What are dental professionals' perceptions of stress and its triggers in dentistry; is it perceived that mentoring could help?

Michelle Williams, a dental hygienist and therapist and a tutor, summarises the findings of the dissertation she conducted as part of her MSc in dental education.

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Introduction

Stress in dentistry is well known and researched by many sources.^1,2 Salazar et al.³ also suggest that dentistry can be a stressful and isolating career; despite dentistry being a rewarding career, it has for a long time been acknowledged as a stressful occupation. The British Dental Association (BDA) report a gap between dentists' and the general population's wellbeing.⁴

Current strategies

A framework has recently been published which has been co-produced by representatives from all dental professions.⁵ The aim is for this to facilitate the training of one member of a dental team as a mental health champion.

Resent research

The qualitative study by Larbie, Kemp and Whitehead² highlights some of the fundamental issues affecting dentists; unfortunately, this was limited to looking at only one professional group.

Method

Inclusion criteria: dental professionals.

Exclusion criteria: students.

Design

A case study design was used, with a phenomenological aspect.

Participants

A convenience sampling method was used to recruit.

Results

Six themes were identified after thematic analysis.

Nature of the problem

Feeling alone was a recurring emotion felt in the dental hygienists and therapists group. This could be attributed to the fact that these members of the team often work without chairside assistance and so must do everything themselves. This appears to increase their perceived stress with no feeling of worth within the team.

One hundred percent of participants think that working in dentistry can be stressful and that stress exhibits itself in emotions such as frustration, anxiety and feeling overwhelmed.

Triggers

Some reported triggers of stress are: patients, complaints, appointments, team, equipment, and regulation.

An unfortunate fact of life is that it can be stressful but perhaps this work is suggesting that if there are coping mechanisms in place then the stress is less likely to develop into something more severe.

Some considered themselves to be the issue, citing ‘not being good enough'.

Coping mechanisms

Participants did not have structured coping mechanisms in place and tend to brush things aside.

Prevention

The overarching consensus appears to be that a reduction in working hours can have a positive impact on work life balance.

Support

The interviewees acknowledged that having someone to talk to would be of benefit, however there was some difficulty finding the right person to talk to. Participants felt that family and friends are happy to listen but do not really understand the problem and that peers or supervisors may judge them negatively. There was little to no knowledge about mentoring although when discussed the majority felt that this could be of benefit.

Self-doubt/criticism

There seemed to be a distinct lack of confidence in the majority of the participants interviewed and a generalised reticence to ask for help was displayed by many.

Discussion

The aim of this study was to investigate and gain an understanding of the current perceptions of stress in dentistry, paying particular attention to the triggers of that stress. The perceptions of mentoring were also investigated as it is acknowledged that this may be of benefit not only to the mentees but also the mentors.⁶ The General Dental Council (GDC) require dental professionals to practise evidence-based dentistry; to carry this out, and as the evidence shows that mentoring has a positive impact on professionals and therefore the patients they treat, it is clear that mentoring should not be ignored.⁷

Perceptions

Current perceptions are that working in dentistry can be stressful with 100% of participants reporting this. This research has consolidated the previous acknowledged thoughts that working in dentistry can be or is stressful.

Consequences of stress

Previous research by Bretherton, Chapman, and Chipchase⁸ found that stress occurs when there is a lack of coping mechanisms in place thus leading to an inadequate balance to meet the demands of the situation. The results of the interviews show a general lack of coping mechanisms, ‘it's just a case of getting through the day'. An unfortunate fact of life is that it can be stressful but perhaps this work is suggesting that if there are coping mechanisms in place then the stress is less likely to develop into something more severe. One consequence of not managing stress can be burnout. Burnout is something that many participants said that they have suffered or are suffering from. This could be a result of suffering stress over a period of time thus making it a chronic condition. Gorter and Freeman⁹ consider that a symptom of long-term work-related stress could be professional burnout. Research by Larbie, Kemp and Whitehead² found there to be elevated levels of burnout repeatedly found in dentists. Burnout should therefore be considered as a serious risk to dentists and other dental professionals, causing pressure on the NHS and its staff by lack of available workforce, and could potentially lead to a personal tragedy for individuals and their families. For many years NHS dentistry has been struggling to cope with the number of patients requiring their services. The loss of workforce due to professionals leaving dentistry and the number of professionals suffering with mental health issues and having time off is having a dramatic impact on the resources needed to provide care to the population. Burke, Main, and Freeman¹⁰ found that work-related stress was strongly associated with early retirement of dentists. In the study by Larbie, Kemp and Whitehead² participants identified leaving the profession early as one of the main consequences of burnout and mental ill health thus impacting on the professional's career.

A cause for concern for the GDC and the profession is that a consequence of mental health and burnout is that there could be a negative effect on professional standards and this could have an impact on the standard of care that patients receive - ultimately this will affect dental professional confidence.² As burnout is related to a decline in decision making, it shows consistently that more needs to be in done to protect dentists' and dental professionals' wellbeing. A quarter of dentists were considered to have a considerable burnout risk when assessed.⁹

Triggers

This research has identified some of the common triggers of stress in dentistry. Some of these triggers are things which dental professionals have control over such as equipment, team, and appointment times, and others which they cannot control like patients and over regulation, to name a few. This echoes the results found in previous studies; a significant source of stress for NHS dentists is time constraints.^2,8,11 Most triggers of stress in dentistry are multifactorial in nature, for example: if an appointment is not long enough the clinician will run late and then the next patient might complain that they have been kept waiting and thus this becomes a spiral that is difficult to get out of and becomes more and more stressful. Another source of stress identified is over regulation: ‘we worry all the time about the GDC'.

