By Ewen McColl, Martha Paisi, Anastasios Plessas, Fiona Ellwood and Robert Witton

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©Malte Mueller/fStop/Getty Images Plus


Dentistry has long been described as a stressful profession and evidence points to a range of stressors in some cases quite unique to the dental environment.1 For example, the stress involved when an upper left second molar crown fractures during an extraction at 5 pm on a Friday. In this case the dental nurse has to quickly assemble the surgical kit whilst reassuring the patient (and often the dentist), and other team members who have to stay late and help in cleaning down, manage contaminated instruments and equipment, often when they have somewhere else to be.

Perhaps the trepidation of something going wrong, though no one's fault, adds to this stress as does the worry that a complaint may ensue. This stress can bring about decreased wellbeing, implications to patient care and as a consequence lead to diminished professional standards.2 Whilst skill, experience and organisation can mitigate this stress, what are the key factors that cause stress for the dental team? What signs are there that stress is becoming unmanageable and impacting on mental health? What steps can we take to mitigate this?

Key stressors in dentistry

A recently published survey by Dental Protection of dentists who qualified in the last five years revealed many stressors linked to the rigours of practice.3 There is no doubt that clinically the first five years are a challenge, leaving the sheltered cloisters of dental school to the challenges of autonomous practice, often without the support mechanisms widely available at dental schools.3

The top ten worries for early career dentists as reported in this survey were as follows. This relates to dentists and evidence related to other members of the dental team is very limited:3

  1. 1.

    Making a mistake - 42%

  2. 2.

    Complaints directly from patients after treatment - 25%

  3. 3.

    Confrontation or disagreements with patients during treatment - 17%

  4. 4.

    The impact of COVID-19 on financial security - 17%

  5. 5.

    The impact of COVID-19 on their mental wellbeing - 16%

  6. 6.

    Their career choice - 16%

  7. 7.

    A clinical negligence claim being brought against them - 14%

  8. 8.

    A GDC investigation into their practice - 13%

  9. 9.

    Negative media coverage or reputational damage following a case or claim - 9%

  10. 10.

    Disagreements with colleagues - 8%.

More generally, similar surveys by indemnifiers reveal a range of concerns, no matter the stage of your professional journey. For example, a questionnaire study by the Dental Defence Union (DDU) revealed 78% of dental members surveyed stated they feel stressed and/or anxious on a weekly basis.4

In this study the DDU surveyed 396 members and found that:

  • 45% feel they are unable to spend adequate time with patients

  • 33% feel they are unable to do their jobs effectively

  • 53% would not feel confident in raising a matter regarding their health and wellbeing

  • members were most likely to raise concerns with their family members (89%), colleagues (47%) and/or their GP (40%).

Whilst these percentages are of course concerning, in this report it is important to consider that of the 396 members who were sent the questionnaire in March 2021, there was only a 5.65% response rate.

Undoubtedly time pressures, risk of litigation, patient complaints, and the financial pressures faced in running a practice or working as an associate increase stress levels that may impact on our health. It would not be unreasonable to consider the wider members of the dental team against the backdrop of both the DP3 and DDU4 survey, given that dental nurses work alongside the dentist day-in-day-out. Equally, dental therapists, dental hygienists, orthodontic therapists, and clinical dental technicians are treating and caring for patients, albeit with differing scopes of practice and it is likely they will face similar stresses.

Often members of the dental team let their own health suffer as they strive to do the best for their patients and their families, and do not take time to reflect on the impact this is having on their health generally and their mental health specifically.

Another survey undertaken by the British Dental Association5 alludes to 2,053 respondents and provides a comparable list of stressors to the survey undertaken by Dental Protection. The respondents of this survey were from a broad sample of practitioners, the following stressors were identified as the 'top ten':

  1. 1.

    Threats of complaints/litigation - 79%

  2. 2.

    Dissatisfied patients - 75.1%

  3. 3.

    Risk of making a mistake - 74.9%

  4. 4.

    Red tape/bureaucracy - 74.5%

  5. 5.

    Concerns about the GDC - 72.8%

  6. 6.

    NHS Targets - 72.4%

  7. 7.

    Running behind schedule - 64.9%

  8. 8.

    NHS WORK - 63.2%

  9. 9.

    Working quickly to see as many patients as possible - 62.9%

  10. 10.

    Difficult patients - 61.2%.

In addition to the surveys, a recent review6 adds a further dimension to stressors and health and wellbeing within dentistry, by looking through the lens of determinants. The review goes on to consider such stressors as macro-factors, such as healthcare systems and regulation; meso-factors such as job satisfaction and workplace characteristics and finally, micro-factors as personal aspects, professional career level, and personal and professional relationships.6 Again it becomes apparent that stressors not only have implications for dentists but also for dental care professionals and that one system maps with ease, to all of the professional groups to see them in a similar light.

In the way that the World Health Organisation (WHO) considers not only the socio-economic and physical environment but characteristics and behaviours of individuals as determinants,7 it is perhaps worth looking to the regulator to take this discussion further. As a GDC registrant you must put patients' interests first. But to do this as effectively as possible, you also need to focus on your own health and wellbeing. Section 9 of the GDC standards document8 states the following:

Standard 9.2 You must protect patients and colleagues from risks posed by your health, conduct or performance

9.2.1 If you know, or suspect, that patients may be at risk because of your health, behaviour or professional performance, you must consult a suitably qualified colleague immediately and follow advice on how to put the interests of patients first.

