focused on teaching students how to cope with the tasks they are confronted with (Gorter,
Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 67). Not only will helping
dental students improve coping skills during their time in dental school, but will benefit them
throughout their professional career (Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, &
Humphris, 2008, P. 67)

Students have found, in many ways, different coping strategies to deal with the excessive
stress. Depending on the students emotional intelligence can affect the way in which they cope.
They found those with low emotional intelligence begin to engage in habits to cope with stress
that damage their health (Basudan, Binanzan, & Alhassan, 2017, P. 184) and turn to smoking
and drug use while those with high levels of emotional intelligence adopt reflection and
appraisal as well as social and interpersonal coping methods (Basudan, Binanzan, & Alhassan,
2017, P. 184) turning to family and friends for emotional support, and engage in wholesome
activities unrelated to their school. (Basudan, Binanzan, & Alhassan, 2017, P. 184) It has also be
shown that relationships between students, faculty and peers can really affect the stress of
students. Basudan wrote that when peers act as mentors, stress and anxiety are significantly
reduced (Basudan, Binanzan, & Alhassan, 2017, P. 184). This means that stress can be reduced
when relationships between students, faculty and their peers are providing a helpful environment
for students.

Freeman wrote What is needed now is to determine how the structure of our curricula,
or how our dental school teachers and mentors, or how systematic evaluation systems, may help
identify those students struggling and suffering along the way (Gorter, Freeman, Hammen,
Murtomaa, Blinkhorn, & Humphris, 2008, P. 67). Alzahem wrote it is recommended to
determine the sources of stress amongst dental students to avoid resultant detrimental effects on
their physical and mental health (20) (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011,
P. 9). He classifies prevention and interventions procedures into six categories; First, better
supporting students by explaining expected outcomes and encouraging students to access
students services. Second, providing counselling programs to students. Third, stress
management through friendly approach and student-centered learning. Fourth, relating to
instructors promoting physical exercise and contacting psychologists. Fifth, student reduction
through relaxation and other activities preventing stress. Final, stress prevention and student
selection. (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary,2011, P. 14). As dental educators
study and apply these categories, they can better help student cope with stress.

They have found that the coping mechanisms, for a huge portion of dental students, have
failed when met with the demands of the curriculum and it is brought into debate Whether the
curriculum is too demanding or the students coping skills are insufficient (Gorter, Freeman,
Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 67). But, this is hard to determine as
Alzahem wrote, Few studies discussed the prevention or intervention of stress as compared to
studies that reported sources of stress (Alzahem, Van, Alaujan, Schmidt, & Zamakhshary, 2011,
P. 14). Freeman agreed with Alzahem when he wrote Possibilities for implementation of
training in time management, student self-reflection and effective stress coping strategies, have
not yet been described (Gorter, Freeman, Hammen, Murtomaa, Blinkhorn, & Humphris, 2008,
P. 67). There are more studies done on the causes and sources of stress but, how to prevent them
has not been deeply researched. There should be more studies done to find the true sources of the
stress. From research done, both the students coping skills as well as the curriculum are the
issue and both need to be more researched and addressed so that better programs can be made to
help students manage and cope with stress as well as create a better curriculum and educate staff
and faculty more fully. Freeman agrees with this when he wrote that a sensible step would be to
initiate and investigate possibilities for stress prevention and intervention (Gorter, Freeman,
Hammen, Murtomaa, Blinkhorn, & Humphris, 2008, P. 67). There are many more options and
opportunities for students to cope and prevent stress. Through better investigation these
opportunities and options can be discovered.

The causes and effects of stress in dental students is a great concern for all dental
educators. Through the many studies done, it is known what causes the stress and how it can be
prevented. Although there are many reports done, it is shown that there needs to be more studies
done to better help the students and the curriculum to prevent negative outcomes of stress. This
will help raise more awareness to students and dental educators.

References

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