Support

Participants identified that family and friends were a source of support, but there is a lack of understanding of the profession. There was an apparent lack of understanding or willingness to access formal help, although associations were noted as potential sources of information and help. The participants of the BDA study by Larbie, Kemp, and Whitehead² suggested that accessing support was the main issue, in particular the barriers to access. Whilst blogs are not high on the pyramid of best evidence, one of relevance was found on the BDA's website and as the BDA is a credible source its findings are summarised here. Hammersley¹² reports that only 1% of dentists accessed the BDA's support service during 2021 compared to 5% of doctors [accessing similar support]. Of those who did access help, 70% were women and this upholds the notion that men struggle to seek help regarding mental health, although men are reported as at higher risk of suicide.

Mentoring

There is no research that has been found that has studied not only the perception but also the impact that mentoring can have on dental professionals. This research shows the perception of mentoring to be favourable. The participants had a lack of knowledge regarding mentoring, highlighting a lack of undergraduate training in this area. If, as previous research suggests, mentoring has many positive benefits,¹³ surely this should be being taught, utilised and more readily available. Dental professionals and students should be educated and supported to develop their own coping mechanisms, and therefore increase their resilience to help prevent the risks associated with increasing levels of stress. Effective support should be established with clear information on how and where to seek help or advice. The participants were shocked to find out that all the associations offer help and guidance as do the indemnity and defence unions. Unfortunately, even after highlighting these areas of help, all of the interviewees were still reticent about accessing help. It was acknowledged that talking is one of the main things that helps, but interviewees felt that they would feel more comfortable if this was not someone in a more senior position to them either in the practice or in an association. The interviewees had little knowledge of where to access a mentor. The work of Seath et al.¹⁴ concludes that mentoring is seldom acknowledged as a preventive measure and more often when an issue has occurred. One of the main underpinning thoughts in dentistry and indeed medicine in general is that prevention is better than cure; surely dental professionals should regard their own wellbeing in the same way.

Some degree of stress is inherent when working in dentistry; consequent effects on mental health can be seen if this exceeds an individual's ability to cope.

Self-doubt/criticism

One interesting thing that became apparent during the interviews for this study is the lack of self-confidence in dental professionals and the almost destructive self-criticism. Chapman, Chipchase, and Bretherton's¹⁵ study revealed two interesting but contradictory sides to perfectionism. The first is a side that ensures that dental professionals strive for exacting standards, and which acts as a powerful motivator; the second is a side that conversely means that if these standards are not met then the clinician finds this highly stressful and self-destructive. An interesting concept considered in research by Sancho and Ruiz¹⁶ and Alexander¹⁷ also alludes to this concept and they ask is it dentistry that shapes the personality of dental professionals and makes them so self-critical, or is it the personality type of the people that apply to study as dental professionals that makes them this way?

Importance

Although this research has not explored the risk of suicide in dentistry it would be amiss not to mention that the end point for some of the stresses identified, and the impact of long-term stress and burnout, can be suicide. A special feature published in the British Dental Journal found that three deaths within 12 months had been due to regulation by the primary care trusts (PCTs).¹⁸ The feature was published with the permission of the widow of one of the dentists who had taken his own life. He had written to the BDJ asking for assistance but tragically committed suicide before the response arrived. He wrote: ‘I qualified BDS in 1984. Over the past 28 years I have watched our profession being slowly strangled by bureaucracy and now I am at the point of complete despair'.¹⁸ Whilst suicide is not commonplace it is important to remember that everyone should be treated with compassion, and this is part of the NHS values this should include staff as well as patients.

Conclusion

The consensus is that working in dentistry can be/is stressful and this has been well evidenced/researched over the years. Some degree of stress is inherent when working in dentistry; consequent effects on mental health can be seen if this exceeds an individual's ability to cope. Unfortunately working within dentistry will always remain stressful but to have a successful career, coping mechanisms need to be introduced. This should start at an undergraduate level with mentors being routinely offered to students, remembering that a mentor should not have a more senior role than the student and that they should ideally have had some formal mentoring training. Many of the triggers of stress in dentistry are just part of working with the general public and appointments. Of course, some jobs are less stressful than others and sometimes professionals need to seek a better fit for them; but regardless, there will at times be stress. Preventive coping mechanisms should be put in place to prevent getting into a destructive cycle. Professionals should prioritise their own wellbeing and having a good work-life balance, taking time to relax and do things that are enjoyable.

Author information

Michelle was a dental nurse for 16 years, initially in a general practice and then as a special care dental nurse in the community/hospital setting. She went on to become a dental hygienist and therapist; she currently works as a dental therapist in general practice 1.5 days a week, as a dental hygienist at Liverpool Dental Hospital one day a week, and works with undergraduate BSc and BDS students 2.5 days a week at the University of Liverpool. She holds a level 7 postgraduate certificate in mentoring and an MSc in dental education.