9.2.2 You must not rely on your own assessment of the risk you pose to patients. You should seek occupational health advice or other appropriate advice as soon as possible.

A recent review undertaken on behalf of the GDC9 concludes and indicates that mental health and wellbeing challenges are a common feature during the professional lives of dentists, but as others have noted, to date the evidence is limited in relation to other members of the dental team. It again acknowledges that there is a need to better understand mental health issues and that there is a need to continue to measure the mental health wellbeing of the dental team.

Often members of the dental team let their own health suffer as they strive to do the best for their patients and their families, and do not take time to reflect on the impact this is having on their health generally and their mental health specifically.

Signs that stress is becoming unmanageable

Working in the close confines of a surgery and even closer confines of the mouth can lead to stress on a daily basis. Some level of stress which does not exceed an individual's ability to cope can have a positive influence, but what are the signs that our response to such stressors is beyond the range of normal and likely to lead to issues health wise?

In a 2018 survey commissioned by the Mental Health Foundation and conducted by YouGov of 4,619 people, 74% of UK adults felt so stressed at some point over the previous 12 months that they felt overwhelmed or unable to cope.10

The Mental Health Foundation cite the following as signs that stress is becoming unmanageable:

  • Feelings of constant worry or anxiety

  • Feelings of being overwhelmed

  • Difficulty concentrating

  • Mood swings or changes in mood

  • Irritability or having a short temper

  • Difficulty relaxing

  • Depression

  • Low self-esteem

  • Eating more or less than usual

  • Changes in sleeping habits

  • Using alcohol, tobacco or illegal drugs to relax

  • Aches and pains, particularly muscle tension

  • Feelings of nausea or dizziness

  • Loss of sex drive.

In dentistry, as complexity of treatment increases it is not unusual to worry prior to a procedure and when things go wrong to feel worried. This is normal and part of being a caring clinician with patients as a first priority. However, when this becomes chronic and cumulative that we need to be aware this can impact at work and at home and worth considering steps to mitigate this.

There is a need to ensure that mental health wellness is a key priority in every dental setting, recognising the benefits of prevention, early intervention, and safe signposting and the need to normalise such conversations, whilst reducing stigma.

A study found that time pressure negatively impacts one aspect of dentists' diagnostic performance, namely sensitivity (increased diagnostic errors and omissions of pathology), which can potentially affect patient safety and the quality of care delivered. However, time pressure was found to have less influence on diagnostic specificity.11

Mitigating stress in dentistry

The NHS site Every Mind Matters12 suggests key skills for dealing with stress, but how might this look for members of the dental team? Below is a list of recommendations with some context to relate this to the dental environment:

Split up big tasks

If a task seems overwhelming and difficult to start, try breaking it down into easier chunks, and give yourself credit for completing them. This applies to more complex clinical cases that undoubtedly can lead to stress. Taking time to look at tooth by tooth prognosis then designing a well-structured achievable treatment plan mitigate the stresses of a plan running away with itself and the stresses that involves to all concerned. Stick to the plan and don't jump ahead.

Allow yourself some positivity

Take time to think about the good things in your life. Each day, consider what went well and try to list three things you're thankful for. This may be as a team to meet (team huddle) at the end of the week and focus on what went well and things we are proud off. Share your successes and be proud of what you have achieved as a team.

Challenge your thoughts

The way we think affects the way we feel. Try not to dwell on the negatives as this spreads like a contagion. If in a leadership position reflect on how others might perceive that negativity even when you don't feel like smiling and supporting others.

Be more active

Being active can help you to burn off nervous energy. It will not make your stress disappear, but it can make it less intense. As busy clinical team members finding time to exercise can be a challenge. Try and make this part of your daily routine. Not just for the endorphins released from exercising, but the musculoskeletal benefits for a career bending over cannot be emphasised enough.

Talk to someone

Trusted friends, family and colleagues, or contacting a helpline, can help us when we are struggling. Dentistry and the dental surgery can become a very lonely environment despite the constant interaction with our patients. A problem shared can alleviate many of the anxieties for dental team members. Needless to say many of the emotions you feel are not unusual to you and talking to someone about it often reassures and keeps things in perspective - don't suffer in silence.

It is important to remember there are a wide range of support mechanisms

Summary and conclusions

Dentistry can be a highly rewarding profession for all team members but is not without its stresses. The importance of working as a team to manage this stress cannot be underestimated. Care for each other and be kind to each other as much as we are with our patients. Don't be scared to talk about how you feel and look out for the signs that stress is impacting on your wellbeing inside and outside of work. It is important to recognise that a wide range of changes may need to take place to manage stresses, and this may mean that the workplace environment and the team become cognisant of a supportive culture, which protects against stressors to the mutual benefit of patients and the profession. To this end, there is a need to ensure that mental health wellness is a key priority in every dental setting, recognising the benefits of prevention, early intervention, and safe signposting and the need to normalise such conversations, whilst reducing stigma.