Are the current demands reasonable? Should I be expected to deal with this? Do I have sufficient resource? Am I competent? Can I assess the risk? Do I have the equipment required, appropriate assistance, authority, adequate communication skills? Do I have the knowledge to manage any adverse outcomes? Is the allocated time adequate? Do I have time to do this and manage potential adverse outcomes? Do I need to reschedule, phase the treatment, eat, use the bathroom, arrange for the children to be collected first...?

The solution is clearly very different depending on your analysis. Practising this analysis will often identify a recurring theme which you find causes you to feel stressed. It may be a procedure such as molar root canal or perhaps working with a particular colleague or in a specific surgery.

The impact

Stress has a negative impact on our health. It defies logic to tolerate it and hope someone else may feel inclined to sort it out. It is our individual responsibility to make the changes we need to eliminate stress. This sometimes entails highlighting what is stressing us to others and requesting assistance or an adjustment. All too often we tend to vent steam to anyone (and frequently everyone) about our stress except the individual who may be able to correct it. For instance, dental care professionals and dentists working together will frequently share frustrations or problems in their working relationship with other team members but actively avoid disclosing this to each other. The provision of good dentistry relies almost entirely on good team work. It is impossible to work as a dental professional and remain unaffected by the interactions you have with your team members. We need to be honest with each other and be aware of the impact our behaviour may have on others.

Tim Newton is Professor of Psychology as Applied to Dentistry and Honorary Consultant Health Psychologist at King’s College London Dental Institute. Tim has worked in the behavioural sciences in relation to dentistry for over 20 years, and his particular interests include the management of dental anxiety, interventions to enhance oral health related behaviour and the working life of the dental team. In particular he has published on the sources of stress and burnout amongst dental practitioners as well as designing interventions to alleviate stress.

Dental professionals often present 'hating dentistry' on dissection; however, it transpires this is more a case of disliking a particular aspect of the job or sometimes the place or system in which they provide their care. It is easier to address the component parts – to fight a battle than win a war. Is it the job, a specific element of the job, or where you do your job? The latter is often a significant source of stress and is often the result of a conflict in values. Our personal values are an internal appreciation we have about what is important in life, in our interactions with people and in our work. We cannot opt to leave home without our personal values nor do we remove our values when we put on a dental tunic. Our values are woven into the very fabric of our being, make us who we are, define us and we cannot opt to leave them aside in different contexts. Our personal values come to work with us every day. When we work with people who share our values we feel personally valued, supported, fulfilled and safe. We feel energised, have a shared direction and are inclined to celebrate our collective success. To work in a system or team forcing us to behave contrary to our values creates internal conflict and a sense of sadness leading to a profound lack of motivation and dampening of spirit. If this is not addressed we feel stuck and helpless and can see nothing but years of the same ahead of us and at some point this stops being 'stressful' and becomes depressing. Tragically, this can happen to our very finest professionals.

The result

Stress interferes with our ability to think logically and we often jump to irrational conclusions and sweeping generalisations. This effect can become catastrophic with chronic exposure to stress. Dentistry like all healthcare provision is riddled with risk. There are numerous variables affecting the outcome of the care we deliver and some reside outwith our control. It is a requirement that we identify these risks, communicate them effectively, adapt our practice to contain them and minimise potential unfavourable consequences.

The difficulty arises when stressed practitioners are irrational in their interpretation of this expectation and perceive it as a command to eliminate all risk and understandably become overwhelmed by this responsibility. Consequently, they approach every task with the worst case scenario in mind from the outset resulting in even comparatively simple tasks, such as administering local aesthetic or writing a prescription, seem insurmountable and totally exhausting. They become immersed in fear and panic and view every treatment as a potential trap. This has a knock on effect on behaviour and they often freeze, procrastinate, delay treatments, double check their own actions or lose confidence in other team members. This change is then addressed by employers, team members or patients, which undermines remaining confidence, adds to the stress and further magnifies the risk.

Work becomes increasingly difficult to escape and gradually evenings and nights too become invaded by catastrophic 'what if' scenarios. These are often irrational such as 'what if they were on warfarin but didn't tell me?' and 'what if the antibiotic doesn't work and their airway closes?' To compound matters it's often the way that negative thoughts have poor timing and frequently present at three o'clock in the morning when we should be asleep! They are, however, predictable and invariably culminate with a permanent injury to a patient and erasure by the GDC at which point the alarm sounds heralding another day in the surgery. This is clearly unsustainable and eventually ends up destroying personal lives and leaves our professional identity unrecognisable in ashes at our feet.

Case study: When stress takes over

In the second part of our investigation into stress in dentistry, we've looked at why some people feel the strain more than others. It's not the easiest subject in the world to talk about, and in fact many people don't – which is how and why stress festers and develops. Tim and Brid have explained above why you may be feeling stressed, The vicious circle is something Kate White (alias, as she wishes to remain anonymous), found herself in:

My situation wasn't a good one. I could feel myself getting more stressed every day, and then stressing out further because I was stressed. I almost saw it as a normal way of life after a while and I didn't realise just how bad things got for me. It sort of crept up on me and before I knew it I was trapped in a stress cycle I couldn't get out of.

I was aware of the stresses involved in dentistry from my university days and by the time I started VT and was seeing more patients I noticed that my stressful days were getting more frequent. As an associate this progressed especially when I had busy days. Lots of little things started getting to me, but I thought nothing of them as they were isolated incidents. What I didn't realise at the time (but I can see now) is these small things snowballed into something much bigger which I couldn't control. Everyone has a trigger point or a tipping point when it just becomes too much.

It can be – and is often – something so innocuous you'd ordinarily laugh at it. I was at work in the kitchen and a difference of opinion was aired over tea. That was it for me. I broke down. I knew then I was in a bad place and couldn't carry on the way I was going. At that point I felt like a relief valve had been opened – I had finally accepted I wasn't coping. I told my boss that I couldn't cope and needed some time off, and thankfully they were great. Although I wasn't actually at work the problems were still at the back of my mind even at home and I didn't know how to deal with it. My brain tried to rationalise what was happening by telling myself they were just everyday occurrences but this didn't work – I had almost gone too far to be able to help myself. That is the thing with stress – it can go unnoticed for so long because you're trying to excuse it and not face up to what the problem is. Before you know it your personal life and professional life are in the frying pan.

I personally had a bad time after the tea room incident. I had palpitations at the thought of returning to work, which I knew wasn't healthy. The feeling lingered, and it suddenly started to dawn on me just how much help I needed. The fact that the tea room scenario happened at work made it easier in a way, as it showed everyone first-hand how bad my situation had become. This meant they had the opportunity to support me which thankfully they did.

My boss had read an article Brid had written about stress not long before I broke down and he pointed me in Brid's direction. The one-to-one stress management for dentists was something I knew I needed, and straight away we went right back to basics. Things had got that bad. It took a lot of small baby steps for me to start turning the situation around, but with her help I could feel myself gradually getting back on my feet again. Being a dentist Brid really understood the normal day to day pressures we face, more than a lay person ever could.

Now I feel like a totally different person. Brid helped me realise that stressful situations won't go away, so you can't hope they will or expect someone to tell you they will. What I did and what many other people should look to do (if any of this resonates with their life) is to find coping mechanisms. Previously I wouldn't take a break during a session, which meant I wasn't getting the energy or respite I needed. Brid told me to take a break for five minutes where possible and have a snack or a cup of tea. It meant I could get some air and refuel to keep me fresh throughout the day. It doesn't sound much, but when you're in a stressful environment the smallest things can make the biggest difference.

I have much more confidence now too. I can look at the bigger picture and understand that focusing on what goes wrong isn't healthy. I'm still learning, but almost a year on from my breakdown I feel like I can cope. Sometimes things do go wrong. They may be in your control and they might not. Either way you can't focus on perfection. I felt I had no-one to turn to because I genuinely thought my problems were insignificant and something only I was experiencing. However, I've since realised that we all have insecurities but as dentists we just aren't so good about talking about them in the open.

If there is anyone who feels like they are stressed or things are getting on top of them, my golden piece of advice is to talk to someone. You don't get taught as an undergraduate how to cope in the real world. You get taught how to put practical skills into practice, but everything else you have to work out for yourself. If you're feeling stressed talk to your boss, a colleague, your practice manager, anyone you're comfortable with. It's perfectly normal and I can guarantee you're not the only person feeling the strain. Stress is such a taboo subject, but it is a serious mental health problem that needs more attention. Don't let it fester. Talk to someone. I'm glad I did!